Philip Reiss

Short-Term Outcome and Morbidity of Different Contemporary Urethroplasty Techniques—A Preliminary Comparison

BACKGROUND AND PURPOSE Only few comparative reports about different urethroplasties have been published, addressing success rate (SR), adverse events (AE), and quality of life (QoL). Our purpose was to evaluate SR, AE, and QoL in a contemporary cohort of patients undergoing urethroplasty in the short-term follow-up (FU). PATIENTS AND METHODS Between December 2008 and June 2010, 205 patients underwent urethroplasty for anterior urethral strictures at our institution. A standardized questionnaire was sent to all patients. The primary end point was SR. Secondary end points were AE and QoL. To assess the risk of SR, the Kaplan-Meier method and log-rank test were used. To assess risk factors for urethral stricture recurrence (SRec), univariable Cox regression analysis was used. RESULTS Overall, 140 (68%) patients responded to our questionnaire and were used for analysis. Of these 9%, 85%, and 6% were treated by excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), and mesh graft urethroplasty (MGU), respectively. At 10 months of FU, SR was 87.5%. SRs of EPA, BMGU, and MGU were 100% (n=13/13), 85.7% (n=102/119), and 87.5% (n=7/8), with no significant differences between the groups. In univariable analysis, ≥ 2 vs 1 previous urethroplasties showed a trend toward a reduced SR (hazard risk 2.95; P=0.057). Streaking the urethra (P=0.024) and penile curvature (P=0.026) were significantly more often associated with MGU compared with EPA and BMGU. Postoperative total median (mean) scores were 3.5 (4.8) for the International Consultation on Incontinence Questionnaire Male lower urinary tract symptoms, 15 (15.2) for the International Index of Erectile Function, and 80 (73) for EuroQol visual analogue score; there was no difference between urethroplasty types. CONCLUSION In the short-term FU, urethroplasty demonstrates an excellent SR. Specific SRs of EPA, BMGU, and MGU seem comparable. Despite significant differences in AE, patient reported QoL is high with no difference between the applied techniques.

Substitution Urethroplasty with Closure Versus Nonclosure of the Buccal Mucosa Graft Harvest Site: A Randomized Controlled Trial with a Detailed Analysis of Oral Pain and Morbidity

BACKGROUND Optimal surgical management of the buccal mucosa harvest site in patients with urethral stricture disease during buccal mucosa graft urethroplasty (BMGU) remains controversial. OBJECTIVE To analyze in detail intensity and quality of pain as well as oral morbidity following closure (C) versus nonclosure (NC) of the donor site. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial on 135 patients treated with BMGU between October 15, 2014 and December 18, 2015. INTERVENTION Following computer-based randomization, 63 and 72 patients, respectively, received C and NC of the donor site at the inner cheek. Preoperatively, on days 1, 5, and 21 as well as at 3 and 6 mo postoperatively, patients completed standardized questionnaires, including validated questions on intensity and quality of pain as well as oral morbidity. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The coprimary end points were intensity and quality of oral pain. Secondary end points included oral morbidity and intensity of pain of the perineogenital region. Generalized linear mixed models evaluated the effect of various covariates on intensity and quality of oral pain, oral morbidity, as well as intensity of pain of the perineogenital region. RESULTS AND LIMITATIONS There was noninferiority for NC versus C in intensity and affective quality of oral pain at every time point following BMGU. Oral morbidity and complications included pain, bleeding, swelling, numbness, alteration of salivation and taste, as well as impairment of mouth opening, smiling, whistling, diet, and speech. Time from BMGU had significant effects on intensity (p<0.001) and quality of oral pain (sensory pain: p<0.001, affective pain: p<0.001, total pain: p<0.001). Length of buccal mucosa graft had significant effects on intensity (p=0.001) and quality of oral pain (sensory pain: p=0.020, total pain: p=0.042). CONCLUSIONS NC is noninferior to C of the donor site in intensity and quality of oral pain, and offers a treatment alternative. Time from BMGU and length of the buccal mucosa graft have effects on oral morbidity and complications. PATIENT SUMMARY We investigated pain, morbidity, and complications following closure (C) versus nonclosure (NC) of the buccal mucosa harvest site in patients undergoing buccal mucosa graft urethroplasty (BMGU). We found that NC is not worse than C regarding oral pain. In addition, time from BMGU and length of the buccal mucosa graft have effects on oral morbidity and complications.

