Charles Rew

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs

Purpose: Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. Materials and Methods: We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. Results: A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2–10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1 vs 2 vs 5), repeat self‐dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24‐month stricture‐free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). Conclusions: Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Characteristics of Idiopathic Urethral Strictures: A Link to Remote Perineal Trauma?

OBJECTIVE To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common yet poorly understood entity. PATIENTS AND METHODS We retrospectively reviewed our urethroplasty database to identify men undergoing initial urethral reconstruction from 2007 to 2014 at 1 of 3 hospitals (N = 514). Patients were stratified by stricture etiology, including IUS, acute trauma, iatrogenic, hypospadias, balanitis xerotica obliterans, and radiation. IUS that had a known history of subacute or repetitive blunt force to the perineum (horseback riding, avid cycling, motocross, etc.) were subclassified as subacute or repetitive perineal trauma (SRPT). RESULTS Among 466 men undergoing initial reconstruction with available data, 215 (46%) were IUS cases. The median delay between IUS diagnosis and urethroplasty was 5.2 years, during which time men underwent a median of 2 endoscopic treatments. A total of 51 (24%) IUS cases recalled a distinct history of SRPT. Men with SRPT were slightly younger (median 43 vs 48 years, P = .01) but were remarkably similar in terms of urethral stricture length (2 vs 2 cm, P = .15), location (bulbar 96% vs 89%, P = .41), and treatment success (92% vs 88%; P = .61). Bulbar (-)SRPT and (+)SRPT IUS had similar clinical and morphometric features as those with known acute bulbar trauma with excellent 24-month stricture recurrence-free survival rates (93% vs 92% vs 97%, P = .19). CONCLUSION IUS have clinical features suggesting that many may be related to unrecognized or repetitive perineal trauma. Although treatment tends to be delayed, IUS have excellent urethroplasty success because most are short bulbar strictures amenable to anastomotic urethroplasty.

The Adverse Survival Implications of Bland Thrombus in Renal Cell Carcinoma With Venous Tumor Thrombus

OBJECTIVE To characterize the presence of bland (nontumor) thrombus in advanced renal cell carcinoma and assess the impact of this finding on cancer-specific survival. METHODS A multi-institutional database of patients treated with nephrectomy with caval thrombectomy for locally-advanced renal tumors was assembled from 5 tertiary care medical centers. Using clinicopathologic variables including patient age, body mass index, Eastern Cooperative Oncology Group performance status, tumor stage, grade, nodal status and histology, and nearest-neighbor and multiple-matching propensity score matched cohorts of bland thrombus vs nonbland thrombus patients were assessed. Multivariable analysis for predictors of cancer-specific survival was performed. RESULTS From an initial cohort of 579 patients, 446 met inclusion criteria (174 with bland thrombus, 272 without). At baseline, patients with bland thrombus had significantly worse performance status, higher tumor stage, higher prevalence of regional nodal metastases and higher nuclear grade (P < .01 for all). In both nearest-neighbor and multiple-matching propensity score matched cohorts, the presence of bland thrombus presence was associated with inferior median cancer-specific survival (28.1 months vs 156.8 months, and 28.1 months vs 76.7 months, P < .001 for both). The presence of bland thrombus remained independently associated with an increased risk of cancer-specific mortality on multivariable analysis (hazard ratio 4.33, 95% confidence interval 2.79-6.73, P < .001). CONCLUSION Presence of bland thrombus is associated with adverse survival outcomes in patients treated surgically for renal tumors with venous tumor thrombus. These findings may have important implications in patient counseling, selection for surgery and inclusion in clinical trials.

