De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis

Algorithmic Midline Approach to Perineal Urethrostomy is Associated With Long-term Success and High Patient Satisfaction

OBJECTIVE

To assess surgical success and patient-reported outcomes of perineal urethrostomy via midline approach.

MATERIALS AND METHODS

Charts of patients undergoing primary perineal urethrostomy between May 2008 and June 2022 were reviewed. Background characteristics were assessed; success was defined as freedom from re-intervention. Patient-reported outcome measures were assessed using a cross-sectional phone survey. Several validated questionnaires were used to assess lower urinary tract symptoms, quality of life, and erectile dysfunction.

RESULTS

Among 1768 urethroplasties performed over the study period, 103 patients (5.8%) underwent midline perineal urethrostomy. Surgery was successful in 95.1% of cases (98/103); 5 patients (4.9%) required re-intervention at a median of 8.7 months. Post-operative complications occurred in 5.8% of cases (6/103) and were both mild and self-limited. Forty-nine patients (47.6%) were reached via phone survey at a median of 61 months post-operatively. Some questions were not answered by all patients. Most patients (42/49, 86%) were satisfied or very satisfied with surgical results, and 82% (40/49) reported an improvement in their overall health. Most patients (31/41, 76%) were unbothered by sitting to urinate. Although 20% of patients (10/49) reported post-operative urinary symptoms that interfered "a lot" with their daily life, only 3 (6%) of these patients reported dissatisfaction with the outcome. Regarding sexual function, 64% (27/42) reported indifference to or increased satisfaction with sexual encounters vs before surgery. The rate of de novo erectile dysfunction was 24% (12/49).

CONCLUSION

The midline approach to perineal urethrostomy provides excellent, durable success rates with high levels of patient satisfaction.

The best method for erection function in urethroplasty; is excision and primary anastomosis or buccal mucosal graft urethroplasty?

INTRODUCTION

The aim of this study is to evaluate and compare erection function (EF) after Excision and Primary Anastomosis Urethroplasty (EPAU) and Buccal Mucosal Graft Urethroplasty (BMGU) in bulbar urethral stricture.

METHODS

Patients who underwent urethroplasty were identified retrospectively. The criteria for inclusion in the study were determined as being over 18 years old and under 70 years old, being sexually active. Exclusion criteria are; preoperative severe erectile dysfunction, stricture outside the bulbar urethra, psychosocial incompatibility, urethral stricture related to pelvic fracture, follow-up time less than a year. As the primary endpoint, the International Index of Erectile Function-5 (IIEF-5) was determined as a comparison of EF in the preoperative and third, sixth and twelfth months after surgery. The secondary endpoint was the evaluation of the effects of demographic data, stricture and treatment characteristics on EF.

RESULTS

Fifty patients were identified considering the inclusion/exclusion criteria. It was observed that there were 30 patients who underwent EPAU and 20 patients who underwent BMGU. At the third month after surgery, EF showed a statistically significant decrease in the EPAU group. In both patient groups, it was observed that the early negative effects after the operation in EF started to improve in the sixth month and returned to the baseline level by the first year.

CONCLUSION

EPAU and BMGU techniques have a similar effect on EF in the medium and long term. Both methods can be used safely and effectively in the appropriate patient group.

Effects of continuous use of Tadalafil on male sexual function after posterior urethroplasty: A clinical trial

INTRODUCTION

Posterior urethral injuries in men commonly occur following pelvic and perineal trauma. Erectile dysfunction (ED), whether brought on by the severity of the initial trauma or the surgery itself, is one of the complications in these patients.

MATERIALS AND METHODS

In this study, we divided candidates of posterior urethroplasty due to traumatic urethral injury into intervention and placebo groups; the former received continuous treatment with tadalafil (10 mg daily), and the latter received a placebo. Other services were provided equally to both groups. Before and after the intervention, both groups completed the International Index of Erectile Function version 5 (IIEF-5) questionnaire, and the findings were analyzed.

RESULTS

Forty patients were studied in groups of 20 with a mean age of 43.87 ± 15.70 years. The patient's most common cause of urethral injury was a pelvic fracture. Before the intervention, the mean scores of IIEF for patients in the intervention group and placebo group were 14.85 ± 7.39 and 14.77 ± 6.48, respectively with no statistical significance (p = 0.962) and patients of the groups were similar in terms of the severity of ED. The mean IIEF score in the intervention group was 20.12 ± 4.94 and in the placebo group, it was 18.05 ± 4.88 at the three-month follow-up, with no statistically significant difference (p = 0.063). In both the intervention and placebo groups, the IIEF score was significantly increased by 5.27 ± 4.04 (p < 0.001) and 3.27 ± 2.97 (p < 0.001), respectively. The rate of IIEF increase in the intervention group was higher than in the placebo group during the follow-up at 3-month follow-up with statistical significance. (p = 0.022).

CONCLUSION

The findings of this study suggest that tadalafil, in a 3-month treatment course, may improve erectile function in individuals with mild-to-moderate ED, significantly more than placebo. However, more studies, specifically with longer duration of follow-up and larger populations, are necessary for generalizing the current findings.

Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis

OBJECTIVES

To assess outcomes of transecting vs non-transecting urethroplasty for bulbar urethral stricture in terms of stricture recurrence rate, sexual dysfunction, and patient-reported outcome measures (PROMs) related to lower urinary tract (LUT) function.

METHODS

Electronic literature searches were conducted using PubMed, Cochrane Library, Web of Science and Embase databases. The studied population was limited to men with bulbar urethral stricture included in studies that compared outcomes after transecting and non-transecting urethroplasty. The main outcome appraised was the stricture recurrence rate. Additionally, the incidence of sexual dysfunction appraised in three domains (erectile function, penile complications, and ejaculatory function) and PROMs related to LUT function after transecting vs non-transecting urethroplasty were assessed. The pooled risk ratio (RR) respectively for stricture recurrence, erectile dysfunction and penile complications was calculated using a fixed-effect model with inverse variance method.

