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Li X, Xu C, Ji X, Zhu Z, Cai T, Guo Z, Lin J. Balloon dilation for the treatment of male urethral strictures: a systematic review and meta-analysis. BMJ Open 2024; 14:e071923. [PMID: 38320837 PMCID: PMC10860052 DOI: 10.1136/bmjopen-2023-071923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE The use of minimally invasive endoluminal treatment for urethral strictures has been a subject for debate for several decades. The aim of this study was to review and discuss the safety, efficacy and factors influencing the clinical application of balloon dilation for the treatment of male urethral strictures. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Medline, Web of Science, Cochrane Library and Scopus were searched for publications published before 17 July 2022. STUDY SELECTION Two independent researchers screened and assessed the results, and all clinical studies on balloon dilation for the treatment of urethral strictures in men were included. DATA EXTRACTION AND SYNTHESIS The success rate, rate of adverse events, International Prostate Symptom Scores, maximum uroflow (Qmax) and postvoid residual urine volume were the main outcomes. Stata V.14.0 was used for statistical analysis. RESULTS Fifteen studies with 715 patients were ultimately included in this systematic review. The pooled results of eight studies showed that the reported success rate of simple balloon dilation for male urethral strictures was 67.07% (95% confidence interval [CI]: 55.92% to 77.36%). The maximum urinary flow rate at 3 months (risk ratio [RR]= 2.6510, 95% CI: 1.0681 to 4.2338, p<0.01) and the maximum urinary flow rate at 1 year (RR= 1.6637, 95% CI: 1.1837 to 2.1437, p<0.05) were significantly different after dilation. There is insufficient evidence to suggest that balloon dilation is superior to optical internal urethrotomy or direct visual internal urethrotomy (DVIU) (RR= 1.4754, 95% CI: 0.7306 to 2.9793, p=0.278). CONCLUSION Balloon dilation may be an intermediate step before urethroplasty and is a promising alternative therapy to simple dilation and DVIU. The balloon is a promising drug delivery tool, and paclitaxel drug-coated balloon dilation is effective in reducing retreatment rates in patients with recurrent anterior urethral strictures. The aetiology, location, length, previous treatment of urethral stricture may be associated with the efficacy of balloon dilation. PROSPERO REGISTRATION NUMBER CRD42022334403.
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Affiliation(s)
- Xiaoyu Li
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Chunru Xu
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Xing Ji
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Zhenpeng Zhu
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Tianyu Cai
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Zhenke Guo
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
| | - Jian Lin
- Department of Urology, Peking University First Hospital, Beijing, China
- Institute of Urology, Peking University, Beijing, China
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Oszczudlowski M, Yepes C, Dobruch J, Martins FE. Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis. BJU Int 2023; 132:252-261. [PMID: 37402622 DOI: 10.1111/bju.16108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
OBJECTIVES To assess outcomes of transecting vs non-transecting urethroplasty for bulbar urethral stricture in terms of stricture recurrence rate, sexual dysfunction, and patient-reported outcome measures (PROMs) related to lower urinary tract (LUT) function. METHODS Electronic literature searches were conducted using PubMed, Cochrane Library, Web of Science and Embase databases. The studied population was limited to men with bulbar urethral stricture included in studies that compared outcomes after transecting and non-transecting urethroplasty. The main outcome appraised was the stricture recurrence rate. Additionally, the incidence of sexual dysfunction appraised in three domains (erectile function, penile complications, and ejaculatory function) and PROMs related to LUT function after transecting vs non-transecting urethroplasty were assessed. The pooled risk ratio (RR) respectively for stricture recurrence, erectile dysfunction and penile complications was calculated using a fixed-effect model with inverse variance method. RESULTS In all, 694 studies were screened with 72 identified as relevant. Finally, 19 studies were suitable for analysis. The pooled difference between the transecting and non-transecting groups relating to stricture recurrence was not significant. Overall, the RR was 1.06 (95% confidence interval [CI] 0.82-1.36) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for erectile dysfunction was 0.73 (95% CI 0.49-1.08) and the 95% CI crossed the line of no effect (line RR = 1). Overall, the RR for penile complications was 0.47 (95% CI 0.28-0.76) and the 95% CI did not cross the line of no effect (line RR = 1). Hence, the risk of penile complications was significantly lower in the non-transecting group. CONCLUSIONS Our analysis of available evidence indicates that both transecting and non-transecting urethroplasties, are equal in terms of the recurrence rate. On the other hand, non-transecting techniques are better in terms of sexual function, causing less penile complications.
