Bryan B. Voelzke

Multivariate Analysis of Risk Factors for Long-Term Urethroplasty Outcome

PURPOSE We studied the patient risk factors that promote urethroplasty failure. MATERIALS AND METHODS Records of patients who underwent urethroplasty at the University of California, San Francisco Medical Center between 1995 and 2004 were reviewed. Cox proportional hazards regression analysis was used to identify multivariate predictors of urethroplasty outcome. RESULTS Between 1995 and 2004, 443 patients of 495 who underwent urethroplasty had complete comorbidity data and were included in analysis. Median patient age was 41 years (range 18 to 90). Median followup was 5.8 years (range 1 month to 10 years). Stricture recurred in 93 patients (21%). Primary estimated stricture-free survival at 1, 3 and 5 years was 88%, 82% and 79%. After multivariate analysis smoking (HR 1.8, 95% CI 1.0-3.1, p = 0.05), prior direct vision internal urethrotomy (HR 1.7, 95% CI 1.0-3.0, p = 0.04) and prior urethroplasty (HR 1.8, 95% CI 1.1-3.1, p = 0.03) were predictive of treatment failure. On multivariate analysis diabetes mellitus showed a trend toward prediction of urethroplasty failure (HR 2.0, 95% CI 0.8-4.9, p = 0.14). CONCLUSIONS Length of urethral stricture (greater than 4 cm), prior urethroplasty and failed endoscopic therapy are predictive of failure after urethroplasty. Smoking and diabetes mellitus also may predict failure potentially secondary to microvascular damage.

Analysis of Diagnostic Angiography and Angioembolization in the Acute Management of Renal Trauma Using a National Data Set

PURPOSE To our knowledge data on diagnostic angiography and angioembolization after renal trauma have been limited to single institution series with small numbers. We used the National Trauma Data Bank® to investigate national patterns of diagnostic angiography and angioembolization after blunt and penetrating renal trauma. MATERIALS AND METHODS All renal injuries treated between 2002 and 2007 were identified in the National Trauma Data Bank by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Diagnostic angiography and angioembolization were identified by ICD-9 codes and examined. Initial angioembolization was considered a failure if subsequent therapy was needed. Repeat diagnostic angiography was not considered a failure. RESULTS A total of 9,002 renal injuries were available for analysis. A total of 165 patients (2%) underwent diagnostic angiography after renal injury, including 77 (47%) who underwent concomitant angioembolization. Of the patients 78% sustained grade III-V renal injuries. Of the 77 patients with initial angioembolization 68 required successive therapy. Repeat angioembolization was the most common management choice (29% of patients). Secondary angioembolization was durable during the index hospitalization with success in 35 of 36 cases. Successive therapy was required after initial angioembolization for all grade IV and V renal injuries in 48 patients. The overall renal salvage rate was 92%, including 88% for grade IV and V injuries. CONCLUSIONS Successive therapy is common after initial management of renal injury by angioembolization. Close observation is highly recommended after initial angioembolization for grade IV-V renal injuries. National agreement on the use of diagnostic angiography and angioembolization is needed since these procedures may be overused after grade I-III renal injuries.

Risk Factors for Erosion of Artificial Urinary Sphincters: A Multicenter Prospective Study

OBJECTIVE To evaluate the short- to medium-term outcomes after artificial urinary sphincter (AUS) placement from a large, multi-institutional, prospective, follow-up study. We hypothesize that along with radiation, patients with any history of a direct surgery to the urethra will have higher rates of eventual AUS explantation for erosion and/or infection. MATERIALS AND METHODS A prospective outcome analysis was performed on 386 patients treated with AUS placement from April 2009 to December 2012 at 8 institutions with at least 3 months of follow-up. Charts were analyzed for preoperative risk factors and postoperative complications requiring explantation. RESULTS Approximately 50% of patients were considered high risk. High risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. A total of 31 explantations (8.03%) were performed during the follow-up period. Overall explantation rates were higher in those with prior radiation and prior UroLume. Men with prior AUS infection or erosion also had a trend for higher rates of subsequent explantation. Men receiving 3.5-cm cuffs had significantly higher explantation rates than those receiving larger cuffs. CONCLUSION This outcomes study confirms that urethral risk factors, including radiation history, prior AUS erosion, and a history of urethral stent placement, increase the risk of AUS explantation in short-term follow-up.

