The evolution of urethral stricture and urethroplasty practice over 15 years: A single-center, single-surgeon, 1319 urethroplasty analysis.

INTRODUCTION: The management of urethral stricture has evolved over the last several decades. We sought to analyze urethral stricture and urethroplasty trends at a tertiary referral center over a 15-year period. METHODS: Patients undergoing urethroplasty by a single surgeon from August 2003 to July 2018 were analyzed. Patient demographics, urethroplasty techniques, and outcomes were collected in a prospectively maintained database and were categorized into three five-year tertiles based on date of surgery. These tertiles were subsequently retrospectively analyzed for trends and changes in practice. RESULTS: A total of 1319 urethroplasties were completed over the study period. During the first five years (T1), 299 urethroplasties were performed, with 431 and 589 performed in T2 and T3, respectively. Mean overall patient age was 46.8 years, which increased significantly over time (p<0.001). Idiopathic strictures were most common (n=516, 39.1%) and unchanged over time, while proportionately radiation-induced strictures increased (n=9, 3.0% [T1], n=22, 5.1% [T2], n=51, 8.7% [T3]; p=0.001) as did iatrogenic and lichen sclerosus strictures. Mean stricture length (4.7 cm [T1], 4.8 cm [T2], 4.0 cm [T3]; p<0.001) and the mean number of prior endoscopic procedures (3.4 [T1], 3.9 [T2], and 2.5 [T3]; p<0.001] decreased over time. Single-stage urethroplasty with buccal mucosa was the most common technique performed (n=656, 49.7%) that increased in prevalence (p=0.009), while both flap and staged techniques decreased (p=0.008, p=0.004, respectively). Overall success rate was 90.1% (n=1106), which improved significantly with time (n=248, 86.7% [T1], n=359, 90.0% [T2], n=499, 93.4% [T3]; p=0.001). CONCLUSIONS: We observed that patients and treatment of urethral stricture evolved over 15 years in practice, with an increase in patient age, radiation, and iatrogenic and lichen sclerosus strictures, while demonstrating a decrease in stricture length and the number of prior endoscopic procedures performed. Increased use of single-stage urethroplasty using buccal mucosa was observed, which may have contributed to an increase in urethroplasty success over time.

Prospective Assessment of Patient-perceived Short-term Changes in Penile Appearance After Urethroplasty.

OBJECTIVE: To define the incidence and associations of patient-reported penile curvature and shortening after urethroplasty. Alterations in penile curvature or length post-urethroplasty are associated with patient dissatisfaction but are poorly described. METHODS: From 2011 to 2019, 387 patients completed enrollment in a prospective single-centre study assessing patient-reported outcomes pre-operatively and 6-months post-urethroplasty. Primary outcomes of perceived penile shortening and curvature were assessed at 6-months follow-up. Descriptive statistics were used to summarize findings while univariate and multivariate binary logistic regression was used to identify associations between loss of penile length or chordee with other clinical factors. RESULTS: Of the 387 patients, mean age was 49.5 years with mean stricture length of 4.5 cm. Postoperatively, 12.7% of patients perceived penile curvature (8.0% "somewhat", 4.7% "severe") and 22.8% of patients perceived penile shortening (14.5% "somewhat", 8.3% "a lot"). Multivariate binary logistic regression identified stricture location (P = .02) to be associated with perceived curvature while prior urethroplasty (P = .17), type of urethroplasty (P = .08) and other factors were not. Specifically, penile (O.R. 4.27, 95%CI 1.56-11.68, P = .005) and panurethral (O.R. 10.15, 95%CI 3.46-29.77, P <.001) locations were independently associated with this outcome. In a multivariate model, panurethral strictures (O.R. 4.23, 95%CI 1.10-16.20, P = .04) and hypospadias (O.R. 5.46, 95%CI 1.32-22.70, P = .02) were associated with patient perceived shortening while other factors such as age (P = .19), type of urethroplasty (P = .14) and other etiologies or locations were not. CONCLUSION: Clinically significant changes in penile appearance are more common post-urethroplasty than generally thought. Stricture location and etiology are important predictors of these patient-perceived changes.