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Affiliation(s)
| | - Christian Yepes
- Belgrade Centre for Genital Reconstructive Surgery, Belgrade, Serbia
| | - Jakub Dobruch
- Urology Clinic, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Francisco E Martins
- Department of Urology, School of Medicine, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
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Jamil ML, Perecman A, Sherman A, Sullivan T, Christ K, Hansma A, Burks E, Vanni AJ. Urinary microbiome differences between lichen sclerosus induced and non-lichen sclerosus induced urethral stricture disease. World J Urol 2023; 41:2495-2501. [PMID: 37421420 DOI: 10.1007/s00345-023-04490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE To describe differences in the urinary microbiome of patients with pathologically confirmed lichen sclerosus (LS) urethral stricture disease (USD) vs non-lichen sclerosus (non-LS) USD pre- and post-operatively. METHODS Patients were pre-operatively identified and prospectively followed, all underwent surgical repair and had tissue samples obtained to make a pathological diagnosis of LS. Pre- and post-operative urine samples were collected. Bacterial genomic DNA was extracted. Alpha and beta diversity measurements were calculated and compared. A zero-inflated negative binomial model was utilized to compare taxa abundances between disease status and surgery status. RESULTS Urine samples were obtained from both cohorts, 69 samples in total: 36 samples were obtained pre-operatively and 33 samples were obtained post-operatively. Ten patients provided both a pre-operative and post-operative urine sample. Twenty-six patients had pathological evidence of LS and 33 patients did not. There was a statistically significant difference in alpha diversity between the pre-operative urine samples of patients with non-LS USD and LS USD, (p = 0.01). There was no significant difference in alpha diversity within post-operative urine samples between patients with non-LS USD and LS USD, (p = 0.1). A significant difference was observed in Weighed UniFrac distances with respect to disease and operative status, (p = 0.001 and 0.002). CONCLUSIONS LS USD have significant alterations in diversity and differential abundance of urine microbiota compared to non-LS USD controls. These findings could be used to guide further investigations into the role of the urinary microbiome in LS USD pathogenesis, severity of presentation, and stricture recurrence.
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Affiliation(s)
- Marcus L Jamil
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Aaron Perecman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Amanda Sherman
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Travis Sullivan
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Kimberly Christ
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
| | - Alexandra Hansma
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
| | - Eric Burks
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA
- Tufts University, Medford, MA, USA
- Boston Medical Center, Boston, Massachusetts, USA
| | - Alex J Vanni
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA, 01805, USA.
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Saurabh N. Significance of inflammatory biomarkers and urethral histology in patients with urethral stricture disease in relation to treatment outcome—a single centre prospective study in the north-eastern part of India. AFRICAN JOURNAL OF UROLOGY 2022. [DOI: 10.1186/s12301-021-00252-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Background
Inflammation plays a very important role in defining the urethral stricture. Inflammatory biomarkers may play an important role in predicting the underlying pathophysiology as well as outcome of surgery. Histology of urethral strictures along with histology of urethra proximal and distal to stricture segment may have a role in predicting the outcome of the surgery. The literature discussing this aspect is rare; thus, this novel study aimed to find out the role of inflammatory biomarkers and urethral histology in predicting the outcome of surgery in urethral stricture disease.
Methods
This prospective study had 105 patients with age more than 15 years with urethral stricture. Baseline characteristics, routine blood tests including inflammatory blood markers (CRP, ESR, HbA1C, fasting insulin, serum ferritin, etc.) were recorded. They underwent various types of surgery, and first biopsy was taken from stricture segment and second biopsy from proximal to stricture segment and third biopsy from distal to stricture segment and evaluated for the presence of features of lichen sclerosus and inflammation. Primary endpoint was to diagnose the role of inflammatory biomarkers and histology of stricture in stricture recurrence.
Results
Their mean age was 43.3 ± 13.46 years. Mean CRP of 11.54 ± 3.64 in patients with failure and 9.59 ± 2.77 in patients with successful outcome (p 0.025). Other inflammatory biomarkers like HbA1C, fasting insulin, ESR, serum ferritin, NLR had no significant correlation with the outcome. The presence of features of lichen sclerosus like hyperkeratosis and severe inflammation in stricture segment predicted higher likelihood of failure. Histology of proximal and distal segment of urethral stricture had no significant relationship in predicting outcome. Staged urethroplasty with buccal mucosal graft outperformed single-stage urethroplasty in biopsy-proven LS strictures.
Conclusions
The present study found a negative impact of increased CRP and the presence of features of lichen sclerosus in urethral histology with the outcome of urethral stricture disease. Thus, our study confirms that inflammatory biomarkers (CRP) and histology of stricture segment play a significant role predicting the outcome of surgery.
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Kohli H, Childs B, Sullivan TB, Shevtsov A, Burks E, Kalantzakos T, Rieger-Christ K, Vanni AJ. Differential expression of miRNAs involved in biological processes responsible for inflammation and immune response in lichen sclerosus urethral stricture disease. PLoS One 2021; 16:e0261505. [PMID: 34910765 PMCID: PMC8673646 DOI: 10.1371/journal.pone.0261505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/05/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose To better understand the pathophysiology of lichen sclerosus (LS) urethral stricture disease (USD), we aimed to investigate expression profiles of microRNAs (miRNAs) in tissue samples from men undergoing urethroplasty. Methods Urethral stricture tissue was collected from 2005–2020. Histologic features diagnostic of LS were the basis of pathologic evaluation. Foci of areas diagnostic for LS or non-LS strictures were chosen for RNA evaluation. In an initial screening analysis, 13 LS urethral strictures and 13 non-LS strictures were profiled via miRNA RT-qPCR arrays for 752 unique miRNA. A validation analysis of 23 additional samples (9 LS and 14 non-LS) was performed for 15 miRNAs. Statistical analyses were performed using SPSS v25. Gene Ontology (GO) analysis was performed using DIANA-mirPath v. 3.0. Results In the screening analysis 143 miRNAs were detected for all samples. 27 were differentially expressed between the groups (false discovery p-value <0.01). 15 of these miRNAs individually demonstrated an area under the curve (AUC)>0.90 for distinguishing between between LS and non-LS strictures. 11-fold upregulation of MiR-155-5p specifically was found in LS vs. non-LS strictures (p<0.001, AUC = 1.0). In the validation analysis, 13 of the 15 miRNAs tested were confirmed to have differential expression (false discovery p-value <0.10). Conclusions To our knowledge this is the first study evaluating miRNA expression profiles in LS and non-LS USD. We identified several miRNAs that are differentially expressed in USD caused by LS vs other etiologies, which could potentially serve as biomarkers of LS USD. The top eight differentially expressed miRNAs have been linked to immune response processes as well as involvement in wound healing, primarily angiogenesis and fibrosis.
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Affiliation(s)
- Harjivan Kohli
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Brandon Childs
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Travis B. Sullivan
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Artem Shevtsov
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Eric Burks
- Department of Pathology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Thomas Kalantzakos
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Kimberly Rieger-Christ
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
| | - Alex J. Vanni
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, United States of America
- * E-mail:
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Attia A, Morton A, Raveenthiran S, Samaratunga H, Desai D. Lichen sclerosus presenting as an isolated bulbar urethral stricture. Urol Case Rep 2021; 39:101794. [PMID: 34401348 PMCID: PMC8349755 DOI: 10.1016/j.eucr.2021.101794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/30/2022] Open
Abstract
Lichen sclerosus (LS) is a chronic inflammatory condition of the anogenital skin that can cause significant urinary and sexual dysfunction in men, particularly by means of destructive urethral disease. LS is traditionally thought to progress from the meatus with migration along the urethra proximally, however we present a case describing an isolated bulbar urethral stricture secondary to LS. To our knowledge, this has only been reported in the literature in one previous study. Clinician recognition of LS as a potential cause of isolated bulbar urethral stricture disease is important as this has ramifications on follow up and successful management.