RESULTS

In all, 694 studies were screened with 72 identified as relevant. Finally, 19 studies were suitable for analysis. The pooled difference between the transecting and non-transecting groups relating to stricture recurrence was not significant. Overall, the RR was 1.06 (95% confidence interval [CI] 0.82-1.36) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for erectile dysfunction was 0.73 (95% CI 0.49-1.08) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for penile complications was 0.47 (95% CI 0.28-0.76) and the 95% CI did not cross the line of no effect (line RR = 1). Hence, the risk of penile complications was significantly lower in the non-transecting group.

CONCLUSIONS

Our analysis of available evidence indicates that both transecting and non-transecting urethroplasties, are equal in terms of the recurrence rate. On the other hand, non-transecting techniques are better in terms of sexual function, causing less penile complications.

Erectile function after different techniques of bulbar urethroplasty: does urethral transection make a difference?

PURPOSE

We aimed to compare the impact of urethral transection after different techniques of bulbar urethroplasty on erectile function outcome.

MATERIALS AND METHODS

We retrospectively reviewed the records for 245 patients who underwent different urethroplasty techniques for bulbar urethral stricture between February 2013 and January 2021. The comparison between the transecting and non-transecting cohorts included patients' demographics, clinicopathological features of the urethral stricture, post-urethroplasty erectile function, and success of urethroplasty. Outcomes were erectile function status verified by IIEF5-15 score at preoperative, three months, and 12 months post-surgery. We defined Post-urethroplasty ED as a decrease of 5 points or more.

RESULTS

The urethroplasty success rate of the entire cohort was 86.9% after a mean follow-up of 45.59 ± 21 months. Out of 245 patients, 18 (7.3%) experienced 90-day complications. Transecting bulbar urethroplasty techniques were performed in 74 patients (30.2%), while non-transecting techniques were performed in 171 patients (69.8%). there were no differences between the cohorts regarding urethroplasty success (87.8% Vs. 86.5%, Mantel-Cox test p = 0.93) or postoperative complications (8.1% Vs. 7%, p = 0.73). Transient ED was evident in the transecting cohort as reported in 8.1% compared to 2.9% for the non-transecting (p = 0.07).Still, but de novo permanent ED was comparable (4.1% Vs. 2.9%, p = 0.65), for transecting and non-transecting, respectively.

CONCLUSIONS

Unfortunately, some patients who undergo transecting techniques of bulbar urethroplasty experience transient erectile dysfunction that can improve within the first post- urethroplasty year; however, de novo permanent erectile dysfunction is uncommon after different techniques of bulbar urethroplasty and is not predisposed by urethral transection.

Tunica albuginea versus buccal mucosa graft urethroplasty for anterior urethral stricture: A prospective randomised pilot study

Objective

The objective of the study was to compare the outcome of tunica albuginea urethroplasty (TAU) and buccal mucosa graft (BMG) urethroplasty for anterior urethral stricture.

Methods

Thirty patients who met the inclusion criteria were randomised into two groups: TAU (Group A) and BMG urethroplasty (Group B). Surgical outcome was evaluated with pre- and post-operative work-up involving retrograde urethrogram, voiding cystourethrogram, uroflowmetry, and urethroscopy. Patients were followed up till 1 year.

Results

Mean duration of surgery was statistically significant between two groups (p=0.0005). Maximum urine flow rate was comparable when compared between two groups (p=0.22) but statistically significant when compared pre- and post-operatively (p<0.001). At follow-up of 1 year, the successful outcomes were 80% in Group A and 87% in Group B. A total of five patients who had unsuccessful results required redo urethroplasty. Complications were minimal in both the groups.

Conclusion

TAU provides outcomes equivalent to those of BMG urethroplasty. TAU has less operative time, easy to perform, and beneficial in patients with poor oral hygiene.

Erectile and voiding function outcomes after buccal mucosa graft urethroplasty for long-segment bulbar urethral stricture: ventral versus dorsal onlay technique

PURPOSE

To compare the impact of dorsal versus ventral onlay buccal mucosa graft bulbar urethroplasty on postoperative erectile function status.

MATERIALS AND METHODS

We retrospectively reviewed the records for 232 patients who underwent dorsal and ventral onlay buccal mucosa graft bulbar urethroplasty from March 2012 to April 2021. Outcomes were urinary and erectile function status as assessed by IIEF5-15 score at preoperative, three months, and 12 months post-urethroplasty. We compared the dorsal and ventral only techniques at the different follow-up visits using difference-in-differences analysis.

RESULTS

165 patients met our inclusion criteria; the overall success rate was 87.9% after a mean follow-up of 52.3 ± 18.5 months. Of the patients, 17.6% experienced a 90-day complication. When comparing dorsal and ventral only techniques, there were no significant differences in terms of success rate (88.3% vs. 87.1%, Mantel-Cox test p = 0.68) or postoperative complications (15.5% Vs. 19.4%, p = 0.3). Likewise, there was no significant difference between both techniques regarding postoperative erectile function as assessed by IIEF5-15 score after three months (26.28 ± 2.53 Vs. 26.37 ± 2.41; p = 0.836) and twelve months (26.88 ± 2.45 Vs. 26.48 ± 1.98; p = 0.532). We detected a post-urethroplasty transient ED in (3.9% vs. 1.6%; p = 0.41), and permanent ED in (1.9% vs. 3.2%; p = 0.6) for dorsal and ventral onlay, respectively.

