Scandinavian Journal of Urology
ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: http://www.tandfonline.com/loi/isju20
Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker & Lars Grenabo To cite this article: Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker & Lars Grenabo (2015): Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures, Scandinavian Journal of Urology To link to this article: http://dx.doi.org/10.3109/21681805.2015.1030689
Published online: 08 Apr 2015.
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Date: 06 November 2015, At: 10:38
http://informahealthcare.com/sju ISSN: 2168-1805 (print), 2168-1813 (electronic) Scand J Urol, 2015; Early Onlne: 1–4 DOI: 10.3109/21681805.2015.1030689
ORIGINAL ARTICLE
Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker and Lars Grenabo
Downloaded by [Florida Atlantic University] at 10:38 06 November 2015
Department of Urology, Sahlgrenska University Hospital, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg, Sweden
Abstract
Key Words:
Objective. The aim of this study was to evaluate outcomes and possible risk factors for failure of open urethroplasty due to penile urethral strictures. Materials and methods. A retrospective chart review was undertaken of 90 patients with penile stricture undergoing 109 open urethroplasties between 2000 and 2011. In 80 urethroplasties, a one-stage procedure was performed: 68 of these had a pediculated penile skin flap, nine had a free buccal mucosal graft and three had a free skin graft. A two-stage procedure using buccal mucosa was performed in 29 urethroplasties. Failure was defined as when further urethral instrumentation was needed. Results. The mean age in the one-stage and two-stage groups were 50 and 54 years, respectively. The success rates in the corresponding groups were 65% and 72%, with follow-up times of 63 and 40 months, respectively. Multivariable analyses disclosed body mass index (BMI) and previous urethral surgery to be significant risk factors for failure in the one-stage group. Failure over time significantly decreased during the study period. Conclusions. Both one- and two-stage penile urethroplasty demonstrated success rates in line with previous reports. Limited experience, high BMI and previous urethral surgery appear to be associated with less favourable outcome.
BMI, clinical experience, risk factors, urethral stricture, urethroplasty
Introduction Penile urethroplasty, often because of poor tissue quality, is technically more challenging than bulbar urethral surgery and the results have been reported to be less satisfactory [1,2]. Local flaps are considered by some to be superior to grafts in penile strictures owing to the need for a satisfactory vascularization of the substitute [3–7]. The stricture is often complex in nature, sometimes appearing after failed previous urethroplasties [8] or previous hypospadias repair [9], and may be associated with conditions such as lichen sclerosus [10–12]. One surgical option for these patients, depending on complexity and aetiology [10], is the two-stage technique using buccal mucosa [13]. There are some reports on possible risk factors that may affect the outcome after urethroplasty, but the findings are far from consistent [14,15]. The aim of this retrospective study was to assess possible risk factors for failure and the outcome of surgical techniques for penile strictures with a long follow-up.
History Received 20 October 2014 Revised 25 February 2015 Accepted 10 March 2015 Online 9 April 2015
urethral stricture, defined as a stricture located distal to the separation of the crura, during 2000–2011. In total, 109 procedures in 90 patients were included in the study. Isolated meatal strictures were not included because at this centre conventional urethroplasties were not performed in these patients. Eighty of the 109 procedures were a one-stage procedure with a skin flap, the Orandi technique (n = 68), a free graft of buccal mucosa (n = 9) or a free skin graft (n = 3). Twenty-nine two-stage procedures were performed in patients with more complicated strictures. In this group, 12 patients had lichen sclerosus. The following risk factors were analysed: stricture length, age, body mass index (BMI), lichen sclerosus, hypospadias, previous internal urethrotomy/previous urethroplasty and clinical experience. The reason why the hypospadias group was separated from those who had undergone previous urethral surgery was the anatomical difference in these patients, due to a defective closure of the penile shaft. Six patients died during the study period and all of them had a follow-up of more than 12 months.
Materials and methods Study population
Follow-up criteria
The authors retrospectively reviewed the charts of all urethroplasties at Sahlgrenska University Hospital due to penile
Follow-up intervals were 3, 12 and 24 months, and more if deemed necessary. If the patient was satisfied with his
Correspondence: Teresa O. Ekerhult, Department of Urology, Sahlgrenska University Hospital, Institute of Clinical Sciences at Sahlgrenska Academy, Elevhemmet, Bruna stråket 11, Go €teborg, SE-41345, Sweden. E-mail: [email protected] 2015 Informa Healthcare.
