Affirming Long-Term Outcomes After Contemporary Urethroplasty: The Adverse Impact of Increasing Stricture Length, Lichen Sclerosus, Radiation, and Infectious Strictures

PURPOSE

There is a paucity of reported long-term outcomes after contemporary urethroplasty. Our objective is to determine the long-term success of modern urethroplasty and identify factors associated with stricture recurrence in this context.

MATERIALS AND METHODS

Patients undergoing urethroplasty from July 2003 to May 2013 with at least 100 months of follow-up were identified. Long-term outcomes including stricture recurrence and patient satisfaction were evaluated by review of regional/provincial electronic records and telephone interview. Urethroplasty failure was defined as a recurrent stricture (<16F) confirmed on cystoscopy. Cox regression was used to evaluate variables associated with long-term stricture recurrence.

RESULTS

A total of 733 patients were identified with ≥ 100 months follow-up. Median patient age was 45 years, stricture length was 4.7 cm, and 85.8% failed prior endoscopic treatment. At a median follow-up of 12.3 years, 89 recurrences were observed. Cumulative incidence of stricture recurrence was 6%, 10%, and 12% after 1, 5, and 10 years, respectively. From a patient-reported perspective, 89% of patients reported being satisfied with the outcome of surgery. On multivariable analyses, increasing stricture length (HR 1.1, 95% CI 1.05-1.15; P < .001) and stricture etiology (P < .001), in particular lichen sclerosus (HR 4.46, 95% CI 2.25-9.53), radiation (HR 4.25, 95% CI 1.65-10.9), and infectious strictures (HR 5.27, 95% CI 2.03-13.7), were independently associated with stricture recurrence.

CONCLUSIONS

This study affirms the widely held belief that modern urethroplasty provides high long-term patency and patient-reported satisfaction. Patients with longer strictures as well as those with lichen sclerosus, radiation, and infectious etiologies have a higher hazard of stricture recurrence in the long term.

Is There Any Benefit to the Use of Antibiotics with Indwelling Catheters after Urologic Surgery in Adults

Antibiotic stewardship in urologic reconstruction is critically important, as many patients will require indwelling catheters for days to weeks following surgery and thus are at risk of both developing catheter-associated urinary tract infections (CAUTI) as well as multi-drug resistant (MDR) uropathogens. Accordingly, limiting antibiotic use, when safe, should help reduce antibiotic resistance and the prevalence of MDR organisms. However, there is significant heterogeneity in how antibiotics are prescribed to patients who need indwelling urethral catheters post-operatively. We performed a literature review to determine if there are benefits in the use of antibiotics for various clinical scenarios that require post-operative indwelling catheters for greater than 24 h. In general, for patients undergoing prostatectomy, transurethral resection of the prostate, and/or urethroplasty, antibiotic administration may be limited without increased risk of CAUTI. However, more work is needed to identify optimal antibiotic regimens for these and alternative urologic procedures, whether certain sub-populations benefit from longer courses of antibiotics, and effective non-antibiotic or non-systemic therapies.

Deletion of Mocos Induces Xanthinuria with Obstructive Nephropathy and Major Metabolic Disorders in Mice

Background

Xanthinuria type II is a rare autosomal purine disorder. This recessive defect of purine metabolism remains an under-recognized disorder.

Methods

Mice with targeted disruption of the molybdenum cofactor sulfurase (Mocos) gene were generated to enable an integrated understanding of purine disorders and evaluate pathophysiologic functions of this gene which is found in a large number of pathways and is known to be associated with autism.

Results

Mocos-deficient mice die with 4 weeks of age due to renal failure of distinct obstructive nephropathy with xanthinuria, xanthine deposits, cystic tubular dilation, Tamm-Horsfall (uromodulin) protein (THP) deposits, tubular cell necrosis with neutrophils, and occasionally hydronephrosis with urolithiasis. Obstructive nephropathy is associated with moderate interstitial inflammatory and fibrotic responses, anemia, reduced detoxification systems, and important alterations of the metabolism of purines, amino acids, and phospholipids. Conversely, heterozygous mice expressing reduced MOCOS protein are healthy with no apparent pathology.

Conclusions

Mocos-deficient mice develop a lethal obstructive nephropathy associated with profound metabolic changes. Studying MOCOS functions may provide important clues about the underlying pathogenesis of xanthinuria and other diseases requiring early diagnosis.

Application of dermoscopy image analysis technique in diagnosing urethral condylomata acuminata

BACKGROUND

In this study, cases with suspected urethral condylomata acuminata were examined by dermoscopy, in order to explore an effective method for clinical.

OBJECTIVE

To study the application of dermoscopy image analysis technique in clinical diagnosis of urethral condylomata acuminata.