CONCLUSIONS

Onlay Buccal mucosa graft urethroplasty is a highly effective surgery in treating long-segment bulbar urethral stricture. The dorsal and ventral only techniques were comparable regarding urinary and erectile function outcomes. Additionally, both techniques have no significant negative impact on post-urethroplasty erectile function status.

Three-Piece Inflatable Penile Prosthesis Implantation for the Treatment of Severe Erectile Dysfunction Following a Complex Pelvic Fracture: A Case Report

Pelvic fracture is one of the common causes of erectile dysfunction (ED). The pathophysiology of ED following pelvic injury is quite complicated and comprises vascular, neurogenic, corporal, as well as psychogenic causes. Penile prosthesis implantation is the third-line treatment of ED due to any reason including pelvic trauma that poorly responds to other standard treatments. In this study, we reported a case of a 33-year-old man with severe erectile dysfunction and urethral stricture following a complex pelvic fracture due to a traffic accident who was successfully implanted with a three-piece inflatable penile prosthesis at People's Hospital 115. At the sixth month of follow-up, this device has been working effectively, the patient had the ability to attain full erection for sexual intercourse. Both the patient and the partner are satisfied with their sexual lives. ED is a long-term consequence of pelvic fracture. The high proportion of young patients with a demand for erection rehabilitation and complex pathophysiology make the treatments even more challenging. Penile implant surgery is a potential treatment for refractory ED patients suffering from pelvic trauma.

Recent Trends and Advances in Anterior Urethroplasty

While patient preference often helps guide treatment decisions, poor long-term success combined with cumulative risk of repeat endoscopic treatments and the complications innately associated with urethral stricture emphasize that urethroplasty is most often the best choice for successful treatment in the long-term. This has led to the need to better refine urethroplasty techniques and optimize patient outcomes. Urethroplasty has now largely transitioned to a day-surgery procedure in the majority of centers. Some evidence suggests that avoiding urethral transection and/or avoiding overzealous urethral mobilization may lead to a reduction in post-operative sexual dysfunction. The trend toward single stage penile urethroplasty with buccal mucosal grafts likely minimizes patient morbidity without compromising urethroplasty success. For urethroplasty success to further improve particularly in patients at high risk for stricture recurrence, the synergistic potential of combining wound healing enhancing agents with evolving tissue-engineering represents an exciting future opportunity in the quest to perfect urethroplasty outcomes.

'Pee'BuSt Trial: A single-centre prospective randomized study comparing functional and anatomic outcomes after augmentation urethroplasty with penile skin graft versus buccal mucosa graft for anterior urethral stricture disease

Purpose

To assess the surgical outcomes of augmentation urethroplasty (AU) using penile skin graft (PSG) compared to buccal mucosa graft (BMG) in anterior urethral stricture disease.

Method

Between January 2018 and January 2019, 100 patients with anterior urethral stricture planned for AU were randomized into PSG or BMG arms (CTRI/2018/07/015028). Anatomic and functional variables were compared pre-operatively and post-operatively. Primary outcome was success rate at 18 months and it was defined if any of the three criteria were met, i.e. either maximum urinary flow (Qmax) > 15 ml/s or urethral calibration of 16 French or ability to traverse the repair with 17 French cystoscope. Secondary outcomes were functional parameters such as International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) Score, Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EJD), and Urethral Stricture Surgery-Patient Related Outcome Measure (USS-PROM).

Results

Pre-operative variables were comparable between both the arms. Median duration of follow-up was 22 months (18–24 months). At 18 months, the success rates of AU with PSG and BMG were comparable (89% v/s 91%; p = 0.70, 95% CI-0.33 to 5.21). The improvements in Qmax (p = 0.06), IPSS (p = 0.43) and USS-PROM (p = 0.49) were comparable between the two arms. There was no statistically significant difference in the IIEF-Erectile domain (p = 0.07), IIEF-Orgasmic domain (p = 0.11) and MSHQ-EJD (p = 0.20) following AU at 18 months. Clavien–Dindo grade I complications were 12.7% in PSG and 16.7% in BMG.

Conclusion

This study provides level 1 evidence of no statistical significant difference in outcomes of AU using BMG or PSG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03843-x.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review

PURPOSE

The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given.

MATERIALS AND METHODS

To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed.

RESULTS

Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL.

CONCLUSIONS

The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

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.

Erectile and Ejaculatory Dysfunction After Urethroplasty

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.

Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes

PURPOSE

To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture.

METHODS

Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated.

RESULTS

Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively).

CONCLUSIONS

EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed.

Evaluation of erectile function after anastomotic vs substitutional urethroplasty for bulbar urethral stricture

Objective

Patients and methods

Results

Conclusion

Patient-reported outcomes after buccal mucosal graft urethroplasty for bulbar urethral strictures: results of a prospective single-centre cohort study

OBJECTIVES

To describe patient-reported outcome measures (PROMs) after buccal mucosa graft (BMG) urethroplasty.

MATERIALS AND METHODS

We prospectively collected PROMs in patients who underwent BMG urethroplasty for bulbar urethral strictures between October 2009 and February 2017. Preoperatively and at the first, second and third postoperative follow-up visits, patients completed five PROM questionnaires: the International Prostate Symptom Score (IPSS); the IPSS Quality of Life questionnaire; the Urogenital Distress Inventory Short-Form questionnaire (UDI-6); the International Index of Erectile Function (IIEF)-5 questionnaire, combined with IIEF-Q9 and IIEF-Q10 for assessing ejaculatory and orgasmic functions; and the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) questionnaire. In addition to using these questionnaires, we evaluated maximum urinary flow rate (Q_max ), post-void residual urine volume and total voided urine volume at each follow-up visit. Buccal pain and discomfort were assessed using a visual analogue scale (VAS). Comparison of questionnaire scores was performed using a paired Wilcoxon rank-sum test. Treatment failure was defined as any need for urinary diversion or urethral instrumentation after surgery.

