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.

The Impact of Social Deprivation on Anterior Urethral Stricture Recurrence After Urethroplasty - A Trauma and Urologic Reconstructive Network of Surgeons (TURNS) Analysis.

INTRODUCTION AND OBJECTIVES: Several factors influence recurrence after urethral stricture repair. The impact of socioeconomic factors on stricture recurrence after urethroplasty is poorly understood. This study aims to assess the impact that social deprivation, an area-level measure of disadvantage, has on urethral stricture recurrence after urethroplasty. METHODS: We performed a retrospective review of patients undergoing urethral reconstruction by surgeons participating in a collaborative research group. Home zip code was used to calculate Social Deprivation Indices (SDI; 0-100), which quantifies the level of disadvantage across several sociodemographic domains collected in the American Community Survey. Patients without zip code data were excluded from the analysis. The Cox Proportional Hazards model was used to study the association between SDI and the hazard of functional recurrence, adjusting for stricture characteristics as well as age and body mass index. RESULTS: Median age was 46.0 years with a median follow up of 367 days for the 1452 men included in the study. Patients in the fourth SDI quartile (worst social deprivation) were more likely to be active smokers with traumatic and infectious strictures compared to the first SDI quartile. Patients in the fourth SDI quartile had 1.64 times the unadjusted hazard of functional stricture recurrence vs patients in the first SDI quartile (95% CI 1.04-2.59). Compared to anastomotic ± excision, substitution only repair had 1.90 times the unadjusted hazard of recurrence. The adjusted hazard of recurrence was 1.08 per 10-point increase in SDI (95% CI 1.01-1.15, P = .027). CONCLUSIONS: Patient social deprivation identifies those at higher risk for functional recurrence after anterior urethral stricture repair, offering an opportunity for preoperative counseling and postoperative surveillance. Addressing these social determinants of health can potentially improve outcomes in reconstructive surgery.

Statistics as a Social Activity: Attitudes toward Amalgamating Evidence.

Amalgamation of evidence in statistics is conducted in several ways. Within a study, multiple observations are combined by averaging, or as factors in a likelihood or prediction algorithm. In multilevel modeling or Bayesian analysis, population or prior information is combined with data using the weighted averaging derived from probability modeling. In a scientific research project, inferences from data analysis are interpreted in light of mechanistic models and substantive theories. Within a scholarly or applied research community, data and conclusions from separate laboratories are amalgamated through a series of steps, including peer review, meta-analysis, review articles, and replication studies. These issues have been discussed for many years in the philosophy of science and statistics, gaining attention in recent decades first with the renewed popularity of Bayesian inference and then with concerns about the replication crisis in science. In this article, we review the amalgamation of statistical evidence from different perspectives, connecting the foundations of statistics to the social processes of validation, criticism, and consensus building.

Accurately Defining the Incidence and Associations of 90-Day Complications after Urethroplasty: Adverse Impact of Patient Comorbidities, Preoperative Bacteriuria and Prior Urethroplasty.

PURPOSE: The purpose of this study was to determine the incidence of 90-day complications after urethroplasty and identify factors associated with them. MATERIALS AND METHODS: A single-institution, 2-surgeon retrospective review was performed on patients undergoing urethroplasty from August 2003-June 2020. Variables included the incidence, type and Clavien-Dindo grade of complications, patient age, individual comorbidities, comorbidity component of the Charlson Comorbidity Index (CCI), smoking status, obesity (body mass index ≥35 kg/m2), bacteriuria, type of urethroplasty, stricture etiology, length, location, prior endoscopic procedures, previous urethroplasty and preoperative suprapubic catheterization. The primary outcome was the incidence of significant 90-day complications defined as Clavien grade ≥2. Descriptive statistics were used to summarize the results and binary logistic regression was used to examine the factors associated with 90-day complications. RESULTS: Of the 1,611 patients included in the analysis, 90-day complications (Clavien ≥2) occurred in 7.9% (128/1,611) and were wound related (3.5%), urinary tract infection (3.4%), cardiovascular (0.4%), catheter-related (0.2%), hematuria (0.1%) or retention (0.1%). On univariable binary logistic regression stricture location (p=0.04), stricture length (p=0.009), CCI (p <0.0001), prior urethroplasty (p=0.01) and bacteriuria (p=0.002) were associated with complications, while age (p=0.3), etiology (p=0.2), smoking (p=0.2), obesity (p=0.3), failed endoscopic treatment (p=0.8), indwelling suprapubic catheter (p=0.7) and type of urethroplasty (p=0.09) were not. On multivariable analysis, increasing CCI (Odds Ratio 1.31, 95% CI 1.10-1.56; p=0.003), prior urethroplasty (OR 1.86, 95% CI 1.09-3.17; p=0.02) and preoperative bacteriuria (OR 1.67, 95% CI 1.14-2.45; p=0.009) remained associated with 90-day complications. CONCLUSIONS: Patients with increased comorbidities, prior urethroplasty and preoperative bacteriuria are at higher risk for complications after urethroplasty and should be counseled accordingly in a shared decision-making model of care.

