Short-Term Outcome and Morbidity of Different Contemporary Urethroplasty Techniques

Abstract

Background and Purpose:

Only few comparative reports about different urethroplasties have been published, addressing success rate (SR), adverse events (AE), and quality of life (QoL). Our purpose was to evaluate SR, AE, and QoL in a contemporary cohort of patients undergoing urethroplasty in the short-term follow-up (FU).

Patients and Methods:

Between December 2008 and June 2010, 205 patients underwent urethroplasty for anterior urethral strictures at our institution. A standardized questionnaire was sent to all patients. The primary end point was SR. Secondary end points were AE and QoL. To assess the risk of SR, the Kaplan-Meier method and log-rank test were used. To assess risk factors for urethral stricture recurrence (SRec), univariable Cox regression analysis was used.

Results:

Overall, 140 (68%) patients responded to our questionnaire and were used for analysis. Of these 9%, 85%, and 6% were treated by excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), and mesh graft urethroplasty (MGU), respectively. At 10 months of FU, SR was 87.5%. SRs of EPA, BMGU, and MGU were 100% (n=13/13), 85.7% (n=102/119), and 87.5% (n=7/8), with no significant differences between the groups. In univariable analysis, ≥2 vs 1 previous urethroplasties showed a trend toward a reduced SR (hazard risk 2.95; P=0.057). Streaking the urethra (P=0.024) and penile curvature (P=0.026) were significantly more often associated with MGU compared with EPA and BMGU. Postoperative total median (mean) scores were 3.5 (4.8) for the International Consultation on Incontinence Questionnaire Male lower urinary tract symptoms, 15 (15.2) for the International Index of Erectile Function, and 80 (73) for EuroQol visual analogue score; there was no difference between urethroplasty types.

Conclusion:

In the short-term FU, urethroplasty demonstrates an excellent SR. Specific SRs of EPA, BMGU, and MGU seem comparable. Despite significant differences in AE, patient reported QoL is high with no difference between the applied techniques.

Introduction

U rethroplasty is a complex procedure that is too seldom performed.¹ Indeed, all too often, patients with recurrent strictures still undergo multiple urethrotomies, despite its poor success rate (SR) (ie, below 10%).² In patients with urethral stricture recurrence (SRec), urethroplasty is, however, the gold standard of therapy.³ Adding to the complexity of the disease, different urethroplasty techniques, depending on location, length, etiology of the stricture, and surgeon ability, are described.⁴

In 2003, our study group reported statistically comparable long-term SRs of urethroplasty using excision and primary anastomosis (EPA), buccal mucosa graft (BMG), mesh graft (MG), and penile or scrotal flaps.⁵ At that time, flaps were most commonly used, and buccal mucosa graft urethroplasty (BMGU) represented a relatively novel surgical approach with limited experience.⁵ Because a BMG is easy to harvest, easy to handle, and has a good graft take, it has mostly replaced the indication for flap or other surgical techniques, becoming the most common type of graft in the management of urethral strictures.⁶

Despite its increasing use, however, only few adequately powered studies have addressed its SR, adverse events (AE), and quality of life (QoL), and compared with other contemporary urethroplasty techniques. To address this void, we retrospectively analyzed the SR, AE, and QoL of patients who underwent either EPA, BMGU, or mesh graft urethroplasty (MGU) at our center.

Patients and Methods

Patient cohort

Between December 1, 2008 and June 30, 2010, a referral cohort of 230 patients underwent urethroplasty because of urethral stricture disease. After obtaining Institutional Review Board approval and patient consent, patients' data were prospectively entered in our urethroplasty database and retrospectively reviewed. To avoid selection bias, patients undergoing Boutoniere (n=2), meatoplasty (n=7), hypospadia and fistula (n=10; n=6) repair were excluded from the study.

Surgical procedure: Indication, preoperative and postoperative management

Preoperatively, patients were evaluated with medical history, physical examination, urine culture, residual urine measurement, uroflowmetry, and a combined retrograde and antegrade urethrography (RUG/AUG). All patients had negative urine culture results before surgery. The indication for the type of urethroplasty performed was based primarily on the urethral stricture's length, location(s), and previous interventions. In short bulbar strictures (≤1 cm), EPA was performed; in panurethral strictures, a two-staged MGU. In all others, a one- (bulbar onlay, penile Asopa or modified Barbagli technique) or two-staged BMGU was undertaken.^7
–9

On the basis of a European practice pattern, the following peri- and postoperative management were applied: Intraoperatively, a transurethral and suprapubic catheter were placed. Patients treated with EPA and second stage of BMGU or MGU had the transurethral catheter removed at day 7 after surgery, and an AUG was performed via suprapubic catheter. Patients with one-stage BMGU were routinely discharged on day 5 after surgery, had the transurethral catheter removed at day 10, and underwent an AUG before voiding per urethra on postoperative day 21 in the outpatient clinic. In case of extravasation, the suprapubic catheter was left in until an AUG was repeated 2 weeks later. Patients with a first stage of BMGU or MGU were discharged on day 10, after being taught how to manage bandaging the open urethra. Closure of the urethra (second stage) was performed 3 months later.