2 T. O. Ekerhult et al. micturition after 2 years of follow-up, he was discharged and instructed to come back if micturition problems reappeared. Sweden is a small country with good medical coverage. Few centres perform open urethroplasties. Therefore, if a patient experiences problems with micturition after having been discharged, he will invariably be referred back to this clinic. Failure was defined as the appearance of a new stricture or a fistula, needing surgical intervention, such as internal urethrotomy, dilatation or a redo urethroplasty. Stricture recurrence or fistula appearance was diagnosed at cystoscopy during follow-up, combined with the patient’s symptoms such as a poor urine stream, dribbling, leakage, low urinary flow or a urinary retention episode.
Downloaded by [Florida Atlantic University] at 10:38 06 November 2015
Surgical techniques Preoperatively, all patients underwent cystoscopy, sometimes using a ureteroscope; if this was infeasible, a combined retrograde and antegrade urethrography was performed. An antibiotic, such as trimethoprim/sulpha or a quinolone, was given immediately preoperatively. Anticoagulant was standard throughout the hospital stay. All surgical procedures were carried out by two surgeons (LG and KL). There were no obvious indications for choosing one procedure over the other. The indications varied throughout the study period for the different procedures, depending on increased experience, the authors’ own and others. For example, using a two-stage procedure in patients with lichen sclerosus was more frequently applied in the late phase of the study period. One-stage surgery One-stage urethroplasty was mainly carried out using the technique described by Orandi, with a pediculated penile skin flap. Furthermore, nine free buccal grafts and three free skin grafts were used. The free grafts were positioned dorsally or laterally on one of the cavernosal bodies. Five free grafts were sutured perineally after inverting the penis behind the scrotum, in the late phase of the study period (2011). All sutures were made with 4.0 or 5.0 running polyglyconate sutures. A 16 Ch silicone urethral catheter was introduced when one side was sutured, and was left in place for 12 days. Two-stage surgery The stricture, and the abnormal urethra with scar tissue, was completely excised and a temporary urethrostomy was created. After measurement of the stricture length the decision was made to use one or two buccal mucosal grafts. The grafts were cleaned of underlying fatty tissue and meshed. After graft suture a firm dressing was applied for 5 days to prevent the development of underlying haematomas. After 4–6 months the second stage procedure was performed with tubularization of the graft, followed by a 16 Ch catheter for 12 days. Postoperative period Free mobilization was recommended for all patients. Antibiotics were given from the day of surgery and continued until
Scand J Urol, 2015; Early Online: 1–4
3 days after removal of the catheter. Urethrography before catheter removal was not performed as routine, but limited to selected cases. Patients were advised to abstain from sexual activity for 6 weeks postoperatively. Statistical analysis Proportions in categories were compared with Fisher’s exact test. Associations with surgical outcome were examined with univariate and multivariate binary logistic regressions. All statistical tests were two sided and p values less than 0.05 were considered significant. The statistical calculations were performed with SPSS, version 20.0.0 for Mac. The protocol was approved by the University of Gothenburg regional ethical review board (663-11).
Results The penile urethroplasty groups are described in Table 1. Success rates were 65% and 72% for one-stage and two-stage procedures, respectively (Table 2).
Table 1. Description of 109 penile urethroplasties. Urethroplasty type
Patients Age (years) Follow-up (months) Stricture length (cm) Body mass index 16–19 (underweight) 20–25 (normal) 26–29 (overweight) >30 (obese) Pre-internal urethrotomy Pre-urethroplasty Hypospadias Lichen sclerosus
One-stage
Two-stage
80 50 (19–79) 63 (13–144) 3.4 (0.5–12)
29 54 (20–77) 40 (15–118) 4.5 (0.5–13)
2 39 25 13 36 (45) 37 (46) 25 (31) 18 (23)
3 12 7 7 8 19 14 12
(28) (66) (48) (41)
Data are shown as n, mean (range) or n (%).