Outcomes after recto‐anastomosis fistula repair in patients who underwent radical prostatectomy for prostate cancer

To assess fistula recurrence rate and health‐related quality of life (HRQL) after repair, as well as the impact on continence and erection in patients with recto‐anastomotic fistula after radical prostatectomy (RP). In recent publications, the numbers of cases of recto‐urinary fistulae after RP are relatively small. Success rates at fistula closure are good; however, data about functional outcomes and HRQL are more restricted.

PD60-10 SUBSTITUTION URETHROPLASTY WITH CLOSURE VERSUS NON-CLOSURE OF THE BUCCAL MUCOSA GRAFT HARVEST SITE: FINAL RESULTS OF A RANDOMIZED CONTROLLED TRIAL WITH A DETAILED ANALYSIS OF PAIN AND MORBIDITY

INTRODUCTION AND OBJECTIVES: Patient and disease characteristics influence ureteric stricture management with DJ stents, metallic stents, endoscopic, or reconstructive surgery. Memokaths are an option with reported 90-100% patency and 14-30% complication rates, but the published literature is limited by small sample size and short follow-up duration up to 22 months. Objective: To independently analyse 5-year Memokath stent outcomes, identifying variables associated with good outcomes to update clinical guidelines. METHODS: Management of obstructed ureteric stricture patients with Memokath stents was reviewed independently using electronic patient records. Outcomes included time to first complication, complications’ incidence and severity. Multiple linear regression was performed identifying variables linked with particular outcomes. RESULTS: 100 patients aged 23-87 years (mean 57) received Memokath stents for ureteric obstruction, 59% for malignant strictures, with 20% bilateral. Only 25 patients had no complications: either alive with, or dying of their primary malignancy with their original Memokath. Median time to complication in the remaining 75 patients was 12.5 months with Memokaths lasting longer in patients with malignancy (p1⁄40.02). Multiple linear regression analyses showed that increased eGFR (p1⁄40.005) and age (p1⁄40.0001) independently significantly predicted greater Memokath lifespan, while co-morbidities, stricture length and location, and underlying pathology, did not. 5 year outcomes: 25 patients had a Memokath in situ: 14 still alive with the original. 22 had other stents, while 12 required major surgery. 66% of patients with most severe complications (need for major surgery or dialysis) were in the benign group. CONCLUSIONS: Memokaths are a reasonable option for patients with malignant ureteric obstruction and life expectancy up to 1 year. Age and eGFR greater than 45 predicted longer Memokath duration. Patient and stricture variables other than aetiology did not affect Memokath durability, but should be considered for delivery of the most appropriate patient-centred individualised care. 5 year complication rates were significantly higher than previously reported (75 vs 25%). Updated practice guidelines would aid future patient selection and counselling, as well as encouraging protocolled follow-up and patient reported outcomes assessment, when considering metallic stent drainage for ureteric obstruction.

MP52-17 ENDOSCOPIC TREATMENT OF POSTERIOR URETHRAL STRICTURES FOLLOWING SIMPLE AND RADICAL PROSTATECTOMY: SUCCESS AND INCONTINENCE RATES