Standardized nonvalidated questionnaire

A standardized questionnaire was sent to all patients (n=205) on July 31, 2010. This questionnaire consists of two parts: The first one includes nonvalidated questions to assess the etiology of urethral stricture disease, previous treatments, number of pads used preoperatively, and postoperative complications and AE. For the second part, we used a questionnaire according to a patient-reported outcome measure by Jackson and associates (J-PROM).¹⁰ The J-PROM is a tool to assess voiding, lower urinary tract symptoms (LUTS), symptom-specific and general QoL for urethral stricture surgery and is essentially derived from five different questionnaires: The International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms (ICIQ MLUTS) module,^11,12 including a separate LUTS-specific QoL question from the ICIQ MLUTSqol, Peeling's voiding picture,¹³ the EuroQol 5D which includes pain assessment, and the visual analogue score.¹⁴ In addition, the International Index of Erectile Function¹⁵ was used to assess postoperative sexual symptoms. Finally, we translated the questionnaire into German and retranslated it into English. In total, our questionnaire consists of 49 questions.

End points

As previously described,¹⁶ SRec was defined as any required form of postoperative reintervention (including recatheterization or dilation). SR was our primary study end point and the secondary end points were AE and QoL.

Statistical analysis

Data were stratified according to the three surgical techniques: EPA, BMGU, and MGU. The Kaplan-Meier method was used to assess SRec-free survival. In addition, the log-rank test (pairwise comparison) was performed to assess differences between urethroplasty types and SRec survival. Univariable Cox regression analysis was applied to identify risk factors (RF) for early SRec. The Wilcoxon test was used to compare functional outcomes of maximal flow rate and residual urine. Mann-Whitney test and Kruskal-Wallis-H test were used to compare outcomes of QoL between the different surgical techniques. The chi-square test was used to assess whether different AEs were associated with the surgical techniques. Statistical significance was considered by a two-sided P value<0.05. SPSS® 17.0 was used.

Results

After exclusion of 25 patients because of specified exclusion criteria, the final cohort comprised 205 men. Questionnaire analysis included 140 (68%), who had complete data and responded to our self-reported mail-out questionnaire. Median age of this cohort was 56 years (range 14–84). Lichen sclerosus was present and the underlying cause for urethral stricture in 4.3% (6/140) of patients, who all underwent BMGU. Urethral strictures were located in the bulbus in two-thirds of cases, and a one-stage procedure was performed in 86.5%. According to location and length of the urethral strictures, the majority of patients had BMGU (85%) compared with EPA (9%) and MGU (6%) (Table 1). Median follow-up was 8 months (range 1–22); there was no difference in follow-up between the three groups. Postoperative voiding trial was successful in 93% of cases. There was a statistically significant improvement between median preoperative and postoperative maximal uroflow (7.4 mL/s vs 30.9 mL/s; P=0.002) and median residual urine (45 mL vs 18.7 mL; P=0.042), with no differences between the surgical techniques (P>0.05).

Table 1.

Patient Characteristics of 140 Patients Who Underwent Urethroplasty for Urethral Stricture Disease

	Overall	EPA (n=13)	BMGU (n=119)	MGU (n=8)
Median follow-up (months)	8.0	8.1	7.9	5.8
Median age (years)	56	36	60	54
Stricture location
Bulbar	64.3%	100%	66.1%	12.5%
Penobulbar	8.4%	-	9.3%	12.5%
Penile	20.3%	-	22%	75%
Transplant length (cm)
≤2	13.9%	100%	6.8%	-
2.1–5.9	50.3%	-	57.3%	12.5%
≥6	35.8%	-	35%	87.5%
One-stage procedure	86.5%	100%	89.1%	-
Two-stage procedure	13.5%	-	8.9%	100%

EPA=excision and primary anastomosis; BMGU=buccal mucosal graft urethroplasty; MGU=mesh graft urethroplasty.

