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Moring N, Juneau A, Feustel PJ, Anele UA, Inouye BM. Current urethroplasty trends in recent GURS fellowship graduates. World J Urol 2024; 42:443. [PMID: 39046552 DOI: 10.1007/s00345-024-05153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 06/27/2024] [Indexed: 07/25/2024] Open
Abstract
PURPOSE To assess self-reported urethroplasty success rates and outcomes of recent GURS fellowship graduates and compare these data to the large body of published urethroplasty outcomes literature. METHODS A voluntary survey was distributed from June 1 to June 30, 2023 to GURS fellowship graduates of the last 5 years. Participants were surveyed on time since graduation, operative volume, outcomes, and quoted success rates for urethroplasty. Data were then analyzed using descriptive statistics, binary logistic regression, and correlative analyses. RESULTS We received responses from 49/101 (48.5%) GURS graduates. Five-year post-graduates were most represented (44.7%). The majority (52.2%) consider 81-90% of urethroplasty successful, without significant change with years in practice. Approximately 65% quoted excision and primary anastomosis (EPA) as > 90% successful. Over half of the respondents had performed > 60 urethroplasties since graduation. Only 31.3% of respondents reported re-intervening in > 10% of their postop patients, with a weak positive correlation between years in practice and need for re-intervention (p 0.01). Nearly 20% of respondents referred patients to an external reconstructionist. CONCLUSION Increased length of time in practice does not result in higher reported urethroplasty success rates, counseling on successful outcomes, or rates of re-intervention and complications. Our survey highlights that the traditionally used success rates for urethroplasty may not be reflective of new graduates and lower volume reconstructive surgeons in their early career.
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Affiliation(s)
- Nikolas Moring
- Department of Urology, Albany Medical Center, 25 Hackett Blvd, Albany, NY, 12208, USA.
| | - Andrea Juneau
- Urology, University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Uzoma A Anele
- Urology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Brian M Inouye
- Department of Urology, Albany Medical Center, 25 Hackett Blvd, Albany, NY, 12208, USA
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2
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Gutierrez WR, Luo Y, Dahmoush L, Oleson JJ, Schlaepfer CH, Breyer BN, Elliott SP, Myers JB, Vanni AJ, Juhr D, Christel KN, Erickson BA. Deep Phenotyping the Anterior Urethral Stricture: Characterizing the Relationship Between Inflammation, Fibrosis, Patient History, and Disease Pathophysiology. J Urol 2024; 212:153-164. [PMID: 38593413 PMCID: PMC11166509 DOI: 10.1097/ju.0000000000003962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Anterior urethral stricture disease (aUSD) is a complex, heterogeneous condition that is idiopathic in origin for most men. This gap in knowledge rarely affects the current management strategy for aUSD, as urethroplasty does not generally consider etiology. However, as we transition towards personalized, minimally invasive treatments for aUSD and begin to consider aUSD prevention strategies, disease pathophysiology will become increasingly important. The purpose of this study was to perform a deep phenotype of men undergoing anterior urethroplasty for aUSD. We hypothesized that unique biologic signatures and potential targets for intervention would emerge based on stricture presence/absence, stricture etiology, and the presence/absence of stricture inflammation. MATERIALS AND METHODS Men with aUSD undergoing urethroplasty were recruited from one of 5 participating centers. Enrollees provided urethral stricture tissue and blood/serum on the day of surgery and completed patient-reported outcome measure questionnaires both pre- and postoperatively. The initial study had 3 aims: (1) to determine pediatric and adult subacute and repeated perineal trauma (SRPT) exposures using a study-specific SRPT questionnaire, (2) to determine the degree of inflammation and fibrosis in aUSD and peri-aUSD (normal urethra) tissue, and (3) to determine levels of systemic inflammatory and fibrotic cytokines. Two controls groups provided serum (normal vasectomy patients) and urethral tissue (autopsy patients). Cohorts were based on the presence/absence of stricture, by presumed stricture etiology (idiopathic, traumatic/iatrogenic, lichen sclerosus [LS]), and by the presence/absence of stricture inflammation. RESULTS Of 138 enrolled men (120 tissue/serum; 18 stricture tissue only), 78 had idiopathic strictures, 33 had trauma-related strictures, and 27 had LS-related strictures. BMI, stricture length, and stricture location significantly differed between cohorts (P < .001 for each). The highest BMIs and the longest strictures were observed in the LS cohort. SRPT exposures did not significantly differ between etiology cohorts, with > 60% of each reporting low/mild risk. Stricture inflammation significantly differed between cohorts, with mild to severe inflammation present in 27% of trauma-related strictures, 54% of idiopathic strictures, and 48% of LS strictures (P = .036). Stricture fibrosis did not significantly differ between cohorts (P = .7). Three serum cytokines were significantly higher in patients with strictures compared to stricture-free controls: interleukin-9 (IL-9; P = .001), platelet-derived growth factor-BB (P = .004), and CCL5 (P = .01). No differences were observed in the levels of these cytokines based on stricture etiology. However, IL-9 levels were significantly higher in patients with inflamed strictures than in patients with strictures lacking inflammation (P = .019). Degree of stricture inflammation positively correlated with serum levels of IL-9 (Spearman's rho 0.224, P = .014). CONCLUSIONS The most common aUSD etiology is idiopathic. Though convention has implicated SRPT as causative for idiopathic strictures, here we found that patients with idiopathic strictures had low SRPT rates that were similar to rates in patients with a known stricture etiology. Stricture and stricture-adjacent inflammation in idiopathic stricture were similar to LS strictures, suggesting shared pathophysiologic mechanisms. IL-9, platelet-derived growth factor-BB, and CCL5, which were elevated in patients with strictures, have been implicated in fibrotic conditions elsewhere in the body. Further work will be required to determine if this shared biologic signature represents a potential mechanism for an aUSD predisposition.
