Updates on Management of Biochemical Recurrent Prostate Cancer

OPINION STATEMENT

Patients with biochemical recurrent prostate cancer (BCR) are a heterogeneous group, whereby a personalized approach to management is critical. Patients with high-risk features such as PSA doubling time (PSADT) ≤ 9-12 months warrant earlier imaging for metastasis detection and consideration for intensified therapy (beyond intermittent androgen deprivation alone) during this phase of BCR-only disease. The BCR phase represents a unique opportunity to impact disease survival and delay metastasis progression. There is compelling evidence from the EMBARK trial that ADT monotherapy is no longer the optimal consideration for high-risk BCR patients.

Expression-based subtypes define pathologic response to neoadjuvant immune-checkpoint inhibitors in muscle-invasive bladder cancer

Checkpoint immunotherapy (CPI) has increased survival for some patients with advanced-stage bladder cancer (BCa). However, most patients do not respond. Here, we characterized the tumor and immune microenvironment in pre- and post-treatment tumors from the PURE01 neoadjuvant pembrolizumab immunotherapy trial, using a consolidative approach that combined transcriptional and genetic profiling with digital spatial profiling. We identify five distinctive genetic and transcriptomic programs and validate these in an independent neoadjuvant CPI trial to identify the features of response or resistance to CPI. By modeling the regulatory network, we identify the histone demethylase KDM5B as a repressor of tumor immune signaling pathways in one resistant subtype (S1, Luminal-excluded) and demonstrate that inhibition of KDM5B enhances immunogenicity in FGFR3-mutated BCa cells. Our study identifies signatures associated with response to CPI that can be used to molecularly stratify patients and suggests therapeutic alternatives for subtypes with poor response to neoadjuvant immunotherapy.

Predictors of Failed Same-Day Catheter Removal After Holmium Laser Enucleation of the Prostate

OBJECTIVE

To determine factors associated with failure of same-day trial of void (SDTOV) following holmium laser enucleation of the prostate (HoLEP).

BACKGROUND

HoLEP is increasingly utilized for patients with benign prostatic hyperplasia. Advancements in technology have improved operative efficiency and hemostasis making same-day, catheter-free discharge possible.

METHODS

We conducted a retrospective review on 190 patients undergoing HoLEP from July, 2021 to January, 2022 by a single center. We assessed pre- and intra-operative variables associated with our primary outcome: failure of same-day catheter removal. Post-operative complications and outcomes at a ≤7 days and 3-month follow up were examined. Continuous and categorical variables were analyzed using unpaired t-tests (Mann Whitney) and chi-square, respectively. Univariate and multivariable logistic regression models were fitted to examine the associations of failed SDTOV.

RESULTS

Of 190 candidates for a SDTOV, 90% (171/190) were successful. We found no difference between SDTOV success and failures with regards to age, comorbidities, presence of pre-operative urinary retention, anesthesia factors, operative time, volume resected, enucleation time, and morcellation time (all P>0.05). Pre-operatively, 26.3% (50/190) were on antiplatelet and 6.3% (12/190) were on anticoagulation. While pre-operative antiplatelet therapy was not associated with SDTOV failure (P=0.78), pre-operative anticoagulation use was (4.7% vs. 21.1%, P=0.021). Patients who continued anticoagulation through surgery had the highest rate of SDTOV failure (2.3% (4/171) vs. 15.8% (3/19), P=0.023). For those with successful SDTOV, 4.1% (7/171) required catheterization following discharge. At 3 months, no patient required catheterization.

CONCLUSION

On the day of surgery, patients eligible for SDTOV successfully voided 90% of the time. History of preop anticoagulation, whether continued or held, increased SDTOV failure.

First-in-human Intravesical Delivery of Pembrolizumab Identifies Immune Activation in Bladder Cancer Unresponsive to Bacillus Calmette-Guérin

BACKGROUND

Intravenous immune checkpoint inhibition is an effective anticancer strategy for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) but may be associated with greater systemic toxicity compared with localized therapies.

OBJECTIVE

We assessed the safety and antitumor activity of intravesical pembrolizumab combined with BCG.

DESIGN, SETTING, AND PARTICIPANTS

A 3 + 3 phase 1 trial of pembrolizumab + BCG was conducted in patients with BCG-unresponsive NMIBC (NCT02808143).