The overall SR was 87.5% at 10 months of follow-up (Fig. 1). SRs for EPA vs BMGU vs MGU were 100%, 85.7%, and 87.5%, respectively. There was no significant difference between EPA vs MGU (P=0.83); EPA vs BMGU (P=1.6); and MGU vs BMGU (P=0.75).

FIG. 1.

Kaplan-Meier plot of overall success rate of 140 patients who underwent urethroplasty because of urethral stricture disease.

In univariable Cox regression analyses, none of previous treatments predicted SRec. A previous urethroplasty (n=42, 30%) showed a trend toward statistical significance (hazard risk [HR]=1.73; 95% confidence interval [CI] 0.96–3.11, P=0.07) for early SRec. After dichotomization of patients with ≥2 vs 1 previous urethroplasties, patients with two or more previous urethroplasties showed a trend toward a higher risk of SRec (HR=2.95; 95% CI 0.97–8.99, P=0.057). Previous catheterization (n=60, 44.1%; HR=1.43; 95% CI 0.57–3.60, P=0.45); dilation (n=76, 54.3%; HR=1.10; 95% CI 0.44–2.80, P=0.84); or urethrotomy (n=111, 79.3%; HR=0.55; 95% CI 0.19–1.54, P=0.25) were not associated with the risk of early SRec.

This also applied to different age categories with SRs of 88.1% for patients ≤49 years (HR=0.66; 95% CI 0.25–1.69, P=0.38), 87.3% between 50 and 70 years (HR=1.12; 95% CI 0.44–2.90, P=0.81), and 84.6% ≥71 years (HR=1.674; 95% CI 0.55–5.05, P=0.37) and other intrinsic stricture characteristics such as location (HR=1.18; 95% CI 0.78–1.79, P=0.43) and stricture length (HR=1.76; 95% CI 0.83–3.69, P=0.14). Between one- (n=107) and two (n=12) staged BMGU, no statistically significant difference regarding early SRec (HR=1.20; 95% CI 0.27–5.26, P=0.81) was observed.

Streaking the urethra was significantly more frequent in patients with MGU compared with those treated with EPA or BMGU (P=0.024) (Table 2). Also, penile curvature was significantly more often associated with MGU (P=0.026). Severe donor site morbidity defined as severe pain at the place of graft harvesting occurred in 10.7% of patients with no significant difference between BMG and MG (11.8% vs 12.5%, P=0.42). Table 3 shows several aspects of QoL. There were no differences in regard to postoperative voiding, erectile function, and health-related QoL between the surgical techniques. Based on the J-PROM, postoperative QoL improvement and satisfaction with the surgical procedure was 80% and 79%, respectively. There was no difference between the urethroplasty types.

Table 2.

Proportion of Early Adverse Events of 140 Patients Who Underwent Urethroplasty for Urethral Stricture Disease

	All		EPA (n=13)		BMGU (n=119)		MGU (n=8)
	n	%	n	%	n	%	n	%	P value
Urinary tract infection	36	25.7	2	15.4	31	26.1	3	37.5	0.52
Streaking urethra	60	43.8	2	15.4	52	44.8	6	75.0	0.024^a
Postvoid dribbling (frequently)	23	16.4	6	15.4	74	16.8	5	62.5	0.95
Curvature of penis (severe)	2	1.7	0	0	1	1.0	1	14.3	0.026^a
Shortening of penis (severe)	6	4.3	1	7.7	5	4.2	0	0	0.70
Painful ejaculation	13	9.3	0	0	12	10.1	1	12.5	0.49
Graft donor site morbidity (severe)	15	10.7	-	-	14	11.8	1	12.5	0.44
Incontinence (≥2 pads/day)	14	10	1	7.7	12	10.1	1	12.5	0.94
Sensoric disturbance glandula (severe)	10	7.1	1	7.7	9	7.6	0	0	0.72
Paresthesia scrotal skin/penis (severe)	8	5.7	0	0	8	6.7	0	0	0.47

Statistically significant variable.

EPA=excision and primary anastomosis; BMGU=buccal mucosal graft urethroplasty; MGU=mesh graft urethroplasty.

Table 3.