Determining Perioperative Practice Patterns in Urethroplasty: A Survey of Genitourinary Reconstructive Surgeons.

OBJECTIVE: To better delineate perioperative urethroplasty practice patterns among reconstructive urologists given that management strategies in reconstructive urology have generally been poorly described. METHODS: An online survey examining perioperative management of anterior urethroplasty patients was administered to Society of Genitourinary Reconstructive Surgeons (GURS) members between August-October 2019. Questions pertained to tissue transfer, pharmacologic prophylaxis, catheter use, follow-up, and post-operative care. RESULTS: A total of 248 GURS members were invited to participate, with a response rate of 57.2% (n = 142). Most participants performed >20 urethroplasties per year (n = 108, 76.1%). Almost all respondents (97.9%, n = 139) used intraoperative intravenous antibiotics. A minority of surgeons used intraoperative pharmacologic thromboembolism prophylaxis (n = 57, 40.1%). Surgeons prefer buccal mucosa for grafting (n = 138, 97.2%) with many leaving the donor site open (n = 76, 53.5%). Only 21.8% (n = 31) of surgeons prescribe bedrest for patients and 25.4% (n = 36) routinely place drains. Postoperatively, oral antimicrobials are routinely administered (n=100, 70.4%), with most continuing until the urinary catheter is removed (70, 72.2%). Patients commonly had a urethral catheter for 2-3 (n = 72, 58.5%) or 3-4 weeks (n = 37, 30.1%). At catheter removal, surgeons routinely perform urethral imaging with contrast (n=96, 67.6%). Most surgeons prefer some form of objective investigation (n = 111, 78.2%) (uroflowmetry [n = 91, 82.0%], post-void residual [n = 88, 79.3%]). Cystoscopy is also commonly performed (n = 64, 57.7%). These investigations are routinely performed at 2-3 (n = 49, 44.2%) or 4-6 months (n = 38, 34.2%) postoperatively. CONCLUSION: Despite general consensus on urethroplasty management options, heterogeneity remains in the areas of antibiotic use, VTE prophylaxis, donor site management, catheter management, and follow-up assessment.

Single-Stage Reconstruction of Fossa Navicularis Strictures Using a "Sliding-T" Dorsal Inlay Urethroplasty With Buccal Mucosal Graft.

OBJECTIVE: To describe a single-stage urethroplasty for fossa navicularis strictures using a "sliding-T" dorsal inlay technique with buccal mucosa. Strictures of the fossa navicularis are challenging. Endoscopic treatments typically offer only temporary relief and necessitate lifelong instrumentation. Reconstruction should provide an unobstructed urethra, slit-like meatus, preserve sexual function, and create a cosmetically appealing glans. The ideal urethroplasty technique has not yet been elucidated despite various described single-stage and multistaged approaches. METHODS: A retrospective review from January 2013 to May 2018 was performed to identify patients undergoing single-stage urethroplasty for fossa navicularis strictures. The primary outcome was urethroplasty success defined as the ability to easily pass a 16 Fr flexible cystoscope with a minimum of 12-month follow-up. Secondary outcome measures included 90-day complications, de novo erectile dysfunction, chordee, and patient satisfaction assessed at ~6-months postoperatively with the question, "Overall, are you satisfied with the result of your operation for urethral stricture?" RESULTS: Twenty-seven patients underwent reconstruction of fossa navicularis strictures using buccal mucosa with a "sliding-T" dorsal inlay urethroplasty technique. Stricture etiology was most commonly lichen sclerosus (70.4%; n = 19), iatrogenic (18.5%; n = 5), or idiopathic (11.1%; n = 3). Mean stricture length was 3.2 cm ± 1.2 [1-4] and mean patient age was 47.3 years [19-71]. Around 92.6% (n = 25) of patients failed prior endoscopic treatment while 7.4% (n = 2) failed prior urethroplasty. At a mean follow-up of 29.6 (12-60) months the success rate was 92.4% (n = 25). Both recurrences were managed successfully with meatotomy. 90-day complications (Clavien ≥2) occurred in 2 patients (7.4%) (surgical site infection treated with antibiotics). Functionally, 1 patient (3.7%) experienced de novo erectile dysfunction, 1 (3.7%) reported mild chordee, and 96.3% (26/27) of patients were satisfied with the outcome of surgery. CONCLUSION: Reconstruction of fossa navicularis strictures using buccal mucosa with a single-stage "sliding-T" dorsal inlay technique provides satisfying anatomic and functional outcomes with a low rate of associated complications.