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Affiliation(s)
- Wade R. Gutierrez
- University of Iowa, Carver College of Medicine, Department of Urology
| | - Yi Luo
- University of Iowa, Carver College of Medicine, Department of Urology
| | - Laila Dahmoush
- University of Iowa, Carver College of Medicine, Department of Pathology
| | - Jacob J. Oleson
- University of Iowa, College of Public Health, Department of Biostatistics
| | | | | | | | - Jeremy B. Myers
- University of Utah, Department of Surgery, Division of Urology
| | | | - Denise Juhr
- University of Iowa, Carver College of Medicine, Department of Urology
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3
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Hu S, Quint M, Boysen WR, Coon D, Odeluga N, Dy GW, Pusic AL, Kaur MN. A Content and Readability Analysis of Genitourinary and Sexual Health-Related Patient-Reported Outcome Measures in Gender-Affirming Care. Urology 2024:S0090-4295(24)00495-3. [PMID: 38936626 DOI: 10.1016/j.urology.2024.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/10/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To the evaluate the readability and comprehensiveness of genitourinary and sexual health-related patient-reported outcomes (PROMs) used in gender-affirming care. METHODS Common PROMs that measure genitourinary and sexual health-related outcomes in gender-affirming care literature were identified from six recent systematic reviews. Readability analysis was completed at the level of individual items and full scale using established readability assessment tool, including Flesch Kincaid Grade Level (FKGL), Gunning Fog Score (GF), Coleman Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG) Index. The concepts measured by the PROMs were evaluated for comprehensiveness. RESULTS Twenty-five PROMs were included, of which 12 assessed genitourinary outcomes and 13 assessed sexual health outcomes. A total of seven genitourinary domains and eight sexual health domains were identified during concept mapping. Readability analysis showed a median PROM grade level of 9.0 and 9.5 in genitourinary and sexual PROMs, respectively. The Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction v2.0 had the lowest median reading grade level of 5.7, and the Female Sexual Function Index has the highest median reading grade level of 13.9. No single PROM was found to be comprehensive. Multiple PROMs contained double-barreled items or used outdated terminology. CONCLUSION Most PROMs used in the genital gender-affirming literature failed to meet the readability recommendations for patient-facing material and were culturally unfit for use in transgender and gender-diverse individuals. None of the PROMs were found to be comprehensive for evaluating outcomes of gender-affirming care. Validated gender-affirming care-specific PROMs that are comprehensible, comprehensive, and relevant are urgently needed.
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Affiliation(s)
- Sophia Hu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Meg Quint
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Stanford University School of Medicine, Stanford, CA
| | - William R Boysen
- Department of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Devin Coon
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Geolani W Dy
- Department of Urology, Oregon Health and Science University, Portland, OR
| | - Andrea L Pusic
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Manraj N Kaur
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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4
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Pina IM, Omar AM, Floyd MS. Medical photography and the reconstructive urologist: A 6-month prospective study. Urologia 2024:3915603241241183. [PMID: 38651825 DOI: 10.1177/03915603241241183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Medical photography has multiple, important roles. The education of medical practitioners, documentation of disease, response to treatment, research, publication, intraoperative recording and trauma documentation all rely on medical photography. Additionally, there are important medicolegal implications pertaining to medical photography across many medical disciplines. Other than specific image use to document cases, there remains a paucity of urological literature regarding the use of medical photography in Urology. The aims of this 6-month study were to document the use of medical photography by a Reconstructive Urological Service in a tertiary referral centre and to assess the range of urological conditions photographed. A secondary aim was to specifically document intraoperative use of the medical photography.
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Affiliation(s)
- Ines M Pina
- Department of Reconstructive Urology, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, Merseyside, UK
| | - Ahmad M Omar
- Department of Reconstructive Urology, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, Merseyside, UK
| | - Michael S Floyd
- Department of Reconstructive Urology, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, Merseyside, UK
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5
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Rahav NJ, Udah M, Cohen S, Bdolah-Abram T, Chertin B, Shenfeld OZ. Proximal Urethrostomy Versus Urethroplasty for Complex Urethral Strictures. EUR UROL SUPPL 2024; 62:91-98. [PMID: 38486615 PMCID: PMC10937552 DOI: 10.1016/j.euros.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Background The optimal treatment for complex urethral stricture (CUS) is yet to be determined. Comparisons of methods based on validated questionnaires or objective outcome measures are lacking. Objective To compare proximal urethrostomy and urethroplasty for CUS using objective measures and validated questionnaires, and to evaluate trends in subgroups of patients who underwent proximal urethrostomy as the intended definitive treatment versus first-stage urethroplasty. Design setting and participants We identified all patients who underwent proximal urethrostomy at our center from 2004 to 2021. The control group comprised patients who underwent urethroplasty for CUS (strictures >6 cm, recurrent posturethroplasty strictures, or CUS due to lichen sclerosus or past hypospadias surgery). Outcome measurements and statistical analysis The primary outcome was a recurrent stricture at a minimal follow-up of 1 yr. The secondary outcomes included validated questionnaires, uroflowmetry, and residual urine volume. Survival was compared by a Kaplan-Meier analysis. Results and limitations The study included 57 proximal urethrostomy and 75 urethroplasty patients. Results for these two groups were as follows: the cumulative incidence of stricture recurrence over a median follow-up of 46 mo was 22.6% for proximal urethrostomy versus 36.2% for urethroplasty (p = 0.106); no statistically significant differences were observed between groups in terms of postoperative quality of urination or life, satisfaction with outcome, and erectile function. Both groups had a significant improvement in urinary flow after surgery (19.65 vs 20.29 ml/s), with no difference between the groups (p = 0.796); the proximal urethrostomy group had a significant improvement in postvoid residual after surgery, but there was no difference between the groups in the last follow-up visit (79.16 vs 52.03 ml; p = 0.245). A subgroup analysis of the proximal urethrostomy group showed no significant differences in cumulative primary or secondary outcomes. Limitations included the retrospective design and the relatively small study population. Conclusions Comparisons of the two groups revealed no significant differences in stricture recurrence, results of validated questionnaires, or objective measures of urination. Patient summary Proximal urethrostomy is equivalent to urethral reconstruction, and it should be offered as a viable solution for complex urethral stricture.
