Joceline S. Fuchs

Improving Outcomes of Bulbomembranous Urethroplasty for Radiation-induced Urethral Strictures in Post-Urolume Era

OBJECTIVE To evaluate contemporary outcomes of excision and primary anastomosis (EPA) for the treatment of radiation-induced urethral strictures (RUS). PATIENTS AND METHODS A retrospective review of 72 patients undergoing EPA for RUS from 2007 to 2015 by a single surgeon was performed. We analyzed overall and long-term success rates of EPA urethroplasty and compared patient cohorts from two groups, 2007-2012 vs 2013-2015 (post-Urolume). RESULTS During the course of the study, we noted a near doubling of patient volume from the earlier (6.2 patients/year) to later (11.7 patients/year) cohorts. Among the 37 men treated from 2007 to 2012, we identified an EPA success rate of 70% compared with the improved 86% success rate in the subsequent cohort of 35 men treated from 2013 to 2015 (P = .07). Single dilation was successful in 50% of initial and 40% of subsequent cohort patients in the treatment of recurrence. Initial and subsequent cohorts varied only in regard to stricture length (mean 2.0 cm vs 3.0 cm in initial and subsequent cohorts, P = .001) and number treated with Urolume stent (initial 5 vs none in the later cohort, P = .03). Length of follow-up (median 50 [17-97] months for the initial and 22 [6-34] months for the later cohort) was not associated with recurrence. CONCLUSION Increasing numbers of RUS patients are presenting for urethral reconstruction in the post-Urolume era. With increasing experience, we improved success rates of EPA urethroplasty to over 85% despite increased stricture length.

CHANGING TRENDS IN RECONSTRUCTION OF COMPLEX ANTERIOR URETHRAL STRICTURES: FROM SKIN FLAP TO PERINEAL URETHROSTOMY

OBJECTIVE To evaluate procedural trends and outcomes for reconstruction of complex strictures at our tertiary center over the last decade. METHODS We retrospectively reviewed complex urethral reconstruction comparing 3 techniques: (1) buccal mucosal graft (BMG), (2) penile skin flap, or (3) perineal urethrostomy (PU) at our center (2007-2017) with ≥6 months follow-up. Strictures amenable to anastomotic repair were excluded. Success was defined as no need for further operative management. RESULTS Among 1129 strictures cases, 403 complex strictures were identified for analysis (median length 4.5 cm). Median age was 53.2 years (standard deviation ± 14.9). Reconstruction was most commonly performed using BMG (61.3%), followed by penile skin flap (21.6%) and PU (19.1%). PU use has increased steadily over the past decade, rising from 4.3% of case volume in 2008 to 38.7% in 2017 (P = .01). Over time, the proportion of reconstruction using BMG has remained stable, while penile skin flaps are now less commonly utilized. Over a median follow-up of 50.7 months, 16.9% (68/403) patients failed at a median of 13.9 months. Success rates were higher following PU (94.8%) compared to BMG and skin flaps (78.5% and 78.2%, respectively) (P = .003) despite PU patients being older (median age 62.6 years), having longer strictures (median 5.0 cm) and more commonly having lichen sclerosus (LS) (22.1%). CONCLUSION Over a decade of a urethral reconstructive practice, PU has increasingly become preferred for older patients with long strictures and adverse etiology. BMG urethroplasty rates remain stable, while penile skin flap use is decreasing. Success rates of PU for these complex strictures are markedly higher than those of grafts and flaps.

Low Serum Testosterone is Present in Nearly Half of Men Undergoing Artificial Urinary Sphincter Placement

OBJECTIVES To report the prevalence of low serum testosterone (LST) in men undergoing artificial urinary sphincter (AUS) placement at a single high-volume institution. METHODS We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from January 2015 to January 2018 to identify men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. Patients with only posttreatment testosterone levels were excluded. Demographic characteristics and clinical outcomes were compared between men with and without LST. RESULTS Among 113 patients who underwent AUS with pretreatment serum testosterone levels drawn an average of 2.2 months before AUS surgery, 45.1% (51 of 113) met criteria for LST, including 18 patients on androgen deprivation therapy. The rate of primary LST was 34.7% (33 of 95). The median total serum testosterone level among men with LST was 118 ng/dL (interquartile range 6-211), and 413 mg/dL (interquartile range 333-550) in the normal serum testosterone group. There were no differences in patient age, history of radiation, erectile dysfunction, or other comorbidities between the groups. Body mass index was higher in the LST group compared to normal serum testosterone (30 vs 27 kg/m2, P = .001). Cuff size and rates of transcorporal cuff placement were similar between groups. CONCLUSION Nearly one-half of men with stress urinary incontinence undergoing AUS placement present with LST. While AUS cuff erosion appears to be more common in men with LST, further study is needed to determine if treating LST will reduce cuff erosion rates.

