Abstract
ObjectivesTo evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty.Patients and methodsMonocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan–Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM).ResultsOverall, 47 patients were available for final analyses. Median age was 70 (IQR 65–74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28–68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome.ConclusionThe success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.
Highlights
Despite the increasing uptake of active surveillance, interventional therapies such as radiation therapy (RT) and radical prostatectomy represent a cornerstone in the treatment of localized prostate cancer (PCa) [1]
Stricture prevalence was higher in case of combination therapy [4] and these modalitydependent trends were corroborated in a SEER-Medicare linked cohort with 10-year propensity-weighted cumulative incidences of 9.6%, 12%, and 19% after brachytherapy, external beam RT, and combination therapy, respectively [3]
In the absence of level I evidence to prove the superiority of one technique over the other, all of those reports suffer from a lack of urethral stricture-specific validated patient-reported outcome measurements (PROMs) [12]
Summary
Despite the increasing uptake of active surveillance, interventional therapies such as radiation therapy (RT) and radical prostatectomy represent a cornerstone in the treatment of localized prostate cancer (PCa) [1]. While the available evidence on urethroplasty for radiationinduced strictures is very limited, reports are congruent regarding a significantly shorter recurrence-free survival compared to strictures of non-radiogenic etiology [5,6,7,8]. Such complexity is mainly promoted by prostatic radionecrosis [9], proximity to the urinary sphincter due to the bulbomembranous location in the majority of cases [4], and impaired tissue vascularity [10]. In patients with a history of RT, it is highly relevant to assess urinary incontinence (UI), erectile dysfunction (ED), and quality of life in a standardized fashion, as many patients are rendered incontinent after urethroplasty and may present with ED due to extensive radiation fibrosis
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