Success rate of repeat flexible ureteroscopy following previous failed access: An analysis of stent duration.

INTRODUCTION: Approximately 8% of patients that undergo therapeutic or diagnostic ureteroscopy will have the procedure aborted and ureter stented due to failed access. The primary objective of this study was to assess mean stent duration prior to repeat ureteroscopy and to calculate the associated successful access rate. METHODS: This retrospective, descriptive study evaluated all patients undergoing interval ureteroscopy following a failed procedure by endourologic surgeons at the University of Alberta from 2016-2018. Patients declining interval ureteroscopy, or those with malignant/known ureteral strictures were excluded from the study. The primary outcome measures were median time to salvage ureteroscopy and the rate of successful access of the repeat procedure. RESULTS: A total of 119 patients were identified as having a failed ureteroscopy during our study period. First-time and recurrent stone formers accounted for 64 (53.8%) and 47 (39.5%) patients, respectively. Median stent duration to second procedure was 17 days (average 20, range 10-84). Most patients had their repeat ureteroscopy at 14 days or greater (81.5%); 22 (18.5%) patients had their repeat ureteroscopy between 10 and 13 days. The success rate of a second ureteroscopy after stenting was 99.2% (118/119). CONCLUSIONS: Ureteric stenting following failed ureteroscopy leads to exceedingly high rates of successful access at interval procedure (99.2%). The standard duration of ureteric stenting employed at our institution is two weeks. Of the patients that underwent an accelerated second procedure (between 10-13 days of stenting), all had successful access at their interval procedure.

Improvement in Storage Related Lower Urinary Tract Symptoms following Urethroplasty: A Prospective Cohort Study.

PURPOSE: In patients with lower urinary tract symptoms, storage related symptoms induce the greatest degree of bother. When associated with urethral stricture, it is unclear how these specific symptoms respond to urethroplasty. This study aims to evaluate the prevalence and effect of urethroplasty on patient reported storage lower urinary tract symptoms. MATERIALS AND METHODS: This prospective cohort study evaluated patients undergoing urethroplasty for urethral stricture from 2012-2019. Patients were administered the International Prostate Symptom Score preoperatively and 6 months posturethroplasty. The primary outcomes were change in urinary frequency, urgency, nocturia and composite storage symptom measure according to International Prostate Symptom Score. Symptoms were considered clinically significant if they were graded 3 or greater for the individual domains, and greater than 6 for the combined score. Wilcoxon signed-rank test was used to compare results. RESULTS: A total of 387 patients completed the International Prostate Symptom Score preoperatively and postoperatively. Median age was 50 years and median stricture length was 4.5 cm. Cystoscopic success at 6 months was 96.1%. Preoperatively, urinary frequency, urgency and nocturia were common symptoms (52.5%, 48.8% and 41.6%, respectively). Postoperatively, these rates decreased to 11.6%, 11.4% and 11.1%, respectively, reductions that were significant (p <0.0001) across all domains. Overall storage symptom scores improved significantly (median 8 preoperatively vs 2 postoperatively, p <0.0001). On binary logistic regression, no factor was associated with a lack of response, including stricture recurrence (p=0.44), age (p=0.45), stricture length (p=0.63), location (p=0.13), etiology (p=0.17), number of failed endoscopic treatments (p=0.53) and prior urethroplasty (p=0.06). CONCLUSIONS: Urethroplasty yields clinically and statistically significant improvements in storage related lower urinary tract symptoms in men with urethral stricture.