INTRODUCTION AND OBJECTIVES: Bladder neck contracture (BNC) after radical prostatectomy (RP) is a common yet understudied complication with significant adverse quality of life implications. Here we identify patient groups that are at highest risk for BNC after RP. METHODS: Years 1987 to 2013 of a prospectively maintained single institution RP registry were queried for patients with and without BNC. Those with prior TURP or radiotherapy were excluded. Descriptive statistics, univariate and multivariate logistic regressions (with forward stepwise entry), and receiver operating curves were employed to identify predictors of BNC. The impact of BNC on functional and oncologic outcomes was then assessed. RESULTS: Out of 17,954 men with a mean follow up of 10 years after RP, 858 (4.8%) developed BNC. Men with BNC had higher risk features than those without BNC: cT3/4 (10.3% vs 5.3%, p<0.001), biopsy Gleason score 8-10 (10.4% vs 7.3%, p<0.001), and higher PSA (11.9 vs 8.6, p<0.001). Multivariate logistic regression modeling identified several significant associations with BNC development after RP (Table 1). Importantly, BNC independently increases the risk of 1 or more incontinence pads per day at 1 year after RP (OR 1.755, 95% CI 1.405-2.191, p<0.001). However, the occurrence of BNC was not associated with 20-year oncologic outcomes. CONCLUSIONS: About 5% of patients will develop a BNC after RP and this incidence has declined over time. Nevertheless, the presence of a BNC is independently associated with a 75% increased risk of urinary incontinence following RP. Accordingly, we uncovered several novel risk factors for BNC, including: greater BMI, prostate volume, advanced pT stage, urine leak, early UTI, need for transfusion, and lack of nerve sparing. Validation of these findings is warranted to help design interventions that may reduce the incidence of BNC even further.

MP-12.02 The Electronic Modular Artificial Sphincter ARTUS: Results of the Cadaver Study

Hypothesis / aims of study The AMS 800 sphincter is considered to be the gold standard in the treatment of severe stress incontinence. However the permanent pressure on the urethra can result in severe complications, i.e. tissue atrophy, urethral arrosion. A new electronic device which can compress successive parts of the urethra intermittently can reduce these risks. Based on the animal studies we start the usability test in cadavers.

90 OUTCOME OF CONTEMPORARY URETHROPLASTY AT A TERTIARY CARE CENTER

INTRODUCTION AND OBJECTIVES: To evaluate the stricture free survival rate, adverse events and quality of life (QoL) of urethroplasty in the short term follow-up. METHODS: We retrospectively evaluated our patients who underwent urethroplasty between 12/08 and 07/10 at the University Medical Center Hamburg-Eppendorf, Germany. A standardized nonvalidated questionnaire was sent to all patients in September 2010. Primary end point was the stricture free survival rate, defined as no stricture recurrence. Secondary endpoints were adverse events and QoL. RESULTS: Within 19 months 205 patients underwent urethroplasty due to urethral stricture at different localisations and extend. One hundred forty four patients (70%) with a mean age of 56 years (range 14–84) and a mean follow up of 10.2 months (1–22), responded to our questionnaire. Of this cohort 9%, 85% and 6% were treated by primary excision and re-anastomosis (EPA), buccal mucosa graft (BMG) and mesh graft (MG) urethroplasty, respectively. Overall, 18/144 (12.5%) recurrences were documented and specifically 0%, 14.3% and 12.5 % for EPA, BMG and MG. In Kaplan Meier analysis there was no statistical significant difference concerning the stricture recurrence free survival between the three surgical techniques. Furthermore, no risk factor as localisation, stricture length and number of previous surgeries was identified for early stricture recurrence. Adverse events as incontinence, curvature, shortening and post void wiping out of the urethra were most often associated with MG urethroplasty. However, statistical significant difference was not shown (p 0.05). Neither, there was a statistical significant difference found in QoL nor satisfaction with surgical outcome between the three techniques of urethroplasty (p 0.7). CONCLUSIONS: At our center contemporary urethral surgery signifies a BMG for the majority of patients. Stricture recurrence free survival for EPA, BMG and MG seems comparable. However, EPA demonstrates excellent success rates of urethroplasty in the short term follow up. Differences in adverse events are not statistically significant between EPA, BMG and MG and do not seem to have an impact on quality of life and satisfaction of surgical outcome.