Assessment of the Male Urethral Reconstruction Learning Curve

International Expert Consensus on Development of a State of the Art Male Perineal Anatomy Simulation Model for Urethroplasty and Artificial Urinary Sphincter Insertion

OBJECTIVE

To create a high-fidelity, non-biohazardous, simulation model to train for urethroplasty or placement of artificial urinary sphincters (AUS) in the bulbar urethra. Narrow, deep and dark: the male perineum is a technically difficult area for learners to gain surgical skills and confidence.

METHODS

Nineteen high volume reconstructive urologists were recruited to complete a Delphi process to reach an expert consensus on parameters and design specifications for simulation. Consensus (>80%) was reached regarding procedural realism, anatomical realism, and educational effectiveness. Using validated 3D printing and hydrogel molding techniques, we fabricated a model incorporating expert determined aspects. Prototypes were sent to 11 (58%) of the experts who performed skin-to-skin AUS and urethroplasty simulations. Autopsy and questionnaires evaluated the model to determine if the consensus-defined deliverables were met, and confirm the realism of anatomy during the procedures.

RESULTS

Overall, experts agreed the model could function as a training tool for urethral surgery. 91%, 82%, and 100% agreed the model procedurally replicates the steps necessary to complete urethral exposure, tissue textures/behaviors, and overall anatomical relationships, respectively. Experts agreed on the fidelity of perineal incision/exposure (91%), urethral dissection/exposure (100%), placement of AUS pump (89%) urethral cuff measurement (100%) urethral spatulation (91%), and urethral mucosal suture placement (91%).

CONCLUSION

We successfully designed a high-fidelity, non-biohazardous, simulation model for urethral procedures in the perineum utilizing expert consensus. The model displayed high procedural and anatomical realism, and has potential as an effective educational platform. This as a groundbreaking tool to enhance training in complex urethral surgeries, bridging the gap between theory and practice.

Development and Validation of the Length, Segment, and Etiology Anterior Urethral Stricture Disease Staging System Using Longitudinal Urethroplasty Outcomes Data From the Trauma and Urologic Reconstructive Network of Surgeons

PURPOSE

The purpose of this study was to create and validate an anterior urethral stricture disease (aUSD) staging system based on the previously validated Length (L), Urethral Segment (S), and Etiology (E; LSE) classification system.

MATERIALS AND METHODS

The Trauma and Urologic Reconstructive Network of Surgeons (TURNS) prospective database was used to create and validate the staging system. A novel Urethroplasty Triad Score was created to aid in ranking the stagings into stricture severity based on (1) functional outcomes, (2) location of urethral meatus (eg, orthotopic, perineal), and (3) number of surgeries required for repair. Staging was secondarily validated in a non-TURNS dataset and then compared with 2 previously described aUSD severity scores-the U-score and the LSE score.

RESULTS

Five aUSD stages, with 10 total substages, were ultimately created: stage I-short bulbar, stage II-long bulbar, stage III-penile/fossa of favorable etiology, stage IV-penile/fossa of adverse pathology, and stage V-pan-urethral (3-segment). Mean Urethroplasty Triad Score decreased (increasing severity) with each substage, with the linear trend being validated in both the separate validation cohort and within the individual TURNS. LSE staging was superior to the LSE score and U-score in predicting the need for multiple stages or a nonorthotopic meatus and was similar in predicting surgical outcomes.

CONCLUSIONS

Each stage and substage of this novel LSE staging system was shown to provide unique information on stricture characteristics, repairs, and surgical outcomes. The LSE staging system will improve communication of stricture complexity/severity with our patients and organize aUSD for multi-institutional outcomes studies and clinical trial recruitment purposes.

The impact of a continuing international partnership and multiple intensive hands-on workshops on the success rate of bulbar EPA urethroplasty in a low-middle income country: an early experience

Background

Thailand has one of the 10 highest national rates of traffic accidents, leading to a high incidence of urethral stricture from bulbar straddle and pelvic fracture urethral injuries. Various treatment options are offered including urethroplasty; however, failure rates are high leading to a significant societal burden. Outreach relationships were established between the United States of America (USA), Vietnam, and Thailand by creating an intensive hands-on workshop and mentorship model to improve urethroplasty success. We aim to report the impact of this partnership and hands-on training on bulbar excision and primary anastomosis (EPA) success rates.

