Abstract
Background:
Urethroplasty is often successful for the treatment of male urethral stricture disease, but limited data exists on recurrence management. Our goal was to evaluate direct visual internal urethrotomy (DVIU) as a treatment option for isolated, recurrent strictures after urethroplasty.
Methods:
We retrospectively identified male patients who underwent urethroplasty from 1999 to 2013 and developed an isolated, recurrent stricture at the urethroplasty site treated with DVIU. Success was defined as lack of symptomatology and no subsequent intervention. Comparative analysis identified characteristics and stricture properties associated with success.
Results:
A total of 436 urethroplasties were performed in 401 patients at our institution between 1999 and 2013. Stricture recurrence was noted in 64 (16%) patients. Of these, 47 (73%) underwent a DVIU. A total of 37 patients met inclusion criteria and underwent 50 DVIU procedures at the urethroplasty site. A single DVIU was successful in 13 of 37 patients (35%). A total of 4 of 6 patients required a second DVIU (67%). Overall, 17 of 43 (40%) of the total DVIUs were successful after urethroplasty. Success did not differ by age, stricture length or location, surgical technique, radiation history, prior urethroplasty or DVIU, time to failure, or etiology.
Conclusions:
Post-urethroplasty DVIU for isolated, recurrent strictures may be offered as a minimally invasive treatment option. Approximately 40% of patients were spared further intervention.
Introduction
Current reports show that up to 50% of recurrences for urethroplasty are short fibrous strictures at either the proximal or distal anastomotic site [Barbagli et al. 2006; Rosenbaum et al. 2015; Morey and McAninch, 1997]. Direct visual internal urethrotomy (DVIU) has been proposed as a valid, minimally invasive salvage procedure [Barbagli et al. 2006; Rosenbaum et al. 2015; Morey and McAninch, 1997]. Our goal was to further evaluate DVIU as a treatment option for isolated, post-urethroplasty strictures. We also aimed to identify patient and operative characteristics predictive of DVIU success in such patients.
Materials and methods
After Institutional Review Board approval, a retrospective chart review was performed to identify all urethroplasties [Current Procedural Terminology (CPT) codes 53410, 15740, 40818, 53415, 53415] performed at our institution from 1999 to 2013. Patients with symptomatic recurrence undergoing a subsequent DVIU at the previous urethroplasty site were then identified from this cohort using CPT code 52648. Patients were excluded for multifocal stricture recurrence or progression to urethral stent placement.
Patient demographics, operative details, and initial stricture properties including length, location (penile/meatal/fossa navicularis, bulbar, or prostatomembranous) and etiology were assimilated. The surgical technique [excision and primary anastomosis (EPA), buccal mucosa graft urethroplasty (BMGU), or penile fasciocutaneous flap (PFF)] was based on surgeon preference incorporating data from preoperative imaging, disease etiology, prior intervention, stricture length, location and tissue quality. Initial stricture length was determined by preoperative imaging and intraoperative measurement. Patients were evaluated after urethroplasty with subjective symptom assessment, the American Urological Association symptom score (AUA-SS) questionnaire, cystoscopy, uroflowmetry, and post-void residual.
Patients with a symptomatic recurrence at the urethroplasty stricture site were evaluated uniformly with cystoscopy and radiographic imaging [retrograde urethrogram (RUG) or voiding cystourethrogram] prior to DVIU. Stricture recurrence was defined as a symptomatic stricture requiring operative intervention. DVIU was then performed in the standard fashion at the urethroplasty site [Kaufman and Milam, 2012]. The urethral incision was considered adequate when the cystoscope or urethrotome easily passed into the bladder. An indwelling catheter was generally left for 3–7 days in our series, although recent data and the AUA guidelines suggest that a urethral catheter may be safely removed 72 h after an uncomplicated DVIU [Wessells et al. 2016; Yuruk et al. 2016].