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.

Outcomes of Endoscopic Realignment of Pelvic Fracture Associated Urethral Injuries at a Level 1 Trauma Center

PURPOSE We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma. MATERIALS AND METHODS A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal. RESULTS A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years. CONCLUSIONS Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

Snail expression is an independent predictor of tumor recurrence in superficial bladder cancers

BACKGROUND Epithelial-mesenchymal transition (EMT) is known to play an important role in the development of tumor invasion and progression in tumors of epithelial origin. OBJECTIVES Our aim was to investigate the role of Snail transcription repressor family members in human bladder pathogenesis. MATERIAL AND METHODS We evaluated levels of Snail and Slug in 87 patients who received transurethral resection of a transitional cell carcinoma at our institution during the period from June 1999 until November 2003. Immunohistochemistry was performed on tissue microarrays, and expression correlated with pathological variables and clinical outcomes. Degree and intensity of Snail and Slug staining was quantified by immunohistochemistry. RESULTS There was no apparent enrichment in strong vs. weak staining for either Snail (43.7% vs. 56.3%) or Slug (46% vs. 54%) in the superficial bladder tumors. Univariate analysis determined that tumor focality and Snail expression were significantly associated with tumor recurrence (P < 0.05). Only for tumor focality did such a relationship exist when assessing tumor progression. Multivariate analysis using the Coxs proportional hazards model revealed similar results to that of the univariate analysis. Snail expression (P = 0.038) and tumor focality (P = 0.011) were independent and significant prognostic factors for tumor recurrence in all patients. However, only tumor focality was an independent predictor of tumor progression (P = 0.034). CONCLUSIONS High expression of Snail in superficial bladder tumors is a strong predictor of tumor recurrence enhancing risk stratification and prognostication.

Critical Review of Existing Patient Reported Outcome Measures After Male Anterior Urethroplasty

PURPOSE Male urethral stricture disease can be recurrent and debilitating. The aim of any intervention is to allow men to return to a normal state of voiding while maintaining a strong quality of life. A systematic review of the literature was conducted to assess for the use of patient reported outcome instruments after male anterior urethroplasty. MATERIALS AND METHODS A review of PubMed® was conducted to identify studies that used a patient reported outcome measure to assess patient outcome after open surgical correction of male strictures. Preference was given to studies that used an instrument in the preoperative and postoperative setting. However, use of an outcome measure solely in the postoperative setting was also accepted. After article selection, the 8 attributes recommended by the Scientific Advisory Committee were used to analyze the measurement properties of each patient reported outcome measure. RESULTS A total of 15 studies were identified that included an instrument to assess patients with anterior urethral strictures. The studies used differing instruments to assess anterior urethral strictures in a nonuniform manner. Four studies used a lower urinary tract symptoms instrument, 8 used a sexual/ejaculatory dysfunction instrument, and 3 used a lower urinary tract symptoms and sexual/ejaculatory function instrument. There was only 1 report that described the development of a urethroplasty specific patient reported outcome instrument. CONCLUSIONS Continued effort is necessary to develop a powerful instrument to assess patient reported outcomes after male urethroplasty. The importance of patient perspective is vital to understanding the success of open urethral reconstruction.

Intralesional Injection of Mitomycin C at Transurethral Incision of Bladder Neck Contracture May Offer Limited Benefit: TURNS Study Group