Methods

The University of California, Irvine Medical Center (UC Irvine), USA, Binh Dan Hospital, Vietnam, and Thammasat University Hospital (TUH), Thailand developed partnerships in urethroplasty training since 2020. Urologists from Thailand seeking expertise in urethroplasty joined intensive hands-on workshops for two 2-week periods. An ongoing mentorship relationship subsequently developed. Important infrastructure similar to that at UC Irvine, a urethroplasty Center of Excellence, was established at TUH to include the purchase of identical urethroplasty and urethral imaging-specific equipment and supplies. Subsequent workshops were attended and hosted at TUH. A database was created to compare success rates before and 12 months after completing the workshops and establishing infrastructure. Cystoscopy 4 months after surgery was performed to assess anatomical success.

Results

The study included 29 patients with bulbar urethral stricture who underwent bulbar EPA. There were 19 patients from before the establishment of the partnership that included workshops and infrastructure development. The overall success rate was 57.14%, whereas in comparison, success rates of over 98% were published at Centers of Excellence. After establishing the partnership, bulbar EPA was performed in 10 cases. The success rate increased to 90% (P=0.001) which included anatomical success defined as wide patency on cystoscopy 4 months after surgery and a subsequent absence of recurrent voiding symptoms. The patients who underwent urethroplasty during the workshop and learning period were excluded from this study.

Conclusions

Developing and continuing international partnerships with a mentorship model and multiple intensive hands-on workshops, including established appropriate hospital infrastructure could improve the success rate of bulbar urethroplasty in countries seeking to develop a urethroplasty Center of Excellence.

Evaluating the impact of a urethral reconstruction fellowship on urethral stricture disease management at a regional hospital

Background

Internationally, there is a trend towards early urethroplasty for treatment of urethral stricture, as opposed to endoscopic management, which is associated with short-lived patency and frequent retreatments. The objective of this study was to compare the outcomes of urethral stricture management before and after gaining urethral reconstruction expertise through a fellowship programme.

Methods

This was a retrospective case-control study that compared the characteristics, management, and outcomes of urethral stricture disease managed over two consecutive periods of time-pre-fellowship period (September 2016 to September 2019) and the post-fellowship period (October 2019 to September 2022).

Results

There were 37 patients in the pre-fellowship group and 30 patients in the post-fellowship group. Regarding treatment choice, the proportion of patients undergoing index urethroplasty significantly increased from 2.7% to 36.7% [odds ratio (OR) 18.9, 95% confidence interval (CI): 2.7 to 209.8, P<0.008], due to early recognition of strictures not amenable endoscopic treatment. Retreatment became less frequent post-fellowship (37.8% vs. 16.7%, OR 2.99, 95% CI: 1.6 to 5.9, P=0.001). Average number of procedures per patient also reduced (1.65±0.98 vs. 1.23±0.63, P=0.04). Also, there was a trend towards improved overall patency rate at 6-month in the post-fellowship period compared to the pre-fellowship group.

Conclusions

This study has demonstrated that urethral reconstruction expertise was correlated to the increased exposure of urethral stricture patients to urethroplasty as a more efficacious procedure, and was associated with reduced retreatment rates. The expertise can bring cost benefits for patients and regional institutions.

Bulbar urethroplasty techniques and stricture recurrence: differences between end-to-end urethroplasty versus the use of graft

Urethral stricture (US) affects most commonly the anterior portion of the urethra, concretely the bulbar, with a significant incidence in men. Open urethroplasty is the gold standard treatment. However, stricture recurrence (SR) remains a current subject of concern. The aim of the present review is to provide an updated literature summary on surgical urethroplasty techniques for bulbar US and prognostic factors for SR, comparing the different approaches. For short strictures, excision and primary anastomosis (EPA) is the preferred option, with success rates exceeding 90%. Substitution techniques are usually required for longer strictures (>2-3cm). Buccal mucosa graft (BMG) remains the first choice as it complies with ideal features, with no significant differences regarding the site of graft implantation. Stricture length, time since urethroplasty and number of previous urethral interventions are risk factors for failure. Also, surgeon's experience affects technique selection and future outcomes. There seems to be consensus on a higher SR rate following substitution techniques compared to EPA, which appears to be influenced by the stricture length, usually longer in the former group. Furthermore, there is a trend in favor of endoscopic management of SR, except for long and complex recurrences where grafts should be used. In conclusion, multiple urethroplasty techniques are available and selection must be carefully individualized, focusing on stricture characteristics, patient's history, and surgeon's experience. Well-designed studies with clear definitions and follow-up protocols are still necessary to develop standardized guidelines on the management of bulbar US.