Defining Success after Anterior Urethroplasty: An Argument for a Universal Definition and Surveillance Protocol.

PURPOSE: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. MATERIALS AND METHODS: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology. RESULTS: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology. CONCLUSIONS: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

Urethroscopic Findings following Urethroplasty Predict the Need for Secondary Intervention in the Long Term: A Multi-Institutional Study from Trauma and Urologic Reconstructive Network of Surgeons.

PURPOSE: Postoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure. MATERIALS AND METHODS: We evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (<17Fr) that the cystoscope could not be passed. Failure was stricture recurrence requiring a secondary intervention. RESULTS: The median followup time was 64.4 months (range 55.3-80.6) and the time to initial surveillance urethroscopy was 3.7 months (range 3.1-4.8) following urethroplasty. Secondary interventions were performed in 29 of 194 (15%) with normal lumens, 11 of 60 (18.3%) with ≥17Fr strictures and 32 of 50 (64%) with <17Fr strictures (p <0.001). The 1-, 3- and 9-year cumulative probability of intervention was 0.01, 0.06 and 0.23 for normal, 0.05, 0.17 and 0.18 for ≥17Fr, and 0.32, 0.50 and 0.73 for <17Fr lumen groups, respectively. Patient-reported outcome measures performed poorly to differentiate the 3 groups. CONCLUSIONS: Early cystoscopic visualization of scar recurrence that narrows the lumen to <17Fr following urethroplasty is a significant long-term predictor for patients who will eventually undergo a secondary intervention.

Urinary Symptom Nonresponse ("LUTS Failure") after Urethroplasty: Incidence and Associations.

PURPOSE: An ill-defined proportion of patients undergoing urethroplasty fail to experience improvement in lower urinary tract symptoms (LUTS) despite being stricture-free. We aim to identify the incidence, associations and causes of "LUTS failure" after urethroplasty. MATERIALS AND METHODS: Patients undergoing urethroplasty over a 6-year period were offered enrollment in a prospective study examining urinary function after urethroplasty. Patients were assessed preoperatively and 6 months postoperatively using the International Prostate Symptom Score (IPSS) and cystoscopy. "LUTS failure" was defined as ≤3-point improvement in IPSS despite an anatomically successful urethroplasty. Multivariable logistic regression was utilized to evaluate the association between patient factors and "LUTS failure." RESULTS: Of 365 patients meeting inclusion criteria, mean postoperative IPSS (20.3 vs. 5.4, p <0.0001) and median urinary quality of life (UQOL; 5 vs. 1; p <0.0001) were significantly improved. Despite being stricture-free, 7.7% of patients reported "LUTS failure" and 10.1% reported UQOL nonresponse. On multivariable logistic regression, increasing age (OR 1.04, 95% CI 1.01-1.06; p=0.006) and hypospadias (OR 18.2, 95% CI 2.1-156.0; p=0.008) were associated with "LUTS failure," while stricture location (p=0.76), length (p=0.14), previous urethroplasty (p=0.96), failed endoscopic treatment (p=0.17), type of urethroplasty (p=0.93) and other etiologies were not. Qualitatively, the most likely causes of "LUTS failure" were detrusor underactivity (39.3%), overactivity (21.4%), pelvic floor dysfunction (21.4%) or benign prostatic hyperplasia (14.3%). Only increasing age was associated with UQOL nonresponse (OR 1.03, 95% CI 1.01-1.07; p=0.02). CONCLUSIONS: While many patients experience improved voiding function after urethroplasty, 7.7% experience "LUTS failure" and 10.1% report UQOL nonresponse. Both occurrences are independently associated with increasing patient age and most commonly related to detrusor underactivity.