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Affiliation(s)
- Nir J. Rahav
- Center for Reconstructive and Functional Urology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Mohamad Udah
- Department of Urology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sarit Cohen
- Department of Urology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Boris Chertin
- Department of Urology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ofer Z. Shenfeld
- Center for Reconstructive and Functional Urology, Shaare Zedek Medical Center, Jerusalem, Israel
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6
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Verla W, Mantica G, Waterloos M, Adamowicz J, Frankiewicz M, Cocci A, Rosenbaum CM, Campos-Juanatey F, Vetterlein MW. Treatment Success After Urethroplasty: The Ongoing Quest for a Pragmatic and Universal Definition. Eur Urol Focus 2023:S2405-4569(23)00033-0. [PMID: 36792406 DOI: 10.1016/j.euf.2023.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
There is no consensus on the ideal definition of success after urethroplasty, which makes research, quality control, and comparisons challenging. Ongoing research endeavors are focused on achieving consensus regarding the optimal battery of outcomes for evaluation of patients after urethroplasty.
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Affiliation(s)
- Wesley Verla
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Guglielmo Mantica
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy
| | - Marjan Waterloos
- Department of Urology, Ghent University Hospital, Ghent, Belgium; Department of Urology, AZ Maria Middelares, Ghent, Belgium
| | - Jan Adamowicz
- Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Andrea Cocci
- Department of Urology and Andrology, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Felix Campos-Juanatey
- Andrology and Reconstructive Urology Unit, Marqués de Valdecilla University Hospital, School of Medicine, Cantabria University, IDIVAL, Santander, Spain
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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7
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Mantica G, Verla W, Cocci A, Frankiewicz M, Adamowicz J, Campos-Juanatey F, Rosenbaum CM, Waterloos M, Kluth LA, Vetterlein MW. Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria. Res Rep Urol 2022; 14:423-426. [PMID: 36568569 PMCID: PMC9785114 DOI: 10.2147/rru.s396025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.
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Affiliation(s)
- Guglielmo Mantica
- IRCCS Ospedale Policlinico San Martino, Genova, Italy,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy,Correspondence: Guglielmo Mantica, IRCCS San Martino Hospital, University of Genova, Largo Rosanna Benzi 10, Genova, 16132, Italy, Tel +390105555964, Email
| | - Wesley Verla
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Andrea Cocci
- Department of Urology and Andrology, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Jan Adamowicz
- Department of Regenerative Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Felix Campos-Juanatey
- Andrology and Reconstructive Urology Unit, Marques de Valdecilla University Hospital, IDIVAL, Santander, Spain
| | | | - Marjan Waterloos
- Department of Urology, Division of Reconstructive Urology, Ghent University Hospital, Ghent, Belgium
| | - Luis A Kluth
- Department of Urology, University Medical Center Frankfurt, Frankfurt/Main, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Topcuoglu M, Topaloglu H, Kartal İ, Kokurcan A, Sarı H, Yalçınkaya F. Assessments of ReDo buccal mucosal urethroplasty in terms of functional outcomes. Int Urol Nephrol 2022; 54:2547-2553. [PMID: 35838830 DOI: 10.1007/s11255-022-03279-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE We aimed to assess the success rates and functional outcomes of ReDo buccal mucosal graft urethroplasty (BMGU) following failed primary BMGU and evaluate the oral morbidity and changes in quality of life (QoL) after this surgery. MATERIALS AND METHODS Data of the patients with recurrent anterior urethral stricture who underwent ReDo BMGU after failed primary BMGU were retrospectively reviewed. The collected data included the results of the urethral stricture surgery patient-reported outcome measure-lower urinary tract symptoms (USS-PROM-LUTS) and euro-quality of life visual analog scale (EQ-VAS) questionnaires performed preoperatively before and one year after surgery. The cohort was divided into two groups according to procedural success, and these groups were compared. RESULTS Thirty-two men patients were included. Among these, twenty-seven (84.3%) cases were considered successful following ReDo BMGU. The pre-ReDo BMGU mean stricture length was significantly longer in the failure group (2.3 ± 0.6 vs. 4.4 ± 1.2 cm, p = 0.001). Except for one patient with persistent oral numbness, no severe complication was reported postoperatively in the first year. The mean USS-PROM-LUTS score decreased significantly, while the mean LUTS-related quality of life score increased significantly following ReDo BMGU (p < 0.001, p < 0.001). In addition, the mean total EQ-VAS score increased significantly from 62.75 to 78.45, indicating remarkable improvement (p < 0.001). CONCLUSIONS Although less favorable outcomes can be anticipated in ReDo BMGU due to extensive scar tissue formation and reduced vascularity, high success and patient satisfaction rates and low oral morbidity rates were detected in ReDo BMGU cases.