Post-DVIU treatment success was defined as lack of symptomatology and no further need for additional interventions, including self-dilation. Patients requiring post-DVIU dilation regimens or any subsequent surgical intervention were considered failures in this analysis. Patients were followed at regular intervals with subjective assessment, AUA-SS, and uroflowmetry, though the latter two variables were not available for all patients.
Patients were then stratified into two groups: successes and failures. Variables including age, length and location of the initial stricture, time to urethroplasty failure, urethroplasty technique, radiation history, prior urethroplasty, number of pre-urethroplasty DVIUs, and etiology of the original stricture were compared between groups using the two-sample Student’s t-test with unequal variance or the Fisher exact test. Logistic regression was then performed to identify individual predictors associated with post-urethroplasty DVIU success. The level of statistical significance was set at p < 0.05. The statistical software program STATA, version 13 (College Station, TX, USA) was employed for all statistical analysis.
Results
There were 436 urethroplasties performed in 401 patients at our institution between 1999 and 2013. Stricture recurrence was noted in 64 (16%) patients. Of these, 47 (73%) underwent a DVIU. Of these, 10 were excluded: DVIU at a site other than the prior urethroplasty (5), and urethral stent history (5). A total of 37 patients met inclusion criteria and underwent 50 DVIU procedures at the urethroplasty site. Descriptive statistics of the cohort are shown in Table 1. Urethral stricture locations and urethroplasty techniques (EPA, BMGU, PFF) are shown in Table 2. A single DVIU was successful in 13 of 37 patients (35%). A second DVIU was successful in 4 of 6 patients (67%). Overall, 17 of 43 (40%) of the total DVIUs were successful after urethroplasty. Time to urethroplasty failure was defined as the time interval between urethroplasty and DVIU. There was no difference in DVIU success among patients with an early stricture recurrence (<3 months) compared with those with a delayed recurrence (>3 months), 40% versus 48%, (p = 0.7), respectively. Follow-up data were available for 10 patients at 48–164 months and 14 patients at 12–48 months. Overall, four patients had less than 6 months of follow up at our institution. Median follow up after DVIU intervention was 23 months (range 0.5–164). For the patients classified as failures after DVIU, patients were managed with self-intermittent catheterization/self-dilation (9), repeat urethroplasty (5), office dilations (3), and observation (3). Our comparative analysis did not identify any statistical significance between those deemed successes or failures with regard to age (p = 0.8), stricture length (p = 0.8), stricture location (p = 0.7), urethroplasty technique (p = 0.3), radiation history (p = 0.2), prior urethroplasty (p = 0.7), prior DVIU (p = 0.6), overall time to urethroplasty failure (p = 0.7), and etiology of the original stricture (p = 0.6) (Table 3).
Descriptive statistics of cohort.
BMGU, buccal mucosa graft urethroplasty; DVIU, direct visual internal urethrotomy; EPA, excision and primary anastomosis; PFF, penile fasciocutaneous flap.
Urethroplasty technique utilized by urethral stricture location.
BMGU, buccal mucosa graft urethroplasty; EPA, excision and primary anastomosis; PFF, penile fasciocutaneous flap.
Comparative analysis of risk factors for DVIU success or failure.
BMGU, buccal mucosa graft urethroplasty; DVIU, direct visual internal urethrotomy; EPA, excision and primary anastomosis; PFF, penile fasciocutaneous flap; SD, standard deviation.
Discussion
Post-urethroplasty DVIU for isolated, recurrent strictures may be offered as a minimally invasive treatment option. In our study, 17 of 43 (40%) of the total DVIUs were successful after urethroplasty. A single DVIU was successful in 13 of 37 (35%) patients, with 4 of these patients requiring a second DVIU (11%). We were unable to identify any patient or operative characteristics predictive of DVIU success.