Improvement in Storage Related Lower Urinary Tract Symptoms following Urethroplasty: A Prospective Cohort Study.

PURPOSE: In patients with lower urinary tract symptoms, storage related symptoms induce the greatest degree of bother. When associated with urethral stricture, it is unclear how these specific symptoms respond to urethroplasty. This study aims to evaluate the prevalence and effect of urethroplasty on patient reported storage lower urinary tract symptoms. MATERIALS AND METHODS: This prospective cohort study evaluated patients undergoing urethroplasty for urethral stricture from 2012-2019. Patients were administered the International Prostate Symptom Score preoperatively and 6 months posturethroplasty. The primary outcomes were change in urinary frequency, urgency, nocturia and composite storage symptom measure according to International Prostate Symptom Score. Symptoms were considered clinically significant if they were graded 3 or greater for the individual domains, and greater than 6 for the combined score. Wilcoxon signed-rank test was used to compare results. RESULTS: A total of 387 patients completed the International Prostate Symptom Score preoperatively and postoperatively. Median age was 50 years and median stricture length was 4.5 cm. Cystoscopic success at 6 months was 96.1%. Preoperatively, urinary frequency, urgency and nocturia were common symptoms (52.5%, 48.8% and 41.6%, respectively). Postoperatively, these rates decreased to 11.6%, 11.4% and 11.1%, respectively, reductions that were significant (p <0.0001) across all domains. Overall storage symptom scores improved significantly (median 8 preoperatively vs 2 postoperatively, p <0.0001). On binary logistic regression, no factor was associated with a lack of response, including stricture recurrence (p=0.44), age (p=0.45), stricture length (p=0.63), location (p=0.13), etiology (p=0.17), number of failed endoscopic treatments (p=0.53) and prior urethroplasty (p=0.06). CONCLUSIONS: Urethroplasty yields clinically and statistically significant improvements in storage related lower urinary tract symptoms in men with urethral stricture.

Artificial urinary sphincter or a second adjustable transobturator male system offer equivalent outcomes in patients whom required revision on the initial ATOMS device: An international multi-institutional experience.

AIM: To evaluate treatment options after surgical revision of adjustable transobturator male system (ATOMS) and the results of further incontinence implantation. MATERIALS AND METHODS: A retrospective multicenter study evaluating patients with surgical revision of ATOMS in academic institutions. Causes and factors affecting revision-free interval were studied and also the frequency of device explant and placement of second ATOMS or artificial urinary sphincter (AUS) at surgeon discretion. Operative results, complications (Clavien-Dindo), and efficacy (postoperative pad-test, pad-count, patient satisfaction, and patient global impression of improvement [PGI-I scale]) of each treatment option were compared. RESULTS: Seventy-eight out of 902 patients (8.65%) with ATOMS underwent surgical revision at 4.1 ± 2.4 years mean follow-up and 75 (8.3%) were explanted. The main causes for revision included persistence of incontinence (35.9%) and scrotal port erosion (34.6%). Independent risk factors of the shortened revision-free interval were previous anti-incontinence surgery (HR, 1.83; 95% CI, 1.06-3.16; p = 0.007) and port erosion (HR, 1.83; 95% CI, 1.06-3.16; p = 0.0027). Fifty-eight (6.4%) received a second implant: 31 repeated ATOMS and 27 AUS. Operative time was longer for AUS (p = .003). The visual analog scale of pain at hospital discharge (p = 0.837) and postoperative complications (p = 0.154) were equivalent. The predominant cuff size for AUS was 4.5 cm (59.3%). Mean follow-up after the second implant was 29.1 ± 25.8 months. Postoperative efficacy of secondary treatment results favored ATOMS based on pad-test (p = 0.016), pad-count (p = 0.029), patient satisfaction (p = 0.04), and PGI-I (p = 0.025). CONCLUSIONS: ATOMS surgical revision due to different reasons generally leads to device explant. Rescue treatment is possible with ATOMS or AUS. No difference in postoperative complications was detected between secondary devices, but efficacy favors repeating ATOMS implantation.

