Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures?

Outcomes and predictive factors for re-stricture with urethroplasty methods for anterior urethra stricture

OBJECTIVES

We wished to compare the treatment success of urethroplasty methods (EPA and BMG) used for anterior urethra stricture after unsuccessful internal urethrotomy.

METHODS

A total of 85 and 51 patients, respectively, who underwent excision and primary anastomosis (EPA) and buccal mucosal graft (BMG) urethroplasty due to recurrent strictures after direct vision internal urethrotomy (DVIU) were evaluated retrospectively. On the uroflowmetry test, >15 ml/s urine flow and residual urine (PVR) below 50 ml were determined as success criteria. Cox regression analysis investigated the probable predictive factors for surgery success. Kaplan-Meier analysis assessed stricture free survival after redo-urethroplasty.

RESULTS

After surgery, EPA and BMG patients were followed for 31.9 ± 9.8 (4-40) and 30.7 ± 10.3 (4-40) months. At the end of this follow-up duration, success was obtained for 71 (83.5%) and 44 (86.3%) patients. Mean re-stricture times were 13.9 ± 6.0 (4-19) and 10.2 ± 5.1 (4-26) months. Most re-strictures had penile location (10 (71.5%) and 7 (100%)). After one session of DVIU, there was 100% success in both groups, but after >3 sessions of DVIU, success fell to 70.3% and 78.3% in the groups respectively. Patients with high numbers of DVIU sessions had longer durations for urethroplasty surgery. Apart from complications related to the donor field in the oral region with BMG and four patients who developed fistula (7.8%), complications were similar in both groups.

CONCLUSIONS

In this series of cases, it was not possible to identify which of the techniques employed provides the best result or predictive factors for stenosis recurrence after correction procedures for anterior urethral stenosis.

A prospective, multi-center, open-label, single-arm phase 2b study of autologous adult live cultured buccal epithelial cells (AALBEC) in the treatment of bulbar urethral stricture

PURPOSE

To evaluate the safety and efficacy of autologous adult live cultured buccal epithelial cells (AALBEC) in treatment and management of bulbar urethral stricture in men.

METHODS

This was a prospective, multi-center, open-label, single-arm phase 2b study. A total of 18 male patients with bulbar urethral stricture of at least 1 - 4 cm in length were enrolled in the study. All 16 patients had AALBEC implanted and were included in the safety set. Change in total American Urology Association (AUA) symptom score, urinary flow rates assessed by uroflowmetry and a requirement for surgery after 24 weeks from baseline were determined in patients. Data of treatment efficacy were analyzed.

RESULTS

The AUA score at baseline was 21 (3.9) that showed a statistically significant reduction starting from week 2 [8 (4.4), p = 0.0001] which sustained until week 24 [2 (1.2), p = 0.0005]. Overall mean total AUA symptom score was reduced by 90.5% after the treatment. Significant reductions from baseline at week-24 were also observed in voiding time (92.5 (47.3) vs. 51.9 (17.4) s, p = 0.0046) and flow time [86.9 (48.2) vs. 47.9 (19.6) s, p = 0.0052]. All patients showed absence of any significant adverse events.

CONCLUSION

Significant improvement was seen in the AUA symptom score and uroflowmetry parameters and no patients required surgery during 24 weeks post-treatment. It can be concluded that AALBEC is a safe and effective treatment for bulbar urethral stricture of 1 - 4 cm length to improve the quality of life and the physiological function of urethra.

Classification systems for anterior urethral stricture disease in men: a systematic review

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.

Can proliferative hypertrophic scars of the median sternotomy incision predict the occurrence and characteristics of urethral stricture?

Objectives:

To investigate the correlation between the characteristics of urethral stricture and incision scars in patients with urethral stricture and median sternotomy incision.

Methods:

We identified 368 patients who had undergone internal urethrotomy between January 2014 and December 2017. A total of 49 male patients with a median sternotomy scar and diagnosed with urethral stricture were retrospectively evaluated. The median sternotomy incision scars were assessed using the Vancouver Scar Scale (VSS) and the patients were divided into 2 groups. Group I consisted of patients with a VSS score of <4 points, and those with ≥4 points constituted group II. The groups were compared in terms of age, smoking habit, body mass index, diabetes mellitus, hypertension, urethral stricture etiology, length and localization, and stricture relapse after intervention.

Results:

The mean total VSS score was 2.0 points in group I and 7.46 points in group II. There was a significant correlation between the VSS total score and the urethral stricture length among the whole study population (correlation coefficient value=0.481; p<0.001). The urethral stricture was longer as the VSS score increased.

Conclusion:

A poorly healed median sternotomy incision scar can predict a poor wound healing in the urethra tissue. Further large scale, multi-center and prospective studies are needed to clarify this relationship.

The effect of recurrent direct vision internal urethrotomy for short anterior urethral strictures on the disease course and the predictors of treatment failure

INTRODUCTION

The objective of this study was to investigate the disease course after direct vision internal urethrotomy (DVIU) for short anterior urethral strictures.

METHODS

We retrospectively analyzed 94 patients who underwent DVIU of the anterior urethra. Patients' age, etiology, length and localization of the strictures, total number of DVIU procedures, comorbidities, and other data were evaluated.