PURPOSE Injection of mitomycin C may increase the success of transurethral incision of the bladder neck for the treatment of bladder neck contracture. We evaluated the efficacy of mitomycin C injection across multiple institutions. MATERIALS AND METHODS Data on all patients who underwent transurethral incision of the bladder neck with mitomycin C from 2009 to 2014 were retrospectively reviewed from 6 centers in the TURNS. Patients with at least 3 months of cystoscopic followup were included in the analysis. RESULTS A total of 66 patients underwent transurethral incision of the bladder neck with mitomycin C and 55 meeting the study inclusion criteria were analyzed. Mean ± SD patient age was 64 ± 7.6 years. Dilation or prior transurethral incision of the bladder neck failed in 80% (44 of 55) of patients. Overall 58% (32 of 55) of patients achieved resolution of bladder neck contracture after 1 transurethral incision of the bladder neck with mitomycin C at a median followup of 9.2 months (IQR 11.7). There were 23 patients who had recurrence at a median of 3.7 months (IQR 4.2), 15 who underwent repeat transurethral incision of the bladder neck with mitomycin C and 9 of 15 (60%) who were free of another recurrence at a median of 8.6 months (IQR 8.8), for an overall success rate of 75% (41 of 55). Incision with electrocautery (Collins knife) was predictive of success compared with cold knife incision (63% vs 50%, p=0.03). Four patients experienced serious adverse events related to mitomycin C and 3 needed or are planning cystectomy. CONCLUSIONS The efficacy of intralesional injection of mitomycin C at transurethral incision of the bladder neck was lower than previously reported and was associated with a 7% rate of serious adverse events.

Multi-institutional 1-Year Bulbar Urethroplasty Outcomes Using a Standardized Prospective Cystoscopic Follow-up Protocol

OBJECTIVE To evaluate multi-institutional outcomes of bulbar urethroplasty utilizing a standardized cystoscopic follow-up protocol. METHODS Eight reconstructive surgeons prospectively enrolled urethral stricture patients in a multi-institutional study and performed postoperative cystoscopy at 3 and 12 months. Anatomic failure was defined as the inability to pass a flexible cystoscope without force. Functional failure was defined as the need for a secondary procedure. Men not compliant with the 12-month cystoscopy were called and asked if any interval secondary procedures had been performed. Patients with bothersome voiding complaints at cystoscopy were considered symptomatic. RESULTS Of 213 men in study, 136 underwent excisional urethroplasty (excision and primary anastomosis [EPA]) and 77 underwent repair with buccal grafts. Cystoscopy compliance was 79.8% at 3 months and 54.4% at 12 months. Anatomic success rates were higher at 3 vs 12 months for EPA repairs (97.2% [106 of 109] vs 85.5% [65 of 76; P=.003] but not buccal repairs (85.5% [53 of 62] vs 77.5% [31 of 40]; P=.30). Functional success rates at a year were higher but statistically similar to anatomical success rates (EPA-90.3% [93 of 103]; P=.33; buccal-87% [47 of 54]; P=.22). Of the 20 anatomic recurrences, only 13 (65%) were symptomatic at the time of cystoscopic diagnosis. CONCLUSION Rates of success are lower when using the anatomic vs traditional definition. Of recurrences found by cystoscopy, only 65% were symptomatic. One-year patient cystoscopy compliance was poor and its ability to be used as the gold standard screening methodology for recurrence is questionable.

A national study of trauma level designation and renal trauma outcomes

PURPOSE We examined the initial management of renal trauma and assessed patterns of management based on hospital trauma level designation. MATERIALS AND METHODS The National Trauma Data Bank is a comprehensive trauma registry with records from hospitals in the United States and Puerto Rico. Renal injuries treated at a member hospital from 2002 to 2007 were identified. We classified initial management as expectant, minimally invasive (angiography, embolization, ureteral stent or nephrostomy) or open surgical management based on ICD-9 procedure codes. The primary outcome was use of secondary therapies. RESULTS Of 3,247,955 trauma injuries in the National Trauma Data Bank 9,002 were renal injuries (0.3%). High grade injuries demonstrated significantly higher rates of definitive success with the first urological intervention at level I trauma centers vs other trauma centers (minimally invasive 52% vs 26%, p <0.001), and were more likely treated successfully with conservative management (89% vs 82%, p <0.001). When adjusting for other known indices of injury severity, and examining low and high grade injuries, level I trauma centers were 90% more likely to offer an initial trial of conservative management (OR 1.90; 95% CI 1.19, 3.05) and had a 30% lower chance of patients requiring multiple procedures (OR 0.70; 95% CI 0.52, 0.95). CONCLUSIONS Following multivariate analysis conservative therapy was more common at level I trauma centers despite the patient population being more severely injured. Initial intervention strategies were also more definitive at level I trauma centers, providing additional support for tiered delivery of trauma care.