Urethroplasty For Urethral Stricture Disease Research Articles

Early Post-Operative Events After Urethroplasty in Obese Patients: A Multi-Institutional Retrospective Series

ObjectiveTo compare early urethroplasty outcomes in non-obese, obese and morbidly obese patients undergoing urethroplasty for urethral stricture disease. The impact of obesity on outcomes is poorly understood but will be increasingly important as obesity continues to rise. MethodsPatients underwent urethroplasty at one of five institutions between January 2016 and December 2020. Obese (BMI 30–39.9, n=72) and morbidly obese (BMI > 40, n=49) patients were compared to normal weight (BMI <25, n = 29) and overweight (BMI 25-29.9, n=51) patients. Demographics, comorbidities, and stricture characteristics were collected. Outcomes including complications, recurrence, and secondary interventions were compared using univariate and multivariate analysis. Results201 patients (Mean BMI 34.1, Range 18.4-65.2) with mean age 52.2 years (SD=17.2) were analyzed. Median follow-up time was 3.71 months. Obese patients were younger (p=0.008), had more anterior (p<0.001), iatrogenic and LS-associated strictures (p=0.036). 60-day complication rate was 26.3% with no differences between cohorts (p= 0.788). 9.5% of patients had extravasation at catheter removal, 18.9% reported stricture recurrence, and 7.4% required additional interventions. Obese patients had greater estimated blood loss (p=0.001) and length of stay (p=0.001). On multivariate analysis, smoking associated with contrast leak (OR 7.176, 95% CI 1.13-45.5) but not recurrence or need for intervention (p=0.155, 0.927). ConclusionsObese patients in our cohort had more anterior, iatrogenic, and LS-related strictures. However, obesity is not associated with complications, contrast leak, secondary interventions, or recurrence. Obese had higher blood loss and length of stay. Urethroplasty is safe and effective in obese patients.

Long-term Sexual Function and Quality of Life in Women Following Substitution Urethroplasty.

To assess the long-term quality of life (QOL) and sexual function (SF) in women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasty for urethral stricture disease. Between January 2016 and September 2022, women who underwent either dorsal on-lay (DO) or ventral inlay (VI) urethroplasties and had at least a six-month follow-up been included. Using the Female Sexual Function Index (FSFI) and WHO-QOL bref questionnaires, the QOL and SF were evaluated. Scores were compared between the two groups after being examined for internal validity. A sub-group analysis was carried out based on the procedure's success. With follow-up periods ranging from 6 to 86months, 25 patients who received VI urethroplasty and 10 patients who underwent DO urethroplasty were included. Both scores demonstrated strong internal consistency. The cumulative QOL and FSFI scores were comparable in both groups (p = 0.53 and p = 0.83, respectively). Significantly high scores were noted in the physical health domain (76.5 ± 9.9 vs 62.33 ± 10.97; p = 0.03; (95% CI = 0.72-24.4)) and the environmental domain (75.75 ± 3.84 vs 66.00 ± 4.24; p = 0.01 (95% CI = 2.64-16.85) in patients with successful VI and DO urethroplasties respectively. Addictions, low socioeconomic status and protracted symptom duration were associated with low QOL scores. Old age was related to low FSFI scores. Substitution urethroplasty, despite the approach, showed good QOL and SF scores. Long symptom duration, addictions, and poor socioeconomic status were associated with low QOL whereas old age independently influenced low FSFI scores.

Outcomes of Urethroplasty for Synchronous Anterior Urethral Stricture Utilizing the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System

To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort. Data were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups. One thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P=.3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P=.003, S2a, P=.001, S2b, P=.01 and S2c, P=.02 and E classifications: E3a, P=.004 and E6, P=.03, were associated with increased odds of functional failure. Repair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.