Augmented Anastomotic Urethroplasty is Independently Associated with Failure after Reconstruction for Long Bulbar Urethral Strictures.

PURPOSE: Controversy exists regarding the optimal urethroplasty technique, particularly for long bulbar urethral strictures requiring buccal mucosal graft. We assessed the relative outcomes of augmented anastomotic urethroplasty vs dorsal onlay in the setting of bulbar urethroplasty using a dorsal buccal mucosal graft. MATERIALS AND METHODS: A retrospective review was performed on all patients who underwent bulbar urethroplasty with dorsal buccal mucosal graft between October 2003 and March 2019. Around 2011 institutional technique shifted from routinely performing transecting augmented anastomotic urethroplasty to nontransecting dorsal onlay. Anastomotic urethroplasty without buccal mucosal graft, ventral onlay, staged, flap and circumferential reconstructions were excluded. The primary outcome was stricture recurrence defined as less than 16Fr on cystoscopy. Secondary outcomes included 90-day complications and de novo erectile dysfunction at 6 months. RESULTS: Of the 836 patients who underwent bulbar urethroplasty during the study period 507 met inclusion criteria. Of these, 221 patients received an augmented anastomotic urethroplasty while 286 underwent dorsal onlay urethroplasty. Mean patient age and stricture length were 45.4±14.8 years and 4.4±1.5 cm, respectively. Overall success rate was 93.9% (476 of 507) with a mean followup of 78.9 months. On multivariate analysis augmented anastomotic urethroplasty (HR 4.8, p=0.002), increasing stricture length (HR 1.2, p=0.002) and iatrogenic strictures (HR 3.2, p=0.03) were independently associated with stricture recurrence, while comorbidity (p=0.06), prior endoscopic treatment (p=0.41), prior urethroplasty (p=0.89) and other etiologies were not. There was no difference between cohorts with respect to Clavien 2 or greater complications (3.6% vs 4.2%, p=0.74) or de novo erectile dysfunction (5.9% vs 5.6%, p=0.89). CONCLUSIONS: Augmented anastomotic urethroplasty is independently associated with stricture recurrence when compared to a pure dorsal onlay technique.

An epidemiologic overview of a tertiary referral practice for male paediatric lichen sclerosus.

Within the paediatric population, changing patterns of circumcisions have confounded the epidemiology and presentation of lichen sclerosus (LS). We sought to evaluate the incidence, demographics, and clinical features of patients presenting to a single Albertan paediatric urologist with LS. This retrospective descriptive analysis evaluated all paediatric patients referred for phimosis to a single paediatric urologist in Edmonton, Alberta. Chief complaints/symptoms, date of birth, and date of circumcision were identified. The primary outcome of interest was the proportion of circumcisions with pathologically confirmed LS. From July 2006 to March 2016, 4,163 patients were seen for phimosis of the approximate 12,000 new referrals. Hundred phimosis patients had clinically suspected LS. Of those adequately reported, 81 (81/83) were microscopically confirmed to be LS with a mean age of 9.6 years and median age of 8.9 years (range 4.1 to 16.1 years). This cohort represented 2.0% of phimosis referrals and approximately 0.7% of all referrals to our paediatric urologist. When compared to physiologic phimosis, these patients had higher rates of dysuria (n=28, 34.6% versus n=1, 1.0%, P<0.0001) and urinary retention (n=18, 22.2% versus n=1, 1.0%, P<0.0001) as presenting complaints. LS of the paediatric male genitalia is an uncommon, albeit clinically significant disease entity. The clinical diagnosis for the trained practitioner is very accurate.

An Antenatally Detected Pure Malignant Rhabdoid Tumor of the Bladder.