INTERVENTION

Pembrolizumab was given intravesically (1-5 mg/kg for 2 h) beginning 2 weeks prior to BCG induction until recurrence. Urine profiling during treatment and spatial transcriptomic profiling of pre- and post-treatment tumors were conducted to identify biomarkers that correlated with response.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Safety and tolerability of immune checkpoint inhibition were assessed, and Kaplan-Meier survival analysis was performed.

RESULTS AND LIMITATIONS

Nine patients completed therapy. Median follow-up was 35 months for five patients still alive at the end of the trial. The trial was closed due to the COVID-19 pandemic. Grade 1-2 urinary symptoms were common. The maximum tolerated dose was not reached; however, one dose-limiting toxicity was reported (grade 2 diarrhea) in the only patient who reached 52 weeks without recurrence. One death occurred from myasthenia gravis that was deemed potentially related to treatment. The 6-mo and 1-yr recurrence-free rates were 67% (95% confidence interval [CI]: 42-100%) and 22% (95% CI: 6.5-75%), respectively. Pembrolizumab was detected in the urine and not in blood. CD4⁺ T cells were significantly increased in the urine after treatment, and a transcriptomic analysis identified decreased expression of T-cell exhaustion markers in late recurrences.

CONCLUSIONS

We demonstrate that intravesical pembrolizumab is safe, feasible, and capable of eliciting strong immune responses in a clinical setting and should be investigated further.

PATIENT SUMMARY

Direct application of pembrolizumab to the bladder is a promising alternative for non-muscle-invasive bladder cancer unresponsive to Bacillus Calmette-Guérin and should be investigated further.

Role of Chromatin Modifying Complexes and Therapeutic Opportunities in Bladder Cancer

BACKGROUND

Chromatin modifying enzymes, mainly through post translational modifications, regulate chromatin architecture and by extension the underlying transcriptional kinetics in normal and malignant cells. Muscle invasive bladder cancer (MIBC) has a high frequency of alterations in chromatin modifiers, with 76% of tumors exhibiting mutation in at least one chromatin modifying enzyme [1]. Additionally, clonal expansion of cells with inactivating mutations in chromatin modifiers has been identified in the normal urothelium, pointing to a currently unknown role of these proteins in normal bladder homeostasis.

OBJECTIVE

To review current knowledge of chromatin modifications and enzymes regulating these processes in Bladder cancer (BCa).

METHODS

By reviewing current literature, we summarize our present knowledge of external stimuli that trigger loss of equilibrium in the chromatin accessibility landscape and emerging therapeutic interventions for targeting these processes.

RESULTS

Genetic lesions in BCa lead to altered function of chromatin modifying enzymes, resulting in coordinated dysregulation of epigenetic processes with disease progression.

CONCLUSION

Mutations in chromatin modifying enzymes are wide-spread in BCa and several promising therapeutic targets for modulating activity of these genes are currently in clinical trials. Further research into understanding how the epigenetic landscape evolves as the disease progresses, could help identify patients who might benefit the most from these targeted therapies.

The Northwestern University Novel Urology Residency Curriculum: Updated Outcomes from a 13-Year Experience with Flexible Residency Training and Electives

INTRODUCTION

We evaluated educational outcomes and satisfaction following institution of a novel, flexible and urology-driven resident curriculum.

METHODS

A new urology resident curriculum was instituted at Northwestern University in 2006. Rotation schedules and resident electives were recorded annually. Operative case logs and American Urological Association In-Service Examination scores were collected prospectively. Residents and faculty rated satisfaction with the residency program on a 5-point Likert scale from "poor" to "outstanding." Differences in cases logged, In-Service Examination scores and satisfaction ratings under the new and prior curricula were compared.

RESULTS

Curriculum changes included full 5-year urology oversight of the residency curriculum by the program director, 8 months of urology rotations in the first postgraduate year and 2 months of general surgery during the second postgraduate year. General surgery rotations were modified annually based on educational rationale and feedback. Cases logged per resident and In-Service Examination scores were comparable between old and new curricula groups. All residents matriculating under the new curriculum took and passed their written boards. The percentage of faculty and residents describing the program as "outstanding" increased from 50% in 2004‒2005 to 82% in 2017‒2018. Program satisfaction increased significantly when comparing the first and last 6 years (percent rating "outstanding": 56.1±2.1% vs 71.6±10.0%, p=0.028).