Clinical application values of a novel synthetic training simulator for bulbar urethral anastomosis

Purpose

This study aimed to report a newly developed, high-fidelity synthetic simulator to simulate excision and primary anastomotic (EPA) bulbar urethroplasty and its clinical use for new practitioners in shortening the learning curve.

Material and Methods

The bulbar urethral anastomosis simulator consists of several standardized components created according to the actual size of the male patient. Interns, novice residents, and fellows inexperienced with urethral reconstruction (n = 10, 5, 5) from different medical centres were invited to participate in the training programme. Two reconstructive urology experts monitored each practice. Following the training, three kinds of validity testing were used to assess the simulator: face, content, and construct. In the intern group, the task performance in the first five training sessions and the last five training ones were compared using a self-control approach. In the resident and fellow group, the real surgical data, including estimated blood loss, operative duration, and 6-month post-operative success rate of trainees after training, are plotted, which are compared with that of reconstructive urology experts (n = 5) included retrospectively to study the effectiveness of the simulator in shortening the learning curve.

Results

The overall mean satisfaction rate for the simulators was inspiring and evaluated by experts. In the intern group, significant improvement can be achieved through 10 training sessions (p < 0.05). In clinical practice, the intraoperative indicators and surgical success rate of both the training groups showed the tendency to close or even better than those in the expert group. In terms of the learning curve, training groups performed better compared with experts in the early stages of their careers.

Conclusions

In conclusion, this synthetic training simulator for bulbar urethral anastomosis is novel, effective, and convenient for beginners of different groups. The training course can bridge the gap between preclinical use and actual surgery via this simulator.

Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures

Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.

Routine Imaging After Bulbar Urethral Reconstruction Does Not Impact Surgical Outcomes and May Not Be Necessary

OBJECTIVE

To assess whether omitting routine post-operative imaging adversely impacts clinical outcomes after bulbar urethroplasty. Contrast imaging is commonly performed prior to catheter removal after urethroplasty but the clinical need for this is unclear.

METHODS

This was a matched, case-control analysis comparing patients undergoing routine voiding cystourethrogram (VCUG) prior to catheter removal after bulbar urethroplasty to patients without imaging. Patients were matched with respect to age, stricture etiology, length, and urethroplasty technique. Follow-up consisted of clinical assessment 3 weeks post-operatively for VCUG/catheter removal, cystoscopy at 3-4 months with clinical assessment annually. Outcome measures were 90-day complications (Clavien ≥2) and stricture recurrence (failure to pass a 16-Fr flexible cystoscope on follow-up). Chi-square and Kaplan-Meier analysis were conducted where appropriate.

RESULTS

Hundred patients undergoing bulbar urethroplasty with VCUG prior to catheter removal were compared to 100 matched case controls without imaging. Groups did not differ with respect to failed endoscopic treatment (P = .82), prior urethroplasty (P = .09), comorbidities (P = .54), smoking (P = .42), or pre-operative bacteriuria (P = 1.00). The incidence of extravasation in the VCUG group was 2%. Overall 90-day complications were 9.5% and 15 patients developed recurrence with a median follow-up of 174 months. On chi-square analysis, 90-day complications did not differ between patients undergoing VCUG and those without (12% vs 7.0%; P = .34). On log-rank analysis, stricture recurrence did not differ between groups (P = .44).

CONCLUSION

Routine imaging with VCUG after bulbar urethroplasty does not influence the risk of post-operative complications or stricture recurrence. Surgeons should consider avoiding this potentially unnecessary examination in routine clinical practice.