Pediatric malignant rhabdoid tumors are a rare entity with poor prognosis. The extrarenal variants of this disease are sparsely presented within the literature. Our case represents, to our knowledge, the first antenatally detected bladder-variant. At 19 months of age, this patient has benefited from early detection and intervention and remains disease free following partial cystectomy and chemotherapy.

Evaluating the role for renal biopsy in T1 and T2 renal masses: A single-centre study.

INTRODUCTION: Once used primarily in the identification of renal metastasis and lymphomas, various urological bodies are now adopting an expanded role for the renal biopsy. We sought to evaluate the role of the renal biopsy in a Canadian context, focusing on associated adverse events, radiographic burden, and diagnostic accuracy. METHODS: This retrospective review incorporated all patients undergoing ultrasound (US)/computed tomography (CT)-guided biopsies for T1 and T2 renal masses. There were no age or lesion size limitations. The primary outcome of interest was the correlation between initial biopsy and final surgical pathology. A binomial logistic regression analysis was conducted to determine any confounding factors. Secondary outcomes included the accuracy of tumour cell typing, grading, the safety profile, and radiographic burden associated with these patients. RESULTS: A total of 148 patients satisfied inclusion criteria for this study. Mean age and lesions size at detection were 60.9 years (±12.4) and 3.6 cm (±2.0), respectively. Most renal masses were identified with US (52.7%) or CT (44.6%). Three patients (2.0%) experienced adverse events of note. Eighty-six patients (58.1%) proceeded to radical/partial nephrectomy. Our biopsies held a diagnostic accuracy of 90.7% (sensitivity 96.2%, specificity 87.5%, positive predictive value 98.7%, negative predictive value 70.0%, kappa 0.752, p<0.0005). Binomial logistic regression revealed that age, lesion size, number of radiographic tests, time to biopsy, and modality of biopsy (US/CT) had no influence on the diagnostic accuracy of biopsies. CONCLUSIONS: Renal biopsies are safe, feasible, and diagnostic. Their role should be expanded in the routine evaluation of T1 and T2 renal masses.

Serum follicle-stimulating hormone levels predict time to development of castration-resistant prostate cancer.

INTRODUCTION: Treatment of advancing prostate cancer focuses on blocking the activation of the androgen receptor with resultant prolonged perturbation of the hypothalamic-pituitary-gonadal axis. Androgen deprivation therapy (ADT) is marked, however, by eventual progression to castration- resistant prostate cancer (CRPC). Emerging evidence has postulated that follicle-stimulating hormone (FSH) may lead to proliferative and mutagenic responses of prostate cancer. We investigated the association of serum FSH and time to castration resistance. METHODS: This was a single-centre retrospective study assessing serum FSH levels of patients undergoing ADT for advancing prostate cancer. The primary outcome was time of ADT initiation to the development of CRPC. For each patient on treatment and with castrate levels of testosterone, the maximum FSH value between ADT commencement and CRPC was identified and recorded. FSH was analyzed as a continuous and categorical variable. Cox multivariate regression in a step-wise fashion was used to explore the association between FSH levels and time to CRPC. RESULTS: From a database of 323 prostate cancer patients actively managed with ADT, 103 men had a documented FSH value while castrate, with 45 men progressing to CRPC. The mean ± standard deviation maximum FSH value of these patients was 6.66 ± 4.22 mIU/mL (range: 1.5-28.1). The mean duration from ADT commencement to CRPC was 3.03 ± 0.34 years (range: 0.36-9.71). Univariate analysis suggested a trend of a negative correlation between FSH values and time to castrate resistance. A FSH value of less than or equal to the lowest tertile (4.8 mIU/mL) was associated with a longer time to CRPC (hazard ratio 0.46; p = 0.006). In the Cox regression analysis, elevated FSH was associated with a shorter duration time to CRPC (p = 0.03). CONCLUSIONS: This retrospective, single-centre study would suggest there may be an association between serum FSH levels and time to CRPC for men treated palliatively with ADT for advancing prostate cancer. Further clinical investigation in a larger cohort of men is required to determine any clinical utility of FSH as a biomarker of progression or target for therapy.