Table 2. Outcome and risk factors for failure in one- and two-stage urethroplasties for penile stricture. One-stage (n = 80)
Outcome
Two-stage (n = 29)
Stricture, n Fistula, n Success rate
23 5 65%
Risk factor
OR (95% CI)
p
OR (95% CI)
p
BMI Age Lichen sclerosus Preop/DVIU
1.2 1.0 1.1 6.7
0.042* 0.297 0.842 0.02*
1.2 (0.9–1.5) 0.9 (0.8–1.0) 0.3 (0.02–3.3) 0.4 (0.04–3.7)
0.25 0.136 0.307 0.424
(1.0–1.4) (0.9–1.0) (0.3–4.1) (1.4–33.3)
3 5 72%
BMI = body mass index; Preop/DVIU = previous urethroplasty or/and direct vision internal urethrotomy; OR = odds ratio; CI = confidence interval. *Statistically significant (p < 0.05, multivariate analysis).
Risk factors for failure in urethroplasty
Downloaded by [Florida Atlantic University] at 10:38 06 November 2015
DOI: 10.3109/21681805.2015.1030689
Age, stricture length and hypospadias were not significant risk factors for failure in either group. Multivariate analyses found previous urethroplasty surgery and BMI to be significant risk factors for failure in the one-stage group, but not in the two-stage group (Table 2). This finding also holds true for BMI when assessing only the 68 Orandi skin flaps (univariate analysis; p 0.02), excluding the free grafts. An odds ratio increase of 1.2 was observed for every unit increase in BMI. Considering the categorical cut-off BMI above 30, defined as obesity (according to the WHO), an odds ratio of 5.6 (95% confidence interval 1.5–20.3) with a p value of 0.009 was found. Lichen sclerosus and age in the two-stage group were not significant risk factors in the multivariate analyses, although trends were noted in the univariate analyses, both with a p value of 0.07. Twenty-six of 36 of the failures appeared within a 2 year follow-up time (Table 3). The first 55 one- and two-stage urethroplasties were compared with the last 54 during the study period, which demonstrated a significant decrease in failure rate (Table 4).
Discussion The definition of failures varies in different studies of urethroplasties, which may explain the differences in success rate [16]. The following definition was used in the present study: a new stricture or a fistula necessitating surgical intervention, such as internal urethrotomy, dilatation or a new open urethroplasty. Fistula formation is not always defined as a failure in other studies. However, the success rates in both one- and two-stage procedures in this investigation were similar to those in previous studies [6,11,16–19]. In this series, with a long-term follow-up, limited experience, obesity and previous urethroplasty/internal urethrotomy resulted in an increased risk of failure. Obesity, in this series defined as BMI greater than 30, resulted in a significant increase in failure, with an odds ratio
Table 3. Failure during follow-up in one- and two-stage urethroplasties. Failures (n = 36) One-stage (n = 28) Time to failure (years) n
5 1
5 0
Table 4. Outcome of the first 55 consecutive penile urethroplasties compared to the last 54 during 2000–2011. (n = 109)
First half
Second half
No failure Fistula Restricture Total
29 8 18 55
44 2 8 54
Fisher’s exact test: p = 0.002, odds ratio = 0.235, 95% confidence interval = 0.1–0.6.