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Affiliation(s)
- Arsany Attia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - Andrew Morton
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - Sheliyan Raveenthiran
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - Hemamali Samaratunga
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia.,Aquesta Specialised Uropathology, Toowong, Queensland, 4066, Australia
| | - Devang Desai
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia.,Faculty of Medicine, Griffith University, Mount Gravatt, Queensland, 4122, Australia.,Faculty of Medicine, University of Southern Queensland, Darling Heights, Queensland, 4350, Australia.,Toowoomba Urology, Toowoomba, Queensland, 4350, Australia
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7
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Medical and Surgical Management of Genital Lichen Sclerosus. CURRENT SEXUAL HEALTH REPORTS 2020. [DOI: 10.1007/s11930-020-00258-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Chung ASJ, Suarez OA. Current treatment of lichen sclerosus and stricture. World J Urol 2019; 38:3061-3067. [DOI: 10.1007/s00345-019-03030-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022] Open
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A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9046430. [PMID: 31139658 PMCID: PMC6500724 DOI: 10.1155/2019/9046430] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/31/2019] [Indexed: 12/21/2022]
Abstract
To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.
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Cotter KJ, Hahn AE, Voelzke BB, Myers JB, Smith TG, Elliott SP, Alsikafi NF, Breyer BN, Vanni AJ, Buckley JC, Zhao LC, Broghammer JA, Erickson BA. Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group. Urology 2019; 130:167-174. [PMID: 30880075 DOI: 10.1016/j.urology.2019.01.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 12/31/2018] [Accepted: 01/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.
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Affiliation(s)
| | - Amy E Hahn
- Department of Urology, University of Iowa, Iowa City, IA
| | | | | | | | | | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA
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Guo H, Peng X, Jin C, Wang L, Chen F, Sa Y. Lichen Sclerosus Accompanied by Urethral Squamous Cell Carcinoma: A Retrospective Study From a Urethral Referral Center. Am J Mens Health 2018; 12:1692-1699. [PMID: 29926751 PMCID: PMC6142166 DOI: 10.1177/1557988318782095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To evaluate the characteristics of lichen sclerosus (LS) accompanied by urethral squamous cell carcinoma (USCC) and to raise urologists' awareness about the early management of LS, a retrospective analysis was performed on the clinical features, diagnosis, treatment, and prognosis of 18 male genital LS accompanied by USCC patients who were referred to Shanghai Sixth People's Hospital between June 2000 and August 2014. All of the patients had a long-term history of LS, urethral strictures, and urethral dilatation. Seven patients are with distal (glanular or penile) USCC, 10 patients with proximal USCC, and one with entire USCC. The most common presentation, except for LS and urethral strictures, was periurethral abscess, followed by extraurethral mass, pelvic pain, urethrocutaneous fistula, hematuria, and bloody urethral discharge. All had primary surgical excision that was adapted to tumor location and extension. All of the USCC were positive for P53 and Ki-67. P16 was positive in four cases of human papillomavirus (HPV)-associated USCC and negative in 14 cases of HPV-independent USCC. Patients with distal USCC had a significant longer survival time than proximal USCC ( p < .05). LS should be treated early to prevent the disease progression. LS probably has some associations with USCC. Distal USCC has a relatively better prognosis than proximal USCC.
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Affiliation(s)
- Hailin Guo
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China.,3 Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xufeng Peng
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China
| | - Chongrui Jin
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China
| | - Lin Wang
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China.,3 Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Chen
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China.,3 Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yinglong Sa
- 1 Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,2 Shanghai Eastern Urological Reconstruction and Repair Institute, Shanghai, China
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Abstract
Distal urethral strictures comprise meatal or glandular stenoses and occur due to trauma, iatrogenic instrumentalization, infection, skin diseases such as lichen sclerosus or idiopathically. Given that 18% of anterior strictures (bulbar, penile, or glandular) are located in the very distal part, meatal/glandular stricture disease represents a non-negligible subgroup among all urethral strictures. The prevalence within Western industrialized countries is estimated to be approximately 0.6-0.9%, which translates into a total of 250,000 men being affected in Germany. Without any therapy, there is a severe risk of functional damage to the kidneys and the remaining urinary tract as well as significant reduction of quality of life. The therapeutic success of regaining sufficient micturition and a satisfying cosmetic result can only be obtained by means of surgical intervention. Besides dilatation and urethrotomy, preferably a single or multiple staged open urethroplasty with transplantation of autogenous genital or non-genital tissue can be performed. The choice of the appropriate surgical concept depends on stricture etiology, comorbidity status, and the patient's compliance. In case of histologically diagnosed lichen sclerosus, the use of genital skin should be avoided. To date, there are no universally accepted recommendations regarding the optimal use of substitution techniques. However, the use of oral mucosal tissue grafts seem to be the most promising, given low recurrence rates, and thus can be considered as the current gold standard.
