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PD34-10 VALUE OF EARLY SURVEILLANCE CYSTOURETHROSCOPY AFTER BULBAR URETHROPLASTY ON RECURRENCE RISK: A TURNS STUDY
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PD34-08 REAL-WORLD EFFECTIVENESS OUTCOMES FOR URETHROPLASTY Robert Goldfarb*, Steven Brandes, New York, NY; Peter Kirk, Tudor Borza, Yongmei Qin, Ted Skolarus, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Urethral stricture disease is common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, guidelines increasingly recommend urethroplasty based on its high success rates. Whether real world, community practice outcomes mirror those of large volume single center institutional series is unknown. For these reasons, we conducted a population-based study of patients treated with urethroplasty and their outcomes. METHODS: We identified male patients who underwent urethroplasty between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed utilization of endoscopic treatments (urethrotomy and dilation) prior to and after urethroplasty. We defined urethroplasty failure by any subsequent urethral dilation, urethrotomy, or urethroplasty after initial urethroplasty. We examined factors associated with failure using multivariable logistic regression and Cox proportional hazards models. RESULTS: We identified 1345 patients treated with urethroplasty. Urethroplasty failure occurred in 344 (26%) of patients. Repeat urethroplasty was performed in 139 (40%) of failures (range 28). Increased number of endoscopic treatments prior to first urethroplasty was associated with urethroplasty failure. The mean (SD) time to failure was 270 42 days. CONCLUSIONS: Our population-based study demonstrated significantly lower success rates for urethroplasty than previously published reports. Strategies to achieve better outcomes for patients with urethral stricture disease include increasing referrals to reconstructive urologic surgeons, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment. Source of Funding: None
PD34-09 THE UTILITY OF UROFLOWMETRY PARAMETERS IN URETHROPLASTY SURVEILLANCE IS LIMITED Yooni Yi*, Paholo Barboglio Romo, Bahaa Malaeb, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Limited data supports the use of uroflowmetry parameters (Qmax:max flow; Qave: average flow; VV: voided volume) to assess for urethral patency and rule out stricture recurrence in post-urethroplasty surveillance. METHODS: From years 2012-2015, data were collected on 125 patients who underwent anterior and posterior urethroplasties and had follow-up at 3 and 12 months with cystoscopy, International Prostate Symptom Score (I-PSS) and uroflowmetry parameters. The ability to pass a 17 French flexible cystoscope was defined as a successful repair. Analyzing the receiver operating characteristics we calculated the area under the curve (AUC) to compare uroflowmetry parameters and I-PSS against cystoscopy. RESULTS: There were 208 encounter visits within the first 12 months, of which there were 164 cystoscopy procedures. Success was determined in 147/164 (90%). Uroflowmetry parameters were provided in 105 patients and 103 subjects were not able to void or had a VV < 100 mL. I-PSS data was available for 136 patients. Qmax of 10 ml/sec has a high positive predictive (92%) value and our study confirmed a significant AUC of 0.75 (p¼0.002). However, the NPV is limited and cystoscopy showed that half of these subjects with a low flow (<10 ml/ sec) won’t have a stricture. The AUC for Qmax 15 mL was 0.705 (p ¼ 0.002) with a sensitivity of 92% and specificity of 34%. When comparing (Qmax-Qave) > 8 to cystoscopy, the AUC was 0.691 (p ¼ 0.018) with a
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
93% sensitivity and 29% specificity. When assessing the AUC of I-PSS Weakness score of <3, the AUC was found to not be significant. No significance was found when completing a univariate analysis of I-PSS total score and quality of life score to cystoscopy. CONCLUSIONS: Uroflowmetry parameters of Qmax >10 mL, Qmax >15 mL, Qmax-Qave > 8 mL are not specific enough to determine recurrences of urethral stricture. The I-PSS total score, weakness score or QOL are neither sensitive nor specific enough to detect recurrences.