3
of 5.6. Breyer et al. [15] showed similar results in all types of urethroplasty. Obesity is a globally acknowledged risk factor for diminished health [20]. It is also associated with diabetes and with the metabolic syndrome, resulting in impaired tissue healing [21]. The fact that BMI over 30 was not a significant risk factor in the two-stage surgery may indicate that a two-stage procedure should be performed more often in obese patients. In 36 of the one-stage procedures (n = 80), a repeated internal urethrotomy had been performed, which probably had increased the density and the length of spongiofibrosis, making surgery more difficult [22]. This may explain why previous urethroplasty/urethrotomy was a significant risk for restricture in the one-stage group. It is the authors’ contention that internal urethrotomy should be avoided in penile strictures. There was a significant decrease in failure rate when comparing the first consecutive 55 cases to the last 54 cases. Thus, experience in urethral surgery and probably the selection of an appropriate method seem to be of paramount importance for success. Twenty-six of 36 failures appeared within the first 2 years, a rate in agreement with other studies [18,23]. The limited experience at this centre in the early period of the study made fistula formation four times as frequent than in the late period. Too small grafts and not using enough tissue to cover the urethra in several layers were presumably the reasons for failure, apparent as both restricture and fistula formation. No significant difference was shown for the assumed risk factors in the two-stage procedure group. This group had a slightly shorter follow-up time than the one-stage group. Less sensitivity for risk factors and better outcome suggest that a two-stage procedure should perhaps be performed more frequently, at least in complicated cases. Sometimes the first stage plate erodes and scar formation occurs. In such cases, one should consider redoing the plate to improve the outcome, according to Andrich et al. [24]. This was done only once in the present series. Another patient was already satisfied after the first stage, showing that some patients have suffered so much that anything that makes micturition work at all is good enough. In the one-stage group, free grafts (n = 12 with four failures) were as effective as pediculated flaps (n = 68 with 24 failures), with success rates of 67% and 65%, respectively. Nine of the free grafts were buccal mucosa, which has been proven to be a reliable tissue as a graft for both one- and two-stage urethroplasties [25]. The use of a free graft, combined with the inverted penile operation technique, appears to be of advantage to achieve good results and to prevent penile skin loss and chordae formation, which are sometimes seen in penile skin flap operations. Previous studies have reported stricture length greater than 4 cm to be a risk factor for failure [14,15,18,26]. This observation could not be verified in this study, which may be explained by the fact that earlier studies analysed urethroplasties as a whole group, whereas in this series only penile strictures were evaluated. Another reason could be that in this study two-stage surgeries were performed more frequently in patients with long strictures. This also appears to be true for the patients with lichen sclerosus.
4 T. O. Ekerhult et al.
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This study is retrospective, without randomization, which is a limitation. This group started to perform two-stage procedures from 2003 and they had a shorter follow-up than the one-stage group. However, the patients were subjected to a very rigid follow-up regimen and, moreover, all surgical procedures were performed by the same two surgeons. In conclusion, both one- and two-stage penile urethroplasties demonstrate a success rate in line with previous reports. Limited clinical experience, obesity and previous urethral surgery appear to be associated with less favourable outcomes.
Scand J Urol, 2015; Early Online: 1–4
[10] [11]
[12] [13] [14]
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[15]
References
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Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031–41. Kumar S, Bansal P, Vijay MK, Dutta A, Tiwari P, Sharma PK, et al. Buccal mucosal graft urethroplasty in long segment anterior urethral stricture – is it gold standard? Saudi J Kidney Dis Transpl 2013;24:115–20. Dubey D, Kumar A, Mandhani A, Srivastava A, Kapoor R, Bhandari M. Buccal mucosal urethroplasty: a versatile technique for all urethral segments. BJU Int 2005;95:625–9. Morey AF, Duckett CP, McAninch JW. Failed anterior urethroplasty: guidelines for reconstruction. J Urol 1997;158:1383–7. Orandi A. One-stage urethroplasty: 4-year followup. J Urol 1972;107:977–80. Singh O, Gupta SS, Arvind NK. Anterior urethral strictures: a brief review of the current surgical treatment. Urol Int 2011;86:1–10. Wessells H, McAninch JW. Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction. World J Urol 1998;16:175–80. Barbagli G, Selli C, Tosto A. Reoperative surgery for recurrent strictures of the penile and bulbous urethra. J Urol 1996;156: 76–7. Lee OT, Durbin-Johnson B, Kurzrock EA. Predictors of secondary surgery after hypospadias repair: a population based analysis of 5,000 patients. J Urol 2013;190:251–5.