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Affiliation(s)
- Murat Topcuoglu
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey.,Department of Urology, Medical School of Aladdin Keykubat University, Alanya, Antalya, Turkey
| | - Hikmet Topaloglu
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey.
| | - İbrahim Kartal
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey.,Department of Urology, Faculty of Medicine, Kutahya Health Science University, Kutahya, Turkey
| | - Alihan Kokurcan
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey
| | - Hilmi Sarı
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey
| | - Fatih Yalçınkaya
- Department of Urology, University of Health Sciences, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ziraat Mah. Şehit Ömer Halisdemir Cad. No: 20, 06110, Dışkapı, Ankara, Turkey
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9
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Agochukwu-Mmonu N, Radix A, Zhao L, Makarov D, Bluebond-Langner R, Fendrick AM, Castle E, Berry C. Patient reported outcomes in genital gender-affirming surgery: the time is now. J Patient Rep Outcomes 2022; 6:39. [PMID: 35467181 PMCID: PMC9038968 DOI: 10.1186/s41687-022-00446-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 04/02/2022] [Indexed: 11/16/2022] Open
Abstract
Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.
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Affiliation(s)
- Nnenaya Agochukwu-Mmonu
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA.
- Department of Population Health, NYU School of Medicine, New York, NY, USA.
| | - Asa Radix
- Department of Medicine, NYU School of Medicine, New York, NY, USA
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Lee Zhao
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Danil Makarov
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | | | - A Mark Fendrick
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Elijah Castle
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Carolyn Berry
- Department of Population Health, NYU School of Medicine, New York, NY, USA
- Department of Medicine, NYU School of Medicine, New York, NY, USA
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10
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Nilsen OJ, Holm HV, Ekerhult TO, Lindqvist K, Grabowska B, Persson B, Sairanen J. To Transect or Not Transect: Results from the Scandinavian Urethroplasty Study, A Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting. Eur Urol 2022; 81:375-382. [PMID: 35012771 DOI: 10.1016/j.eururo.2021.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/20/2021] [Accepted: 12/14/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Open surgical treatment of short bulbar urethral strictures (urethroplasty) is commonly performed as transecting excision and primary anastomosis (tEPA) or buccal mucosa grafting (BMG). Erectile dysfunction and penile complications have been reported, but there is an absence of randomised trials. OBJECTIVE To evaluate sexual dysfunction and penile complications after urethroplasty with tEPA versus BMG. DESIGN, SETTING, AND PARTICIPANTS Centres in Finland, Sweden and Norway participated. Patients with a bulbar urethral stricture of ≤2 cm without previous urethroplasty were randomised. The primary endpoints were the degree of erectile dysfunction and penile complications. Follow-up was 12 mo. INTERVENTION Patients were randomised to either tEPA or BMG urethroplasty. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Sexual dysfunction was measured using the International Index of Erectile Function, 5-item version (IIEF-5) and a penile complications questionnaire (PCQ) designed for this study. Continuous data were analysed using analysis of covariance and categorical data were compared using a χ2 test. RESULTS AND LIMITATIONS A total of 151 patients were randomised to either tEPA (n = 75) or BMG (n = 76). The tEPA group reported more penile complications (p = 0.02), especially reduced glans filling (p = 0.03) and a shortened penis (p = 0.001). There were no differences in postoperative IIEF-5 total scores. Recurrence rates were similar in both groups (12.9%) but the study was not designed to detect differences in recurrence rates. The PCQ is not validated, which is a limitation. CONCLUSIONS More patients reported penile complications after urethroplasty with tEPA than with BMG. This should be considered when choosing the operative method, and patients should be informed accordingly. PATIENT SUMMARY This study compared two common operations for repair of narrowing of the male urethra. Neither of the two methods seems to cause worsened erections. However, penile problems are more common after the transection technique than after the grafting technique.
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Affiliation(s)
- Ole Jacob Nilsen
- Department of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | - Teresa O Ekerhult
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Klas Lindqvist
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Beata Grabowska
- Department of Urology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Beata Persson
- Department of Urology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jukka Sairanen
- Department of Urology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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11
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Teymourian H, Saeedi N, Salimi H. Comparison of Epidural Dexmedetomidine Versus Ropivacaine Infusion Effectiveness in Preventing Erection Following Reconstructive Urethral Surgery: A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e114259. [PMID: 34540636 PMCID: PMC8438744 DOI: 10.5812/aapm.114259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/16/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background One of the most common devastating problems that occur after urethroplasty is erection, which causes surgical complications (fistula, wound dehiscence, and surgical graft failure) and the need for repairing the complications. We attempted to compare the effect of continuous epidural infusion of dexmedetomidine and ropivacaine as a post-surgical erection prevention strategy. Objectives In this study, we aimed to compare the effect of dexmedetomidine and ropivacaine epidural infusion on the incidence of erection after reconstructive urethral surgery. Methods An RCT was conducted on 45 patients who were scheduled for reconstructive urethral surgery. They were randomly divided into three groups: (1) control (n = 15), (2) epidural dexmedetomidine (n = 15), (3) and epidural ropivacaine (n = 15). The control group received oral medication after surgery according to the conventional method (cyproterone compound tablets 50 mg BD and diazepam tablets 2 mg TDS for a week) to prevent erection. The DEX group received dexmedetomidine as continuous epidural infusion, and the ROP group received ropivacaine in addition to the conventional method. The occurrence of erection during day and night was recorded separately until the seventh day after surgery. Due to the long-time interval between case selection, participants from different groups were not matched with each other. Results The incidence of erection in the dexmedetomidine group was lower than that in the ropivacaine group per person (0.87) and significantly lower than in the control group (2.8 per person). Also, there was significantly less erection in the ropivacaine group (1.2 per person) than in the control group. Our study showed that erection after surgery significantly decreased with the continuous epidural infusion of dexmedetomidine and ropivacaine. Conclusions Dexmedetomidine seems to have a significant preventive effect on erection after reconstructive urethral surgery.