While urethroplasty is the gold standard for the treatment of male urethral stricture disease [Morey and McAninch, 1997; Hosseini and Tavakkoli Tabassi, 2008; Corriere, 2001; Flynn et al. 2003] strictures can recur at the anastomotic site due to the heterogeneous pathology of urethral stricture disease. Some authors surmise urethral ischemia and the resulting defects in the imbibition and inosculation phase for graft uptake or graft contraction as etiologies for failure [Barbagli et al. 2006]. Others have reported contributing factors to urethroplasty failure as incomplete excision of the stricture, excessive anastomotic tension, or inadequate fixation to allow for mucosa-to-mucosa apposition [Koraitim, 2012]. Surgical technique and graft compromise is difficult to assess in a retrospective fashion, but certainly can contribute to urethroplasty failure.
Morey and McAninch reported an 88% success rate of DVIU specifically for post-EPA urethroplasty recurrence [Morey and McAninch, 1997]. The previous excision of the surrounding fibrosis in this salvage setting was thought to contribute to the higher success rates, as only a narrow fibrotic ring was present at the EPA site. Rosenbaum and colleagues recently reported the results of their cohort of 43 patients who underwent DVIU for a short (<1 cm), ‘veil-like’ stricture recurrence after BMGU [Rosenbaum et al. 2015]. Overall success was 60.5% at 15 months, defined as Qmax >15 ml/s and no evidence of stricture on imaging or cystoscopy. Rosenbaum and colleagues also evaluated the history of radiation, prior DVIU, stricture location, length, time to recurrence, and age, and could not identify risk factors that predicted DVIU success for BMGU recurrent strictures. Similarly, we also did not find a correlation for these risk factors, though this is a limitation of our dataset; our small numbers are not powered to truly determine a difference.
In a series by Barbagli and colleagues, 12 of the 22 (55%) BMGU failures involved the whole graft, while the remaining 10 (45%) were located at the anastomotic sites [Barbagli et al. 2006]. The failures involving the whole graft were initially treated with perineal urethrostomy of which six subsequently underwent urethrostomy closure and new BMGU. The failures at the anastomotic sites were found to be white, fibrous ring strictures not more than 1 cm in length and located evenly at both the proximal and distal anastomotic sites. A total of seven of these patients underwent DVIU, and while the remaining three underwent open repair; the authors noted in hindsight that these may have been amenable to DVIU instead. There is no stratification of the success of the salvage procedures but 16 of the 22 failures (73%) had a satisfactory final outcome and no further intervention at the mean follow up of 38 months. The recurrences in our series correspond most consistently with these discrete anastomotic ring strictures as described by Morey and McAninch, Rosenbaum and colleagues, and Barbargli and colleagues [Barbagli et al. 2006; Rosenbaum et al. 2015; Morey and McAninch, 1997].
Though the stricture etiologies of most of our patients were not pelvic fracture urethral defects (PFUDs), there are several studies that address stricture recurrence in this setting. A recent study by Fu and colleagues described a 9.6% recurrence rate for over 500 urethroplasties performed for PFUDs [Fu et al. 2013]. Meeks and colleagues performed a meta-analysis of 86 articles, which included 5000 men with a history of urethroplasty, and identified an overall recurrence rate of 15.6%, similar to the 16% identified in our study [Meeks et al. 2009]. Recurrence was evaluated using a multi-tiered approach involving uroflowmetry (56%), AUA-SS patient symptoms (47%), retrograde urethrogram (51%), and cystoscopy (46%) based on percentage of overall use.
Hosseini and Tavakkoli Tabassi reported on 12 cases of DVIU for recurrent stricture after posterior urethroplasty in children [Hosseini and Tavakkoli Tabassi, 2008]. Their main aim was to evaluate the results of early (within 6 weeks of urethroplasty) versus delayed (after 12 weeks of urethroplasty) DVIU. The etiology of the primary stricture was trauma and all stricture lengths were 0.5–1 cm. After DVIU, patients underwent a self-dilation protocol for 4 months. At a mean follow up of 5 years after termination of the dilation protocol, the stricture-free rate was 66.6% after early and 33.3% after delayed DVIU (p = 0.03). Additionally, the median time to stricture recurrence was 14 months after early DVIU and 6 months after delayed DVIU. The authors hypothesized that this was the result of progression and maturation of scar with the passage of time. In our study, there was no difference in DVIU outcomes when comparing urethroplasty failure time of <3 months with >3 months.
