Sclerosis as a predictive factor for failure after bulbar urethroplasty: a prospective single-centre study

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

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.

Ectopic Germinal Centres with B and T Cells and Follicular Dendritic Cell Networks in Urethral Stricture Tissue: Possible Avenue for Immunological Treatments

Background

The underlying cause of a urethral stricture can sometimes be obscure. It is possible that an injury to the urethra induces an immunological cascade that generates scar tissue and fibrosis, eventually resulting in a stricture. If such immunological reactions could be better elucidated, immunological therapies could possibly emerge.

Objective

To evaluate if ectopic germinal centres exist in urethral stricture disease.

Design, setting, and participants

Resected stricture specimens from 45 patients undergoing open bulbar urethroplasty with excision and anastomosis were assessed. Histopathological characteristics, such as fibrosis (grade I–III), inflammation, and sclerosis, were evaluated using immunostaining for CD3 (T cells), CD20 (B cells), and CD21 (follicular dendritic cells).

Outcome measurements and statistical analysis

The primary outcome measure was the presence or absence of a germinal centre. The secondary outcome was evaluation of any correlation between the degree of fibrosis and germinal centres. Fisher’s exact test was used for univariate analysis.

Results and limitations

In six patients, ectopic germinal centres were found. In ten patients, there was no inflammation at all. There was no correlation found between the degree of fibrosis and the abundance of immunohistochemically detected immune cells.

Conclusions

Ectopic germinal centres, with B and T cells as well as follicular dendritic cell networks, do exist in urethral stricture disease. This finding may open up for novel research avenues on the possibility of adopting immunological treatments for urethral stricture disease.

Patient summary

In patients with a narrowing of the urethra due to any kind of trauma, we looked for the presence of centres of immunological reaction in urethral tissue. We identified these immunological centres (also called germinal centres) in some patients. This intriguing finding suggests that immunological treatments may have potential for men with scar tissue in a narrowed urethra.

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.

Is neutrophil to lymphocyte ratio a predictive factor for recurrence of urethral stricture?

INTRODUCTION

Due to spongiofibrosis and inflammatory processes underlying the pathogenesis of urethral stricture, it is possible that the neutrophil-lymphocyte ratio (NLR) may give essential information about the course of the disease and recurrence possibilities. Our study aims to evaluate the correlation between NLR and recurrence rates.

METHODS

A total of 512 patients who underwent direct visual internal urethrotomy (DVIU) due to urethral stricture in our clinic between February 2010 and January 2018 were evaluated retrospectively.

RESULTS

The median follow up for non-recurrent and recurrent groups after DVIU was 30 and 36 months, respectively. During the follow-up, 280 (54.7%) of the patients had recurrences, and 232 (45,3%) had no recurrences. The mean time for recurrence after DVIU was 6,5±1,4 months, with a range of 1-36 months. The mean NLR in the non-recurrence group was 2,02±0,87, with a median of 1.9, and 3,66±2,30, with a median of 3 in the recurrence group. A highly significant statistical difference was observed between two groups in terms of neutrophil count and NLR (p: 0.000 - both). The area under curve value for NLR was 0.767, with a standard error of 0.021 (95% CI 0.727-0.808). The cut-off value of NLR was determined as 2.25, with a 70% sensitivity and 67,7% specificity.

CONCLUSION

By using NLR, the inflammatory features of the urethral tissue can be predicted, and possible recurrences after surgery can be estimated. Consequently, open urethroplasty techniques can be used in cases with a significant NLR value instead of the recurrent endoscopic procedure.