[Urethroplasties for male urethral strictures: Success rates and predictive factors]

INTRODUCTION

Urethroplasty has reported success rates ranging from 60 to 98%. Predictive factors for recurrence are rarely studied, postoperative urinary drainage modalities are not investigated. The primary objective was to evaluate the success rate of urethroplasty in our center. Secondary objectives were to identify recurrence predictive factors.

METHODS

A single-center retrospective cohort including men treated with urethroplasty for stricture between 2007-2017, followed up for a minimum of 12 months. Recurrence was defined as the necessity of a new procedure (endo-urethral or surgical). Data from penile urethra (SUP) and bulbo-membranous urethra (SUBM) stenosis were analyzed separately. Recurrence-free survival (success) was analyzed according to the Kaplan-Meier model. The characteristics of the patients, the stenosis, the surgical technique, the modalities of postoperative urinary drainage were analyzed in subgroups for the bulbo-membranous urethra looking for a correlation with recurrence.

RESULTS

A total of 103 patients included: 25 with SUP, 78 with SUBM. The overall success rate was 69%, CI95% [60-79] with a mean follow-up of 62.85 months. The success was 68%, CI95%[46-82] for SUP, 69.23%, CI95% [58-78] for SUBM. Recurrences occurred during the first 12 months. Only postoperative suprapubic urinary drainage was a predictive factor (HR=0.947, CI95% [0.905-0.992]). A period longer than 14 days reduced recurrence by 37%.

CONCLUSION

Urethroplasty had a success rate of 69%, comparable to published series. Suprapubic urinary drainage improved the surgery outcomes.

LEVEL OF PROOF

2, Grade B.

Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis

OBJECTIVES

To evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP).

METHODS

A retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test.

RESULTS

Among 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months.

CONCLUSION

PUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.

Anterior Urethroplasty for the Management of Urethral Strictures in Males: A Systematic Review

OBJECTIVE

To identify the currently utilised techniques of anterior urethroplasty described in literature for treatment of urethral strictures, assess the effectiveness of the identified techniques based on re-stricture and complication rates, evaluate, and suggest treatment options based on current evidence for urethral strictures at different locations and of different lengths.

METHODS

A systematic review of the MEDLINE, EMBASE, Scopus and Cochrane Library databases from conception up to September 2020 was performed. Primary outcomes included success rates measured via re-stricture rates and the post-operative maximum urinary flow rate (Qmax). Secondary outcomes included patient reported complication rates.

RESULTS

A total of 52 papers, including 7 RCTs, met the inclusion criteria. Forty studies described the use of free graft urethroplasty with a median success rate of 86.5% (IQR = 8.1). The best outcomes were found in dorsal onlay buccal mucosa grafting in the penile urethra (86.6%). Twelve described the use of pedicled flap urethroplasty with a median success rate of 76% (IQR = 14.4). Excision and Primary Anastomosis results were reported in 5 studies and showed an overall highest success rate of 89.7% (IQR = 7.0) but involved the shortest strictures of median lengths of 2.1 cm (IQR = 0.48).

CONCLUSION

Graft urethroplasty showed optimal outcomes when utilised in penile and bulbar strictures, with dorsal onlay buccal mucosa grafting presenting with the largest evidence base and best outcomes overall. Flap urethroplasty had the highest success rates in panurethral and bulbar strictures, while anastomotic urethroplasty had the greatest success in bulbar and penobulbar strictures.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization

BACKGROUND

Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population.

METHODS

Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results.

RESULTS

A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion.

CONCLUSIONS

Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

Long term outcomes of one-stage augmentation anterior urethroplasty: a systematic review and meta-analysis

OBJECTIVE

The objective is to summarize and characterize the long-term success of anterior augmentation urethroplasty (AU) in published series. The current literature on AU consists largely of retrospective series reporting intermediate follow-up and incompletely characterize the long term outcomes of AU.

MATERIALS AND METHODS

A systematic literature review was performed consistent with PRISMA guidelines to characterize long-term outcomes of AU with a minimum upper limit follow-up of 100 months. Penile/preputial skin flaps and graft and oral mucosal graft urethroplasties were included. The primary outcome was stricture-free survival for one-stage AU. Secondary analysis evaluated differences in outcomes based on two failure definitions: the need for intervention versus presence of recurrent stricture on cystoscopy or urethrography. Hazard rates were induced from the reported failure rates of one-stage AU and fixed and random effect models were fitted to the data. Additional subset analysis, removing potential confounders (lichen sclerosus, hypospadias and penile skin graft), was performed.