Urethral Reconstruction in Aging Male Patients

OBJECTIVE To report stricture characteristics, complications, and treatment outcomes among elderly men undergoing urethral reconstruction. MATERIALS AND METHODS A retrospective review of urethroplasty cases and outcomes by a single surgeon from 2007 to 2014 was performed. Men were stratified by decade of life at time of surgery (<50, 50-59, 60-69, ≥70 years). Individuals with a history of hypospadias were excluded. RESULTS Among 514 urethroplasty procedures, 184 (36%) were evaluated in men ≥60 years. When stratified by decade of life, elderly men were more likely to have a history of radiation therapy (0% vs 5% vs 19% vs 50%; P <.0001) and experience treatment failure (6% vs 16% vs 20% vs 26%; P <.0001) during follow-up (median 63 months). The estimated 60-month stricture recurrence-free survival decreased with increasing age at time of urethroplasty (94% vs 89% vs 78% vs 74%; P <.0001). In patients ≥60 years, success rates of anastomotic, substitution, and urethrostomy techniques were 80%, 65%, and 88%; anastomotic urethroplasty success improved after excluding those patients with prior radiation. After surgery, elderly were more likely to have voiding dysfunction and <90-day Clavien ≥3 complications requiring endoscopic intervention. On multivariable analysis, advancing age per decade beyond 50 years was independently associated with risk of urethroplasty failure-50-59 (hazard ratio [HR] 2.39; P = .02), 60-69 (HR 2.80; P = .009), and ≥70 (HR 3.43; P = .003). CONCLUSION Urethroplasty is safe and effective in the majority of elderly men. Early reconstructive intervention with anastomotic urethroplasty or urethrostomy techniques may optimize outcomes. Voiding dysfunction and prostatic obstruction are common in this population and should be pursued as clinically indicated.

Increased use of antihypertensive medications after partial nephrectomy vs. radical nephrectomy

PURPOSE A prospective study of partial vs. radical nephrectomy demonstrated worse overall survival in patients undergoing partial nephrectomy which appeared to be driven by cardiovascular outcomes. We sought to determine if the blood pressures or use of antihypertensive medications differed between patients who underwent partial or radical nephrectomy. MATERIALS AND METHODS A tertiary-referral institutional renal mass database was queried for patients between 2006 and 2012 undergoing partial or radical nephrectomy. Serial blood pressure follow-up, clinicopathologic variables, and changes in medications were collected. Patients were excluded for inadequate data, noncurative-intent surgery, noncancer surgical indication, and absence of medication information. Time-dependent hemodynamic changes were compared by split-plot analysis of variance and addition to antihypertensive regimen was studied as time-to-event survival analyses with Kaplan-Meier curves and a Cox proportional hazards model. RESULTS A final cohort of 264 partial nephrectomy and 130 radical nephrectomy cases were identified. Patients undergoing partial nephrectomy were younger, more likely to have T1 tumors, and had lower preoperative creatinine (P<0.001 for all). No differences were noted on postoperative hemodynamics (P>0.05). Significantly more patients who underwent partial nephrectomy added antihypertensive medications postoperatively (P≤0.001) and surgical treatment remained as a significant independent predictor on Cox regression (hazard ratio = 2.51, P = 0.002). Limitations include the retrospective nature of the study and potential for unidentified confounders. CONCLUSION Hemodynamic parameters after radical or partial nephrectomy may be different. The etiology of this observation, is currently unexplored. Additional prospective mechanistic investigations are warranted.

PD60-12 GERIATRIC URETHROPLASTY: LESSONS LEARNED FROM URETHRAL RECONSTRUCTION IN ELDERLY MEN

RESULTS: We identified a total of 75,522 patients treated for male urethral stricture disease with 125,498 total procedures. This is the largest reported cohort of urethral stricture procedures in the literature. The majority of patients were treated with endoscopic surgery (98.8%), with only 1,515 patients undergoing urethroplasty. After adjustment, younger age (adjusted odds ratio (aOR), age 40 vs. age 60 years, 8.2; 95% CI, 7.2-9.4) and higher annual income (aOR, income

PD60-02 DELAY OF URETHROPLASTY IS ASSICIATED WITH LONGER STRICTURES AND MORE COMPLICATED REPAIRS

40K vs.

PD34-12 TERTIARY URETHROPLASTY: IS THE THIRD TIME A CHARM?

100,00K, 0.7; 95% CI, 0.5-0.9) were each associated with receipt of urethroplasty. Total standardized costs for endoscopic treatment was

MP72-20 DIFFERENTIAL HEMODYNAMIC AND ANTIHYPERTENSIVE CHANGES AFTER PARTIAL NEPHRECTOMY VERSUS RADICAL NEPHRECTOMY

115,724,899 compared to

Role of cytoreductive nephrectomy in renal cell cancer (RCC) with venous tumor thrombus.

3,678,066 for urethroplasty. CONCLUSIONS: Our population-based study of insured patients demonstrated very low use of urethroplasty in real-world practice, despite recommendations for use and superior success rates. Income disparities in urethroplasty utilization is concerning and may indicate health access disparity. Strategies to increase the use of high value surgery for patients with urethral stricture disease include increasing referrals to reconstructive urologists, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment.