Urethroplasty delay results in more complex repair

Boston-Delay to urethroplasty for bulbar urethral strictures is associated with repetitive interventions, stricture lengthening, and more complex repairs that have a greater risk for failure, while scheduling-related delay to reconstruction exposes men to risk for stricture-related complications, according to separate studies presented at the AUA annual meeting in Boston.

The consequences of delayed urethroplasty were investigated in a study undertaken by urologists at UT Southwestern Medical School, Dallas. They conducted a retrospective review of data from 278 men who underwent urethroplasty performed by a single surgeon, senior author Allen F. Morey, MD. All included men had a primary bulbar stricture and follow-up of at least 2 years. Men were excluded if they had prior urethral reconstructive surgery, penile pelvic fracture, or radiation-induced strictures. The findings were published online in the Journal of Urology (Aug. 19, 2017).

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Patients were stratified into three groups based on the number of years between primary stricture diagnosis and urethroplasty: <5 (n=136), 5-10 (n=71), and >10 (n=71). The analyses showed that the proportion of men who had endoscopic management was significantly higher in the subgroup with a delay >10 years than among those who waited <5 or 5-10 years (94% vs. 62% and 73%). Men waiting >10 years also had a significantly higher number of endoscopic treatments compared with their counterparts having delays of <5 and 5-10 years (median, 5 vs. 1 and 2) and were nearly three times as likely to perform self-dilation (34% vs. 13% and 14%).

An analysis looking at impact of delay on having a stricture length ≤2 cm versus >2 cm at the time of urethroplasty was performed using the >2 cm threshold as a surrogate marker for a more complex reconstruction. Compared with subgroups of men who underwent urethroplasty within 5 years or after waiting 5-10 years, the cohort with a delay >10 years had a higher incidence of stricture length >2 cm (56% vs. 40% and 39%) and more often needed a complex repair with a substitution technique (34% vs. 17% and 17%).

An analysis of the association between stricture length and urethroplasty outcome showed that the estimated 24-month stricture-free survival rate was significantly worse in patients whose stricture was >2 cm than in men with a shorter stricture (83% vs. 96%).

“Our data suggest that urethroplasty delay is associated with symptomatic intervals that are often managed by repetitive urethral manipulations that ultimately just kick the can down the road. Not only are these endoscopic treatments ineffective, but they seem to be counterproductive because they increase the risk for a longer stricture that will require a more complex reconstruction and is associated with an increased risk of urethroplasty failure,” said Boyd R. Viers, MD, who was a trauma and genitourinary reconstruction fellow at UT Southwestern Medical School at the time of the study. He is currently assistant professor of urology at Mayo Clinic, Rochester, MN.

Results of a multivariate analysis showed that number of endoscopic treatments was the only independent predictor of having a stricture >2 cm; each procedure increased the risk by 6%. Direct visual internal urethrotomy (DVIU) was the only factor that independently predicted urethroplasty failure; each consecutive DVIU raised the risk by 19%.

Next: Impact of prolonged wait time examined

Impact of prolonged wait time examined

Separately, investigators from the University of Alberta, Edmonton, analyzed the incidence and predictors of complications due to urethral stricture among men waiting for urethroplasty at their institution. Their retrospective review, published online in the Journal of Urology (Sept. 9, 2017), included 276 men who were operated on from 2009 to 2013.

The men had a median age of 44 years, and their strictures were predominantly bulbar (67%) with a median length of 4 cm. Most men were catheter-free, but 11% were being managed with a suprapubic catheter and 1.5% were performing clean intermittent catheterization (CIC). Eighty-three percent had failed a prior endoscopic procedure and 2% had failed previous urethroplasty.

The median interval from when the decision was made to have urethroplasty and the procedure was performed was 151 days. During that wait time, 44 men (16%) experienced a complication at a median of 43 days.

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Urinary tract infection requiring antibiotic treatment was the most common complication (57%) followed by acute urinary retention (21%), catheter-related issues (16%), and acute genitourinary pain not attributable to infection or catheterization (7%). In a univariate analysis, catheter dependence, number of prior endoscopic treatments, and longer surgical wait time were predictors of complications. For the multivariate analysis, catheter-dependent status was stratified by catheter type, and both CIC and having a suprapubic tube were independent predictors of complications, increasing the risk 6.5-fold and 5.2-fold, respectively. Previous urethroplasty, which showed a trend to being a predictor in the univariate analysis (p=.06), was also an independent predictor of complications in the multivariate analysis, increasing risk by 1.6-fold.

A Kaplan-Meier analysis estimating freedom from complications corroborated the findings of the multivariate analysis, showing that patients without a catheter had a much better complication profile than their counterparts managed with either CIC or a suprapubic tube.

“Wait lists for urethroplasty at centers in America, Canada, and Europe are increasing. We believe ours is the first study to look at the morbidity of urethroplasty wait times,” said Nathan Hoy, MD, urology resident at the University of Alberta, who worked on the study with Keith Rourke, MD, and colleagues.

“Our findings suggest that to minimize morbidity, urethroplasty wait time should be less than 43 days and that scheduling should be prioritized for patients with prior urethroplasty and catheters because they appear to be more likely to develop a stricture-related complication,” Dr. Hoy said.

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