CONCLUSIONS

After 13 years with the novel curriculum, resident case numbers and In-Service Examination scores remained similar while faculty/resident satisfaction increased. Direct control of general surgery rotations enabled adjustments based on educational rationale. These results demonstrate that a urology-directed and flexible residency program can be instituted without compromising learner outcomes.

Genetic Factors Associated with Prostate Cancer Conversion from Active Surveillance to Treatment

Men diagnosed with low-risk prostate cancer (PC) are increasingly electing active surveillance (AS) as their initial management strategy. While this may reduce the side effects of treatment for prostate cancer, many men on AS eventually convert to active treatment. PC is one of the most heritable cancers, and genetic factors that predispose to aggressive tumors may help distinguish men who are more likely to discontinue AS. To investigate this, we undertook a multi-institutional genome-wide association study (GWAS) of 5,222 PC patients and 1,139 other patients from replication cohorts, all of whom initially elected AS and were followed over time for the potential outcome of conversion from AS to active treatment. In the GWAS we detected 18 variants associated with conversion, 15 of which were not previously associated with PC risk. With a transcriptome-wide association study (TWAS), we found two genes associated with conversion (MAST3, p = 6.9×10-7 and GAB2, p = 2.0×10-6). Moreover, increasing values of a previously validated 269-variant genetic risk score (GRS) for PC was positively associated with conversion (e.g., comparing the highest to the two middle deciles gave a hazard ratio [HR] = 1.13; 95% Confidence Interval [CI]= 0.94-1.36); whereas, decreasing values of a 36-variant GRS for prostate-specific antigen (PSA) levels were positively associated with conversion (e.g., comparing the lowest to the two middle deciles gave a HR = 1.25; 95% CI, 1.04-1.50). These results suggest that germline genetics may help inform and individualize the decision of AS-or the intensity of monitoring on AS-versus treatment for the initial management of patients with low-risk PC.

Revisiting One-Stage Urethroplasties for Distal Urethral Strictures

Background: Reconstructive approaches for distal urethral strictures range from simple meatotomy to utilizing grafts or flaps depending on the etiology, length and location. We describe a contemporary cohort of distal urethral strictures and report a surgical technique termed distal one-stage urethroplasty developed to address the majority of distal urethral strictures encountered. Methods: Thirty-four patients were included. The mean age was 56.7 years (range 15.7–84.9 years), the mean stricture length was 1.1 cm (0.5–1.5) and the mean follow-up was 42.5 months (28–61.3). Results: The vast majority of distal strictures (27/34 (79.4%)) were treated with our hybrid one-stage approach combining a distal urethral reconstruction with excision of the scar tissue without the need to use grafts or flaps. The average stricture length was 0.68 cm and average operative time was 24.43 min. Post-operative spraying was reported in a minority of patients (4/27 (14.8%)). The length of stricture and surgery were significantly longer in those 7/34 (20.6%) patients in whom grafts or flaps were used (2.88 cm and 154.8 min, respectively, p < 0.001 for both when compared to the hybrid one-stage approach). We noted 6/34 (17.6%) recurrences of distal urethral strictures, all of which were treated successfully with graft and flap repairs. Conclusions: The vast majority of distal urethral strictures are amenable to a distal one-stage urethroplasty, avoiding the use of grafts and/or flaps while achieving reasonable outcomes. This limited approach, at least initially, is associated with shorter operative time and time of catheter placement and avoids morbidity associated with graft or flap harvesting. Spraying of urine is seldomly encountered and comparable to other approaches addressing distal urethral strictures.

Narrative review of penile distal urethroplasties and suggestions for optimizing outcomes

Distal urethral strictures can be a challenging entity for urologists. Endoscopic maneuvers such as optical internal urethrotomies or dilations are even less successful than in other urethral locations and the repeated trauma will increase the scarring which advocates for a urethroplasty as primary option for patient management. Success rates of distal urethroplasties have been lower than those for other urethral strictures due to the anatomy of the distal urethra with a very thin corpus spongiosum associated with decreased mucosal blood supply. Also, the high prevalence of lichen sclerosus in this population with circumferential scarring is often a complicating factor. However, in the past two decades several surgical techniques have been described and further developed which has led to significant improvement in stricture recurrence rates. Meatoplasties are indicated for strictures limited to the meatus and involve opening of the stenotic meatus with subsequent reconstruction of it to minimize spraying of urine. Often, however, distal urethral strictures involve the fossa navicularis and may even extend further proximally. These strictures can be addressed with dorsal or ventral inlay procedures using buccal mucosa graft. In addition or alternatively, skin flaps can be mobilized to increase the urethral diameter. Lastly, multi-stage urethroplasty with buccal mucosa are a very successful approach yet given the high success rates of above mentioned procedures are usually reserved for revision surgery or most severe distal urethral strictures. In the following report, we are describing a variety of surgical techniques and their indication which should allow the practicing urologist to successfully address all encountered distal urethral strictures.