EXCISION AND PRIMARY ANASTOMOSIS RECONSTRUCTION FOR TRAUMATIC STRICTURES OF THE PENDULOUS URETHRA

OBJECTIVES To present a multi-institutional experience with functional and patient-reported outcomes among men undergoing excision and primary anastomosis (EPA) urethroplasty for pendulous urethral strictures. METHODS We describe the technique and present our experience with EPA for focal penile strictures. Patients undergoing urethroplasty (2004-2017) at 2 tertiary referral centers were reviewed, of whom 14 (0.7%) underwent EPA of radiographically confirmed pendulous urethral strictures. Validated questionnaires were utilized to evaluate overall improvement (Patient Global Impression of Improvement), urinary bother (International Prostate Symptom Score), and sexual function (International Index of Erectile Function-5). Treatment success was defined as urethral patency without need for subsequent reconstruction. RESULTS Among 14 men undergoing penile EPA, 13/14 (93%) had durable treatment success over a median follow-up of 43 months. No patient reported penile curvature postoperatively. Stricture etiology in most cases was posttraumatic (12/14), of which 4 had a history of urethral disruption secondary to penile fracture and 8 iatrogenic trauma. Median age was 51 years (IQR 30-60) and stricture length 1.0 cm (IQR 1.0-1.4). Erectile function was normal in 8/14 patients preoperatively, and postoperative median International Index of Erectile Function was 21. Most men reported significant global improvement in condition (median Patient Global Impression of Improvement 2, IQR 1-3) and most had only mild urinary bother (median International Prostate Symptom Score 4, quality of life 1). The single treatment failure had a history of hypospadias with multiple prior urethral procedures. CONCLUSION For men with short strictures of the pendulous urethra, EPA has a high success rate, without adverse sequelae such as erectile function or penile curvature.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.

Erosion rates of 3.5-cm artificial urinary sphincter cuffs are similar to larger cuffs

To compare long‐term outcomes and erosion rates of 3.5‐cm artificial urinary sphincter (AUS) cuffs vs larger cuffs amongst men with stress urinary incontinence (SUI), with and without a history of pelvic radiotherapy (RT).

Role of Chronic Suprapubic Tube in the Management of Radiation Induced Urethral Strictures

Introduction: We examined the role of chronic suprapubic tube drainage in patients with radiation induced urethral stricture disease. Methods: A retrospective review was performed of patients undergoing evaluation and treatment of radiation induced urethral stricture. Differences in patient and stricture characteristics among those treated with chronic suprapubic tube vs urethral reconstruction were evaluated. Results: Among 75 patients who received suprapubic tube for radiation induced urethral stricture 37 (49%) selected chronic suprapubic tube and 38 (51%) ultimately underwent urethroplasty. Mean age was 70.9 years and mean followup was 25.3 months after suprapubic tube placement. Preoperative stress urinary incontinence improved after suprapubic tube placement in 20 of 33 (61%) patients. Accordingly, men with stress urinary incontinence were significantly more likely to be treated with chronic suprapubic tube (73%) compared to those proceeding to reconstruction (27%, p <0.001). Among those with persistent stress urinary incontinence after suprapubic tube, 11 of 16 (69%) underwent artificial urinary sphincter placement (urethroplasty 3 of 3 vs chronic suprapubic tube 8 of 13, p=0.19). On multivariable analysis the lack of preoperative stress urinary incontinence remained predictive of proceeding to reconstruction (OR 0.17, 95% CI 0.06–0.49, p=0.001). Among patients treated with chronic suprapubic tube, complications including stone formation or urinary urgency were reported in 27%. Conclusions: Although radiation induced urethral stricture can usually be managed effectively with urethroplasty, chronic suprapubic tube remains a viable management option, especially for men with preoperative stress urinary incontinence.