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Affiliation(s)
- Simon Zeller
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Luis A Kluth
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Klinik für Urologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Surgical Management of the Concealed Penis in Adults. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0138-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Incidence of Urethral Stricture in Patients with Adult Acquired Buried Penis. Adv Urol 2017; 2017:7056173. [PMID: 28465682 PMCID: PMC5390610 DOI: 10.1155/2017/7056173] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/05/2017] [Accepted: 03/13/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction. Concealed-buried penis is an acquired condition associated with obesity, challenging to both manage and repair. Urethral stricture is a more common disorder with multiple etiologies. Lichen sclerosus is a significant known cause of urethral stricture, implicated in up to 30%. We hypothesize that patients with buried penis have a higher rate of urethral stricture and lichen sclerosus than the general population. Methods. We retrospectively reviewed a single surgeon's (CM) case logs for patients presenting with a buried penis. All patients were evaluated for urethral stricture with cystoscopy or retrograde urethrogram either prior to or at the time of repair for buried penis. Those that had surgical repair or biopsy were reviewed for presence of lichen sclerosus. Results. 39 patients met inclusion criteria. Of these, 13 (33%) had associated stricture disease. The location of the strictures was bulbar urethra (38%), penile urethra (15%), and meatus or fossa navicularis (62%). Five patients had lichen sclerosus and urethral stricture disease, while 3 had lichen sclerosus without stricture. 11/13 stricture patients were treated. Six underwent dilation, 3 underwent meatotomy, and 2 underwent urethroplasty. No significant recurrences of stricture were seen. Conclusion. Patients with a concealed penis are more likely than the general population to have a urethral stricture and/or LS. Patients presenting with concealed penis should also be evaluated for a urethral stricture.
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López-Carmona-Pintado F, Díaz-Convalia E, Cano-García MDC, Domínguez-Amillo A, Valderrama-Illana P, Arrabal-Polo MÁ. Estudio caso-control en hombres con liquen escleroso y atrófico genital. Rev Int Androl 2016. [DOI: 10.1016/j.androl.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Osterberg EC, Gaither TW, Awad MA, Alwaal A, Erickson BA, McAninch JW, Breyer BN. Current Practice Patterns Among Members of the American Urological Association for Male Genitourinary Lichen Sclerosus. Urology 2016; 92:127-31. [PMID: 26948526 PMCID: PMC4896157 DOI: 10.1016/j.urology.2016.02.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/18/2016] [Accepted: 02/20/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the practice patterns of urologists who treat male genitourinary lichen sclerosus (MGU-LS) via a national web-based survey distributed to American Urological Association members. METHODS A 20-question survey was collected from a random sample of American Urological Association members. Respondents answered questions on their practice patterns for MGU-LS diagnosis, treatment of symptomatic urethral stricture disease, surveillance, and follow-up. RESULTS In total, 309 urologists completed the survey. The majority of respondents reported practicing more than 20+ years (37.5%) within an academic (31.7%) or group practice (31.1%) setting. The majority of respondents saw 3-5 men with MGU-LS per year (32.7%). The most common locations of MGU-LS involvement included the glans penis (66.2%), foreskin (26.3%), and/or the urethra (5.8%). Respondent first-line treatment for urethral stricture disease was direct visual internal urethrotomy (26.6%) and second-line treatment was referral to subspecialist (38.4%). After controlling for the number of patients evaluated with MGU-LS per year, those with reconstructive training were more likely to perform a primary urethroplasty for men with symptomatic urethral stricture disease (adjusted odds ratio 13.1, 95% confidence interval 5.1-33.8, P < .001). They were also more likely to counsel men on the associated penile cancer risks (adjusted odds ratio 4.6, 95% confidence interval 1.7-12.5, P < .01). CONCLUSION Reconstructive urologists evaluate the most number of patients with MGU-LS and are more likely to perform primary urethroplasty for urethral stricture disease. Men with MGU-LS should be referred to a reconstructive urologist to understand the full gamut of treatment options.