Survival by T Stage for Patients with Localized Bladder Cancer: Implications for Future Screening Trials

BACKGROUND: There is insufficient data to recommend screening for bladder cancer (BC). For future BC screening trials, it is important to understand how and if tumor (T) stage can act as a surrogate outcome marker for overall (OS) and cancer-specific (CSS) survival. OBJECTIVE: To characterize OS and CSS between primary tumor (T) stages in non-metastatic bladder cancer (BC) patients. METHODS: Non-metastatic BC patients were identified in the National Cancer Database (NCDB; 2004-2015) (n = 343,163) and National Cancer Institute Surveillance, Epidemiology, and End Results database (SEER) (n = 130,751). Cox multivariable regression compared relationships between T stage (LGTa, HGTa, Tis, LGT1, HGT1, T2-T4) and OS or CSS for all patients and sub-cohorts. RESULTS: Compared to stage LGTa as a reference, overall (SEER; NCDB) and cancer-specific (SEER) survival significantly declined with increasing T stage. Using SEER, OS ranged from HGTa (HR 1.16, CI 1.13–1.21, p < 0.001) to T4 (HR 5.70, CI 5.41–6.00, p < 0.001) with a steep inflection between HGT1 (HR 1.68, CI 1.63–1.73, p < 0.001) and T2 (HR 3.39, CI 3.30–3.49, p < 0.001), which was verified with NCDB. The association of stage and CSS was even more pronounced: HGTa (84% 10 year-CSS, HR 1.94, CI 1.81–2.08, p < 0.001), Tis (82% 10 year-CSS, HR 2.28, CI 2.09–2.47, p < 0.001), LGT1 (84% 10 year-CSS, HR 2.30, CI 2.11–2.51, p < 0.001), HGT1 (72% 10 year-CSS, HR 4.24, CI 4.01–4.47, p < 0.001), T2 (48% 10 year-CSS, HR 12.18, CI 11.57–12.82, p < 0.001), T3 (45% 10 year-CSS, HR 14.60, CI 13.63–15.64, p < 0.001), and T4 (29% 10 year-CSS, HR 22.76, CI 21.19–24.44, p < 0.001). CONCLUSIONS: Earlier T stage at diagnosis was associated with better OS largely due to differences in CSS. A clinically significant difference between Stage I and Stage II was verified herein in multiple cohorts. Therefore, earlier stage at diagnosis, specifically preventing muscle invasive BC, could potentially improve survival.

Association between inflammatory bowel disease and prostate cancer: A large-scale, prospective, population-based study

Inflammatory bowel disease (IBD) is an established risk factor for colorectal cancer. Recent reports suggesting IBD is also a risk factor for prostate cancer (PC) require further investigation. We studied 218 084 men in the population-based UK Biobank cohort, aged 40 to 69 at study entry between 2006 and 2010, with follow-up through mid-2015. We assessed the association between IBD and subsequent PC using multivariable Cox regression analyses, adjusting for age at assessment, ethnic group, UK region, smoking status, alcohol drinking frequency, body mass index, Townsend Deprivation Index, family history of PC and previous prostate-specific antigen testing. Mean age at study entry was 56 years, 94% of the men were white, and 1.1% (n = 2311) had a diagnosis of IBD. After a median follow-up of 78 months, men with IBD had an increased risk of PC (adjusted hazard ratio [aHR] = 1.31, 95% confidence interval [CI] = 1.03-1.67, P = .029). The association with PC was only among men with the ulcerative colitis (UC; aHR = 1.47, 95% CI = 1.11-1.95, P = .0070), and not Crohn's disease (aHR 1.06, 95% CI = 0.63-1.80, P = .82). Results are limited by lack of data on frequency of health care interactions. In a large-scale, prospective cohort study, we detected an association between IBD, and UC specifically, with incident PC diagnosis.

Anti-TNF agents and potential effects on male fertility: are men being counseled?

