Revision urethroplasty success is comparable to primary urethroplasty: a comparative analysis

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.

Sexual function after anterior urethroplasty: a systematic review

Background

Urethral surgery outcomes are often evaluated by assessing urinary flow and urethral patency. However, sexual consequences may appear after urethroplasty, impairing quality of life and patient’s perception of success.

The aim of this study is to assess the relationship between anterior urethral reconstruction and postoperative sexual dysfunction, including the proposed factors predicting sexual outcomes.

Methods

We searched in PubMed database using the terms: “anterior urethroplasty”, bulbar urethroplasty” or “penile urethroplasty”, and “sexual dysfunction”, “erectile function” or “ejaculation”. Articles were independently evaluated for inclusion based on predetermined criteria. Systematic data extraction was followed by a comprehensive summary of evidence.

Results

Thirty-eight studies were included for final analysis. No randomised trial on the topic was found. Urethral surgery might affect different aspects of sexual function: erectile function, ejaculatory function, penile shape and length, and genital sensitivity, leading to severe sexual dysfunction. Patient perception of sexual impairment was related to post-operative satisfaction.

Conclusions

Sexual dysfunction after anterior urethral reconstruction is an important issue that must be appropriately discussed during preoperative patient counselling. Reported outcomes after anterior urethroplasty should include sexual consequences and relevance, evaluated using validated tools.

Analysis of the Determinants, Characteristics and Management of Recurrent Urethral Strictures

Background:

The presentation and management of the recurrent urethral stricture varies and depends largely on the initial treatment and the characteristics of the recurrent stricture. What are the likely determinants of recurrence?

Patients and Methods:

This is a retrospective review of all patients who had urethroplasties from January 2013 to December 2017 for anterior urethral strictures in our institution. Patients with a recurrence of the strictures were identified and reviewed, while patients with hypospadias and posterior urethral stenosis or contractures were excluded from the study. The etiology, length, site, and type of urethroplasties were evaluated as variables that may contribute to the recurrence of strictures using inferential statistics and logistic regression analysis. Time to recurrence was analyzed using the Kaplan–Meier method.

Results:

A total of 206 urethroplasties for anterior urethral strictures were evaluated with recurrence of strictures noted in 29 patients and a recurrence rate of 14.1%. Recurrence was higher in long-segment strictures, penobulbar strictures, and postinflammatory strictures. Pedicle flaps were used in 45% of the strictures that reoccurred. Using Chi-square, the length, site, of urethroplasties were statistically significant determinants of recurrence; however, only the site of stricture was found to be statistically significant following logistic regression analysis. The site of recurrence was in the bulbar urethra in 79% and the penile urethra in 21%. The choice of treatment of the recurrent strictures was anastomotic urethroplasty in 76.5%. The mean time to failure in this study was 13 months with a range of 6-120 months.

Conclusion:

In this study, the site of stricture was found to be the most determinant of stricture recurrence, with penobulbar strictures mostly implicated. Long-segment strictures were also noted to contribute to some extent in recurrence. These recurrent strictures were mostly short-segment strictures in the bulbar urethra which were amenable to excision and anastomosis to achieve cure.

Canadian Urological Association guideline on male urethral stricture

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient's quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.

Calibration of urethra with anti-scar gel as a new preventive method for stricture recurrence after urethroplasty performed due to refractory anterior urethral stricture disease

Introduction

The aim of this article was to determine if scar contraction can be prevented by calibration of urethra with anti-scar gel (ASG).

Material and methods

The authors operated on 36 men with recurrent urethral strictures (US). Strictures were localized in the penile (n = 26), penile and bulbar (8) or in the bulbar (2) part of the urethra. In 34 patients, dorsal inlay buccal mucosa graft urethroplasty (BMGU) was performed and in the remaining 2 patients dorsal onlay BMGU was performed. First calibration was done one month after operation by hegar size 3.5 (diameter in millimeters) with ASG. Patients were instructed how to perform this action and repeated this action for 4-6 weeks. Then, every 4-6 weeks, the size of the calibrator was increased by 0.5 up to 6.0, if it was introduced with ease. Results were assessed by uroflowmetry and urethral calibration. Afterwards, calibrations were carried out twice a week for 6 months and then once a week for another 6 months followed by once a month.

Results

Mean follow-up was 61 months. In uroflowmetry examination, voiding improved in all patients. Both preoperative mean Qmax and mean Qavg increased, the former from 6.2 to 22.5 ml/s, the latter from 4.3 to 12.4 ml/s, (p <0.001), at 12 months post-operation. Mean post-void residual volume (PVR) decreased from 89 ml before operation to 10 ml, (p <0.001), at 12 months post-operation. Mean inner urethral size increased from 3.9 mm one month post-operation to 5.4 mm, (p <0.001), 9 months post-operation. No recurrent US was detected in any of the patients.

Conclusions

Routine calibration with ASG prevents scar contraction after urethroplasty in the long-term. Calibration of urethra with ASG is a safe and effective method of postoperative management.