Urethral Cancer After Urethroplasty: A Case Report and Review of the Literature

ObjectiveTo review and report data on transformation to urethral carcinoma after urethroplasty for urethral stricture disease. Primary urethral carcinoma is a rare entity, and guidelines lack high quality data from which to cite. Urethroplasty is a highly effective treatment for urethral stricture disease, though in rare cases complications may include development of urethral carcinoma. MethodsA systematic PubMed search was performed to identify all articles describing patients with urethral carcinoma after urethroplasty. Data were collected on the following parameters: patient age and sex, indication for urethroplasty, presentation of cancer, imaging, pathology, presence of metastasis, intervention, and outcome. ResultsThe final cohort included fourteen patients, 13 from previously published cases and one from our institution. The median patient age at presentation was 60, most had endoscopic management prior to urethroplasty, and the majority presented with decreased urinary stream. All patients developed squamous cell carcinoma of the urethra. Patients underwent radical resection, lymph node dissection, chemotherapy, or radiotherapy, often in combination. A majority of patients had died at the time of case report. ConclusionDevelopment of urethral squamous cell carcinoma, particularly after urethroplasty, is a rarely encountered process. Patients and urologists must have a high index of suspicion and investigate symptoms such as fistula or lower urinary tract symptoms, even if these occur many months or even years after buccal mucosa graft . By compiling previously reported cases and adding an additional case to the literature, we hope that familiarity with this entity will lead to earlier recognition and diagnosis of disease.

Preoperative and intraoperative factors predictive of complications and stricture recurrence following multiple urethroplasty techniques

ObjectivesTo investigate factors predictive of postoperative recurrence and complications in patients undergoing urethroplasty for stricture repair at a single center.Patients and methodsWe retrospectively reviewed the records of 108 men who underwent urethroplasty for urethral stricture disease (USD) at a single center from 2016 to 2020. Demographic data, comorbidities, stricture history including etiology and prior treatments, patient‐reported symptoms, and outcomes data were collected for analysis. Data were analyzed in aggregate, then, stratified by type of urethroplasty performed. Descriptive statistics, univariate analysis, multivariate logistic regression, and intergroup comparisons were completed using STATA, with an alpha value of 0.05 and a confidence interval of 95%.ResultsThe median age of our patients was 58 years (interquartile range: 42‐69; range: 29‐83), with a median stricture length of 2.0 cm (interquartile range: 1.0‐4.5; range: 0.5‐10). The most common stricture etiology was iatrogenic (n = 33, 31%) and the most common urethroplasty was anterior anastomotic urethroplasty (n = 38, 35%), followed by buccal mucosal graft (BMG) urethroplasty (n = 35, 32%). Twenty‐four patients (22%) had stricture recurrence. Within the aggregate data, recurrence was significantly predicted by obesity (BMI > 30) (Odds Ratio [OR] 3.2, 95% Confidence Interval [CI]: 1.06‐10), and the presence of postoperative complications (OR 6.3, CI: 1.9‐21). The presence of any postoperative complications within 90 days was significantly predicted by stricture length ≥ 5 cm (OR 3.5, CI 1.09‐12) and recurrence (OR 6.0, CI 1.7‐21).ConclusionDespite serving as the most definitive treatment for urethral stricture management, stricture recurrence and postoperative complications are not uncommon after urethroplasty. Obesity and stricture length negatively impact outcomes while a penile stricture location is associated with a lower recurrence rate, though this is not statistically significant.

Is Standardization Transferable? Initial Experience of Urethral Surgery at the University Hospital Frankfurt.

Background: Since January 2018 performance of urethroplasties is done on regular basis at the University Hospital Frankfurt (UKF). We aimed to implement and transfer an institutional standardized perioperative algorithm for urethral surgery (established at the University Hospital Hamburg-Eppendorf—UKE) using a validated Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) in patients undergoing urethroplasty at UKF.Materials and Methods: We retrospectively analyzed all patients who underwent urethroplasty for urethral stricture disease between January 2018 and January 2020 at UKF. All patients were offered to revisit for clinical follow-up (FU) and completion of USS-PROM. Primary end point was stricture recurrence-free survival (RFS). Secondary endpoints were functional outcomes, quality of life (QoL), and patient satisfaction.Results: In total, 50 patients underwent urethroplasty and 74 and 24% had a history of previous urethrotomy or urethroplasty, respectively. A buccal mucosal graft urethroplasty was performed in 86% (n = 43). After patient's exclusion due to lost of FU, FU <3 months, and/or a pending second stage procedure, 40 patients were eligible for final analysis. At median FU of 10 months (interquartile-range 5.0–18.0), RFS was 83%. After successful voiding trial, the postoperative median Qmax significantly improved (24.0 vs. 7.0 mL/s; p < 0.01). Conversely, median residual urine decreased significantly (78 vs. 10 mL; p < 0.01). Overall, 95% of patients stated that QoL improved and 90% were satisfied by the surgical outcome.Conclusions: We demonstrated a successful implementation and transfer of an institutional standardized perioperative algorithm for urethral surgery from one location (UKE) to another (UKF). In our short-term FU, urethroplasty showed excellent RFS, low complication rates, good functional results, improvement of QoL and high patient satisfaction. PROMs allow an objective comparison between different centers.

Sexual Dysfunction Following Urethroplasty for Urethral Stricture Disease

To review the relationship between different techniques of urethroplasty on sexual function, discuss the limitations of current literature, and report on novel techniques for improving sexual function following urethroplasty. Recent literature utilizing prospective trials comparing different techniques of urethroplasty (transecting vs. non-transecting) have shown no significant difference in postoperative sexual function outcomes. It is now apparent that postoperative sexual outcomes play a significant role in overall patient satisfaction with urethroplasty. Current scientific evidence is limited by either low sample size, heterogeneous patient populations, differing urethroplasty techniques, varied stricture etiologies, differing follow-up protocols, or the reliance on self-reporting of sexual function by patients through either validated or non-validated questionnaires. Urethroplasty-specific questionnaires are being developed to better characterize sexual dysfunction postoperatively. Current data support an overall low impact of urethroplasty on sexual function; however, the more nuanced aspects of sexual function have not been adequately defined due to the limitations of current literature. Further investigation utilizing standardized questionnaires with the ability to elicit data regarding the different elements of sexual function will be necessary for further characterization of the impact of urethroplasty in order to optimize patient outcomes.

Measuring stress and allostatic load in Indigenous Australians: A systematic review and analysis of biomarker studies

In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence.We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, “How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?” Possible answers were never—0 to all the time—3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities.Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%.The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

MP35-04 DOES POST-OPERATIVE CONTRAST EXTRAVASATION PORTEND STRICTURE RECURRENCE? RESULTS FROM A MULTI-INSTITUTIONAL SURGICAL OUTCOMES RESEARCH GROUP

INTRODUCTION AND OBJECTIVE: Post-operative urethrogram is used to assess urethral healing after urethroplasty for urethral stricture disease (USD). The sequelae of post-operative contrast extravasation (CE) on post-operative urethrogram is unknown. We hypothesize urinary extravasation and presence of CE on post-operative urethrogram is inconsequential for disease recurrence. METHODS: We utilized the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as < 17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting recurrence of USD. RESULTS: Among 1101 patients with cystoscopy follow-up, 54(4.9%) had contrast extravasation (CE) on initial post-operative urethrogram. Among those 54, 74.1% developed an anatomic recurrence versus 13% of patients without a CE (p<0.001). Similarly, functional recurrence was 9.3% with CE versus 3.2 % without CE (p=0.04). Patients with CE were more likely to report post-operative urinary tract infection (12.9% vs. 2.7%; p<0.01). Wound infection was reported in 7.4% vs. 2.6% for those with and without CE, respectively (p=0.04). When corrected by frequency of repair area itself, CE occurred in 15.9% of penile repairs, 13.3% of distal penile repairs, 8.5 % of repairs spanning more than one location and 3.0% of bulbar repairs. Sensitivity of post-operative urethrogram in predicting recurrence in this cohort was 27.3%, specificity 98.7%, positive predictive value (PPV) 77.8%, and negative predictive value (NPV) 89.3%. 45 of 54 patients with CE had a recurrence of some kind, equating to a 22.2% urethroplasty success rate for those with CE within 1 year. CONCLUSIONS: Based on these results we reject our initial hypothesis: Post-operative urethrogram has a high specificity but low sensitivity for recurrence during short term follow-up. Those with urinary extravasation incur a high risk of anatomic recurrence, in particular, and potentially such patients warrant increased monitoring.Source of Funding: None

Autologous buccal mucosa harvest under local anesthesia: Feasibility, safety, and acceptance for substitution urethroplasty.

Objective:The objective of the study is to report our experience with buccal mucosa harvest under local anesthetic agent infiltration for urethroplasty.Materials and Methods:All patients who had buccal mucosa graft harvest under local anesthesia (1% Xylocaine) for repair of their urethral stricture, from January 2007 to December 2016, were retrospectively studied from two public urologic service centers. The demographic data of the patient, length of graft harvested, complications recorded, among other things, were entered into a pro forma and the data were analyzed using IBM SPSS Statistics version 16.Results:A total of 102 patients underwent urethroplasty with buccal mucosa harvested under local anesthesia; however, only 88 patients had complete data for analysis. The mean age was 55.03 years (±12.30). The mean harvested graft length was 5.41 cm (±2.62 cm). There was no need for conversion to general anesthesia. The majority of them (94.3%) reported that it was “easy” or “very easy” to maintain the mouth opened during the procedure. Over 91% do not have difficulty opening their mouth after the harvest. Only a patient had bothersome primary hemorrhage that required gauze packing. No significant oral cavity pain was experience in 69.3% of patients; among those with pain, the perineal pain was more. Over 90% of the patients will be willing to undergo the procedure again under local anesthetic infiltration again.Conclusion:Buccal mucosa harvest under local anesthesia infiltration is feasible, safe, and acceptable among our patients who had urethroplasty for urethral stricture disease.