Short-Term Follow-Up of Quality of Life of 140 Patients Who Underwent Urethroplasty for Urethral Stricture Disease

	All	EPA	BMGU	MGU	P value
Urinary symptoms
ICIQ-MLUTS score Median (mean)	3.5 (4.8)	2 (3.7)	4 (5)	2.5 (3.4)	0.99
Peeling's voiding picture Median (mean)	2 (1.8)	1 (1.4)	2 (1.8)	1.5 (1.8)	0.63
Erectile function
IIEF score Median (mean)	15 (15.2)	15 (15.6)	15 (15.2)	12 (13.4)	0.35
Health-related QoL
ICIQ-MLUTS qol Urinary symptoms interfere with life – a little or not at all	75.7%	76.9%	77.3%	62.5%	0.55
EQ-5D: Severe pain postoperatively	3.7%	0%	4.3%	0%	0.63
EQ-5D VAS Median (mean)	80 (73)	85 (73)	80 (73)	78 (72)	0.29
Surgical outcome
J-PROM: Quality of life improvement	80.0%	92.3%	78.2%	85.8%	0.37
J-PROM: Satisfaction surgical procedure	78.4%	69.2%	79%	85.8%	0.66

EPA=excision and primary anastomosis; BMGU=buccal mucosal graft urethroplasty; MGU=mesh graft urethroplasty; ICIQ-MLUTS=Incontinence Questionnaire Male Lower Urinary Tract Symtpoms module; IIEF=International Index of Erectile Function; QoL=quality of life; ICIQ-MLUTS qol=LUTS-specific QoL question of Incontinence Questionnaire Male Lower Urinary Tract Symptoms module; EQ-5D=EuroQol 5D; EQ-5D VAS=EuroQol 5D Visual analogue score; J-PROM=patient-reported outcome measure by Jackson and associates.¹⁰

Discussion

We confirmed previous findings of excellent surgical results with EPA, providing no single SRec in this study.³ This is based on the favorable pathology of short strictures³ and our strict therapy algorithm (indication for EPA for short bulbar strictures: ≤1cm at RUG/AUG). More than 80% of our urethroplasties had a stricture longer than 2 cm, and almost one third were not located exclusively to the bulbar urethra, indicating the need of substitution graft. At our institution, oral buccal mucosa is used as the favorite substitution graft because it allows the most diverse techniques. A previous study has shown that BMG had a significantly better outcome than penile skin grafts (PSG) at intermediate follow-up.¹⁷ Despite the increasing use of BMG, it has its limitations when facing very long or panurethral strictures. Therefore, at our center, MGU is the standard care of treatment if the stricture disease extends the limits of BMG harvesting (>15 cm).

Nearly 80% of all patients had ≥1 urethrotomy in this study. We confirmed previous findings that urethrotomy did not represent a risk factor for SRec.¹⁸ Interestingly, patients with more than one previous urethroplasty showed a trend toward a greater risk for SRec—however, without statistical significance.

Streaking the urethra (75%) and penile curvature (14.3%) were significantly associated with MGU. This is because the fibrotic residuals of the corpus spongiosum are often entirely resected, resulting in a widely reconstructed but tensionless neourethra. Having used graft techniques in more than 90% of our study cohort, severe donor site morbidity was in 10.7% of patients. All resolved, however, with conservative management.

Jackson and associates¹⁰ recently presented a validated questionnaire, which measures several aspects of patient-reported outcome for urethral surgery. We used J-PROM within our self-devised questionnaire and, despite the missing preoperative evaluation, a postoperative comparison between the surgical techniques was possible and showed an excellent outcome throughout all types of urethroplasty. As short- and long-term data show excellent outcome between different techniques of urethroplasty, the validation of a PROM by Jackson and colleagues points out the change in direction in contemporary urethroplasty: The definition of success is not exclusively measured by stricture-free recurrence rates themselves, but by minimization of postoperative AE and QoL improvement. Indication for different types of contemporary urethroplasty will need to take into account patient characteristics such as age, stricture location and length, but also erectile function and individual expectations.

This present study was not devoid of limitations. First and foremost are limitations because of its retrospective character over a short follow-up. We did not adjust for the different types of urethroplasty, resulting in a heterogenous cohort of patients. We tried to demonstrate, however, the importance and advantages of a strict therapy algorithm, following the same indication for every urethral stricture: Length, location, and previous interventions. In our case control study, the questionnaire did not specify in regard to donor site morbidity; ie, we could not control for the time of occurrence, location, and length of postoperative wound pain in patients harvesting full thickness skin graft from the inner thigh or BMG. Furthermore, we could not control for the changes in perioral numbness by different periods.

Conclusion

In the short-term follow-up, SRs of urethroplasties are encouraging. Despite intrinsic differences in AE between the different techniques, QoL and postoperative satisfaction with the surgical procedure are high.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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Short-Term Outcome and Morbidity of Different Contemporary Urethroplasty Techniques—A Preliminary Comparison