Primary versus Redo Urethroplasty: Results from a Single-Center Comparative Analysis

Objectives

To explore the differences between primary and redo urethroplasty and to directly compare according stricture-free survival (SFS). Materials and Methods. Data of all male patients who underwent urethroplasty at Ghent University Hospital were collected between 2000 and 2018. Exclusion criteria for this analysis were age <18 years and follow-up <1 year. Two patient groups were created for further comparison: the primary urethroplasty (PU) group (no previous urethroplasty) and redo urethroplasty (RU) group (≥1 previous urethroplasty), irrespective of prior endoscopic treatments. A comparison between groups was performed using the Mann–Whitney U test and Fisher's Exact test. SFS was calculated using Kaplan–Meier statistics. A functional definition of failure, being the need for further urethral manipulation, was used. Uni- and multivariate Cox regression analyses were performed on the entire patient cohort.

Results

805 patients were included. Median (IQR) follow-up of the PU (n = 556) and RU (n = 556) and RU (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (p=0.1). The RU group involved more penile strictures (

Conclusions

Several differences between primary and redo urethroplasties exist. Redo urethroplasty entails a distinct patient population to treat and is, in general, associated with lower stricture-free survival than primary urethroplasty, although more homogeneous series are required to corroborate these results. Prior urethroplasty and diabetes are independent risk factors for urethroplasty failure.

Outcome of buccal mucosa graft urethroplasty: a detailed analysis of success, morbidity and quality of life in a contemporary patient cohort at a referral center

BACKGROUND

To evaluate outcome of buccal mucosa graft urethroplasty (BMGU) for the treatment of urethral stricture disease, including a detailed analysis of success, morbidity and quality of life (QoL).

METHODS

Between 12/05/2008 and 07/21/2010, 187 patients with urethral stricture disease, who were treated with BMGU at our University Medical Center, received a standardized questionnaire, evaluating postoperative success, morbidity and QoL. The primary endpoint was the success, i.e., stricture recurrence-free survival plus patients' satisfaction with surgery. Secondary endpoints included erectile function, voiding symptoms, pain and health-related QoL, which were assessed with a modified Urethral Stricture Surgery Patient Reported Outcome Measure (USS PROM), including the Erectile Function domain of the International Index of Erectile Function (IIEF-EF), Incontinence Questionnaire Male Lower Urinary Tract Symptoms Module (ICIQ-MLUTS) and EuroQol-5 dimensions (EQ-5D).

RESULTS

In total, 83 patients (51.9%) completed the questionnaire. Bulbar, penile and panurethral strictures were found in 69 patients (83.1%), 13 patients (15.7%) and one patient (1.2%), respectively. The median length of the stricture was 5 cm (range: 1-16). At a median follow-up of 46 months (range: 36-54), 65 patients (78.3%) had no stricture recurrence and were satisfied with BMGU. Median scores for ICIQ-MLUTS, IIEF-EF and EQ-5D visual analogue scale were 6, 22 and 80, respectively. Based on USS PROM, postoperative improvement of QoL and satisfaction with BMGU was found in 67 patients (80.7%) and 68 patients (81.9%), respectively.

CONCLUSIONS

In patients with urethral stricture disease, BMGU offers excellent success, morbidity and QoL.

Redo-urethroplasty for the management of recurrent urethral strictures in males: a systematic review

Purpose

Redo-urethroplasty is a challenge for any genitourethral surgeon, with a number of techniques previously described. This systematic review aims to identify the surgical techniques described in the literature and evaluate the evidence for their effectiveness in managing recurrent urethral strictures.

Materials and methods

A systematic review of the MEDLINE and EMBASE databases from 1945 to July 2018 was performed and the urethroplasty procedures were classified according to the site and surgical technique. Primary outcomes included success rates measured via re-stricture rates and the post-op maximum urinary flow rate. Secondary outcomes included complication rates and patient-reported quality of life.

Results

A total of 39 identified studies met the inclusion criteria. Twenty-two studies described the use of excision and primary anastomotic urethroplasty with success rates showing wide variability (58–100%). Success rates reported according to the site of the stricture also varied: bulbar (58–100%) and posterior (69–100%) recurrent strictures. One-stage substitution urethroplasty was described in 25 studies with success rates of 18–100%, with the best outcomes reported for bulbar (58–100%) and hypospadias-related (78.6–82%) strictures. Two-stage substitution urethroplasty was described in 12 studies with the success rates of 20–100%, with the best evidence related to hypospadias-related and posterior urethral strictures. The buccal mucosa graft was the graft source with the best evidence for substitution urethroplasty (18–100%).

Conclusions

Trends of effectiveness were identified for redo-urethroplasty modalities in different locations. However, the current levels of evidence are limited to small observational studies, highlighting the need for further larger prospective data to evaluate different techniques used for recurrent urethral strictures.

Electronic supplementary material

The online version of this article (10.1007/s00345-019-02709-7) contains supplementary material, which is available to authorized users.