METHODS

A total of 220 suspected urethral condylomata acuminata were clinically diagnosed first with the naked eyes, and then by using dermoscopy image analysis technique. Afterwards, a comparative analysis was made for the two diagnostic methods.

RESULTS

Among the 220 suspected urethral condylomata acuminata, there was a higher positive rate by dermoscopy examination than visual observation.

STUDY LIMITATIONS

Dermoscopy examination technique is still restricted by its inapplicability in deep urethral orifice and skin wrinkles, and concordance between different clinicians may also vary.

CONCLUSION

Dermoscopy image analysis technique features a high sensitivity, quick and accurate diagnosis and is non-invasive, and we recommend its use.

Effectiveness of syndromic management for male patients with urethral discharge symptoms in Amazonas, Brazil

BACKGROUND

Urethral discharge syndrome (UDS) is characterized by the presence of purulent or mucopurulent urethral discharge.The main etiological agents of this syndrome are Neisseria gonorrhoeae and Chlamydia trachomatis.

OBJECTIVES

To evaluate the effectiveness of the syndromic management to resolve symptoms in male urethral discharge syndrome cases in Manaus, Amazonas, Brazil.

METHODS

Retrospective cohort of male cases of urethral discharge syndrome observed at a clinic for sexually transmitted disease (STD) in 2013. Epidemiological and clinical data, as well as the results of urethral swabs, bacterioscopy, hybrid capture for C.trachomatis, wet-mount examination, and culture for N.gonorrhoeae, were obtained through medical chart reviews.

RESULTS

Of the 800 urethral discharge syndrome cases observed at the STD clinic, 785 (98.1%) presented only urethral discharge syndrome, 633 (79.1%) returned for follow-up, 579 (91.5%) were considered clinically cured on the first visit, 41(6.5 %) were considered cured on the second visit, and 13(2.0%) did not reach clinical cure after two appointments. Regarding the etiological diagnosis, 42.7% of the patients presented a microbiological diagnosis of N.gonorrhoeae, 39.3% of non-gonococcal and non-chlamydia urethritis, 10.7% of C.trachomatis and 7.3% of co-infection with chlamydia and gonococcus. The odds of being considered cured in the first visit were greater in those who were unmarried, with greater schooling, and with an etiological diagnosis of gonorrhea. The diagnosis of non-gonococcal urethritis reduced the chance of cure in the first visit.

STUDY LIMITATION

A study conducted at a single center of STD treatment.

CONCLUSION

Syndromic management of male urethral discharge syndrome performed in accordance with the Brazilian Ministry of Health STD guidelines was effective in resolving symptoms in the studied population. More studies with microbiological outcomes are needed to ensure the maintenance of the syndromic management.

Functional Effects of Bulbospongiosus Muscle Sparing on Ejaculatory Function and Post-Void Dribbling after Bulbar Urethroplasty

PURPOSE

Bulbar urethroplasty outcomes studies have shown low but significant rates of post-void dribbling and ejaculatory dysfunction. The bulbospongiosus muscle is involved with the expulsion of seminal fluid and urine from the bulbar urethra and, thus, we hypothesized that performing urethroplasty using a technique that does not split the muscle may result in better postoperative patient reported ejaculatory function and less post-void dribbling.

MATERIALS AND METHODS

We performed a multi-institutional matched, case-control analysis comparing men treated with a bulbospongiosus sparing technique to men treated with the traditional nonbulbospongiosus sparing technique. Preoperative and postoperative (3 to 12 months) ejaculatory function was assessed using the 4 ejaculatory questions of the Male Sexual Health Questionnaire short form as well as a patient perception questionnaire. Post-void dribbling was assessed using a validated urethroplasty questionnaire.

RESULTS

A total of 25 patients who underwent bulbospongiosus sparing urethroplasty and 25 who underwent nonbulbospongiosus sparing urethroplasty were matched by total preoperative Male Sexual Health Questionnaire score, age, and performance of excision and primary anastomosis. The bulbospongiosus sparing and nonbulbospongiosus sparing groups had similar postoperative total Male Sexual Health Questionnaire scores (15.24 vs 15.40, respectively, p=0.90) and there were no significant postoperative questionnaire score changes in either group (bulbospongiosus sparing 14.56 to 15.24, p=0.4; nonbulbospongiosus sparing 14.64 vs 15.40, p=0.44). Individual responses to the Male Sexual Health Questionnaire were analyzed and no statistically significant difference was found between the groups. Rates of postoperative post-void dribbling and perception of ejaculatory function were similar between the groups.

CONCLUSIONS

Sparing the bulbospongiosus muscle during urethroplasty does not seem to have a significant impact on patient reported ejaculatory function or post-void dribbling compared with nonbulbospongiosus sparing urethroplasty at early followup.