Understanding the Relationship between Chronic Systemic Disease and Lichen Sclerosus Urethral Strictures.

PURPOSE: Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men. MATERIALS AND METHODS: We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups. RESULTS: Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050-1.130), and were more likely to have hypertension (aOR 2.028, 1.21-3.41) and be active tobacco users (aOR 2.0, 1.36-3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9-4.2). CONCLUSIONS: Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.

Measuring and Predicting Patient Dissatisfaction after Anterior Urethroplasty Using Patient Reported Outcomes Measures.

PURPOSE: Subjective measures of success after urethroplasty have become increasingly valuable in postoperative monitoring. We examined patient reported satisfaction following anterior urethroplasty using objective measures as a proxy for success. MATERIALS AND METHODS: Men 18 years old or older with urethral strictures undergoing urethroplasty were prospectively enrolled in a longitudinal, multi-institutional urethroplasty outcomes database. Preoperative and postoperative assessment included questionnaires to assess lower urinary tract symptoms, pain, satisfaction and sexual health. Analyses controlling for stricture recurrence (defined as the inability to traverse the reconstructed urethra with a flexible cystoscope) were performed to determine independent predictors of dissatisfaction. RESULTS: At a mean followup of 14 months we found a high 89.4% rate of overall postoperative satisfaction in 433 patients and a high 82.8% rate in those who would have chosen the operation again. Men with cystoscopic recurrence were more likely to report dissatisfaction (OR 4.96, 95% CI 2.07-11.90) and men reporting dissatisfaction had significantly worse uroflowmetry measures (each p <0.02). When controlling for recurrence, multivariate analysis revealed that urethra and bladder pain (OR 1.71, 95% CI 1.05-2.77 and OR 2.74, 95% CI 1.12-6.69, respectively), a postoperative decrease in sexual activity (OR 4.36, 95% CI 2.07-11.90) and persistent lower urinary tract symptoms (eg straining to urinate OR 3.23, 1.74-6.01) were independent predictors of dissatisfaction. CONCLUSIONS: Overall satisfaction after anterior urethroplasty is high and traditional measures of surgical success strongly correlate with satisfaction. However, independently of the anatomical appearance of the reconstructed urethra, postoperative pain, sexual dysfunction and persistent lower urinary tract symptoms were predictors of patient dissatisfaction.

Developing and Implementing a Cloud-Based Software Solution for Tracking Ureteral Stents: A Pilot Study.

Introduction: As many as 12.5% of patients who undergo ureteral stent placement fail to have their stent removed in a timely manner. Because retained stents can be a source of substantial morbidity, there is a need for solutions to help urologists track their stented patients. Materials and Methods: We developed a cloud-based software that is agnostic to the device manufacturer and can be seamlessly integrated into the electronic health record (EHR). The software automatically registers patients who undergo ureteral stent placement and then follows them through their postoperative course to ensure timely follow-up for device removal. To validate our software's performance, we reviewed the medical records of patients who underwent stent placement for any indication at our institution between February 1, 2018, and February 28, 2018. Results: During our 1-month pilot study, a total of 51 ureteral stents were placed during 49 procedures that were performed on 46 patients. Our software effectively captured all of these procedures. It was able to properly distinguish 31 procedures where the patient who underwent stenting had follow-up scheduled before surgery. More importantly, it alerted our schedulers to 18 procedures for which no return visit had been scheduled. Furthermore, our software was able to register follow-up attendance, correctly identifying 10 procedures where patients failed to arrive. Conclusion: We describe a high-fidelity software solution for automated tracking of ureteral stents that is agnostic to the device manufacturer and can be seamlessly integrated into the EHR, causing minimal disruption to provider workflows.

New Persistent Opioid Use After Outpatient Ureteroscopy for Upper Tract Stone Treatment.

OBJECTIVE: To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery. METHODS: Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS. RESULTS: In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03). CONCLUSION: Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.

The Relationship Between Diabetes, Diabetes Severity, Diabetes Biomarkers, and the Presence of Lower Urinary Tract Symptoms: Findings From the National Health and Nutrition Examination Survey.