RESULTS

A total of 97 patients met the inclusion criteria. The first postoperative follow-up visit was at a median of 2.1 months (n = 97/97), and the second and third visits were after a median of 7.8 (n = 82/97) and 17.0 months (n = 70/97), respectively. Significant improvements compared to baseline were observed in IPSS, and IPSS-QOL, UDI-6 and ICIQ-LUTS-QOL scores at the first follow-up, and remained improved during the follow-up period (P ≤ 0.001). Patients with mild to no baseline erectile dysfunction experienced a significant decline in erectile function at the first follow-up (median [interquartile range {IQR}] preoperative IIEF-5 score 23.0 [21.0-25.0] vs median [IQR] IIEF-5 score at first follow-up 19.5 [16.0-23.8]; P ≤ 0.001). This decline fully recovered during further follow-up (median [IQR] IIEF-5 score at third follow-up 24.0 [20.5-25.0]; P = 0.86). No significant changes in median orgasmic and ejaculatory function were noted. The first postoperative median (IQR) VAS score was 3.0 (2.0-4.45), and a significant improvement in local pain and discomfort was observed during the follow-up (median [IQR] VAS at third follow-up: 0.0 [0.0-1.0]; P ≤ 0.001). Nine patients (9/97; 9.3%) had treatment failure. Stratifying recurrence based on a difference of <10 mL/s vs ≥10 mL/s between preoperative and postoperative Q_max could not demonstrate a significant difference (P = 0.06).

CONCLUSION

Significant improvements in voiding symptoms and quality of life after surgery were reported. Patients with good baseline erections recovered erectile function during follow-up, although a significant decrease in erectile function was observed at the first follow-up. This study highlights the importance of PROMs in urethral reconstructive surgery, emphasizing that success should not be defined only by stricture-free survival.

The Male Urethra: Imaging and Surgical Approach for Common Pathologies

Urethral pathology is common in clinical practice and important to recognize. It is essential to recognize urethral pathology on imaging and to understand how to best image the urethra. In this way, the radiologist can provide the urologist with the necessary information prior to intervention. Basic knowledge of commonly performed urethral surgeries can help the radiologist understand the expected appearance of the post-treatment urethra and common postoperative complications.

Comprehensive Prospective Assessment of Patient-reported Outcomes Following Urethroplasty

OBJECTIVE

To better define patient-reported outcomes after urethroplasty. While urethroplasty is the most effective treatment for urethral stricture, the majority of outcomes are reported using surgeon-defined endpoints.

METHODS

Patients were enrolled in a prospective study evaluating patient-reported outcomes after urethroplasty from 2012 to 2018. A number of domains were assessed preoperatively and 6 months postoperatively using both validated and nonvalidated measures including satisfaction, voiding function, urinary quality of life, erectile/ejaculatory function, penile appearance/curvature, and genitourinary pain.

RESULTS

Of 357 patients completing the study, mean age was 49.7 years with mean stricture length of 4.4 cm. Total 95.9% of patients were stricture-free on 6-month cystoscopy. Eighty percent of patients reported being satisfied with surgery, while 7.3% of patients were unsatisfied. Voiding function was globally improved after urethroplasty including International Prostate Symptom Score (19.3 vs 6.0; P < .0001), urinary quality of life (4.7 vs 1.6; P < .0001), postvoid dribbling (2.7 vs 2.5; P = .04), and sitting to void (2.4 vs 1.9; P < .0001). Additionally, genitourinary pain improved postoperatively (2.2 vs 1.6; P < .0001). Mean erectile function remained unchanged (17.7 vs 17.2; P = .46) but 12.0% of patients reported new onset erectile dysfunction. Reported ejaculatory dysfunction did not change significantly postoperatively (P = .13) but 7.1% of patients reported new ejaculatory dysfunction. Total 6.7% and 3.1% of patients complained of bothersome loss of penile length or curvature, respectively.

CONCLUSION

Urethroplasty improves voiding function and genitourinary pain associated with urethral stricture. While sexual function is preserved for the majority of patients, a small proportion of patients describe new onset erectile dysfunction, penile shortening or curvature and should be counselled accordingly.

Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM)

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.

Analysis of a 7-year national online audit of the management of open reconstructive urethral surgery in men

OBJECTIVE

To conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK.

METHODS

Between 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform. Surgeon-entered information was collected in 95 fields regarding the stricture aetiology, prior management, mode of presentation, type of surgery and outcomes, with a potential 283 variable responses in the 95 fields. Data were analysed to compare UK practice with that reported in the contemporary literature and with guidelines.

RESULTS

Data on 4809 men were entered by 39 centres and 50 surgeons. Field completeness was 70.7%, 74.3% and 53.7% for preoperative, operative and follow-up data, respectively. Referral for stricture reconstruction frequently followed two prior endoscopic procedures and the stricture was not always assessed anatomically before surgery. Urinary retention was a common symptom in men awaiting reconstruction. Short unifocal strictures of the anterior urethra were the commonest reason for referral, whilst lichen sclerosus and hypospadias generated a significant volume of revisional stricture surgery. Lower numbers of very complex interventions are required for the management of posterior urethral pathology. Although precise criteria for determining success are not clear, management of urethral reconstruction in the UK was found to have a low risk of Clavien-Dindo grade 3 or higher complications, and was associated with outcomes similar to those reported in contemporary series except in the management of posterior urethral fistulae.

CONCLUSIONS

Online databases can provide volume data on the management of reconstructive urethral surgery across a multiplicity of centres in one country. They can also indicate compliance with accepted standards of, and expected outcomes from, this tertiary practice.