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Venn SN, Mundy AR. Urethroplasty for balanitis xerotica obliterans. Br J Urol 1998;81:735–7. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009;55:945–56. Palminteri E, Brandes SB, Djordjevic M. Urethral reconstruction in lichen sclerosus. Curr Opin Urol 2012;22:478–83. Riechardt S, Fisch M. Two-stage urethroplasty with buccal mucosa. BJU Int 2012;109:150–62. Breyer BN, McAninch JW, Whitson JM, Eisenberg ML, Mehdizadeh JF, Myers JB, et al. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol 2010;183: 613–17. Breyer BN, McAninch JW, Whitson JM, Eisenberg ML, Master VA, Voelzke BB, et al. Effect of obesity on urethroplasty outcome. Urology 2009;73:1352–5. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011;59:797–814. Mundy AR. The long-term results of skin inlay urethroplasty. Br J Urol 1995;75:59–61. Mellon MJ, Bihrle R. Ventral onlay buccal mucosa urethroplasty: a 10-year experience. Int J Urol 2014;21:190–3. Barbagli G, Morgia G, Lazzeri M. Retrospective outcome analysis of one-stage penile urethroplasty using a flap or graft in a homogeneous series of patients. BJU Int 2008;102:853–60. Genne-Bacon EA. Thinking evolutionarily about obesity. Yale J Biol Med 2014;87:99–112. Mydlo JH. The impact of obesity in urology. Urol Clin North Am 2004;31:275–87. Barbagli G, Palminteri E, Lazzeri M, Guazzoni G, Turini D. Long-term outcome of urethroplasty after failed urethrotomy versus primary repair. J Urol 2001;165:1918–19. Ekerhult TO, Lindqvist K, Peeker R, Grenabo L. Low risk of sexual dysfunction after transection and nontransection urethroplasty for bulbar urethral stricture. J Urol 2013;190:635–8. Andrich DE, Greenwell TJ, Mundy AR. The problems of penile urethroplasty with particular reference to 2-stage reconstructions. J Urol 2003;170:87–9. JE III, Markiewicz MR, Lukose MA, Margarone Barbagli G, Miller KS, Chuang SK. The oral mucosa graft: a systematic review. J Urol 2007;178:387–94. Kinnaird AS, Levine MA, Ambati D, Zorn JD, Rourke KF. Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: a multivariate analysis of 604 urethroplasties. Can Urol Assoc J 2014;8:E296–300.
ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: http://www.tandfonline.com/loi/isju20
Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker & Lars Grenabo To cite this article: Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker & Lars Grenabo (2015): Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures, Scandinavian Journal of Urology To link to this article: http://dx.doi.org/10.3109/21681805.2015.1030689
Published online: 08 Apr 2015.
Submit your article to this journal
Article views: 14
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju20 Download by: [Florida Atlantic University]
Date: 06 November 2015, At: 10:38
http://informahealthcare.com/sju ISSN: 2168-1805 (print), 2168-1813 (electronic) Scand J Urol, 2015; Early Onlne: 1–4 DOI: 10.3109/21681805.2015.1030689
ORIGINAL ARTICLE
Limited experience, high body mass index and previous urethral surgery are risk factors for failure in open urethroplasty due to penile strictures Teresa O. Ekerhult, Klas Lindqvist, Ralph Peeker and Lars Grenabo
Downloaded by [Florida Atlantic University] at 10:38 06 November 2015
Department of Urology, Sahlgrenska University Hospital, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg, Sweden
Abstract
Key Words:
Objective. The aim of this study was to evaluate outcomes and possible risk factors for failure of open urethroplasty due to penile urethral strictures. Materials and methods. A retrospective chart review was undertaken of 90 patients with penile stricture undergoing 109 open urethroplasties between 2000 and 2011. In 80 urethroplasties, a one-stage procedure was performed: 68 of these had a pediculated penile skin flap, nine had a free buccal mucosal graft and three had a free skin graft. A two-stage procedure using buccal mucosa was performed in 29 urethroplasties. Failure was defined as when further urethral instrumentation was needed. Results. The mean age in the one-stage and two-stage groups were 50 and 54 years, respectively. The success rates in the corresponding groups were 65% and 72%, with follow-up times of 63 and 40 months, respectively. Multivariable analyses disclosed body mass index (BMI) and previous urethral surgery to be significant risk factors for failure in the one-stage group. Failure over time significantly decreased during the study period. Conclusions. Both one- and two-stage penile urethroplasty demonstrated success rates in line with previous reports. Limited experience, high BMI and previous urethral surgery appear to be associated with less favourable outcome.