RESULTS

Ten studies met inclusion criteria, and two studies reported separate outcomes for grafts and flaps, and thus were included separately in the analysis. The mean hazard rate across all studies was 0.0044, the corresponding survival rates at 1 year 0.948, 5 years 0.766, 10 years 0.587, and 15 years 0.45. Subset analysis of the 4 select and homogeneous studies noted 1, 5, 10, and 15 years survival rates of 0.97, 0.96, 0.74, and 0.63, respectively.

CONCLUSIONS

The long-term success rates of augmentation urethroplasty are appear to be worse than previously appreciated and patients should be counseled accordingly. Available at. https://www.intbrazjurol.com.br/pdf/aop/2019-0242RW.pdf.

Exposure of Urology Residents to the Management of Urethral Strictures in Saudi Arabia: Should the Program for Postgraduates Be Customized?

PURPOSE

This study aimed to assess the exposure and knowledge of urology residents in the management of urethral stricture (US) and to determine if they would be able to perform urethroplasty after graduation and whether urethroplasty should be included as a competency in the training program.

PATIENTS AND METHODS

An online survey was sent to all residents enrolled in any urology training program in Saudi Arabia. Fifty-eight (approximately 50%) of the 114 residents who were sent the survey provided responses.

RESULTS

Most of the residents (45 residents, 77.6%) who responded were exposed to fewer than ten cases of US during their last year of training. Fifty-six residents (96.6%) attended five or fewer urethroplasty procedures in their last year of training. Twenty-three (40%) residents did not attend any urethroplasty procedure in the last year. The most common procedures attended by the residents were minimally invasive treatments (89% cystoscopy with dilatation and 79% direct visual internal urethrotomy (DVIU)). Most residents responded that they would manage newly diagnosed 1 cm US with either cystoscopy and dilatation or with DVIU 53 (91%). For the first recurrence of US, 46 (79%) residents responded that they would still prefer dilatation or DVIU. For the second, third, and chronic recurrences of US, 20 (34.5%), 6 (10.3%), and 5 (8.6%) residents, respectively, responded that they would perform dilatation or DVIU. Residents had low expectations for the success rate of urethroplasty; only 32 (55.2%) residents thought it had a high success rate.

CONCLUSION

Urethroplasty is a specialized urological procedure, one that residents have variable exposure to. Privilege to perform such a procedure after graduating should be modified to ensure the best outcome for patients.

Inter-Resident Variability in Urologic Operative Case Volumes Over Time: A Review of the ACGME Case Logs From 2009 to 2016

OBJECTIVES

To assess the effect of the changing landscape of urologic residency education and training on resident operative exposure and inter-resident variability.

METHODS

The Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating urology chief residents were reviewed from Academic Year (AY) 2009-2010 to 2016-2017. Cases were stratified into the 4 ACGME categories - general urology, endourology, oncology, and reconstruction. Linear regression models analyzed the association between training year, volume, and type of cases performed. Inter-resident variability in case exposure was calculated by the difference between the ACGME reported 10th and 90th percentiles.

RESULTS

During the study period, the mean number of cases performed per resident was 1092 (standard deviation 32.7). Although there was no significant change in total case volume, there were changes within case categories. Endoscopic, retroperitoneal oncology, and male reconstruction case volume all increased significantly (Δ20.1%, Δ 5.1%, Δ 8.2%, respectively, all P < .05). This was balanced with a concomitant decrease in pelvic oncology and female reconstruction cases (Δ 10.0% and Δ 14.5%, respectively, both P < .05). There was a 27.8% increase in laparoscopic/robotic cases (P < .001). The ratio difference between the 10th percentile and 90th percentile ranged from a low of 2.5 for retroperitoneal oncology cases to a high of 5.2 for extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy.

CONCLUSION

From AY2009-2010 to 2016-2017, residency case volume has remained constant, but there has been a change in types of cases performed and proliferation of minimally invasive techniques. Significant variability of inter-resident operative experience was noted.