Augmented Anastomotic Urethroplasty is Independently Associated with Failure after Reconstruction for Long Bulbar Urethral Strictures.

PURPOSE: Controversy exists regarding the optimal urethroplasty technique, particularly for long bulbar urethral strictures requiring buccal mucosal graft. We assessed the relative outcomes of augmented anastomotic urethroplasty vs dorsal onlay in the setting of bulbar urethroplasty using a dorsal buccal mucosal graft. MATERIALS AND METHODS: A retrospective review was performed on all patients who underwent bulbar urethroplasty with dorsal buccal mucosal graft between October 2003 and March 2019. Around 2011 institutional technique shifted from routinely performing transecting augmented anastomotic urethroplasty to nontransecting dorsal onlay. Anastomotic urethroplasty without buccal mucosal graft, ventral onlay, staged, flap and circumferential reconstructions were excluded. The primary outcome was stricture recurrence defined as less than 16Fr on cystoscopy. Secondary outcomes included 90-day complications and de novo erectile dysfunction at 6 months. RESULTS: Of the 836 patients who underwent bulbar urethroplasty during the study period 507 met inclusion criteria. Of these, 221 patients received an augmented anastomotic urethroplasty while 286 underwent dorsal onlay urethroplasty. Mean patient age and stricture length were 45.4±14.8 years and 4.4±1.5 cm, respectively. Overall success rate was 93.9% (476 of 507) with a mean followup of 78.9 months. On multivariate analysis augmented anastomotic urethroplasty (HR 4.8, p=0.002), increasing stricture length (HR 1.2, p=0.002) and iatrogenic strictures (HR 3.2, p=0.03) were independently associated with stricture recurrence, while comorbidity (p=0.06), prior endoscopic treatment (p=0.41), prior urethroplasty (p=0.89) and other etiologies were not. There was no difference between cohorts with respect to Clavien 2 or greater complications (3.6% vs 4.2%, p=0.74) or de novo erectile dysfunction (5.9% vs 5.6%, p=0.89). CONCLUSIONS: Augmented anastomotic urethroplasty is independently associated with stricture recurrence when compared to a pure dorsal onlay technique.

Nontransecting Techniques Reduce Sexual Dysfunction after Anastomotic Bulbar Urethroplasty: Results of a Multi-Institutional Comparative Analysis.

PURPOSE: The purpose of this multi-institutional study was to compare outcomes of transecting and nontransecting anastomotic bulbar urethroplasty. MATERIALS AND METHODS: We performed a retrospective, multi-institutional review of the records of 352 patients who underwent transecting or nontransecting anastomotic bulbar urethroplasty performed by 1 of 4 reconstructive urologists from September 2003 to March 2017. Study outcomes were urethroplasty success, defined as urethral patency greater than 16Fr on cystoscopy; de novo sexual dysfunction assessed at 6 months, defined as a 5-point or greater change in the SHIM (Sexual Health Inventory for Men) or a patient reported adverse change; and 90-day complications, defined as Clavien 2 or greater. When appropriate, comparisons were made between the transecting and nontransecting cohorts using the Mantel-Cox test, the t-test or the chi-square test. RESULTS: Of the 352 patients with a mean stricture length of 1.7 cm (range 0.5 to 5) 258 and 94 underwent transecting and nontransecting anastomotic bulbar urethroplasty, respectively. The overall success rate was 94.9% at a mean followup of 64.2 months (range 6 to 170). Of the patients 7.1% experienced a 90-day complication and 11.6% reported sexual dysfunction. When comparing transecting and nontransecting techniques, there was no difference in success (93.8% vs 97.9%, Mantel-Cox test p = 0.18) or postoperative complications (8.1% vs 4.3%, p = 0.25). Patients treated with transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (14.3% vs 4.3%, p = 0.008). On multivariate analysis only transecting urethroplasty was associated with sexual dysfunction (p = 0.01) while age (p = 0.29), stricture length (p = 0.42), etiology (p = 0.99) and surgeon (p = 0.88) were not. CONCLUSIONS: Anastomotic urethroplasty is a highly effective surgery with relatively minimal associated morbidity. Nontransecting anastomotic urethroplasty compares quite favorably to the transecting technique and likely reduces the risk of associated sexual dysfunction.