Use of rectal mucosal grafts in substitution urethroplasty: an early series.

BackgroundTo evaluate the feasibility of use of rectal mucosal grafts for augmentation urethroplasty.MethodsA series of five patients who underwent rectal mucosal graft urethroplasty for urethral stricture disease were identified. Descriptive statistics were used to describe these patients. Primary endpoints were recurrence of stricture and perioperative morbidity.ResultsFive patients underwent rectal mucosal graft augmentation urethroplasty. Four had a history of prior buccal mucosal graft (BMG) urethroplasty and one had a history of head and neck cancer. Rectal mucosa was noted to be thinner and required more tailoring than buccal mucosa. All patients had patent urethras at time of postoperative retrograde urethrogram. A small diverticulum was noted in one patient with no further sequelae. No complications from rectal mucosal graft harvest were noted. All patients with prior buccal grafting subjectively preferred the rectal graft due to fewer side effects. Subjectively, patients with prior buccal grafts preferred the post-operative recovery following rectal mucosal graft urethroplasty.ConclusionsRectal mucosal graft augmentation urethroplasty is a safe alternative in patients with contraindications to buccal grafting with limited morbidity.

Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty

In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence. We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities. Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%. The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

Editorial Comment

Urethroplasty is the definitive surgical treatment for strictures with a success rate of 85-90% for simple procedures and about 80% for extremely complex repairs. 1 Wong S.S. Aboumarzouk O.M. Narahari R. O'Riordan A. Pickard R. Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Rev. 2012; (CD006934) Google Scholar

Tissue Preservation Techniques at the Time of Urethroplasty for Urethral Stricture Disease

Reconstructive surgery for urethral stricture disease seeks to re-establish long-lasting urethral patency while minimizing associated adverse effects. In recent years, genitourinary reconstructive surgeons have developed and refined a number of techniques that seek to decrease the impact of urethroplasty on local tissues including blood supply and innervation. This review presents an outline of recent advances in urethral reconstructive techniques that seek to minimize surgical impact, including tissue preservation, tissue engineering, and minimally invasive approaches and reviews the current state of the literature related to these techniques.

285 - Evaluation of success rate, functional outcome, comorbidity and quality of life in patients with one-stage ventral onlay buccal mucosa graft urethroplasty for urethral stricture disease after radiotherapy using a validated patient-reported outcome measure (PROM)

285 - Evaluation of success rate, functional outcome, comorbidity and quality of life in patients with one-stage ventral onlay buccal mucosa graft urethroplasty for urethral stricture disease after radiotherapy using a validated patient-reported outcome measure (PROM)

Safety and Surgical Outcomes of Same-day Anterior Urethroplasty

To evaluate the safety and feasibility of same-day anterior urethroplasty at our institution and define predictors of postoperative admission and surgical failure. We retrospectively reviewed the charts of 118 consecutive anterior urethroplasties performed at a tertiary care center. Data were analyzed to detect predictors of postoperative admission and urethroplasty failure. The 30-day complications and long-term outcomes were compared between same-day and admitted patients. Ninety-two patients (78%) were discharged on the day of surgery. A penile stricture location compared with a bulbar stricture location (odds ratio: 13.4, P = .009) and having undergone more than 3 prior endoscopic stricture interventions (odds ratio: 10.2, P = .001) were significantly associated with postoperative admission. Patients with a ventral onlay approach were more likely to be discharged home (P = .03), whereas patients with combined repairs were more likely to be admitted (P = .04). Same-day urethroplasty did not increase 30-day postoperative complications, patient emergency room visits, unplanned clinic visits, or phone calls. Success rates did not differ between same-day (89%) and admitted (79%) cohorts, and no individual stricture characteristic was predictive of urethroplasty failure. Same-day anterior urethroplasty is safe and feasible and could help increase utilization of urethroplasty for urethral stricture disease.