Evaluation of outcomes of Urethral Stricture Surgery: psychometric validation of a Polish language version of the Patient-Reported Outcome Measure for urethral stricture surgery

Introduction

The aim of this study is to validate the Polish version of the Urethral Stricture Surgery – Patient-Reported Outcome Measure (USS-PROM) by evaluating its psychometric properties.

Material and methods

Patients with urethral stricture scheduled for urethroplasty between 2014 and 2018 were prospectively enrolled. The results of the USS-PROM were obtained before the operation, and during follow-up visits. The original USS-PROM was translated into Polish and re-translated into English in accordance with the guidelines by Dawson et al. regarding the adaptation process. Psychometric assessment included internal consistency, test-retest reliability, criterion validity and responsiveness.

Results

One hundred twelve patients were included. 54 patients completed the USS-PROM both before and 3 months after the surgery and 39 of them completed the questionnaire 6 months after the surgery to evaluate the test-retest reliability. Cronbach's α for internal consistency of the lower urinary tract symptoms (LUTS) domain score was 0.87. The test-retest intraclass correlation coefficient was 0.82. Spearman's coefficients showed no correlation between USS-PROM's result and maximal urinary flow (Qmax) result before the surgery (rs = 0.13; p >0.05) and a positive correlation between USS-PROM's result and Qmax result at follow up: 3 months after (rs =- 0.56; p <0.05), 6 months after (rs -0.64; p <0.05), and 12 months after (rs = -0.85; p <0.05). There were statistically significant strong and positive correlations between LUTS score and International Prostate Symptom Score (IPSS). Responsiveness of the test was confirmed with non-parametric Friedman's analysis of variance (ANOVA) with Kendall's coefficient of concordance (χ2 ANOVA = 8.95, p = 0.03).

Conclusions

The Polish version of the USS-PROM questionnaire has appropriate psychometric properties and can be used in the assessment of patients with urethral stricture undergoing urethroplasty.

Non-transecting bulbar urethroplasty is favored over transecting techniques

PURPOSE

To present current evidence supporting the vessel sparing technique to reconstruct bulbar urethral strictures via primary anastomosis.

METHODS

English literature review of presented series of transecting and non-transecting bulbar urethroplasty from 2000 to 2018.

RESULTS

Since its introduction in 2007, vessel-sparing excision and primary anastomosis (VS-EPA) has been utilized in multiple centers across the world. Success rates range from 90 to 98%, comparable to traditional transecting EPA. Complication rates and erectile function outcomes are similar or better in VS-EPA, according to recent publications.

CONCLUSIONS

Non-transection excision and primary anastomosis is a well-tolerated, highly successful reconstructive option for short bulbar urethral strictures in appropriately selected patients. Results are comparable with traditional transecting anastomosis and mid-term multinational follow-up has proven efficacy and safety of the technique. Further well-designed multi-institutional studies are necessary to determine superiority to traditional EPA in terms of surgical outcomes and erectile function preservation.

The effect of urethroplasty surgery on erectile and orgasmic functions: a prospective study

Objectives:

to examine the effects of urethroplasty surgery on sexual functions by taking into account age, location of stenosis, length of stenosis and surgical technique parameters.

Materials and Methods:

The prospective study was conducted between January 2015 and August 2017 with 60 cases. Patients were categorized according to age groups (19-65 / 65-75 years), surgery technique and stricture localization and length. Before the urethroplasty operation and postoperative 6th month follow-up, the international index of erectile function (IIEF) form (15 questions), was filled, the relevant domains of sexual function; erectile function (Q1,2,3,4,5,15), orgasmic function (Q9,10) and overall satisfaction (Q13,14) were assessed.

Results:

The mean age of the cases is 54 ± 13. However, preoperative IIEF, sexual satisfaction and orgasmic function averages of patients with a stenosis segment length of 1-3 cm was found to be significantly higher than that of patients with a stenosis segment length of 4-7 cm. Between stenosis segment length groups, there was no statistical difference in terms of preoperative and postoperative sexual functions. And also, there was no statistically significant change in patients’ preoperative and postoperative sexual function scores in terms of localization of stricture and surgery techniques. However, there were statistically significant change in the postoperative IIEF and sexual satisfaction averages according to preoperative averages.

Conclusion:

Our study suggests that urethroplasty surgery itself does not significantly affect erectile function, orgasmic function, and general sexual satisfaction regardless of the type of surgery, localization and length of stenosis. Besides, there was a significant decrease in erectile function in senior adults.

Long-term follow-up of urethral reconstruction for blunt urethral injury at a young age: urinary and sexual quality of life outcomes

INTRODUCTION

Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma.

OBJECTIVE

The purpose was to evaluate long-term urinary outcomes, sexual function, and quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood.

STUDY DESIGN

After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires.

RESULTS

Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4-18), 17 (5-20), and 19 (13.5-21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6-2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were 'very satisfied' and 20% were 'satisfied' with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8-12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5-2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5-24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13-14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5-8).

CONCLUSIONS

Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

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.

Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group

OBJECTIVE

To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group.

METHODS

Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon.

RESULTS

Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%).

CONCLUSION

Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

Excision and Primary Anastomosis for Bulbar Urethral Strictures Improves Functional Outcomes and Quality of Life: A Prospective Analysis from a Single Centre

Background

Excision and primary anastomotic (EPA) urethroplasty remains the gold standard definitive treatment for short urethral stricture disease. For patients, postoperative erectile function and quality of life are the main goals of the surgery. Patient-reported outcome measures (PROMs) are therefore of major importance.

Objective

The objective of this study was to prospectively analyse functional outcomes and patient satisfaction.