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Affiliation(s)
- Houman Teymourian
- Department of Anesthesiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nima Saeedi
- Department of Anesthesiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Hojat Salimi
- Department of Urology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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12
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Mershon JP, Baradaran N. Recurrent Anterior Urethral Stricture: Challenges and Solutions. Res Rep Urol 2021; 13:237-249. [PMID: 34012927 PMCID: PMC8128502 DOI: 10.2147/rru.s198792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/14/2021] [Indexed: 12/05/2022] Open
Abstract
Recurrent male anterior urethral stricture disease is a complex surgical challenge that should be managed by reconstructive urologists with experience in stricture management. Diagnosis of recurrence requires both anatomic narrowing and patient symptoms identified on validated questionnaires, with limited role for intervention in asymptomatic treatment “failures”. Endoscopic management has a very specific role in recurrence, and the choice of technique for urethroplasty depends on pre-operative urethrography and cystoscopy. Surgical success depends on addressing patient concerns, complete stricture excision, tissue quality optimization, and the use of multi-stage repair when indicated. Augmentation with genital skin flaps and/or grafts is often required, with buccal mucosa as the ideal graft source if local tissue is compromised. Salvage options including urinary diversion and perineal urethrostomy must also be considered in debilitated patients with severe disease or repeated treatment failures. Unique patient populations including patients with hypospadias and lichen sclerosis are among the highest risk for repeated recurrence and require special care in surgical technique, graft selection, and post-operative management.
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Affiliation(s)
| | - Nima Baradaran
- The Ohio State University Department of Urology, Columbus, OH, USA
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13
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Lane GI, Gracely A, Uberoi P, Lee U, Smith AL, Anger JT, Theva D, DeLong J, Kowalik C, Padmanabhan P, Powell CR, Carmel ME, Clemens JQ, Cameron AP, Gupta P. Changes in patient reported outcome measures after treatment for female urethral stricture. Neurourol Urodyn 2021; 40:986-993. [PMID: 33719145 DOI: 10.1002/nau.24653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.
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Affiliation(s)
- Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Alyssa Gracely
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Una Lee
- Virginia Mason, Seattle, Washington, USA
| | - Ariana L Smith
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Didi Theva
- Memorial Hospital Miramar, Miramar, Florida, USA
| | | | - Casey Kowalik
- Kansas University Medical Center, Kansas City, Kansas, USA
| | - Priya Padmanabhan
- Kansas University Medical Center, Kansas City, Kansas, USA.,Beaumont Hospital, Royal Oak, Michigan, USA
| | | | - Maude E Carmel
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Vetterlein MW, Gödde A, Zumstein V, Gild P, Marks P, Soave A, Meyer CP, Riechardt S, Dahlem R, Fisch M, Kluth LA. Exploring the intersection of functional recurrence, patient-reported sexual function, and treatment satisfaction after anterior buccal mucosal graft urethroplasty. World J Urol 2021; 39:3533-3539. [PMID: 33709201 PMCID: PMC8510905 DOI: 10.1007/s00345-021-03648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/19/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose To evaluate the interplay of stricture recurrence, sexual function, and treatment satisfaction after substitution urethroplasty. Methods Observational study of men undergoing 1-stage buccal mucosal graft urethroplasty for anterior urethral stricture between 2009 and 2016. Patients were dichotomized by self-reported treatment satisfaction. Sexual function was assessed by validated and non-validated patient-reported outcome measures. Functional recurrence was defined as symptomatic need of re-intervention. Bivariate analyses, Kaplan–Meier estimates, qualitative and quantitative analyses by uni- and multivariable regression were employed to evaluate the interplay of sexual function, functional recurrence, and treatment satisfaction. Results Of 534 men with bulbar (82%), penobulbar (11%), and penile strictures (7.3%), 451 (84%) were satisfied with the surgery. There were no differences in stricture location, previous treatment, graft length, or surgical technique between satisfied and unsatisfied patients (all p ≥ 0.2). Recurrence-free survival was 85% at a median follow-up of 33 mo and decreased significantly with each Likert item towards increasing dissatisfaction (p < 0.001). Dissatisfied patients more often reported postoperative loss of rigidity, tumescence, reduced ejaculatory volume, ejaculatory pain, and reduced penile length (all p ≤ 0.042). In 83 dissatisfied men, functional recurrence (28%) and oral morbidity (20%) were the main drivers of dissatisfaction in qualitative analysis. Multivariable analyses revealed functional recurrence and impaired postoperative ejaculatory function as independent predictors of treatment dissatisfaction (all p ≤ 0.029) after adjusting for confounders. Conclusion We found an association of both functional success and sexual function with patient-reported treatment satisfaction after substitution urethroplasty. Such findings validate the clinical significance of defining the symptomatic need for re-intervention as an endpoint and underline the importance of further research evaluating sexual function before and after open urethral reconstruction. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-021-03648-y.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Almut Gödde
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Valentin Zumstein
- Department of Urology, School of Medicine, University of St, Gallen, St. Gallen, Switzerland
| | - Philipp Gild
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian P Meyer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Luis A Kluth
- Department of Urology, University Medical Center, Frankfurt, Frankfurt (Main), Germany
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15
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Heinsimer K, Wiegand L. Erectile and Ejaculatory Dysfunction After Urethroplasty. Curr Urol Rep 2021; 22:19. [PMID: 33554283 DOI: 10.1007/s11934-021-01039-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF THE REVIEW The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty. RECENT FINDINGS With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty.