Source of Funding: None
PD34-10 VALUE OF EARLY SURVEILLANCE CYSTOURETHROSCOPY AFTER BULBAR URETHROPLASTY ON RECURRENCE RISK: A TURNS STUDY Darshan Patel*, Salt Lake City, UT; Ragheed Al-Dulaimi, salt lake city, UT; Sean Elliott, Minnesota, MN; Alexander Vanni, Burlington, MA; Bradley Erickson, Iowa City, IA; Bryan Voelzke, Seattle, WA; Benjamin Breyer, San Francisco, CA; Christopher McClung, Columbus, OH; Thomas Smith, III, Houston, TX; Angela Presson, Jeremy Myers, Salt Lake City, UT INTRODUCTION AND OBJECTIVES: Surveillance protocols after bulbar urethroplasty vary. Flexible cystourethroscopy allows for direct visualization of the repair and is often used for surveillance. However, repeated cystourethroscopy following urethroplasty is costly and has significant patient burden. We evaluate the use of single cystourethroscopy performed in the early post-operative period and its ability to predict clinical success in men who underwent bulbar urethroplasty. METHODS: We identified patients from TURNS database from 1/1/2010-3/31/2016, who underwent urethroplasty for isolated bulbar strictures and received surveillance cystourethroscopy within 6 months of their procedure. We excluded patients with history of previous urethroplasty, lichen sclerosus, radiation, failed hypospadias repair, and any patients with clinical recurrence prior to surveillance cystourethroscopy. Our primary outcome was utility of cystourethroscopy findings (normal caliber, >17 French strictured rings, or inability to pass scope [<17 French strictured rings]) in predicting risk of clinical recurrence. RESULTS: 844 patients were identified. Mean age and BMI was 43 years (SD:15.5) and 30.0 kg/m2 (SD:6.6), respectively. 41 (5%) patients had a history of diabetes. 42 (5%) patients were current smokers and 72 (9%) were former smokers. 648 (77%) had excision and primary anastomosis and 196 (23%) had substitution urethroplasty with buccal graft. Mean operative stricture length was 3.0 cm (SD:1.8). Median time to first post-operative cystourethroscopy was 3.6 months (IQR: 3.1, 4.0). On cystourethroscopy, 608 (72%) had normal findings, 134 (16%) had >17 French strictured rings, and 102 (12%) had <17 French strictured rings. A total of 32 (4%) patients required a secondary procedure at a median time of 2.05 (IQR: 0.1-10.8) months. Cumulative 1-year rate for secondary procedures for recurrence were 0.01 (95% CI: 0-0.03) for normal urethra on first cystourethroscopy, 0.06 (95% CI:
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0-0.13) for >17 French strictured rings, and 0.27 (95% CI: 0.13-0.39) for <17 French strictured rings (Figure). CONCLUSIONS: Repeated cystourethroscopy has limited use after bulbar urethroplasty in predicting clinical failure in patients with normal caliber urethra on single early surveillance cystourethroscopy.
Source of Funding: None
PD34-12 TERTIARY URETHROPLASTY: IS THE THIRD TIME A CHARM? Travis Pagliara*, Boyd Viers, Charles Rew, Dallas, TX; Lauren FolgosaCooley, Richmond, VA; Alexander Rozanski, Christine Shiang, Jeremy Scott, Allen Morey, Dallas, TX Source of Funding: None
PD34-11 MULTI-INSTITUTIONAL OUTCOMES OF ENDOSCOPIC MANAGEMENT OF STRICTURE RECURRENCE AFTER URETHROPLASTY Shyam Sukumar*, Sean Elliott, Minneapolis, MN; Jeremy Myers, Salt Lake City, UT; Bryan Voelzke, Seattle, WA; Thomas Smith, Houston, TX; Alexandra Carolan, Minneapolis, MN; Michael Maidaa, Bradley Erickson, Iowa City, IA INTRODUCTION AND OBJECTIVES: Approximately 10-20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often with urethral dilation (UD) and direct vision internal urethrotomy (DVIU) but the success rates of these procedures are not well known. METHODS: We retrospectively reviewed bulbar urethroplasty data from 5 surgeons from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS). Men