Design Settings and Participants

We prospectively evaluated 47 patients before and after EPA from August 2009 until February 2017. The first follow-up visit occurred after a median of 2.2 months (n = 47/47), with the second and third follow-ups occurring at a median of 8.5 months (n = 38/47) and 20.2 months (n = 31/47). Before surgery and at each follow-up visit, the patients received five questionnaires: the International Prostate Symptom Score (IPSS), the International Prostate Symptom Score with the Quality of Life (IPSS-QOL) score, the Urogenital Distress Inventory Short Form (UDI-6) score, the International Index of Erectile Function-5 (IIEF-5) score, and the ICIQ-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTS-QOL) score.

Surgical Procedure

Surgery was performed in all cases using the same standardized EPA technique.

Outcome Measurements and Statistical Analysis

Voiding symptoms, erectile dysfunction, and quality of life were analysed using paired sample t-tests, with a multiple-testing Bonferroni correction. Any requirement for instrumentation after surgery was considered treatment failure.

Results and Limitations

Patients with mild or no baseline erectile dysfunction showed significant decline in erectile function at first follow-up (mean IIEF-5 of 23.27 [standard deviation; SD: 2.60] vs. 13.91 [SD: 7.50]; p=0.002), but this had recovered completely at the third follow-up (IIEF-5: 23.25 [SD: 1.91]; p=0.659). Clinically significant improvements were noted in IPSS, IPSS-QOL-score, UDI-6-score, and ICIQ-LUTS-QOL-score at the first follow-up (p<0.0001). These improvements remained significant at the second and third follow-ups (p<0.0001) for all PROMs. Three of the patients experienced stricture recurrence. The main limitations of this study were incomplete questionnaires, loss to follow-up, and low number of patients.

Conclusions

EPA results in an initial decline in erectile function, but full recovery occurred at a median of 20 months. Voiding improved significantly, and a major improvement in quality of life was noted, which persisted for up to 20 months after surgery.

Patient Summary

This study showed the importance of patient-reported outcome measures in indicating the actual outcome of urethral stricture disease surgery.

Evaluation of the effect of urethroplasty for anterior urethral strictures by a validated disease-specific patient-reported outcome measure

PURPOSE

To better understand our urethroplasty outcome, we translated the English version of a urethral stricture surgery patient-reported outcome measure (USS-PROM) into Japanese and used it to evaluate the effect of urethroplasty for anterior urethral strictures.

METHODS

The PROM quantifies lower urinary tract symptoms (LUTS) and health-related quality of life (EQ-5D), and it evaluates overall satisfaction by asking patients to choose "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". 93 Japanese-speaking male patients with anterior urethral stricture who underwent urethroplasty completed it before (baseline) and 6 months after urethroplasty. The psychometric criteria evaluated in the present study were the PROM's internal consistency, test-retest reliability, criterion validity, and responsiveness.

RESULTS

Q_max was negatively correlated with the LUTS-total scores (r = - 0.61). Cronbach's alpha was 0.80 and the test-retest intraclass correlation coefficient for the LUTS-total score was 0.82. 83 patients (89.2%) achieved stricture-free, which was defined as no re-stricture on cystoscopy and no need for additional treatment. The mean total LUTS-score improved from 12.4 at baseline to 3.7 postoperatively (p < 0.0001). The mean EQ-5D visual analogue scores and EQ-5D index improved from 61.2 and 0.76, respectively, at baseline to 77.9 and 0.89 postoperatively (p < 0.0001, p < 0.0001). 55 patients (59.1%) were "very satisfied" with the outcome of their urethroplasty and 33 (35.5%) were "satisfied".

CONCLUSIONS

The Japanese version of the USS-PROM has adequate psychometric properties. Urethroplasty improved not only objective data but also voiding symptoms and health-related QOL, and it resulted in a high rate of patient satisfaction.

Patient-Reported Outcome Measures in Urethral Reconstruction

PURPOSE OF REVIEW

Treatment of anterior urethral stricture disease (USD) has shifted from endoscopic approaches to urethroplasty with significantly higher success rates among reconstructive urologists. This academic stance has led to a critical evaluation of "success" and developing disease-specific instruments to assess surgical outcomes focusing on patients' satisfaction rather than the historical goal of avoiding secondary procedures.

RECENT FINDINGS

Many disease non-specific and/or non-validated patient-reported outcome measures (PROMs) have been utilized to evaluate the voiding symptoms and sexual of function of patients after urethroplasty in the literature. Urethral Stricture Surgery PROM (USS PROM) is the first validated, disease-specific PROM for anterior USD which has been designed in 2001. Urethral Stricture Symptoms and Impact Measure (USSIM) is a comprehensive PROM and is currently being validated at multiple institutions. This article reviews the tools used to assess success after urethroplasty and elaborates the need to develop a comprehensive USD-specific PROM.

Experience with One-Stage Repair of Urethral Strictures Using the Augmented Anastomotic Repair Technique

INTRODUCTION

We report the results of augmented anastomotic repair (AAR) in the treatment of anterior urethral strictures.

MATERIAL AND METHODS

In this retrospective study, we evaluated 71 consecutive patients who had undergone AAR between June 2004 and June 2013. Medical records were reviewed to identify early postoperative complications based on the Clavien-Dindo classification (CDC). Self-developed standardized questionnaires sent to the patients and referring urologists were used to collect data on late complications (>90) days. Stricture recurrence (SR) was defined as any postoperative endoscopic or open surgical intervention on the urethra. The influence of patient demographics, stricture characteristics, and operative procedure performed on the occurrence of SR was analyzed.