BMI, clinical experience, risk factors, urethral stricture, urethroplasty
Introduction Penile urethroplasty, often because of poor tissue quality, is technically more challenging than bulbar urethral surgery and the results have been reported to be less satisfactory [1,2]. Local flaps are considered by some to be superior to grafts in penile strictures owing to the need for a satisfactory vascularization of the substitute [3–7]. The stricture is often complex in nature, sometimes appearing after failed previous urethroplasties [8] or previous hypospadias repair [9], and may be associated with conditions such as lichen sclerosus [10–12]. One surgical option for these patients, depending on complexity and aetiology [10], is the two-stage technique using buccal mucosa [13]. There are some reports on possible risk factors that may affect the outcome after urethroplasty, but the findings are far from consistent [14,15]. The aim of this retrospective study was to assess possible risk factors for failure and the outcome of surgical techniques for penile strictures with a long follow-up.
History Received 20 October 2014 Revised 25 February 2015 Accepted 10 March 2015 Online 9 April 2015
urethral stricture, defined as a stricture located distal to the separation of the crura, during 2000–2011. In total, 109 procedures in 90 patients were included in the study. Isolated meatal strictures were not included because at this centre conventional urethroplasties were not performed in these patients. Eighty of the 109 procedures were a one-stage procedure with a skin flap, the Orandi technique (n = 68), a free graft of buccal mucosa (n = 9) or a free skin graft (n = 3). Twenty-nine two-stage procedures were performed in patients with more complicated strictures. In this group, 12 patients had lichen sclerosus. The following risk factors were analysed: stricture length, age, body mass index (BMI), lichen sclerosus, hypospadias, previous internal urethrotomy/previous urethroplasty and clinical experience. The reason why the hypospadias group was separated from those who had undergone previous urethral surgery was the anatomical difference in these patients, due to a defective closure of the penile shaft. Six patients died during the study period and all of them had a follow-up of more than 12 months.
Materials and methods Study population
Follow-up criteria
The authors retrospectively reviewed the charts of all urethroplasties at Sahlgrenska University Hospital due to penile
Follow-up intervals were 3, 12 and 24 months, and more if deemed necessary. If the patient was satisfied with his
Correspondence: Teresa O. Ekerhult, Department of Urology, Sahlgrenska University Hospital, Institute of Clinical Sciences at Sahlgrenska Academy, Elevhemmet, Bruna stråket 11, Go €teborg, SE-41345, Sweden. E-mail: [email protected] 2015 Informa Healthcare.
2 T. O. Ekerhult et al. micturition after 2 years of follow-up, he was discharged and instructed to come back if micturition problems reappeared. Sweden is a small country with good medical coverage. Few centres perform open urethroplasties. Therefore, if a patient experiences problems with micturition after having been discharged, he will invariably be referred back to this clinic. Failure was defined as the appearance of a new stricture or a fistula, needing surgical intervention, such as internal urethrotomy, dilatation or a redo urethroplasty. Stricture recurrence or fistula appearance was diagnosed at cystoscopy during follow-up, combined with the patient’s symptoms such as a poor urine stream, dribbling, leakage, low urinary flow or a urinary retention episode.
Downloaded by [Florida Atlantic University] at 10:38 06 November 2015
Surgical techniques Preoperatively, all patients underwent cystoscopy, sometimes using a ureteroscope; if this was infeasible, a combined retrograde and antegrade urethrography was performed. An antibiotic, such as trimethoprim/sulpha or a quinolone, was given immediately preoperatively. Anticoagulant was standard throughout the hospital stay. All surgical procedures were carried out by two surgeons (LG and KL). There were no obvious indications for choosing one procedure over the other. The indications varied throughout the study period for the different procedures, depending on increased experience, the authors’ own and others. For example, using a two-stage procedure in patients with lichen sclerosus was more frequently applied in the late phase of the study period. One-stage surgery One-stage urethroplasty was mainly carried out using the technique described by Orandi, with a pediculated penile skin flap. Furthermore, nine free buccal grafts and three free skin grafts were used. The free grafts were positioned dorsally or laterally on one of the cavernosal bodies. Five free grafts were sutured perineally after inverting the penis behind the scrotum, in the late phase of the study period (2011). All sutures were made with 4.0 or 5.0 running polyglyconate sutures. A 16 Ch silicone urethral catheter was introduced when one side was sutured, and was left in place for 12 days. Two-stage surgery The stricture, and the abnormal urethra with scar tissue, was completely excised and a temporary urethrostomy was created. After measurement of the stricture length the decision was made to use one or two buccal mucosal grafts. The grafts were cleaned of underlying fatty tissue and meshed. After graft suture a firm dressing was applied for 5 days to prevent the development of underlying haematomas. After 4–6 months the second stage procedure was performed with tubularization of the graft, followed by a 16 Ch catheter for 12 days. Postoperative period Free mobilization was recommended for all patients. Antibiotics were given from the day of surgery and continued until
Scand J Urol, 2015; Early Online: 1–4
3 days after removal of the catheter. Urethrography before catheter removal was not performed as routine, but limited to selected cases. Patients were advised to abstain from sexual activity for 6 weeks postoperatively. Statistical analysis Proportions in categories were compared with Fisher’s exact test. Associations with surgical outcome were examined with univariate and multivariate binary logistic regressions. All statistical tests were two sided and p values less than 0.05 were considered significant. The statistical calculations were performed with SPSS, version 20.0.0 for Mac. The protocol was approved by the University of Gothenburg regional ethical review board (663-11).