Multi-Institutional Outcomes of Endoscopic Management of Stricture Recurrence after Bulbar Urethroplasty

PURPOSE

Approximately 10% to 20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often by urethral dilation or direct vision internal urethrotomy. In the current study we describe the outcomes of endoscopic management of stricture recurrence after bulbar urethroplasty.

MATERIALS AND METHODS

We retrospectively reviewed bulbar urethroplasty data from 5 surgeons in the TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Men who underwent urethral dilation or direct vision internal urethrotomy for urethroplasty recurrence were identified. Recurrence was defined as the inability to pass a 17Fr cystoscope through the area of reconstruction. The primary outcome was the success rate of recurrence management. Comparisons were made between urethral dilation and direct vision internal urethrotomy, and then between endoscopic management of recurrences after excision and primary anastomosis urethroplasty vs substitutional repairs using time to event statistics.

RESULTS

In 53 men recurrence was initially managed endoscopically. Median time to urethral stricture recurrence after urethroplasty was 5 months. At a median followup of 5 months the overall success rate was 42%. Success after urethral dilation was significantly less than after direct vision internal urethrotomy (1 of 10 patients or 10% vs 21 of 43 or 49%, p <0.001) with a failure HR of 3.15 (p = 0.03). Direct vision internal urethrotomy was more effective after substitutional failure than after excision and primary anastomosis urethroplasty (53% vs 13%, p = 0.005).

CONCLUSIONS

Direct vision internal urethrotomy was more successful than urethral dilation in the management of stricture recurrence after bulbar urethroplasty. Direct vision internal urethrotomy was more successful in patients with recurrence after substitution urethroplasty compared to after excision and primary anastomosis urethroplasty. Perhaps this indicates a different mechanism of recurrence for excision and primary anastomosis urethroplasty (ischemic) vs substitution urethroplasty (nonischemic).

[Redo urethroplasty with buccal mucosa]

Urethral strictures can occur on the basis of trauma, infections, iatrogenic-induced or idiopathic and have a great influence on the patient's quality of life. The current prevalence rate of male urethral strictures is 0.6% in industrialized western countries. The favored form of treatment has experienced a transition from less invasive interventions, such as urethrotomy or urethral dilatation, to more complex open surgical reconstruction. Excision and primary end-to-end anastomosis and buccal mucosa graft urethroplasty are the most frequently applied interventions with success rates of more than 80%. Risk factors for stricture recurrence after urethroplasty are penile stricture location, the length of the stricture (>4 cm) and prior repeated endoscopic therapy attempts. Radiation-induced urethral strictures also have a worse outcome. There are various therapy options in the case of stricture recurrence after a failed urethroplasty. In the case of short stricture recurrences, direct vision urethrotomy shows success rates of approximately 60%. In cases of longer or more complex stricture recurrences, redo urethroplasty should be the therapy of choice. Success rates are higher than after urethrotomy and almost comparable to those of primary urethroplasty. Patient satisfaction after redo urethroplasty is high. Primary buccal mucosa grafting involves a certain rate of oral morbidity. In cases of a redo urethroplasty with repeated buccal mucosa grafting, oral complications are only slightly higher.

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications

OBJECTIVE

To determine which factors are associated with higher costs of urethroplasty procedure and whether these factors have been increasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality.

MATERIALS AND METHODS

We conducted a retrospective analysis using the 2001-2010 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP cost-to-charge ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression, and expressed as odds ratios (OR).

RESULTS

A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated cost was $7321 ($5677-$10,000). Patients with multiple comorbid conditions were associated with extreme costs [OR 1.56, 95% confidence interval (CI) 1.19-2.04, P = .02] compared with patients with no comorbid disease. Inpatient complications raised the odds of extreme costs (OR 3.2, CI 2.14-4.75, P <.001). Graft urethroplasties were associated with extreme costs (OR 1.78, 95% CI 1.2-2.64, P = .005). Variations in patient age, race, hospital region, bed size, teaching status, payor type, and volume of urethroplasty cases were not associated with extremes of cost.

CONCLUSION

Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications, and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.

[Late consequences of urethral injuries. Reconstruction options]

BACKGROUND

Stricture excision and posterior urethroplasty is the most common procedure after posttraumatic urethral strictures.

RESULTS

Re-strictures and fistulas are treated by repeat urethroplasty. Tension-free anastomosis is prerequisite for surgical success. Urinary incontinence after posttraumatic injuries is treated by an artificial urinary sphincter.

Unsuccessful outcomes after posterior urethroplasty

Posterior urethroplasty is the most common strategy for the treatment of post-traumatic urethral injuries. Especially in younger patients, post-traumatic injuries are a common reason for urethral strictures caused by road traffic accidents, with pelvic fracture or direct trauma to the perineum. In many cases early endoscopic realignment is the first attempt to restore the junction between proximal and distal urethra, but in some cases primary realignment is not possible or not enough to treat the urethral injury. In these cases suprapubic cystostomy alone and delayed repair by stricture excision and posterior urethroplasty is an alternative procedure to minimise the risk of stricture recurrence.