who underwent UD or DVIU for a <17F lumen plus symptoms of recurrence were identified. Analyses compared success rates of recurrence management (UD vs. DVIU) and initial urethroplasty type (substitution vs. excisional repair, EPA) using time to event statistics: Kaplan Meier curves and Cox regression models. Failure of UD or DVIU was defined as the inability to pass a 17Fr cystoscope through the urethra into the bladder. RESULTS: There were 53 men with recurrence that were initially managed endoscopically, 10 with UD and 43 with DVIU. Mean time to recurrence after urethroplasty was 7.6 months. At a mean followup of 16.3 months after UD or DVIU, success was 41.5% in the overall cohort: 48.8% for DVIU vs. 10% for UD. Kaplan Meier curves are shown in Figure 1. On Cox modeling, UD had a higher rate of subsequent failure compared to DVIU (hazard ratio, HR: 3.15, p¼0.03). Patients undergoing EPA had a trend towards higher rates of recurrence after secondary endoscopic procedures vs. those undergoing substitution urethroplasty (HR: 2.41, p¼0.05) CONCLUSIONS: DVIU is more successful than UD in the management of stricture recurrence after bulbar urethroplasty. DVIU appears to be more successful for patients with a recurrence after a substitution urethroplasty compared to after an EPA, perhaps indicating a different mechanism of recurrence for EPA (ischemic) versus substitution urethroplasty (technical)
INTRODUCTION AND OBJECTIVES: While repeat urethroplasty following primary treatment failure is often successful, limited data exist describing outcomes among men requiring additional urethral surgeries. We aim to describe the characteristics and outcomes among men undergoing tertiary urethroplasty compared to primary and secondary repairs. METHODS: A retrospective review of over 1000 urethroplasty cases by a single surgeon from 2007-2014 was performed to identify men undergoing primary, secondary, and tertiary urethroplasty procedures. Tertiary urethroplasty was defined as urethral reconstruction following two or more previous urethroplasty failures. Clinical characteristics and outcomes were compared between groups. Mutivariable logistic regression models evaluated the association between number of previous urethral surgeries and treatment success. RESULTS: Among 573 urethroplasty cases having complete data available, 46 (8%) tertiary procedures were compared with 87 (15%) secondary and 440 (77%) primary procedures. Tertiary strictures were more often located in the penile urethra (50% vs 29% vs 17%, p<0.0001), and underwent substitution urethroplasty (61% vs 41% vs 23%, p<0.0001). Failure rates were higher for tertiary cases (37%) vs 20% and 13 % for secondary and primary procedures (p¼0.0001) during follow up (mean 17 months). The estimated 24-month stricture recurrence-free survival was lower for tertiary cases (44% vs 75% vs 75%, p¼0.07), but success rates of perineal urethrostomy (100%) and excision primary anastomosis (90%) were far greater than substitution urethroplasty (50%). Tertiary repairs were more likely to have a history of hypospadias (58% vs 20% vs 2%, p<0.001) and chronic kidney disease (17% vs 5% vs 9%, p¼0.003). No difference was noted in age, medical comorbidities, nor frequency of <90 day complications. On multivariable analysis controlling for history of hypospadias, stricture location, and type of surgery, tertiary urethroplasty was associated with an increased risk of treatment failure relative to primary (OR 2.88, 95% CI 1.29-6.65; p¼0.02) and secondary (OR 2.11, 95%CI 0.87-5.14; p¼0.09) urethroplasty. CONCLUSIONS: While tertiary urethroplasty is associated with an increased risk of treatment failure relative to primary and secondary urethroplasty, many patients can expect to experience durable resolution of obstructive voiding symptoms.