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Affiliation(s)
- Kevin Heinsimer
- Department of Urology, University of South Florida, Tampa General Circle, STC Floor 6, Tampa, FL, 33606, USA.
| | - Lucas Wiegand
- Department of Urology, University of South Florida, Tampa General Circle, STC Floor 6, Tampa, FL, 33606, USA
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16
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Cohen AJ, Patino G, Mirramezani M, Srirangapatanam S, Tresh A, Cheema B, Tai J, Romero D, Enriquez A, Baskin LS, Shadden SC, Breyer BN. Novel measurement tool and model for aberrant urinary stream in 3D printed urethras derived from human tissue. PLoS One 2020; 15:e0241507. [PMID: 33175862 PMCID: PMC7657556 DOI: 10.1371/journal.pone.0241507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023] Open
Abstract
Background An estimated 10% of male adults have split or dribbled stream leading to poor hygiene, embarrassment, and inconvenience. There is no current metric that measures male stream deviation. Objective To develop a novel method to measure spray in normal and abnormal anatomical conformations. Design, setting, and participants We developed a novel platform to reliably describe spray. We used cadaveric tissues and 3D Printed models to study the impact of meatal shape on the urinary stream. Cadaveric penile tissue and 3D printed models were affixed to a fluid pump and used to simulate micturition. Dye captured on fabric allowed for spray detection. Outcome measurements and statistical analysis Spray pattern area, deviation from normal location, and flowrates were recorded. Computational fluid dynamic models were created to study fluid vorticity. Results and limitations Obstructions at the penile tip worsened spray dynamics and reduced flow. Ventral meatotomy improved flowrate (p<0.05) and reduced spray (p<0.05) compared to tips obstructed ventrally, dorsally or in the fossa navicularis. 3D models do not fully reproduce parameters of their parent cadaver material. The average flowrate from 3D model was 10ml/sec less than that of the penis from which it was derived (p = 0.03). Nonetheless, as in cadavers, increasing obstruction in 3D models leads to the same pattern of reduced flowrate and worse spray. Dynamic modeling revealed increasing distal obstruction was correlated to higher relative vorticity observed at the urethral tip. Conclusions We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the urethra and corrective surgeries on the urine stream that would not be feasible in patients. These novel methods require further validation, but offer promise as a research and clinical tool.
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Affiliation(s)
- Andrew J. Cohen
- Brady Urological Institute, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States of America
| | - German Patino
- Hospital Universitario San Ignacio, Bogota, Colombia, United States of America
| | - Mehran Mirramezani
- University of California, Berkeley, Department of Mechanical Engineering, Berkeley, CA, United States of America
| | - Sudarshan Srirangapatanam
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
| | - Anas Tresh
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
| | - Bhagat Cheema
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
| | - Jenny Tai
- Makers Lab Library, University of California San Francisco, San Francisco, CA, United States of America
| | - Dylan Romero
- Makers Lab Library, University of California San Francisco, San Francisco, CA, United States of America
| | - Anthony Enriquez
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
| | - Laurence S. Baskin
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
| | - Shawn C. Shadden
- University of California, Berkeley, Department of Mechanical Engineering, Berkeley, CA, United States of America
| | - Benjamin N. Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, United States of America
- Department of Biostatistics and Epidemiology, University of California, San Francisco, CA, United States of America
- * E-mail:
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17
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Ong M, Duncan C, McGrail M, Desai DJ. Evaluation of patient reported outcome measures post urethroplasty: Piloting a “Trifecta” approach. World J Clin Urol 2020; 9:9-15. [DOI: 10.5410/wjcu.v9.i1.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/27/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Buccal mucosal graft urethroplasty is the gold standard treatment for urethral stricture disease. Toowoomba has obtained a fellowship trained urethroplasty surgeon who has been performing urethroplasties for the last two years. Patient reported outcome measure (PROM) questionnaires allow for a detailed and standardized analysis of success and morbidity post urethroplasty and can be used as a reference point against which urethral surgeons can benchmark their performance.
AIM To assess whether patient compliance rates improved with the use of an abridged PROM questionnaire.
METHODS Our database of urethroplasty patients was searched to identify patients who had completed the original PROM. This is routinely requested to be completed at the 3-, 6- and 12-mo mark. All patients are asked to complete the questionnaire and to bring it back to their next appointment. Our original PROM consists of the international prostate symptom score, the sexual health index measure and the Global Response Assessment. An abridged version of the questionnaire was derived focusing on urinary flow, sexual function and overall quality of life and consisted of three questions.
RESULTS Sixty-six patients were included in our study. Fifty-four patients had been invited to complete the original PROM with an overall compliance rate of 30%. Compliance rates improved to 91% with the introduction of the modified PROM. No correlation between non-compliance and patient factors were found. There was also no significant difference in patient reported quality of life when comparing urinary flow and sexual function.
