Preoperative and intraoperative factors predictive of complications and stricture recurrence following multiple urethroplasty techniques

Objectives

To investigate factors predictive of postoperative recurrence and complications in patients undergoing urethroplasty for stricture repair at a single center.

Patients and methods

We retrospectively reviewed the records of 108 men who underwent urethroplasty for urethral stricture disease (USD) at a single center from 2016 to 2020. Demographic data, comorbidities, stricture history including etiology and prior treatments, patient‐reported symptoms, and outcomes data were collected for analysis. Data were analyzed in aggregate, then, stratified by type of urethroplasty performed. Descriptive statistics, univariate analysis, multivariate logistic regression, and intergroup comparisons were completed using STATA, with an alpha value of 0.05 and a confidence interval of 95%.

Results

The median age of our patients was 58 years (interquartile range: 42‐69; range: 29‐83), with a median stricture length of 2.0 cm (interquartile range: 1.0‐4.5; range: 0.5‐10). The most common stricture etiology was iatrogenic (n = 33, 31%) and the most common urethroplasty was anterior anastomotic urethroplasty (n = 38, 35%), followed by buccal mucosal graft (BMG) urethroplasty (n = 35, 32%). Twenty‐four patients (22%) had stricture recurrence. Within the aggregate data, recurrence was significantly predicted by obesity (BMI > 30) (Odds Ratio [OR] 3.2, 95% Confidence Interval [CI]: 1.06‐10), and the presence of postoperative complications (OR 6.3, CI: 1.9‐21). The presence of any postoperative complications within 90 days was significantly predicted by stricture length ≥ 5 cm (OR 3.5, CI 1.09‐12) and recurrence (OR 6.0, CI 1.7‐21).

Conclusion

Despite serving as the most definitive treatment for urethral stricture management, stricture recurrence and postoperative complications are not uncommon after urethroplasty. Obesity and stricture length negatively impact outcomes while a penile stricture location is associated with a lower recurrence rate, though this is not statistically significant.

Robot assisted radical prostatectomy: the new standard?

Over the past decade, the robotic assisted radical prostatectomy (RARP) has grown increasingly popular and quickly equated itself as the most commonly used modality to treat locally-confined prostate cancer. Despite increased utilization, there is limited comparative research demonstrating superiority for RARP over the conventional radical retropubic prostatectomy (RRP). Furthermore, though perioperative and short-term oncologic outcomes are equivalent if not superior for the robotic approach, the optimal utilization of robotic technology remains to be determined with cost serving as a primary driver. In this review, we performed a literature search to identify comparative effectiveness research as it pertains to RARP versus RRP. We performed a PubMed literature search for a review of articles published between 2000 and 2014 using the following keywords to identify pertinent research: "robot or robotic prostatectomy", "open or retropubic prostatectomy", "cost", "resource utilization". Long-term data comparing RARP and RRP remains limited, though short-term positive surgical margins, biochemical recurrence-free survival, and need for adjuvant therapy appear at least equivocal, if not in favor of RARP versus RRP. Functional outcomes including return of continence and potency favor RARP while cost still favors RRP. Nonetheless, the generalization of results remains difficult with surgeon volume playing a large role in improving efficiency and quality. For the foreseeable future, an increasing number of prostatectomies will continue to be performed robotically. Though RARP appears to offer improved functional outcomes with good short-term oncologic outcomes, there is a need for longer-term studies to assess the true value of RARP. Outcomes aside, rigorous, prospective randomized-controlled trials must also be performed on the cost-effectiveness of RARP to determine its overall utility in an era of health care delivery reform.

A comparison of the robotic-assisted versus retropubic radical prostatectomy

After Walsh's detailed anatomic description of pelvic anatomy in 1979, the retropubic radical prostatectomy (RRP) was the predominant surgical treatment for prostate cancer for more than twenty-five years. Over the past decade, however, the robotic-assisted radical prostatectomy (RARP) has grown increasingly popular and now is the most used surgical modality. Willingness to adopt this approach has been confounded by the novelty of technology and widespread marketing campaigns. In this article, we performed a literature search comparing radical retropubic prostatectomy to robotic-assisted radical prostetectomy with regard to perioperative, oncologic, and quality-of-life outcomes. We performed a PubMed literature search for a review of articles published between 2000 and 2013. Relevant articles were highlighted using the following keywords: robot or robotic prostatectomy, open or retropubic prostatectomy. Perioperative outcomes including decreased blood loss, fewer blood transfusions, and decreased length of hospital stay tend to favor RARP, while perioperative mortality is near negligible in both. Short-term positive surgical margins, prostate-specific antigen recurrence free survival, and need for salvage therapy following RARP are similar to RRP, though data at greater than ten years is limited. Preservation of urinary and sexual function and quality of life favored RARP, though this is dependent on surgeon technique. Finally, cost, though evolving, favors RRP. In our current state, most prostatectomies will continue to be perfromed robotically. Though there is evidence the robotic-assisted radical prostatectomy offers shorter lengths of stay, decreased intraoperative blood loss, faster return of sexual function and continence, there is a paucity on long-term oncologic outcomes. Rigorous, prospective randomized-controlled trials need to be performed to determine the long-term success of the robotic-assisted radical prostatectomy and whether it is cost-effective when its potential advantages are taken into consideration.