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PD34-08 REAL-WORLD EFFECTIVENESS OUTCOMES FOR URETHROPLASTY Robert Goldfarb*, Steven Brandes, New York, NY; Peter Kirk, Tudor Borza, Yongmei Qin, Ted Skolarus, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Urethral stricture disease is common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, guidelines increasingly recommend urethroplasty based on its high success rates. Whether real world, community practice outcomes mirror those of large volume single center institutional series is unknown. For these reasons, we conducted a population-based study of patients treated with urethroplasty and their outcomes. METHODS: We identified male patients who underwent urethroplasty between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed utilization of endoscopic treatments (urethrotomy and dilation) prior to and after urethroplasty. We defined urethroplasty failure by any subsequent urethral dilation, urethrotomy, or urethroplasty after initial urethroplasty. We examined factors associated with failure using multivariable logistic regression and Cox proportional hazards models. RESULTS: We identified 1345 patients treated with urethroplasty. Urethroplasty failure occurred in 344 (26%) of patients. Repeat urethroplasty was performed in 139 (40%) of failures (range 28). Increased number of endoscopic treatments prior to first urethroplasty was associated with urethroplasty failure. The mean (SD) time to failure was 270 42 days. CONCLUSIONS: Our population-based study demonstrated significantly lower success rates for urethroplasty than previously published reports. Strategies to achieve better outcomes for patients with urethral stricture disease include increasing referrals to reconstructive urologic surgeons, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment. Source of Funding: None
PD34-09 THE UTILITY OF UROFLOWMETRY PARAMETERS IN URETHROPLASTY SURVEILLANCE IS LIMITED Yooni Yi*, Paholo Barboglio Romo, Bahaa Malaeb, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Limited data supports the use of uroflowmetry parameters (Qmax:max flow; Qave: average flow; VV: voided volume) to assess for urethral patency and rule out stricture recurrence in post-urethroplasty surveillance. METHODS: From years 2012-2015, data were collected on 125 patients who underwent anterior and posterior urethroplasties and had follow-up at 3 and 12 months with cystoscopy, International Prostate Symptom Score (I-PSS) and uroflowmetry parameters. The ability to pass a 17 French flexible cystoscope was defined as a successful repair. Analyzing the receiver operating characteristics we calculated the area under the curve (AUC) to compare uroflowmetry parameters and I-PSS against cystoscopy. RESULTS: There were 208 encounter visits within the first 12 months, of which there were 164 cystoscopy procedures. Success was determined in 147/164 (90%). Uroflowmetry parameters were provided in 105 patients and 103 subjects were not able to void or had a VV < 100 mL. I-PSS data was available for 136 patients. Qmax of 10 ml/sec has a high positive predictive (92%) value and our study confirmed a significant AUC of 0.75 (p¼0.002). However, the NPV is limited and cystoscopy showed that half of these subjects with a low flow (<10 ml/ sec) won’t have a stricture. The AUC for Qmax 15 mL was 0.705 (p ¼ 0.002) with a sensitivity of 92% and specificity of 34%. When comparing (Qmax-Qave) > 8 to cystoscopy, the AUC was 0.691 (p ¼ 0.018) with a
Vol. 197, No. 4S, Supplement, Sunday, May 14, 2017
93% sensitivity and 29% specificity. When assessing the AUC of I-PSS Weakness score of <3, the AUC was found to not be significant. No significance was found when completing a univariate analysis of I-PSS total score and quality of life score to cystoscopy. CONCLUSIONS: Uroflowmetry parameters of Qmax >10 mL, Qmax >15 mL, Qmax-Qave > 8 mL are not specific enough to determine recurrences of urethral stricture. The I-PSS total score, weakness score or QOL are neither sensitive nor specific enough to detect recurrences.
Source of Funding: None