The ladder of learning in exstrophy closure - A 5 year initial faculty experience

PURPOSE

Closure of bladder exstrophy is one of the most complex reconstructive procedures. Basic concepts of these operations, as well as their subtle nuances, require years of experience. However, the volume of these cases is low. The authors describe the experience of a junior surgeon learning the details of exstrophy closure during fellowship and her initial career.

METHODS

Fellows graduating in 2014 were surveyed for their exstrophy experience during fellowship and the following four years. Operative logs of the junior faculty member were reviewed during the same time. Average operative times were calculated for each year.

RESULTS

Seventeen of the 25 fellows responded to the survey. Eight surgeons did one or fewer exstrophy closures during fellowship; 14 did one or fewer closures as an attending. The junior faculty member assisted in 18 closures as a fellow and 48 exstrophy closures during the next four years. Average operative time decreased from 485 to 309 min from attendingship year one to four.

CONCLUSIONS

There are subtle details inside and outside of the operating room required to ensure a successful outcome in this important step of exstrophy reconstruction. Working alongside senior colleagues is essential to allow the junior surgeon to ascend this ladder of mastering exstrophy closure.

TYPE OF STUDY

Diagnostic.

LEVEL OF EVIDENCE

V.

Learning curve of various type of male urethroplasty

Purpose

To determine the number of cases required to achieve a specified recurrence-free rate (>80%) among urethroplasty types.

Materials and Methods

A retrospective analysis of consecutive patients, who underwent urethroplasty performed by a single surgeon between April 2013 and January 2019, was conducted. Urethroplasty subtypes were divided according to stricture location: penile, bulbar, and posterior. If there was no recurrence for >6 months after surgery, the surgery was considered to be a success. The average success rates among quintile groups were compared to determine the learning curve for each type.

Results

Of 150 patients who underwent urethroplasty, 112 were included in this study. The overall success rate was 89.7% in penile, 97.8% in bulbar, and 74.1% in posterior urethroplasty. Bulbar urethroplasty reached the target success rate in the first quintile group (1–9 cases). Penile urethroplasty also achieved the target success rate in the first quintile group (1–8 cases), and the success rate gradually increased until the fifth quintile group (32–39 cases). In posterior urethroplasty, the target success rate was achieved in the fifth quintile group (20–27 cases).

Conclusions

Bulbar urethroplasty had the fastest learning curve, and posterior urethroplasty the slowest.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Contemporary Management of Bulbar Urethral Strictures

Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.

Trends in Urethral Stricture Disease Etiology and Urethroplasty Technique From a Multi-institutional Surgical Outcomes Research Group

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.

Population Analysis of Male Urethral Stricture Management and Urethroplasty Success in the United States

OBJECTIVE

To examine population-based practice patterns and outcomes related to urethroplasty for urethral stricture management.

METHODS

We conducted a retrospective study of adult males with urethral stricture disease treated from January 2001 to June 2015 using the Clinformatics Data Mart Database. Treatment was defined as urethral dilation, direct visualized internal urethrotomy, and urethroplasty. We then examined anterior or posterior urethroplasty outcomes defining failure as any subsequent procedure specific to urethral stricture disease occurring >30 days after urethroplasty. We used multivariable and time-to-event analysis to examine factors associated with failure.

RESULTS

We identified 75,666 patients treated for urethral stricture disease, with 420 and 367 undergoing anterior and posterior urethroplasty, respectively. Urethroplasty utilization doubled from 2005 to 2015. One- and 5-year failure rates for anterior and posterior urethroplasty were 25% and 18%, and 40% and 25%, respectively, with median times to failure of 5.1 and 4.1 months. Failures were salvaged primarily with direct visualized internal urethrotomy, with salvage urethroplasty in 19% and 12% of anterior and posterior repairs, respectively.

CONCLUSION

Despite increasing population-based urethroplasty utilization over the past decade in our insured cohort, we found higher rates of salvage treatments than reported by high-volume and expert surgeon reports. Further efforts appear warranted to balance workforce expertise and quality of urethroplasty care to meet increasing urethral stricture population needs.