Results The penile urethroplasty groups are described in Table 1. Success rates were 65% and 72% for one-stage and two-stage procedures, respectively (Table 2).
Table 1. Description of 109 penile urethroplasties. Urethroplasty type
Patients Age (years) Follow-up (months) Stricture length (cm) Body mass index 16–19 (underweight) 20–25 (normal) 26–29 (overweight) >30 (obese) Pre-internal urethrotomy Pre-urethroplasty Hypospadias Lichen sclerosus
One-stage
Two-stage
80 50 (19–79) 63 (13–144) 3.4 (0.5–12)
29 54 (20–77) 40 (15–118) 4.5 (0.5–13)
2 39 25 13 36 (45) 37 (46) 25 (31) 18 (23)
3 12 7 7 8 19 14 12
(28) (66) (48) (41)
Data are shown as n, mean (range) or n (%).
Table 2. Outcome and risk factors for failure in one- and two-stage urethroplasties for penile stricture. One-stage (n = 80)
Outcome
Two-stage (n = 29)
Stricture, n Fistula, n Success rate
23 5 65%
Risk factor
OR (95% CI)
p
OR (95% CI)
p
BMI Age Lichen sclerosus Preop/DVIU
1.2 1.0 1.1 6.7
0.042* 0.297 0.842 0.02*
1.2 (0.9–1.5) 0.9 (0.8–1.0) 0.3 (0.02–3.3) 0.4 (0.04–3.7)
0.25 0.136 0.307 0.424
(1.0–1.4) (0.9–1.0) (0.3–4.1) (1.4–33.3)
3 5 72%
BMI = body mass index; Preop/DVIU = previous urethroplasty or/and direct vision internal urethrotomy; OR = odds ratio; CI = confidence interval. *Statistically significant (p < 0.05, multivariate analysis).
Risk factors for failure in urethroplasty
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DOI: 10.3109/21681805.2015.1030689
Age, stricture length and hypospadias were not significant risk factors for failure in either group. Multivariate analyses found previous urethroplasty surgery and BMI to be significant risk factors for failure in the one-stage group, but not in the two-stage group (Table 2). This finding also holds true for BMI when assessing only the 68 Orandi skin flaps (univariate analysis; p 0.02), excluding the free grafts. An odds ratio increase of 1.2 was observed for every unit increase in BMI. Considering the categorical cut-off BMI above 30, defined as obesity (according to the WHO), an odds ratio of 5.6 (95% confidence interval 1.5–20.3) with a p value of 0.009 was found. Lichen sclerosus and age in the two-stage group were not significant risk factors in the multivariate analyses, although trends were noted in the univariate analyses, both with a p value of 0.07. Twenty-six of 36 of the failures appeared within a 2 year follow-up time (Table 3). The first 55 one- and two-stage urethroplasties were compared with the last 54 during the study period, which demonstrated a significant decrease in failure rate (Table 4).