RESULTS

Early postoperative complications were rare events (11.3%) with only one severe CDC complication. Late complications were reported in 46.5% cases. At a median follow-up of 17 months (range 3-114 months), however, 64 patients had no evidence of SR and required no further intervention, giving an overall success rate of 90.1%. Seven patients with SR had a higher body mass index, were older, and had been operated on by less experienced surgeon(s). Most SRs occurred within the first year after surgery.

CONCLUSIONS

AAR was an effective and safe operative technique that allowed one-stage repair in our patients with anterior urethral strictures who needed resection of the scarred urethra and otherwise were not suitable for primary anastomosis or simple substitution urethroplasty.

Clinical utility of hyperbaric oxygen therapy in genitourinary medicine

Hyperbaric oxygen therapy (HBOT) is a medical technique which delivers oxygen at ambient pressures to increase the amount of dissolved oxygen in the blood and oxygen distribution to tissues. There are several beneficial properties of HBOT concomitant with elevated oxygen distribution in tissue including anti-inflammation, angiogenesis through vascular endothelial growth factor proliferation, augmented fibroblast activity through fibroblast growth factor proliferation, tissue and wound repair, enhancement of lymphocyte and macrophage activity, increased male testosterone secretion, and bactericidal activity. Given its renown in treating conditions such as decompression sickness and carbon monoxide poisoning, HBOT is making gradual strides for use in genitourinary medicine due to its low risk and likeliness to achieve favorable results. Early success has been observed in the treatment of Fournier's gangrene, radiation cystitis, and interstitial cystitis via the elimination of clinical symptoms such as pain. Further indications that have exhibited positive outcomes despite HBOT's ambiguous mechanism of action include cyclophosphamide hemorrhagic cystitis, emphysematous cystitis, pelvic radiation disease, radiation-induced proctopathy, dystrophic calcification of the prostate, erectile dysfunction secondary to urethroplasty, priapism, abnormal renal morphology, blood testosterone, calcific uremic arteriolopathy, and hidradenitis suppurativa. For other indications, multicenter studies must be conducted to determine HBOT's true efficacy, mechanism of action, risks, and advantages over conventional treatments.

Penile and Urethral Reconstructive Surgery

Penile and urethral reconstructive surgical procedures are used to treat a variety of urologic diagnoses. Urethral stricture disease can lead to progressive lower urinary tract symptoms and may require multiple surgical procedures to improve patient's symptoms. Male stress urinary incontinence is associated with intrinsic sphincter deficiency oftentimes associated with radical prostatectomy. Men suffering from urethral stricture disease and stress urinary incontinence should be referred to a urologist because multiple treatment options exist to improve their quality of life.

Clinical and Patient-reported Outcomes of 1-sided Anterior Urethroplasty for Long-segment or Panurethral Strictures

OBJECTIVE

To evaluate clinical and patient-reported urinary and sexual outcomes after a long-segment stricture repair using the 1-sided urethral dissection, penile invagination, and dorsal buccal mucosa graft onlay technique described by Kulkarni et al.

METHODS

Patients from 4 institutions after single-stage repairs for long-segment urethral strictures (>8 cm) from January 2002 to April 2016 were reviewed. Technique described by Kulkarni et al was used in all cases. Clinical outcomes included uroflowmetry (Qmax) and post-void residuals. Patient-reported outcome measures included International Prostate Symptom Score survey, Sexual Health Inventory for Men, Male Sexual Health Questionnaire, and Global Response Assessment questionnaire to measure voiding, sexual, ejaculatory symptoms, and overall improvement, respectively.

RESULTS

Seventy-three patients with a minimum of 12 months' follow-up were included. The mean age and stricture length were 56 (21-80) years and 13.6 (8-21) cm, respectively. At a mean follow-up of 44 (12-162) months, 9 of 73 (12%) strictures recurred. The mean baseline International Prostate Symptom Score of 23 (7-24) decreased to 10 (1-17) on follow-up (P <.001). Eight of 42 patients (21.4%) reported an increase, and 6 of 42 patients (14.3%) decreased in Sexual Health Inventory for Men following urethroplasty. Ejaculatory function on Male Sexual Health Questionnaire improved after urethroplasty from 8 preoperatively to 11 postoperatively (P <.004). All patients reported improvement after urethroplasty on Global Response Assessment questionnaire. Post-void dribbling and chordee occurred in 45% and 25% of patients, respectively.

CONCLUSION

Durable patency in most patients is demonstrated in this study. PROMs indicate an improvement in urinary function and moderate effect on sexual function. Transient penile chordee was evident in 25% of patients.

[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.

Definition of Successful Treatment and Optimal Follow-up after Urethral Reconstruction for Urethral Stricture Disease

The definition of a successful urethroplasty, the lack of need for a secondary procedure, is outdated and must be amended to incorporate objective and subjective outcomes. Success is assigned if a flexible cystoscope can traverse the reconstructed urethra without force. Functional success is assigned if patient-reported outcome measures reveal improvement in voiding symptoms and urinary quality of life. Optimal follow-up strategy allows determination of anatomic and functional outcomes, protects genitourinary health, and prevents excessive invasive testing, unnecessary cost, discomfort, anxiety, and risk. Noninvasive objective uroflowmetry has high sensitivity and specificity for detecting recurrence and replaces invasive anatomic evaluation.

Chordee and Penile Shortening Rather Than Voiding Function Are Associated With Patient Dissatisfaction After Urethroplasty

OBJECTIVE

To identify factors that predict patient satisfaction after urethroplasty by prospectively examining patient-reported quality of life scores using 3 validated instruments.

METHODS

A 3-part prospective survey consisting of the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF) score, and a urethroplasty quality of life survey was completed by patients who underwent urethroplasty preoperatively and at 6 months postoperatively. The quality of life score included questions on genitourinary pain, urinary tract infection (UTI), postvoid dribbling, chordee, shortening, overall satisfaction, and overall health. Data were analyzed using descriptive statistics, paired t test, univariate and multivariate logistic regression analyses, and Wilcoxon signed-rank analysis.