Canadian Experience with the Adjustable Transobturator Male System for Post-Prostatectomy Incontinence: A Multicenter Study.

PURPOSE: We assessed the efficacy and safety profile of the ATOMS® (Adjustable Transobturator Male System) for post-prostatectomy incontinence in a multicenter North American setting. MATERIALS AND METHODS: We reviewed outcomes from 8 centers in men who underwent treatment of post-prostatectomy incontinence with an ATOMS. Primary study outcomes were pad changes and continence, defined as requiring 1.0 or 0 pad postoperatively in patients who required 2.0 or more pads preoperatively and 0 pad in those who required more than 1.0 or 2.0 pads preoperatively. Secondary outcomes included improvement, 90-day complications and patient satisfaction. RESULTS: A total of 160 patients were enrolled in study with a median followup of 9.0 months. Preoperative median pad use was 4 per day (IQR 3-5). Of the patients 36.3% reported severe preoperative incontinence, 31.3% received prior radiotherapy and 16.3% underwent previous incontinence surgery. Median postoperative pad use after adjustments was 0.5 per day (IQR 0-1, p <0.001). The overall continence rate was 80.0% with improvement in 87.8% of cases. Of the patients 70.1% underwent a mean ± SD of 2.4 ± 2.7 adjustments (IQR 0-16). The patient satisfaction rate was 86.3%, 22.3% experienced 90-day complications of any grade and 7 (4.4%) experienced Clavien III complications primarily related to the injection port. Patients with a history of radiotherapy were less likely to be continent (62.5% vs 87.9%, p=0.002), improved (77.1% vs 92.6%, p=0.02) or satisfied (69.8% vs 93.2%, p=0.001). Similarly patients with previous incontinence surgery had lower rates of continence, improvement and satisfaction (57.7%, 73.1% and 69.6%, respectively). CONCLUSIONS: In the short term the ATOMS is a safe and efficacious device to treat post-prostatectomy incontinence. Patients with concurrent radiotherapy and previous incontinence surgery respond to treatment but are less likely to be continent, improved or satisfied.

Perinephric Hematoma Size is Independently Associated with the Need for Urological Intervention in Multisystem Blunt Renal Trauma.

PURPOSE: We examined radiographic predictors of intervention for blunt renal trauma independent of AAST-OIS (American Association for the Surgery of Trauma-Organ Injury Scale). MATERIALS AND METHODS: A total of 328 patients with blunt renal trauma from October 2004 to December 2014 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for urological intervention, including angiographic embolization, nephrectomy, renorrhaphy, ureteral stenting or percutaneous drainage. Factors examined included patient age, gender, length of stay, ISS (Injury Severity Score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation and devitalized segment status. Descriptive statistics and binary logistic regression were performed as appropriate. RESULTS: Mean patient age was 37.0 years and mean ISS was 31.7. A total of 31 urological interventions were required in 27 patients (8.2%), including ureteral stenting in 38.7%, angiographic embolization in 32.3%, nephrectomy in 22.6%, renorrhaphy in 3.2% and percutaneous drainage in 3.2%. On univariate analysis AAST-OIS, hematoma diameter, hematoma area, intravascular contrast extravasation, laceration length, laceration number, degree of devitalization and devitalized fragment presence were associated with the need for intervention (each p <0.001). On multivariate analysis only AAST-OIS grade (OR 69.4, 95% CI 6.4-748.3, p <0.001) and hematoma diameter (OR 1.5, 95% CI 1.1-1.9, p = 0.004) or area (OR 1.03, 95% CI 1.01-1.06, p = 0.012) remained associated with urological intervention. CONCLUSIONS: Although AAST-OIS is strongly associated with the need for urological intervention, perinephric hematoma size is also independently associated with this occurrence. Perinephric hematoma diameter should be considered during clinical decision making and incorporated into a revised injury grading system.