BACKGROUND

Adult men with autoimmune conditions are commonly prescribed anti-tumor necrosis factor (anti-TNF) agents; however, there is a paucity of quality evidence as to their effect on male fertility (e.g. semen parameters and sperm quality). Our objective was to determine if men with autoimmune conditions are being counseled regarding the unknown reproductive effects of anti-TNF agents prior to initiation of therapy.

METHODS

A retrospective analysis of 1010 male patients age 18-45 who were prescribed an anti-TNF agent were assessed for (1) receipt of counseling regarding potential reproductive effects; (2) screening for anatomic or laboratory abnormalities associated with infertility; (3) election for sperm cryopreservation.

RESULTS

Only 10.3% of men received counseling, and this was not associated with age (p = 0.77). Those who received counseling were significantly more likely to have a genitourinary exam performed, be assessed for presence of a varicocele, be asked about or endorse low libido or erectile dysfunction, have a testosterone, LH, FSH, or prolactin level checked, and have a semen analysis performed (all, p < 0.0001). Rates of sperm cryopreservation were low, but statistically higher in men who received counseling (5.77% (+) counseling, 1.10% (-) counseling) (p = 0.002).

CONCLUSIONS

The limited current literature lacks a consensus regarding the short- and long-term male reproductive effects of anti-TNF therapy. Despite this lack of clarity, rates of pre-initiation counseling were low. Rates of sperm cryopreservation, while improved in the counseled group remained low, suggesting prescribing physicians may be unaware of this option for patients.

Mutation signatures to Pan-Cancer Atlas: Investigation of the genomic landscape of muscle-invasive bladder cancer

The Cancer Genome Atlas (TCGA) for bladder cancer was published in 2014 with updated annotation of over 400 patients with muscle-invasive bladder cancer (MIBC) in 2017. This tremendous work established the foundation of the genomic landscape of MIBC. The next steps to utilize information from The Cancer Genome Atlas is to (1) identify the causes of mutation, (2) determine the significant differences and sources of heterogeneity, and (3) apply these tools toward patient care. In this review, we discuss the full spectrum of the genomic landscape of MIBC toward the goal of therapeutic application.

Genomic and Therapeutic Landscape of Non-muscle-invasive Bladder Cancer

Non-muscle-invasive bladder cancer (NMIBC) is heterogeneous, but current diagnostic and treatment strategies rely primarily on clinical parameters, lacking individualization to tumor and host genetics and biology. The heterogeneity of NMIBCs is derived from mutations, mutation signatures, chromosomal loss, and disruption of molecular pathways, which ultimately affects tumor progression, recurrence, and responsiveness to intravesical and systemic chemotherapy. Although research is still underway, advances in sequencing technology, insight into differential bacillus Calmette-Guérin responses, and new investigational treatment targets will soon offer clinicians new, precision-based tools to risk stratify and determine treatment regimens for future patients with bladder cancer.

A Review of Botulinum Toxin A for the Treatment of Neurogenic Bladder

Prior to FDA approval of intradetrusor botulinum toxin (BoTA) injections for the treatment of neurogenic bladder, patients' treatment options were limited to use of pharmacotherapies such as antimuscarinics, alpha blockers, and more recently beta agonists (some off-label) or invasive interventions including bladder augmentation and urinary diversion procedures. Herein, we provide a comprehensive literature review detailing the salient clinical literature that led to FDA approval of intradetrusor BoTA for neurogenic bladder. Patients with neurogenic detrusor overactivity and detrusor sphincter dyssynergia have been shown in randomized studies to benefit significantly from intradetrusor BoTA injection with regard to the following parameters: improved voided volume, improved bladder pressure and urodynamic parameters, reduced incidence of urinary tract infection, and improved quality of life. Intradetrusor BoTA injection has revolutionized the treatment landscape for patients with neurogenic bladder by providing them with a safe, efficacious, and cost-effective means to reduce bladder dysfunction, preserve renal function, and reduce the need for invasive, surgical intervention. LEVEL OF EVIDENCE: I.