In a similar patient demographic, Helmy and Hafez reported on 22 children who had undergone DVIU for recurrent stricture diagnosed by retrograde urethrogram after perineal anastomotic urethroplasty for a pelvic fracture urethral disruption [Helmy and Hafez, 2013]. No dilation protocol was utilized. Success was defined as asymptomatic voiding without clinical evidence of residual stricture. All patients had initial strictures <1 cm in length. After a mean follow-up duration of 98 months, 77% had no evidence of recurrent disease and needed no subsequent procedures. Repeat DVIU performed in initial failure was successful in three patients, yielding an overall success rate after second DVIU of 90%. While these outcomes are superior to other series, comorbidities known to compromise wound healing such as smoking and pelvic radiation are not presumed to be risk factors in children, and thus may contribute to lower success rates in the adult population [Rosenbaum et al. 2015; Blaschko et al. 2012]. Similarly, patients at high risk for failure, such as those with lichen sclerosis, radiation, or prior urethral reconstruction were included in our study, which may contribute to our lower success rate (40%).
DVIU is also a minimally invasive treatment option for urethral stricture disease, and may be deemed as appropriate firstline therapy in some patients. Generally, the reported success rates after a single DVIU for primary treatment range from 20–60% [Breyer et al. 2010]. Santucci and Eisenberg demonstrated stricture-free rates that approached 0% after successive DVIU [Santucci and Eisenberg, 2010]. However, these numbers may not necessarily be extrapolated to the post-urethroplasty setting. In fact, there is evidence that DVIU in the salvage setting is more effective. Furthermore, there is clear evidence that primary stricture length and previous endoscopic treatment plays a role in developing recurrence. In a randomized prospective study, Steenkamp and colleagues documented a 40% recurrence rate for strictures <2 cm and an 80% recurrence rate for strictures >4 cm within 12 months after DVIU [Steenkamp et al. 1997]. In fact, a new protocol by Zaid and colleagues proposes a DVIU as initial treatment for recurrent, <1 cm bulbar strictures in patients with no history of previous endoscopic management [Zaid et al. 2016].
Herein, we report DVIU outcomes for post-urethroplasty recurrent strictures with several limitations to this study. We were unable to identify any patient or operative characteristics predictive of DVIU success: our comparative analysis is underpowered with our small sample size. We were also unable to stratify the DVIU intervention by graft type. The retrospective nature of the study may introduce possible treatment selection bias, as the recurrent strictures were determined in general to be most amenable to urethrotomy. Moreover, success rates of primary DVIU have been shown to correlate with follow up [Pansadoro and Emiliozzi, 1996; Elliott et al. 2003]. As such, if these successes are extrapolated to post-urethroplasty DVIU, our mean follow up of 23 months may not capture our long-term failures. Furthermore, many patients follow up with their primary urologists closer to home, returning only with symptom change, which limits our availability to collect long-term data.
Though our numbers are limited, the heterogeneity of our cohort in this preliminary study can provide important clinical information for patient counseling as it includes multiple etiologies, stricture locations, and urethroplasty techniques. As such, we did not exclude patients at high risk for failure. As a result, our success rates may be lower than those previously reported, but this study embodies a representative sample for many clinical practices.
Conclusion
DVIU may be offered as a minimally invasive treatment option for isolated, recurrent strictures after urethroplasty. Overall, approximately 40% of patients in this study were spared self-dilation regimens or further operative intervention. There were not any identifiable patient or operative characteristics predictive of urethroplasty success in this preliminary study, which raises critical questions regarding the ideal management of recurrent strictures for this complicated disease process. Further research is needed to identify predictive factors for DVIU success between these groups.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement
Roger Dmochowski is a consultant for Allergan and Medtronic. Douglas Milam is a consultant for Boston Scientific. Melissa Kaufman is a consultant for Boston Scientific and Cook Myosite. All other authors declare that there is no conflict of interest.