CONCLUSION We recommend the use of PROMs pre- and post-operatively to accurately determine the level of patient satisfaction. We acknowledge the aversion of patients in completing PROMs due to the length of these questionnaires. We propose a simplistic version aimed at the “Trifecta” of urethroplasty comprising of three questions focusing each on urinary flow, sexual function and quality of life. Our modified PROM demonstrated markedly improved compliance rates and can be used as a screening tool to identify patients who might have had a poor outcome and who require a more in-depth assessment.
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Affiliation(s)
- Michelle Ong
- Department of Urology, Toowoomba Hospital, Toowoomba 4350, Queensland, Australia
| | - Catriona Duncan
- Department of Urology, Toowoomba Hospital, Toowoomba 4350, Queensland, Australia
| | - Matthew McGrail
- Department of Head Regional Training Hub Research, University of Queensland Rural Clinical School, Rockhampton 4700, Queensland, Australia
| | - Devang J Desai
- Department of Urology, Toowoomba Hospital, Toowoomba 4350, Queensland, Australia
- University of Queensland Rural Clinical School, Toowoomba 4350, Queensland, Australia
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18
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Urethrogram: Does Postoperative Contrast Extravasation Portend Stricture Recurrence? Urology 2020; 145:262-268. [PMID: 32763321 DOI: 10.1016/j.urology.2020.05.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up. MATERIALS AND METHODS We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease. RESULTS Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year. CONCLUSION Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.
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19
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Mann RA, Virasoro R, DeLong JM, Estrella RE, Pichardo M, Lay RR, Espino G, Roth JD, Elliott SP. A drug-coated balloon treatment for urethral stricture disease: Two-year results from the ROBUST I study. Can Urol Assoc J 2020; 15:20-25. [PMID: 32744999 DOI: 10.5489/cuaj.6661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Mechanical balloon dilation and direct visualization internal urethrotomy (DVIU) are the most widely used treatments for urethral stricture disease in the U.S., but recurrence rates are high, especially after re-treatment. This study investigates the safety and efficacy of the Optilume™ paclitaxel-coated balloon for the treatment of recurrent strictures. METHODS Men with recurrent bulbar strictures ≤2 cm with 1-4 prior endoscopic treatments were treated with the Optilume™ drug-coated balloon. Patients were evaluated within 14 days, three, six, 12, and 24 months post-treatment. The primary safety endpoint was serious urinary adverse events. The primary efficacy endpoint was ≥50% improvement in International Prostate Symptom Score (IPSS) at 24 months. Secondary outcomes included quality of life, erectile function, flow rate, and post-void residual urine volume. RESULTS A total of 53 subjects were enrolled and treated; 46 completed the 24-month followup. Forty-three percent of men had undergone >1 previous dilations, with a mean of 1.7 prior dilations. There were no serious adverse events related to treatment at two years. Success was achieved in 32/46 (70%), and baseline IPSS improved from a mean of 25.2 to 6.9 at 24 months (p<0.0001). Quality of life, flow rate, and post-void residual urine volumes improved significantly from baseline. There was no impact on erectile function. CONCLUSIONS Two-year data indicates the Optilume™ paclitaxel-coated balloon is safe for the treatment of recurrent bulbar urethral strictures. Early efficacy results are encouraging and support further followup of these men through five years, as well as further investigation with a randomized trial.
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Affiliation(s)
- Rachel A Mann
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Ramón Virasoro
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Jessica M DeLong
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Rafael E Estrella
- Clinica Union Medica, Santiago de los Caballeros, Dominican Republic
| | | | | | | | - Joshua D Roth
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
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20
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John A, Kahokehr AA. Classification systems for anterior urethral stricture disease in men: a systematic review. World J Urol 2020; 39:761-769. [PMID: 32451616 DOI: 10.1007/s00345-020-03250-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/07/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To identify and explore the various classification systems that have been proposed for anterior urethral stricture disease (AUSD) and to identify the advantages and disadvantages of each. METHODS A comprehensive systematic review was conducted in MEDLINE, EMBASE, SCOPUS and COCHRANE databases with a search strategy created appropriately. Titles and abstracts of search results were screened by two authors and selected for full-text review. Studies exploring urethral stricture classification, clinical scoring or staging systems used in men over the age of 18 with benign anterior urethral stricture disease were included. RESULTS The search identified 3113 articles, of which 10 were selected for inclusion after scrutiny. Four classification systems were identified. These include ULTRA score, urethral stricture score, cystoscopy-based staging system and Gombe Urethrographic score. These were based on various modalities, including cystoscopy, retrograde urethrogram (RUG) and sonourethrogram (SUG). From the scoring systems identified, the urethral stricture scoring system has multiple external validation studies and is predictive of operative complexity, operative time, recurrence and postoperative complications. CONCLUSIONS Several classification systems have been proposed for AUSD. Each has its advantages and disadvantages. The urethral stricture score has been externally validated and shown to been predictive of surgical outcomes and recurrence. There are no scores that incorporate patient-related outcome measures (PROMs). Many classification systems have yet to provide sufficient external validation. Further external validation studies are needed before the general adoption of a particular system.