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Affiliation(s)
- E Charles Osterberg
- Department of Urology, University of California-San Francisco, San Francisco, CA.
| | - Thomas W Gaither
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Mohannad A Awad
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Amjad Alwaal
- Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Jack W McAninch
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA
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Kirk PS, Yi Y, Hadj-Moussa M, Malaeb BS. Diversity of patient profile, urethral stricture, and other disease manifestations in a cohort of adult men with lichen sclerosus. Investig Clin Urol 2016; 57:202-7. [PMID: 27195319 PMCID: PMC4869564 DOI: 10.4111/icu.2016.57.3.202] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/02/2016] [Indexed: 01/28/2023] Open
Abstract
Purpose Lichen sclerosus (LS) in men is poorly understood. Though uncommon, it is often severe and leads to repeated surgical interventions and deterioration in quality of life. We highlight variability in disease presentation, diagnosis, and patient factors in male LS patients evaluated at a tertiary care center. Materials and Methods We retrospectively reviewed charts of male patients presenting to our reconstructive urology clinic with clinical or pathologic diagnosis of LS between 2004 and 2014. Relevant clinical and demographic information was abstracted and descriptive statistics calculated. Subgroup comparisons were made based on body mass index (BMI), urethral stricture, and pathologic confirmation of disease. Results We identified 94 patients with clinical diagnosis of LS. Seventy percent (70%) of patients in this cohort had BMI >30 kg/m2, and average age was 51.5 years. Lower BMI patients were more likely to suffer from urethral stricture disease compared to overweight counterparts (p=0.037). Patients presenting with stricture disease were more likely to be younger (p=0.003). Thirty percent (30%) of this cohort had a pathologic diagnosis of LS. Conclusions Urethral stricture is the most common presentation for men with LS. Many patients endure skin scarring and have numerous comorbidities. Patient profile is diverse, raising the concern that not all patients with clinical diagnosis of LS are suffering from identical disease processes. The rate of pathologic confirmation at a tertiary care institution is alarmingly low. Our findings support a role for increased focus on pathologic confirmation and further delineation of the subtype of disease based on location and clinical manifestations.
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Affiliation(s)
| | - Yooni Yi
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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19
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Patel CK, Buckley JC, Zinman LN, Vanni AJ. Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques. Urology 2016; 91:215-21. [PMID: 26892645 DOI: 10.1016/j.urology.2015.11.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/12/2015] [Accepted: 11/14/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the intermediate-term outcomes from a large, single institution series of patients with lichen sclerosus (LS) who underwent surgical management of their urethral strictures. MATERIALS AND METHODS We retrospectively reviewed 79 patients who underwent surgical management of their LS urethral strictures from 2003 to 2014, comparing outcomes of patients undergoing a single-stage buccal mucosa graft (BMG) urethroplasty, 2-stage BMG urethroplasty, or perineal urethrostomy (PU). Demographic and surgical outcomes data were collected for all patients. RESULTS Of the 79 patients, the mean follow-up was 32.4 months, mean age was 50.1 years, and the mean body mass index was 35.7, with morbid obesity (body mass index > 35) in 48% of the cohort. The mean stricture length was 9.6 cm (1.5-21 cm), with 62% of patients having a bulbopendulous stricture. Of the 37 patients who were planned for a 2-stage BMG urethroplasty, 9 (24%) patients had stricture recurrence or recurrent LS in the first-stage BMG. Single-stage BMG urethroplasty was performed in 20 patients with a mean stricture length of 9.47 cm (4-21 cm) and a success rate of 75%. Fourteen patients from the cohort received a PU as the primary treatment, with a success rate of 93%. CONCLUSION Management of LS strictures continues to pose challenges to the reconstructive surgeon due to the high rate of stricture recurrence and often progression. Patients undergoing single-stage or 2-stage reconstruction often require revision and must be carefully observed for recurrent urethral stricture. PU offers the highest degree of success and should be considered for all patients.