Current Practice Patterns Among Members of the American Urological Association for Male Genitourinary Lichen Sclerosus

To determine the practice patterns of urologists who treat male genitourinary lichen sclerosus (MGU-LS) via a national web-based survey distributed to American Urological Association members. A 20-question survey was collected from a random sample of American Urological Association members. Respondents answered questions on their practice patterns for MGU-LS diagnosis, treatment of symptomatic urethral stricture disease, surveillance, and follow-up. In total, 309 urologists completed the survey. The majority of respondents reported practicing more than 20+ years (37.5%) within an academic (31.7%) or group practice (31.1%) setting. The majority of respondents saw 3-5 men with MGU-LS per year (32.7%). The most common locations of MGU-LS involvement included the glans penis (66.2%), foreskin (26.3%), and/or the urethra (5.8%). Respondent first-line treatment for urethral stricture disease was direct visual internal urethrotomy (26.6%) and second-line treatment was referral to subspecialist (38.4%). After controlling for the number of patients evaluated with MGU-LS per year, those with reconstructive training were more likely to perform a primary urethroplasty for men with symptomatic urethral stricture disease (adjusted odds ratio 13.1, 95% confidence interval 5.1-33.8, P < .001). They were also more likely to counsel men on the associated penile cancer risks (adjusted odds ratio 4.6, 95% confidence interval 1.7-12.5, P < .01). Reconstructive urologists evaluate the most number of patients with MGU-LS and are more likely to perform primary urethroplasty for urethral stricture disease. Men with MGU-LS should be referred to a reconstructive urologist to understand the full gamut of treatment options.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment.Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise.Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised.The extent and quality of evidence guiding treatment choice for this condition are uncertain. To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness. We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles. We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease. Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5). Two randomised trials were identified.One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease.No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence.The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size. There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs.Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

Urethroplasty: A Geographic Disparity in Care

Urethroplasty is the gold standard for urethral strictures but its geographic prevalence throughout the United States is unknown. We analyzed where and how often urethroplasty was being performed in the United States compared to other treatment modalities for urethral stricture. De-identified case logs from the American Board of Urology were collected from certifying/recertifying urologists from 2004 to 2009. Results were categorized by ZIP codes to determine the geographic distribution. Case logs from 3,877 urologists (2,533 recertifying and 1,344 certifying) were reviewed including 1,836 urethroplasties, 13,080 urethrotomies and 19,564 urethral dilations. The proportion of urethroplasty varied widely among states (range 0% to 17%). The ratio of urethroplasty-to-urethrotomy/dilation also varied widely from state to state, but overall 1 urethroplasty was performed for every 17 urethrotomies or dilations performed. Certifying urologists were 3 times as likely to perform urethroplasty as recertifying urologists (12% vs 4%, respectively, p<0.05). Urethroplasties were performed more commonly in states with residency programs (mean 5% vs 3%). Some states reported no urethroplasties during the observation period (Vermont, North Dakota, South Dakota, Maine and West Virginia). To our knowledge this is the first report on the geographic distribution of urethroplasty for urethral stricture disease. There are large variations in the rates of urethroplasty performed throughout the United States, indicating a disparity of care, especially for those regions in which few or no urethroplasties were reported. This disparity may decrease with time as younger certifying urologists are performing 3 times as many urethroplasties as older recertifying urologists.

Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration

We examined the association of previous transurethral manipulation with stricture complexity and disease duration among men referred for bulbar urethral reconstruction. We retrospectively reviewed the records of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010. Only men treated with initial open surgery for bulbar strictures were included in analysis, thus excluding those with hypospadias, lichen sclerosus, pelvic radiation, prior urethroplasty, incomplete data, or pure penile or posterior urethral stenosis. Cases were divided into 2 groups based on the history of transurethral treatment for urethral stricture before urethroplasty, including group 1-0 or 1 and group 2-2 or greater treatments. Of 101 patients with bulbar urethral stricture and all data available 50 and 51 underwent 0 to 1 and 2 or greater previous transurethral treatments, respectively. Repeat transurethral manipulation was strongly associated with longer strictures and the need for complex reconstruction. Repeat transurethral manipulation of bulbar urethral strictures was also associated with an eightfold increase in disease duration between stricture diagnosis and curative urethroplasty. Repeat transurethral manipulation of bulbar strictures is associated with increased stricture complexity and a marked delay to curative urethroplasty.