Discussion The definition of failures varies in different studies of urethroplasties, which may explain the differences in success rate [16]. The following definition was used in the present study: a new stricture or a fistula necessitating surgical intervention, such as internal urethrotomy, dilatation or a new open urethroplasty. Fistula formation is not always defined as a failure in other studies. However, the success rates in both one- and two-stage procedures in this investigation were similar to those in previous studies [6,11,16–19]. In this series, with a long-term follow-up, limited experience, obesity and previous urethroplasty/internal urethrotomy resulted in an increased risk of failure. Obesity, in this series defined as BMI greater than 30, resulted in a significant increase in failure, with an odds ratio
Table 3. Failure during follow-up in one- and two-stage urethroplasties. Failures (n = 36) One-stage (n = 28) Time to failure (years) n
5 1
5 0
Table 4. Outcome of the first 55 consecutive penile urethroplasties compared to the last 54 during 2000–2011. (n = 109)
First half
Second half
No failure Fistula Restricture Total
29 8 18 55
44 2 8 54
Fisher’s exact test: p = 0.002, odds ratio = 0.235, 95% confidence interval = 0.1–0.6.
3
of 5.6. Breyer et al. [15] showed similar results in all types of urethroplasty. Obesity is a globally acknowledged risk factor for diminished health [20]. It is also associated with diabetes and with the metabolic syndrome, resulting in impaired tissue healing [21]. The fact that BMI over 30 was not a significant risk factor in the two-stage surgery may indicate that a two-stage procedure should be performed more often in obese patients. In 36 of the one-stage procedures (n = 80), a repeated internal urethrotomy had been performed, which probably had increased the density and the length of spongiofibrosis, making surgery more difficult [22]. This may explain why previous urethroplasty/urethrotomy was a significant risk for restricture in the one-stage group. It is the authors’ contention that internal urethrotomy should be avoided in penile strictures. There was a significant decrease in failure rate when comparing the first consecutive 55 cases to the last 54 cases. Thus, experience in urethral surgery and probably the selection of an appropriate method seem to be of paramount importance for success. Twenty-six of 36 failures appeared within the first 2 years, a rate in agreement with other studies [18,23]. The limited experience at this centre in the early period of the study made fistula formation four times as frequent than in the late period. Too small grafts and not using enough tissue to cover the urethra in several layers were presumably the reasons for failure, apparent as both restricture and fistula formation. No significant difference was shown for the assumed risk factors in the two-stage procedure group. This group had a slightly shorter follow-up time than the one-stage group. Less sensitivity for risk factors and better outcome suggest that a two-stage procedure should perhaps be performed more frequently, at least in complicated cases. Sometimes the first stage plate erodes and scar formation occurs. In such cases, one should consider redoing the plate to improve the outcome, according to Andrich et al. [24]. This was done only once in the present series. Another patient was already satisfied after the first stage, showing that some patients have suffered so much that anything that makes micturition work at all is good enough. In the one-stage group, free grafts (n = 12 with four failures) were as effective as pediculated flaps (n = 68 with 24 failures), with success rates of 67% and 65%, respectively. Nine of the free grafts were buccal mucosa, which has been proven to be a reliable tissue as a graft for both one- and two-stage urethroplasties [25]. The use of a free graft, combined with the inverted penile operation technique, appears to be of advantage to achieve good results and to prevent penile skin loss and chordae formation, which are sometimes seen in penile skin flap operations. Previous studies have reported stricture length greater than 4 cm to be a risk factor for failure [14,15,18,26]. This observation could not be verified in this study, which may be explained by the fact that earlier studies analysed urethroplasties as a whole group, whereas in this series only penile strictures were evaluated. Another reason could be that in this study two-stage surgeries were performed more frequently in patients with long strictures. This also appears to be true for the patients with lichen sclerosus.
4 T. O. Ekerhult et al.
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This study is retrospective, without randomization, which is a limitation. This group started to perform two-stage procedures from 2003 and they had a shorter follow-up than the one-stage group. However, the patients were subjected to a very rigid follow-up regimen and, moreover, all surgical procedures were performed by the same two surgeons. In conclusion, both one- and two-stage penile urethroplasties demonstrate a success rate in line with previous reports. Limited clinical experience, obesity and previous urethral surgery appear to be associated with less favourable outcomes.
Scand J Urol, 2015; Early Online: 1–4
[10] [11]
[12] [13] [14]
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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