Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes

OBJECTIVES

Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system.

METHODS

A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr.

RESULTS

We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics.

CONCLUSIONS

Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.

Simplified posterior urethroplasty utilizing laparoscopic instrumentation

Background

Posterior urethral stricture disease presents challenges for even the most skilled reconstructive urologists. Regardless of the surgical technique used, these are complex operations that occur in hard-to-access locations. We describe the use of a novel combination of laparoscopic instrumentation to simplify posterior urethral reconstruction.

Methods

We retrospectively identified patients undergoing a posterior urethral stricture repair utilizing a combination of the RD-180^® suture device and the Securestrap^®. These procedures were performed by a single surgeon at our institution. Patients with greater than or equal to 4 months of follow up were included in the analysis.

Results

From October 2016 to October 2020, 20 patients underwent posterior urethral stricture repair using these laparoscopic instruments. Median age was 70 years (28–90 years). Median follow up was 12 months (5–50 months). Mean stricture length was 3 cm (1.5–16 cm). Median operative time was 150 minutes (120–180 minutes). No peripheral neuropathies or positional injuries were noted. With failure defined as inability to pass a 16-Fr scope, success rate was 95% (19/20 patients).

Conclusions

The combination of the RD-180^® and the Securestrap^® has become essential to our posterior urethral stricture repair armamentarium. Further data and longer follow up is needed to confirm these reliable outcomes.

Complications Based on Prostate Size After Plasmakinetic Enucleation of the Prostate

BACKGROUND Lower urinary tract symptoms among adult men can significantly impact quality of life. We evaluated complications based on prostate size following plasma kinetic enucleation of the prostate. METHODS Patients were grouped into small prostate group (SPG) <75 grams, and large prostate group (LPG) >75 grams based on preoperative imaging. Patient demographics, comorbidities, preoperative international prostate symptoms score (IPSS), bother index (BI), prostate specific antigen (PSA) if indicated, post void residual volume (PVR), indwelling catheter or self-catheterization status, and any prior surgical intervention were evaluated. Postoperatively IPSS, BI, and PVR was assessed at 6 weeks, 4 months, and yearly. Post-operative urge urinary incontinence (UUI), stress urinary incontinence (SUI) and pad use was assessed. RESULTS Between September 2015 and December 2020, 296 bipolar enucleation with minimum 4 month follow-up were evaluated. All postoperative IPSS, BI, PVR and PSA timepoints were significantly decreased compared to pre-operative values (p <0.05). There was no significant difference in the complications between groups. Univariable and multivariable analysis found size <75 grams was predictive of stricture formation and bladder neck contracture. UUI was more common at 6 weeks in the SPG, and SUI was more common at 6 weeks in the LPG, but no difference was noted at the 4 month and 1 year time point. Pad use was equal between the two groups at all time points. CONCLUSIONS PKEP provides an effective treatment option for all prostate sizes, however, prostates <75 grams have a higher rate of BNC and urethral strictures compared to those >75 grams.

Predictors of Storage Symptom Improvement After Plasma Kinetic Enucleation of the Prostate

OBJECTIVE

To investigate which preoperative findings portend poor improvement in storage symptoms in patients undergoing plasma kinetic enucleation of prostate (PKEP).

METHODS

A single surgeon series of patients who had undergone PKEP with minimum 1 year follow up were evaluated. Patients were grouped into those with less than 33% improvement in storage symptoms (LIS) according to the international prostate symptom score (IPSS) and those with greater than 33% improvement in storage symptoms (GIS). Pre and postoperative factors were evaluated, along with IPSS, storage symptoms percentage (the total from frequency, urgency and nocturia divided by the total IPSS), bother index, and post void residual (PVR) at 6 weeks, 4 months, and yearly.

RESULTS

Two hundred sixty-eight patients had a minimum 1 year of follow up and had completed the IPSS. IPSS and bother index improved significantly from preoperatively to all time points post operatively in both groups, but the difference was greater in the GIS group. Patients in the GIS group had significantly larger prostates, more prostatic ingrowth, higher preoperative PVR, and a higher overall IPSS compared to the LIS group. Those in the LIS group had a higher incidence of prior prostate surgery, and a higher BMI. However, storage symptom percentages were equal between the GIS and LIS groups at all time points.

CONCLUSION

Greater prostatic ingrowth, larger prostate volume, higher preoperative PVR volume, and a higher overall IPSS was associated with greater improvement in storage symptoms. Prior prostate surgery and higher BMI portend less improvement in storage symptoms.

Virtue male sling outcomes and application to a contemporary nomogram

INTRODUCTION To report outcomes of our Virtue male sling series and evaluate predictors of surgical success and failure. We also retrofit the Male Stress Incontinence Grading Scale (MSIGS) refined nomogram, including the standing cough test (SCT), to assess its application to our cohort.

MATERIALS AND METHODS

A retrospective review was completed at a single institution over a 4 year period of all Virtue male slings implanted for stress urinary incontinence (SUI). Patient demographics including pad usage per day (PPD) and MSIGS were obtained on all patients after their bladders were filled cystoscopically. Failure was defined as > 1 PPD and/or conversion to another anti-incontinence procedure. Incidence, management and outcomes of complications were also evaluated.

RESULTS

Forty-six men who underwent Virtue male sling at a median follow up of 15.6 months were analyzed with an objective success rate of 78% and a subjective success rate of 85%. Preoperative predictors of surgical success were ability to stop stream on physical exam, lack of total incontinence and no history of posterior urethral stricture. MSIGS alone was not predictive of sling success or failure. Penile numbness occurred in 11% of patients and reoperation with incision of the sutured together transobturator arms improved sensation in all patients.

CONCLUSION

Virtue male sling has high objective and subjective success rates with a manageable side effect profile. Evidence of residual sphincteric function appears to be more predictive of sling success rather than MSIGS.