Incidence and Predictors of Complications due to Urethral Stricture in Patients Awaiting Urethroplasty.

PURPOSE: We examined the incidence and predictors of complications due to urethral stricture in patients awaiting urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent urethroplasty from 2009 to 2013. The primary outcome was complications, defined as any unplanned interaction with the health care system due to urethral stricture during the period between the decision to perform surgery and urethroplasty. RESULTS: A total of 276 patients were identified for analysis. Median stricture length was 4.0 cm and 67.4% of strictures were in the bulbar urethra. The most common stricture etiologies were idiopathic in 47.8% of cases and traumatic in 15.9%. Overall 15.9% of patients presented with a complication with a median time to complication of 43 days. Median surgical wait time was 151 days. Complications included urinary tract infections in 56.8% of patients, acute urinary retention in 20.5%, genitourinary pain in 5.8% and catheter related issues in 15.9%. Univariate analysis suggested that catheter dependent status, number of prior endoscopic treatments, a hypospadias and/or trauma etiology, and prior urethroplasty were potential significant predictors of complications. Multivariate analysis yielded only catheter dependent status (HR 5.2, 95% CI 2.4-11.3, p <0.0001) and prior failed urethroplasty (HR 1.6, 95% CI 1.1-2.3, p = 0.03) as significantly associated with complications. CONCLUSIONS: To our knowledge our study is the first to examine and quantify the morbidity of urethroplasty wait time. Approximately 16% of patients experienced a complication while awaiting urethroplasty. The optimal wait time should be less than 43 days. Patients with prior urethroplasty and catheters at the time of the surgical decision should be prioritized as they may be more likely to experience complications.

Independent Predictors of Stricture Recurrence Following Urethroplasty for Isolated Bulbar Urethral Strictures.

PURPOSE: We evaluated preoperative risk factors associated with stricture recurrence in a large, homogenous series of bulbar urethroplasties. MATERIALS AND METHODS: We analyzed the records of 596 patients who underwent isolated bulbar urethroplasty at a single center from August 2003 to June 2015. Urethroplasty failure was defined as stricture less than 16Fr identified on cystoscopy with a minimum of 12 months of followup. The potential risk factors examined were patient age, stricture etiology, stricture length, diabetes, smoking, obesity, Charlson comorbidity index, previous endoscopic treatment, previous urethroplasty and type of urethroplasty. Univariate and multivariable Cox regression analysis was used to evaluate potential risk factors and associations. RESULTS: Average stricture length was 3.9 cm and mean patient age was 44.4 years. Overall urethral patency was 93.3% and mean followup was 65.4 months (range 12 to 149). Previous endoscopic treatment had failed in 88.1% of patients while previous urethroplasty had failed in 10.7%. On multivariate analysis increased stricture length (HR 1.2, 95% CI 1.1-1.3, p = 0.01), increased patient comorbidity (HR 2.4, 95% CI 1.1-5.3, p = 0.03), obesity (HR 2.9, 95% CI 1.3-6.5, p = 0.01) and infectious strictures (HR 3.7, 95% CI 1.3-10.6, p = 0.02) were associated with stricture recurrence. Previous urethroplasty, the number of failed endoscopic procedures, type of urethroplasty and individual comorbidities such as diabetes, smoking and patient age did not affect the recurrent stricture rate. CONCLUSIONS: Although bulbar urethroplasty has a good stricture-free rate, patients with increased stricture length, increased overall comorbidity, obesity and strictures of infectious etiology are at higher risk for failure. These patients at risk should be counseled accordingly and perhaps be followed more closely after urethroplasty.