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Affiliation(s)
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center, Burlington, MA.
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20
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Erickson BA, Elliott SP, Myers JB, Voelzke BB, Smith TG, McClung CD, Alsikafi NF, Vanni AJ, Brant WO, Broghammer JA, Tam CA, Zhao LC, Buckley JC, Breyer BN. Understanding the Relationship between Chronic Systemic Disease and Lichen Sclerosus Urethral Strictures. J Urol 2016; 195:363-8. [PMID: 26343349 PMCID: PMC4747839 DOI: 10.1016/j.juro.2015.08.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men. MATERIALS AND METHODS We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups. RESULTS Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050-1.130), and were more likely to have hypertension (aOR 2.028, 1.21-3.41) and be active tobacco users (aOR 2.0, 1.36-3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9-4.2). CONCLUSIONS Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.
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Affiliation(s)
- Bradley A. Erickson
- Correspondence: Department of Urology, University of Iowa, 200 Hawkins Dr., 3233 RCP, Iowa City, Iowa 52242 (telephone: 319-356-7221; FAX: 319-356-3900; )
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Belsante MJ, Selph JP, Peterson AC. The contemporary management of urethral strictures in men resulting from lichen sclerosus. Transl Androl Urol 2016; 4:22-8. [PMID: 26816805 PMCID: PMC4708274 DOI: 10.3978/j.issn.2223-4683.2015.01.08] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.
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Affiliation(s)
- Michael J Belsante
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - J Patrick Selph
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Andrew C Peterson
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
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Han JS, Liu J, Hofer MD, Fuchs A, Chi A, Stein D, Dielubanza E, Ballek N, Gonzalez CM. Risk of urethral stricture recurrence increases over time after urethroplasty. Int J Urol 2015; 22:695-9. [DOI: 10.1111/iju.12781] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/03/2015] [Accepted: 03/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Justin S Han
- Smith Institute for Urology; North Shore-Long Island Jewish Health System; New Hyde Park New York USA
| | - Joceline Liu
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - Matthias D Hofer
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - Amanda Fuchs
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - Amanda Chi
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - Daniel Stein
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - Elodi Dielubanza
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | | | - Chris M Gonzalez
- Department of Urology; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
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Current trends in urethral stricture management. Asian J Urol 2015; 1:46-54. [PMID: 29511637 PMCID: PMC5832879 DOI: 10.1016/j.ajur.2015.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/19/2014] [Accepted: 08/26/2014] [Indexed: 01/16/2023] Open
Abstract
The recent International Consultation on Urological Disease (ICUD) panel 2010 confirmed that a urethral stricture is defined as a narrowing of the urethra consequent upon ischaemic spongiofibrosis, as distinct from sphincter stenoses and a urethral disruption injury. Whenever possible, an anastomotic urethroplasty should be performed because of the higher success rate as compared to augmentation urethroplasty. There is some debate currently regarding the critical stricture length at which an anastomotic procedure can be used, but clearly the extent of the spongiofibrosis and individual anatomical factors (the length of the penis and urethra) are important, the limitation for this being extension of dissection beyond the peno-scrotal junction and the subsequent production of chordee. More recently, there has been interest in whether to excise and anastomose or to carry out a stricturotomy and reanastomosis using a Heineke-Miculicz technique. Augmentation urethroplasty has evolved towards the more extensive use of oral mucosa grafts as compared to penile skin flaps, as both flaps and grafts have similar efficacy and certainly the use of either dorsal or ventral positioning seems to provide comparable results. It is important that the reconstructive surgeon is well versed in the full range of available repair techniques, as no single method is suitable for all cases and will enable the management of any unexpected anatomical findings discovered intra-operatively.
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Hillary CJ, Osman NI, Chapple CR. WITHDRAWN: Current trends in urethral stricture management. Asian J Urol 2014. [DOI: 10.1016/j.ajur.2014.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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