OBJECTIVE: To characterize the associations between diabetes mellitus (DM) and lower urinary tract symptoms (LUTS). This study focuses on the relationships between specific diabetic characteristics (eg, severity, biomarkers) and the prevalence of LUTS. MATERIALS AND METHODS: The 2005-2008 cycles of the National Health and Nutrition Examination Survey were queried for men who completed both a DM and a kidney/prostate questionnaire. Men with LUTS were defined as those experiencing at least 1 out of 3 of the following: nocturia, hesitancy, or incomplete emptying. Men with DM were defined as having been diagnosed by a physician and being actively treated. Multivariate logistic regression with sample weighting was performed to assess effects of biomarker levels (HgbA1c, fasting glucose), medication use, and surrogates of disease progression on the presence of LUTS. RESULTS: Of the 2127 male participants, those with DM (n = 405) were more likely to experience at least 1 urinary symptom (adjusted odds ratio 1.63, P <.0001). Men under the age of 70 with long-standing (>5 years) DM were more likely to report LUTS than those with a shorter duration of the disease (<5 years). Diabetes-specific biomarkers (HgbA1c, fasting glucose) were not predictors of LUTS in men with DM. CONCLUSION: DM was confirmed to be strongly associated with patient-reported LUTS in men. Younger men and those with longer-standing disease appear to be most susceptible. In actively treated patients with DM, DM biomarkers were not helpful in predicting individual LUTS. Instead, biomarkers that indirectly reflect DM disease progression were most useful.

The International Prostate Symptom Score (IPSS) Is an Inadequate Tool to Screen for Urethral Stricture Recurrence After Anterior Urethroplasty.

OBJECTIVE: To validate the use of the International Prostate Symptom Score (IPSS) as a stand-alone tool to detect urethral stricture recurrence following urethroplasty. MATERIALS AND METHODS: This study included 393 men who had undergone anterior urethroplasty and were enrolled in a multi-institutional outcomes study. Data analyzed included pre- and post-operative answers to the IPSS in addition to findings from a same- day cystoscopy. IPSS from men found to have cystoscopic recurrence were then compared to scores from those with successful repairs, and receiver operating characteristic curves were plotted to illustrate the predictive ability of these questions to screen for cystoscopic recurrence. RESULTS: Mean postoperative scores were lower (fewer symptoms) in successful repairs; IPSS improved from preoperative values regardless of recurrence. Successful repairs had significantly better degree of improvement in question #5 (assessing weak stream) compared to recurrences. Receiver operating characteristic curves demonstrated the highest area under the curve for the IPSS quality of life question (0.66) that alone outperformed the complete IPSS questionnaire (0.56). CONCLUSION: The IPSS had inadequate sensitivity and specificity to be used as a stand-alone screening tool for stricture recurrence in this large cohort of men, highlighting the need to continue development of a disease-specific, validated patient-reported outcome measure.

Critical Analysis of the Use of Uroflowmetry for Urethral Stricture Disease Surveillance.

OBJECTIVE: To critically evaluate the use of uroflowmetry (UF) in a large urethral stricture disease cohort as a means to monitor for stricture recurrence. MATERIALS AND METHODS: This study included men that underwent anterior urethroplasty and completed a study-specific follow-up protocol. Pre- and postoperative UF studies of men found to have cystoscopic recurrence were compared to UF studies from successful repairs. UF components of interest included maximum flow rate (Qm), average flow rate (Qa), and voided volume, in addition to the novel post-UF calculated value of Qm minus Qa (Qm-Qa). Area under the receiver operating characteristic curves (AUC) of individual UF parameters was compared. RESULTS: Qm-Qa had the highest AUC (0.8295) followed by Qm (0.8241). UF performed significantly better in men ≤40 with an AUC of 0.9324 and 0.9224 for Qm-Qa and Qm respectively, as compared to 0.7484 and 0.7661 in men >40. Importantly, of men found to have anatomic recurrences, only 41% had a Qm of ≤15 mL/s at time of diagnostic cystoscopy, whereas over 83% were found to have a Qm-Qa of ≤10 mL/s. CONCLUSION: Qm rate alone may not be sensitive enough to replace cystoscopy when screening for stricture recurrence in all patients, especially in younger men where baseline flow rates are higher. Qm-Qa is a novel calculated UF measure that appears to be more sensitive than Qm when using UF to screen for recurrence, as it may be a better numerical representation of the shape of the voiding curve.

Assessment of the Male Urethral Reconstruction Learning Curve.

OBJECTIVE: To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. MATERIALS AND METHODS: We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. RESULTS: A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P = .0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P = .0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P = .0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P = .0014). Complications decreased with time (P = .0053). CONCLUSION: This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.