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Affiliation(s)
- Athul John
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5005, Australia.
| | - Arman A Kahokehr
- Adelaide Medical School, University of Adelaide, Adelaide, SA, 5005, Australia.,Flinders University, Adelaide, Australia
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21
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Vetterlein MW, Kluth LA, Zumstein V, Meyer CP, Ludwig TA, Soave A, Riechardt S, Engel O, Dahlem R, Fisch M, Rosenbaum CM. Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM). World J Urol 2020; 38:2863-2872. [PMID: 32067075 PMCID: PMC7644515 DOI: 10.1007/s00345-020-03102-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/21/2020] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES To evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty. PATIENTS AND METHODS Monocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan-Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM). RESULTS Overall, 47 patients were available for final analyses. Median age was 70 (IQR 65-74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28-68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome. CONCLUSION The success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Luis A Kluth
- Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany
| | - Valentin Zumstein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Urology, Cantonal Medical Center St. Gallen, St. Gallen, Switzerland
| | - Christian P Meyer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tim A Ludwig
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Oliver Engel
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Clemens M Rosenbaum
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Urology, Asklepios Medical Center Barmbek, Hamburg, Germany
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22
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Waterloos M, Hollebosch S, Verla W, Spinoit AF, Hoebeke P, Monstrey S, Lumen N. Neo-vaginal Advancement Flaps in the Treatment of Urethral Strictures in Transwomen. Urology 2019; 129:217-222. [DOI: 10.1016/j.urology.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/03/2019] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
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23
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Fuehner C, Dahlem R, Fisch M, Vetterlein MW. Update on managing anterior urethral strictures. Indian J Urol 2019; 35:94-100. [PMID: 31000913 PMCID: PMC6458800 DOI: 10.4103/iju.iju_52_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/18/2019] [Indexed: 06/09/2023] Open
Abstract
A number of techniques have been described for managing anterior urethral strictures in men. In this review, we aimed to summarize contemporary considerations regarding the holistic management of such strictures. The efficacy of reported outcomes is compared to provide evidence-based treatment recommendations. For anterior urethral strictures, durable long-term success rates of >90% may be achieved if the procedure is performed in capable hands at a high-volume referral center, even in recurrent strictures after previous open reconstruction. A one-stage urethroplasty is preferable to avoid a protracted treatment course with multiple interventions after dilation and direct vision internal urethrotomy. Staged urethroplasties are useful in complex anterior strictures providing durable success rates. In addition, perineal urethrostomy represents a valid last resort option with sufficient objective and subjective results. A follow-up evaluation should incorporate objective assessments such as radiographic and functional diagnostics as well as subjective, validated, and disease-specific patient-reported outcome measurement tools to allow for a better comparability and to improve individual risk prediction.
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Affiliation(s)
- Constantin Fuehner
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W. Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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24
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Floyd MS, Omar AM, Baird AD, Anderson PCB. Re: The effect of urethroplasty surgery on erectile and orgasmic functions: a prospective study. Int Braz J Urol 2019; 45:412-414. [PMID: 30735329 PMCID: PMC6541131 DOI: 10.1590/s1677-5538.ibju.2018.0793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Michael S Floyd
- Department of Reconstructive Urology, St Helens & Knowsley Hospital NHS Trust Whiston Hospital, Liverpool, United Kingdom
| | - Ahmad M Omar
- Department of Reconstructive Urology, St Helens & Knowsley Hospital NHS Trust Whiston Hospital, Liverpool, United Kingdom
| | - Andrew D Baird
- Department of Reconstructive Urology, St Helens & Knowsley Hospital NHS Trust Whiston Hospital, Liverpool, United Kingdom
| | - Paul C B Anderson
- Department of Reconstructive Urology, St Helens & Knowsley Hospital NHS Trust Whiston Hospital, Liverpool, United Kingdom
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25
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Chung PH, Vanni AJ, Breyer BN, Erickson BA, Myers JB, Alsikafi N, Buckley J, Elliott SP, Zhao LC, Voelzke BB. Evaluation of Generic Versus Condition-Specific Quality of Life Indicators for Successful Urethral Stricture Surgery. Urology 2018; 126:222-226. [PMID: 30580004 DOI: 10.1016/j.urology.2018.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/09/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the utility of generic health quality of life (QOL) and condition specific indicators as patient reported outcomes measures for urethral stricture surgery. MATERIALS AND METHODS Patient data were obtained from the Trauma and Urologic Reconstructive Network of Surgeons collaborative database. Patients who underwent any successful urethroplasty and completed both pre- and postoperative generic and condition-specific questionnaires were included. RESULTS A total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, p<0.05), Peeling curve (3.1-1.7, p < 0.05), and overall interference of urinary symptoms on life (3.0-1.6, p < 0.05). Mean overall health status visual analog scale (74.2-80.0, p < 0.05) and generic health QOL EQ-5D index scores (0.90-0.95, p < 0.05) also improved; however, individual EQ-5D measures assessing mobility, self-care, and activity level did not change. EQ-5D measures for pain/discomfort (1.48-1.23, p < 0.05) and anxiety/depression (1.33-1.21, p < 0.05) improved, but not to the same extent as stricture-specific measures. More patients reported improvement in condition-specific urethra/penis pain and bladder pain compared to improvement in generic EQ-5D pain/discomfort (p < 0.001). CONCLUSION Generic health QOL indicators are less meaningful in the assessment of urethral stricture surgery and should be replaced with condition-specific outcomes measures. It is important to ensure that appropriate condition-specific outcomes measures are utilized as patient reported outcomes measures become more prevalent in medicine and potentially become utilized to evaluate surgeon outcomes and determine surgeon reimbursement.
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Affiliation(s)
- Paul H Chung
- Department of Urology, Thomas Jefferson University, Philadelphia, PA.
| | - Alex J Vanni
- Department of Urology, Lahey Clinic, Burlington, MA
| | | | | | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | | | - Jill Buckley
- Department of Urology, University of California San Diego, San Diego, CA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York City, NY
| | - Bryan B Voelzke
- Department of Urology, University of Washington Medical Center, Seattle, WA
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