Male Urethral Stricture: American Urological Association Guideline.

PURPOSE: The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture. MATERIALS AND METHODS: A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. RESULTS: The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures. CONCLUSIONS: Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

The effect of urethral transection on erectile function after anterior urethroplasty.

PURPOSE: To prospectively assess the effect of urethral transection on erectile function after anterior urethroplasty. METHODS: From February 2012 to December 2014, 104 patients were enrolled in a prospective study assessing erectile function (EF) after anterior urethroplasty. Participants completed the International Index of Erectile Function (IIEF) questionnaire preoperatively and 6 months postoperatively. Outcome measures were the incidence of erectile dysfunction (ED) defined by ≥5-point change in EF and mean change in the EF domain. Factors examined were urethral transection, stricture location, patient age and other demographics. Fisher's exact test, Student's t test and linear regression were used to evaluate associations when appropriate. RESULTS: Seventeen patients were excluded because of poor EF, leaving 87 patients for analysis. Twenty-two patients (25.3 %) had urethral transection during urethroplasty, while 65 underwent non-transecting techniques (74.7 %). For the entire cohort, IIEF scores remain unchanged (20.16 versus 20.14; p = 0.98). Eighteen patients (20.7 %) developed ED, while 15 (17.2 %) experienced an improvement in EF. Urethral transection was not associated with ED (p = 0.22) or mean change in EF (-0.8 versus +0.2; p = 0.71). Stricture location was not associated with ED, but patient age ≥50 was associated with a decrease in mean postoperative EF (-2.84 versus +1.85; p = 0.04). On linear regression analysis patient age remained independently associated with adverse change in EF (p = 0.05). CONCLUSIONS: Urethroplasty can result in a decline in erectile function in some patients but overall is associated with minimal change in erectile function. Urethral transection is not associated with adverse change in erectile dysfunction after urethroplasty however, advanced patient age is.

Endoscopic Treatment of Vesicourethral Stenosis after Radical Prostatectomy: Outcomes and Predictors of Success.

PURPOSE: We describe patency outcomes and predictors of success for the endoscopic treatment of vesicourethral stenosis after radical prostatectomy. MATERIALS AND METHODS: A retrospective review identified 142 patients who underwent endoscopic treatment for vesicourethral stenosis after radical prostatectomy during a 10-year period. Clinical parameters examined were treatment modality, prior endoscopic treatment, age, concurrent radiotherapy, body mass index 35 kg/m(2) or greater, diabetes and smoking. The primary outcome measure was absence of stenosis (less than 16Fr) on followup cystoscopy. Treatment modalities were divided into 5 groups of holmium laser incision, cold knife incision, electrocautery incision, dilation or UroLume® stent. Descriptive statistics as well as univariate and multivariate logistic regression were performed. RESULTS: A total of 142 patients required 292 endoscopic treatments for a mean of 2.1 treatments per patient. The success rate of a single endoscopic treatment was 44.2%. However, 91% of the patients were ultimately treated successfully with endoscopic measures with a mean followup of 9.7 months. On multivariate analysis treatment modality (OR 0.65, 95% CI 0.52-0.80, p <0.001), prior failed treatment (OR 0.86, 95% CI 0.74-0.99, p=0.04) and smoking (OR 0.55, 95% CI 0.34-0.97, p=0.04) were associated with failure, while age (p=0.85), diabetes (p=0.25), radiotherapy (p=0.68) and body mass index 35 kg/m(2) or greater (p=0.92) were not. Compared to holmium laser incision all modalities except UroLume were associated with treatment failure. CONCLUSIONS: Most patients with vesicourethral stenosis after radical prostatectomy are treated successfully with endoscopic modalities but often require multiple procedures. Unlike anterior urethral strictures, in this specific scenario the use of repeat endoscopic treatments appears justified. Holmium laser incision may be more successful compared to other endoscopic modalities.