Critical Analysis of Patient-reported Complaints and Complications After Urethroplasty for Bulbar Urethral Stricture Disease

Non-transecting anastomotic augmented urethroplasty with dorsal onlay buccal graft for the treatment of bulbous urethral strictures: results and complications

INTRODUCTION

Urethroplasty is the gold standard for the management of urethral strictures. For obliterative bulbar strictures longer than 2 cm, excision primary anastomosis (EPA) cannot be optimally performed, and staged urethroplasty is recommended. To minimize multiple interventions, Augmented Anastomotic Urethroplasty (AAU) was developed. Our hypothesis was that incorporating the vessel sparing approach would improve the results of urethroplasty. and limit complications. Our study aimed to assess the outcomes of non-transecting Anastomotic Augmented Urethroplasty with a buccal graft (ntAAU).

METHOD

From 2019 to 2023, 42 patients underwent ntAAU. Anatomical success was defined as the ability to pass a cystoscope (16,5 Fr) and functional success was determined by a maximum urinary flow rate (Qmax) greater than 15 ml/s. Clinical outcomes were evaluated using patient reported outcome concerning urinary function (USP dysuria, VPPS, six items LUTS, questions 7, 9, 10 from USS-PROM) and erectile function (IIEF-5, EHS).

RESULTS

Anatomical success rate was 90.5% and functional success was 83.3% with a median (IQR) follow-up of 18 (12.5-28.5) months. The complication (urinary infection, suprapubic catheter obliteration, abscess, bleeding) rate was 14.2%. Questionnaires were avaiblable for 31 patients. Median (IQR) USP dysuria score was 0 (0-1), VPPS score was 7 (3-12), and six-item LUTS score was 4 (2-9). The median (IQR) IIEF-5 score was 22 (15.5-25) and EHS score was 3.5 (2-4). Patients with treatment failure were managed with redo-urethroplasties.

CONCLUSION

This technique shows good outcomes and appears to be a valuable option for managing strictures with an obliterative part.

Treatment of Urethral Strictures in Transmasculine Patients

Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.

[Redo urethroplasty with buccal mucosa]

Urethral strictures can occur on the basis of trauma, infections, iatrogenic-induced or idiopathic and have a great influence on the patient's quality of life. The current prevalence rate of male urethral strictures is 0.6% in industrialized western countries. The favored form of treatment has experienced a transition from less invasive interventions, such as urethrotomy or urethral dilatation, to more complex open surgical reconstruction. Excision and primary end-to-end anastomosis and buccal mucosa graft urethroplasty are the most frequently applied interventions with success rates of more than 80%. Risk factors for stricture recurrence after urethroplasty are penile stricture location, the length of the stricture (>4 cm) and prior repeated endoscopic therapy attempts. Radiation-induced urethral strictures also have a worse outcome. There are various therapy options in the case of stricture recurrence after a failed urethroplasty. In the case of short stricture recurrences, direct vision urethrotomy shows success rates of approximately 60%. In cases of longer or more complex stricture recurrences, redo urethroplasty should be the therapy of choice. Success rates are higher than after urethrotomy and almost comparable to those of primary urethroplasty. Patient satisfaction after redo urethroplasty is high. Primary buccal mucosa grafting involves a certain rate of oral morbidity. In cases of a redo urethroplasty with repeated buccal mucosa grafting, oral complications are only slightly higher.

Short-term Complication Rates Following Anterior Urethroplasty: An Analysis of National Surgical Quality Improvement Program Data

OBJECTIVE

To determine the characteristics and predictors of perioperative complications after male anterior urethroplasty.

MATERIALS AND METHODS

The American College of Surgeons-National Surgical Quality Improvement Program is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007 to 2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures, and univariate and multivariate regression analyses were used.

RESULTS

A total of 555 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft or flap placement. Of the patients, 127 (22.9%) went home the same day after surgery, 255 (45.9%) stayed for 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. Forty-seven patients (8.5%) had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%), and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (P = .04) and longer operative times (P = .002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (P = .006). Age, American Society of Anesthesiologists score, and length of stay were not predictive of complication frequency.

CONCLUSION

Anterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications

OBJECTIVE

To determine which factors are associated with higher costs of urethroplasty procedure and whether these factors have been increasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality.

MATERIALS AND METHODS

We conducted a retrospective analysis using the 2001-2010 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP cost-to-charge ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression, and expressed as odds ratios (OR).

RESULTS

A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated cost was $7321 ($5677-$10,000). Patients with multiple comorbid conditions were associated with extreme costs [OR 1.56, 95% confidence interval (CI) 1.19-2.04, P = .02] compared with patients with no comorbid disease. Inpatient complications raised the odds of extreme costs (OR 3.2, CI 2.14-4.75, P <.001). Graft urethroplasties were associated with extreme costs (OR 1.78, 95% CI 1.2-2.64, P = .005). Variations in patient age, race, hospital region, bed size, teaching status, payor type, and volume of urethroplasty cases were not associated with extremes of cost.

CONCLUSION

Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications, and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.