Urethroplasty outcomes improved by 'urethral rest'

Dallas-A "urethral rest" period appears to be beneficial for optimizing disease delineation in patients referred for anterior urethroplasty, say researchers from the University of Texas Southwestern Medical Center, Dallas.

The study authors reviewed 135 consecutive anterior urethroplasty patients operated on by a single surgeon (Dr. Morey) between 2007 and 2009. They identified 28 patients (21%) who were placed on a period of urethral rest for a minimum of 1 month (median, 3 months) prior to their reconstructive procedure. The protocol for urethral rest involves removal of any indwelling urethral catheter, cessation of self-catheterization, and consideration to suprapubic catheter placement. Of the 28 patients put on urethral rest, 15 received elective placement of a suprapubic tube.

"Multiple prior interventions prior to urethroplasty is an established risk factor for postoperative recurrence, which often occurs at the ends of a repair and is presumed to be from failure to recognize the full extent of disease at the time of surgery," said Dr. Terlecki, who is currently an assistant professor of urology at Wake Forest University, Winston-Salem, NC. "Our practice for such patients has been to implement a period of urethral rest based on the hypothesis that urethral defunctionalization allows for progression of soft tissue wound healing so that recently manipulated strictures, which can artificially appear patent, may declare themselves as obliterative. This is important because we feel that obliterative segments require excision.

"Our findings support this hypothesis, along with a recommendation to refrain from urethral instrumentation prior to tertiary referral of patients for anterior urethroplasty because such intervention can complicate the evaluation and delay definitive reconstructive surgery."

Recurrence linked with shorter rest period

During a median postoperative follow-up of 486 days, stricture recurrence was seen in four of 28 patients (14%); one of these had an excision with primary anastomosis, while the others had augmented anastomotic procedures. Recurrent strictures were more often associated with prior urethral dilation or internal urethrotomy and less likely to have been managed with a suprapubic catheter preoperatively. Median duration of urethral rest was significantly shorter among recurrent cases (8 weeks vs. 12 weeks), Dr. Terlecki reported at the 2010 AUA annual meeting in San Francisco.

"Prior histologic studies have shown that hydrodilatation proximal to a stricture may extend tissue injury proximally and that suprapubic diversion may limit such changes. Our clinical results support these findings," he said.

Dr. Terlecki also observed that while the data suggested a slight benefit for extending the period of urethral rest, a prospective study would be needed to help define the optimal duration. In addition, considering that suprapubic tube placement may affect quality of life, prospective data to verify a benefit toward improved surgical outcomes are desired.