International volunteerism and urethral stricture disease: a review

Global health is an ever-expanding area of interest for many healthcare workers around the world. In recent years, it has become apparent that much of the global disease burden is surgical. Urologic disease is no exception—many international organizations send volunteers around the world to support Urologic services in countries that lack capacity and resources. Urethral stricture represents a unique opportunity for specialized surgical management that vastly improves long term morbidity. Here we review the prevalence, etiology, and management of urethral stricture from a global perspective while highlighting impact of international urologic volunteer efforts.

Describing the learning curve for bulbar urethroplasty

Background

Learning curves have been described for a number of urological procedures including radical prostatectomy and laparoscopic nephrectomy but rarely for urethroplasty. We describe the learning curve for bulbar urethroplasty in a single surgeon series.

Methods

A retrospective case note review was performed of 91 consecutive men median age 32 years (range, 15–66 years) having bulbar urethroplasty performed by a single surgeon. Data was collected on type of urethroplasty, restricture rate (as defined by urethrogram and/or flow rate) and duration of follow up. The restricture rates were compared by quartiles and statistical analysis was by ¦Ö² between the first and fourth quartiles.

Results

The 91 men had 42 dorsal onlay buccal mucosal graft (Dorsal BMG), 20 BMG augmented bulbobulbar anastomotic (Augmented Rooftop) and 29 bulbobulbar anastomotic (BBA) urethroplasties performed. Median follow up was 39 months for the first quartile, 42 months for the second, 36 months for the third, and 35 months for the fourth. The restricture rate was 17% in the first quartile, 8.7% in the second and third quartiles and 4.5% in the fourth quartile. There were no restrictures noted after 24 months. There were 4 restrictures in the first quartile and 1 restricture in the fourth quartile (¦Ö² P<0.01).

Conclusions

There is a statistically and clinically significant difference in restricture rates between first and fourth quartiles with rates falling from 17% to 4.5%. There is a learning curve for bulbar urethroplasty with a reduced restricture rate each quartile and it may take as many as 90 cases to reach optimum restricture rates.

Definition of Successful Treatment and Optimal Follow-up after Urethral Reconstruction for Urethral Stricture Disease

The definition of a successful urethroplasty, the lack of need for a secondary procedure, is outdated and must be amended to incorporate objective and subjective outcomes. Success is assigned if a flexible cystoscope can traverse the reconstructed urethra without force. Functional success is assigned if patient-reported outcome measures reveal improvement in voiding symptoms and urinary quality of life. Optimal follow-up strategy allows determination of anatomic and functional outcomes, protects genitourinary health, and prevents excessive invasive testing, unnecessary cost, discomfort, anxiety, and risk. Noninvasive objective uroflowmetry has high sensitivity and specificity for detecting recurrence and replaces invasive anatomic evaluation.

Nontransecting Anastomotic Repair in Urethral Reconstruction: Surgical and Functional Outcomes

PURPOSE

We evaluated the surgical and functional outcomes, and the effect of the learning curve of nontransecting anastomotic repair for short bulbar and posterior urethral strictures.

MATERIALS AND METHODS

A total of 75 patients were treated with nontransecting anastomotic repair for short bulbar strictures in 55 and for posterior strictures in 20. Surgical morbidity was scored using the Clavien-Dindo classification at 3 months. Sexual function was measured using SHIM (Sexual Health Inventory for Men) scoring preoperatively and postoperatively. Post-void dribbling before and after nontransecting anastomotic repair was also determined. To evaluate the learning curve outcomes were evaluated in patients 1 to 25, 26 to 50 and 51 to 75.

RESULTS

Median followup was 30 months. Stricture recurred in 6 patients (8%), all diagnosed within 7 months after nontransecting anastomotic repair. Median operative time was 95 minutes and median hospital stay was 2 days. In 61 patients (81.3%) no surgical morbidity was recorded. Five (6.7%), 6 (8%) and 3 patients (4%) experienced a grade 1, 2 and 3b complication, respectively. Seven of 32 (21.9%) and 2 of 42 evaluable patients (4.7%) reported de novo erectile dysfunction and post-void dribbling, respectively, 3 months after nontransecting anastomotic repair. No difference in outcomes was observed among the 3 patient groups.

CONCLUSIONS

Nontransecting anastomotic repair appears to be safe without a substantial learning curve effect. Patient counseling about possible surgical complications and transient erectile dysfunction is important.