Canine-assisted Therapy as an Adjunct Tool in the Care of the Surgical Patient: A Literature Review and Opportunity for Research

The use of canine-assisted therapy (CAT) in healthcare is expanding and the purpose of this review is to highlight its potential use in the surgical patient. While CAT literature to date has detailed widespread benefits in blood pressure control and improving pain, anxiety, and stress, little research has been performed specifically in surgical patients who may benefit significantly from CAT interventions. Critical points highlighted herein are as follows: (1) Hypertension is common and significantly increases morbidity and mortality associated with elective surgery. Pet ownership and brief CAT interventions (5-20 min) have demonstrated significant reductions in blood pressure and blood pressure variability in both adult and pediatric populations. (2) Pain management is of utmost importance in hospitalized, surgical patients and unfortunately the growing opioid addiction epidemic has complicated our ability to treat postoperative pain. CAT interventions have been shown to reduce self-reported pain. Therefore, CAT represents a cost-effective, safe, and noninvasive approach to pain management. (3) Patient satisfaction is of growing concern as reimbursement by Medicare, Medicaid, and other insurers is now linked to patient reported satisfaction with their hospital stay. While very limited data is available on this subject, some studies have showed that CAT intervention, specifically, improved patient reported satisfaction in multiple categories of the HCAHPS survey compared with patients who did not receive CAT. Overall, this is a novel narrative review detailing the therapeutic efficacy of CAT, highlighting the specific indications of CAT in the surgical patient, and urging further research of CAT in the surgical patient.

ADAM10-Mediated ICOS Ligand Shedding on B Cells Is Necessary for Proper T Cell ICOS Regulation and T Follicular Helper Responses

The proper regulation of ICOS and ICOS ligand (ICOSL) has been shown to be essential for maintaining proper immune homeostasis. Loss of either protein results in defective humoral immunity, and overexpression of ICOS results in aberrant Ab production resembling lupus. How ICOSL is regulated in response to ICOS interaction is still unclear. We demonstrate that a disintegrin and metalloproteinase (ADAM)10 is the primary physiological sheddase of ICOSL in mice and humans. Using an in vivo system in which ADAM10 is deleted only on B cells, elevated levels of ICOSL were seen. This increase is also seen when ADAM10 is deleted from human B cell lines. Identification of the primary sheddase has allowed the characterization of a novel mechanism of ICOS regulation. In wild-type mice, interaction of ICOS/ICOSL results in ADAM10-induced shedding of ICOSL on B cells and moderate ICOS internalization on T cells. When this shedding is blocked, excessive ICOS internalization occurs. This results in severe defects in T follicular helper development and TH2 polarization, as seen in a house dust mite exposure model. In addition, enhanced TH1 and TH17 immune responses are seen in experimental autoimmune encephalomyelitis. Blockade of ICOSL rescues T cell ICOS surface expression and rescues, at least in part, T follicular helper numbers and the abnormal Ab production previously reported in these mice. Overall, we propose a novel regulation of the ICOS/ICOSL axis, with ADAM10 playing a direct role in regulating ICOSL, as well as indirectly regulating ICOS, thus controlling ICOS/ICOSL-dependent responses.

Characteristics of Idiopathic Urethral Strictures: A Link to Remote Perineal Trauma?

OBJECTIVE

To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common yet poorly understood entity.

PATIENTS AND METHODS

We retrospectively reviewed our urethroplasty database to identify men undergoing initial urethral reconstruction from 2007 to 2014 at 1 of 3 hospitals (N = 514). Patients were stratified by stricture etiology, including IUS, acute trauma, iatrogenic, hypospadias, balanitis xerotica obliterans, and radiation. IUS that had a known history of subacute or repetitive blunt force to the perineum (horseback riding, avid cycling, motocross, etc.) were subclassified as subacute or repetitive perineal trauma (SRPT).

RESULTS

Among 466 men undergoing initial reconstruction with available data, 215 (46%) were IUS cases. The median delay between IUS diagnosis and urethroplasty was 5.2 years, during which time men underwent a median of 2 endoscopic treatments. A total of 51 (24%) IUS cases recalled a distinct history of SRPT. Men with SRPT were slightly younger (median 43 vs 48 years, P = .01) but were remarkably similar in terms of urethral stricture length (2 vs 2 cm, P = .15), location (bulbar 96% vs 89%, P = .41), and treatment success (92% vs 88%; P = .61). Bulbar (-)SRPT and (+)SRPT IUS had similar clinical and morphometric features as those with known acute bulbar trauma with excellent 24-month stricture recurrence-free survival rates (93% vs 92% vs 97%, P = .19).

CONCLUSION

IUS have clinical features suggesting that many may be related to unrecognized or repetitive perineal trauma. Although treatment tends to be delayed, IUS have excellent urethroplasty success because most are short bulbar strictures amenable to anastomotic urethroplasty.