RESULTS

Patients were enrolled in the study from February 2011 to December 2014, and a total of 94 patients who underwent a total of 102 urethroplasties completed the study. Patients reported statistically significant improvements in IPSS (P < .001). Ordinal linear regression analysis revealed no association between age, IPSS, or IIEF score and patient satisfaction. Wilcoxon signed-rank analysis revealed significant improvements in pain scores (P = .02), UTI (P < .001), perceived overall health (P = .01), and satisfaction (P < .001). Univariate logistic regression identified a length >4 cm and the absence of UTI, pain, shortening, and chordee as predictors of patient satisfaction. Multivariate analysis of quality of life domain scores identified absence of shortening and absence of chordee as independent predictors of patient satisfaction following urethroplasty (P < .01).

CONCLUSION

Patient voiding function and quality of life improve significantly following urethroplasty, but improvement in voiding function is not associated with patient satisfaction. Chordee status and perceived penile shortening impact patient satisfaction, and should be included in patient-reported outcome measures.

Incidence of De Novo Erectile Dysfunction after Urethroplasty: A Prospective Observational Study

PURPOSE

De novo erectile dysfunction (ED) is a known complication after urethroplasty. Incidence and natural history of de novo ED after urethroplasty is underreported. We assessed the incidence of de novo ED after urethroplasty.

MATERIALS AND METHODS

Consecutive consenting urethroplasty (n=48) patients aged 21 to 50 years from February 2014 to July 2016 with normal preoperative erectile function as determined by an International Index of Erectile Function-5 (IIEF-5) score ≥22 were included and interviewed at 3, 6, and 12 months.

RESULTS

In patients with anterior stricture (n=40), substitution urethroplasty (SU) was performed in 22 patients (55.0%) and end-to-end anastomotic urethroplasty (EEAU) in 18 patients (45.0%). Their mean IIEF-5 score was 24.15±0.8 preoperatively, 20.10±4.2 at 3 months (p<0.001), 22.70±2.3 at 6 months (p=0.0012), and 23.70±1.7 at 12 months (p=0.03), showing a recovery of erectile function with time. All 8 patients with pelvic fracture urethral injury (PFUI) underwent progressive perineal urethroplasty. Their mean IIEF score was 24.0±1.2 preoperatively, 18.8±5.4 at 3 months (p=0.002), 20.9±3.5 at 6 months (p=0.37), and 22.0±1.5 at 12 months (p=0.427). The incidence of ED was similar at 1 year postoperatively between patients with anterior stricture and PFUI and between patients who underwent EEAU or SU for anterior stricture.

CONCLUSIONS

Incidence of ED at 1 year after PFUI is similar to that after surgery for anterior stricture in patients with normal preoperative erectile function. Among the cases of anterior stricture, recovery was better with SU at 3 months and was similar between SU and EEAU at 1 year.

Advances in urethral stricture management

Urethral stricture/stenosis is a narrowing of the urethral lumen. These conditions greatly impact the health and quality of life of patients. Management of urethral strictures/stenosis is complex and requires careful evaluation. The treatment options for urethral stricture vary in their success rates. Urethral dilation and internal urethrotomy are the most commonly performed procedures but carry the lowest chance for long-term success (0–9%). Urethroplasty has a much higher chance of success (85–90%) and is considered the gold-standard treatment. The most common urethroplasty techniques are excision and primary anastomosis and graft onlay urethroplasty. Anastomotic urethroplasty and graft urethroplasty have similar long-term success rates, although long-term data have yet to confirm equal efficacy. Anastomotic urethroplasty may have higher rates of sexual dysfunction. Posterior urethral stenosis is typically caused by previous urologic surgery. It is treated endoscopically with radial incisions. The use of mitomycin C may decrease recurrence. An exciting area of research is tissue engineering and scar modulation to augment stricture treatment. These include the use of acellular matrices or tissue-engineered buccal mucosa to produce grafting material for urethroplasty. Other experimental strategies aim to prevent scar formation altogether.

Primary non-transecting bulbar urethroplasty long-term success rates are similar to transecting urethroplasty

OBJECTIVES

To review the long-term outcomes of transecting versus non-transecting urethroplasty to repair bulbar urethral strictures.

METHODS

A retrospective review was conducted of 342 patients who underwent anterior urethroplasty performed by a single surgeon from 2003 to 2014. Patients were excluded from further analysis if there had been prior urethroplasty, stricture location outside the bulbous urethra, or age <18 years. In the transecting group, surgical techniques used included excision and primary anastomosis and augmented anastomotic urethroplasty. In the non-transecting group, surgical techniques used included non-transecting anastomotic urethroplasty and dorsal and/or ventral buccal grafting. The primary endpoint was stricture resolution in transecting vs. non-transecting bulbar urethroplasty. Success was defined as freedom from secondary procedures including dilation, urethrotomy, or repeat urethroplasty.

RESULTS

One hundred and fifty-two patients met inclusion criteria. At a mean follow-up of 65 months (range: 10-138 months), stricture-free recurrence in the transecting and non-transecting groups was similar, 83% (n = 85/102) and 82% (n = 41/50), respectively (p = 0.84). Surgical technique (p = 0.91), stricture length (p = 0.8), and etiology (p = 0.6) did not affect stricture recurrence rate on multivariate analysis. There was no difference detected in time to stricture recurrence (p = 0.21).

CONCLUSIONS

In this retrospective series, transecting and non-transecting primary bulbar urethroplasty resulted in similar long-term stricture resolution rate. Prospective studies are needed to determine what differences may present in outcomes related to sexual function and long-term success.