RESULTS

The mean age of the patients was 67.2 years. The mean followup duration was 27.1 months. Recurrence was observed in 27.6% of the patients. Recurrence had occurred in these patients at a mean of 12 months. Both the comorbidity score (rs=0.395; p<0.001) and the urinary tract infection (UTI) score (rs=0.492; p<0.001) had significant correlation with the recurrence. In patients with recurrent urethral stricture, as the number of DVIU increased, the length and number of the urethral stricture increased as well. Patients with recurrence had a single stricture in the first DVIU procedure, while the number of strictures increased to a mean of two in the second and/or third DVIU procedures.

CONCLUSION

DVIU is an effective treatment method in short anterior urethral stricture if it has been applied as a first intervention. However, if the stricture recurs, repeated DVIU application appears to be a negative predictive factor. The presence of perioperative treated UTI, smoking, and total number of comorbidities were negative predictive factors for the recurrence of urethral stricture. The disadvantages of our study is that it is retrospective, it includes a low number of patients, and the followup period is short.

Endoscopic Management of Urethral Stricture: Review and Practice Algorithm for Management of Male Urethral Stricture Disease

PURPOSE OF REVIEW

Male urethral stricture disease is characterized by the formation of scar tissue within the urethra resulting in lower urinary tract symptoms, infection, and potentially kidney dysfunction. There is significant variability in clinical practice for the treatment of urethral stricture. We sought to summarize the known data on endoscopic management of urethral stricture disease as part of this larger edition on urethral stricture management.

RECENT FINDINGS

Older studies quoted high rates of success with endoscopic management of urethral stricture, including repeated DVIU. There is now evidence to support a limited role of endoscopic intervention in the management of urethral stricture, and especially strong evidence that repeated endoscopic procedures are not effective. There is poor evidence to support the long-term efficacy of endoscopic urethral stricture management. Furthermore, novel advances in adjunctive therapies have not yet demonstrated durable patency. We discuss the limited role of endoscopic management and suggest an algorithm for its use in stricture management.

Direct Vision Internal Urethrotomy for Short Anterior Urethral Strictures and Beyond: Success Rates, Predictors of Treatment Failure, and Recurrence Management

OBJECTIVE

To determine success rates, predictors of recurrence, and recurrence management of patients treated for short anterior urethral strictures by direct vision internal urethrotomy (DVIU).

MATERIALS AND METHODS

We identified 128 patients who underwent DVIU of the anterior urethra between December 2009 and March 2016. Follow-up was conducted by telephone interviews. Success rates were assessed by Kaplan-Meier estimators. Predictors of stricture recurrence and different further therapy strategies were identified by uni- and multivariable Cox regression analyses.

RESULTS

The mean age was 63.8 years (standard deviation: 16.3) and the overall success rate was 51.6% (N = 66) at a median follow-up of 16 months (interquartile range: 6-43). Median time to stricture recurrence was six months (interquartile range: 2-12). In uni- and multivariable analyses, only repeat DVIU (hazard ratio [HR] = 1.87, 95% confidence interval (CI) = 1.13-3.11, P= .015; and HR=1.78, 95% CI = 1.05-3.03, P = .032, respectively) was a risk factor for recurrence. Of 62 patients with recurrence, 35.5% underwent urethroplasty, 29% underwent further endoscopic treatment, and 33.9% did not undergo further interventional therapy. Age (HR = 1.05, 95% CI = 1.01-1.09, P = .019) and diabetes (HR = 2.90, 95% CI = 1.02-8.26, P = .047) were predictors of no further interventional therapy.

CONCLUSION

DVIU seems justifiable in short urethral strictures as a primary treatment. Prior DVIU was a risk factor for recurrence. In case of recurrence, about one-third of the patients did not undergo any further therapy. Higher age and diabetes predicted the denial of any further treatment.

Predictors of urethral stricture recurrence after endoscopic urethrotomy

OBJECTIVE

The aim of the study was to analyse the clinical-demographic variables of the series and the predictors of urethral stricture recurrence after endoscopic urethrotomy.

MATERIAL AND METHODS

We retrospectively analysed 67 patients who underwent Sachse endoscopic urethrotomy between June 2006 and September 2014. Those patients who had previously undergone endoscopic urethrotomy or urethroplasty were excluded. The other patients who presented urethral stricture were included. We analysed age, weight, smoking habit, and cardiovascular risk factors, as well as the number, location, length and aetiology of the strictures, previous urethrotomies, vesical catheter duration and postsurgical dilatations. A univariate and multivariate analysis was conducted using the chi-squared test or Fisher's test and logistic regression to identify the variables related to recurrence.

RESULTS

Thirty-seven percent of the patients had a relapse. The majority of the patients were older than 60 years (56.7%), obese (74.6%), nonsmokers (88%) and had no cardiovascular factors (56.7%). The majority of the strictures were single (94%), <1cm (82%), bulbar urethral (64.2%), iatrogenic (67.2%) and with no prior urethrotomy (89.6%). The majority of the patients carried a vesical catheter for <15 days (85.1%) and did not undergo postsurgical dilatation (65.7%). Only the length of the stricture was an independent risk factor for recurrence (P=.025; relative risk, 5.7; 95% CI 1.21-26.41).

CONCLUSIONS

In the treatment of urethral strictures through endoscopic urethrotomy, a stricture length >1cm is the only factor that predicts an increase in the risk of recurrence. We found no clinical or demographic factors that caused an increase in the incidence of recurrence. Similarly, technical factors such as increasing the bladder catheterisation time and urethral dilatations did not change the course of the disease. Their routine use is therefore unnecessary.