PD34-10 VALUE OF EARLY SURVEILLANCE CYSTOURETHROSCOPY AFTER BULBAR URETHROPLASTY ON RECURRENCE RISK: A TURNS STUDY Darshan Patel*, Salt Lake City, UT; Ragheed Al-Dulaimi, salt lake city, UT; Sean Elliott, Minnesota, MN; Alexander Vanni, Burlington, MA; Bradley Erickson, Iowa City, IA; Bryan Voelzke, Seattle, WA; Benjamin Breyer, San Francisco, CA; Christopher McClung, Columbus, OH; Thomas Smith, III, Houston, TX; Angela Presson, Jeremy Myers, Salt Lake City, UT INTRODUCTION AND OBJECTIVES: Surveillance protocols after bulbar urethroplasty vary. Flexible cystourethroscopy allows for direct visualization of the repair and is often used for surveillance. However, repeated cystourethroscopy following urethroplasty is costly and has significant patient burden. We evaluate the use of single cystourethroscopy performed in the early post-operative period and its ability to predict clinical success in men who underwent bulbar urethroplasty. METHODS: We identified patients from TURNS database from 1/1/2010-3/31/2016, who underwent urethroplasty for isolated bulbar strictures and received surveillance cystourethroscopy within 6 months of their procedure. We excluded patients with history of previous urethroplasty, lichen sclerosus, radiation, failed hypospadias repair, and any patients with clinical recurrence prior to surveillance cystourethroscopy. Our primary outcome was utility of cystourethroscopy findings (normal caliber, >17 French strictured rings, or inability to pass scope [<17 French strictured rings]) in predicting risk of clinical recurrence. RESULTS: 844 patients were identified. Mean age and BMI was 43 years (SD:15.5) and 30.0 kg/m2 (SD:6.6), respectively. 41 (5%) patients had a history of diabetes. 42 (5%) patients were current smokers and 72 (9%) were former smokers. 648 (77%) had excision and primary anastomosis and 196 (23%) had substitution urethroplasty with buccal graft. Mean operative stricture length was 3.0 cm (SD:1.8). Median time to first post-operative cystourethroscopy was 3.6 months (IQR: 3.1, 4.0). On cystourethroscopy, 608 (72%) had normal findings, 134 (16%) had >17 French strictured rings, and 102 (12%) had <17 French strictured rings. A total of 32 (4%) patients required a secondary procedure at a median time of 2.05 (IQR: 0.1-10.8) months. Cumulative 1-year rate for secondary procedures for recurrence were 0.01 (95% CI: 0-0.03) for normal urethra on first cystourethroscopy, 0.06 (95% CI:
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0-0.13) for >17 French strictured rings, and 0.27 (95% CI: 0.13-0.39) for <17 French strictured rings (Figure). CONCLUSIONS: Repeated cystourethroscopy has limited use after bulbar urethroplasty in predicting clinical failure in patients with normal caliber urethra on single early surveillance cystourethroscopy.
Source of Funding: None
PD34-12 TERTIARY URETHROPLASTY: IS THE THIRD TIME A CHARM? Travis Pagliara*, Boyd Viers, Charles Rew, Dallas, TX; Lauren FolgosaCooley, Richmond, VA; Alexander Rozanski, Christine Shiang, Jeremy Scott, Allen Morey, Dallas, TX Source of Funding: None
PD34-11 MULTI-INSTITUTIONAL OUTCOMES OF ENDOSCOPIC MANAGEMENT OF STRICTURE RECURRENCE AFTER URETHROPLASTY Shyam Sukumar*, Sean Elliott, Minneapolis, MN; Jeremy Myers, Salt Lake City, UT; Bryan Voelzke, Seattle, WA; Thomas Smith, Houston, TX; Alexandra Carolan, Minneapolis, MN; Michael Maidaa, Bradley Erickson, Iowa City, IA INTRODUCTION AND OBJECTIVES: Approximately 10-20% of patients will have a recurrence after urethroplasty. Initial management of these recurrences is often with urethral dilation (UD) and direct vision internal urethrotomy (DVIU) but the success rates of these procedures are not well known. METHODS: We retrospectively reviewed bulbar urethroplasty data from 5 surgeons from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS). Men who underwent UD or DVIU for a <17F lumen plus symptoms of recurrence were identified. Analyses compared success rates of recurrence management (UD vs. DVIU) and initial urethroplasty type (substitution vs. excisional repair, EPA) using time to event statistics: Kaplan Meier curves and Cox regression models. Failure of UD or DVIU was defined as the inability to pass a 17Fr cystoscope through the urethra into the bladder. RESULTS: There were 53 men with recurrence that were initially managed endoscopically, 10 with UD and 43 with DVIU. Mean time to recurrence after urethroplasty was 7.6 months. At a mean followup of 16.3 months after UD or DVIU, success was 41.5% in the overall cohort: 48.8% for DVIU vs. 10% for UD. Kaplan Meier curves are shown in Figure 1. On Cox modeling, UD had a higher rate of subsequent failure compared to DVIU (hazard ratio, HR: 3.15, p¼0.03). Patients undergoing EPA had a trend towards higher rates of recurrence after secondary endoscopic procedures vs. those undergoing substitution urethroplasty (HR: 2.41, p¼0.05) CONCLUSIONS: DVIU is more successful than UD in the management of stricture recurrence after bulbar urethroplasty. DVIU appears to be more successful for patients with a recurrence after a substitution urethroplasty compared to after an EPA, perhaps indicating a different mechanism of recurrence for EPA (ischemic) versus substitution urethroplasty (technical)
INTRODUCTION AND OBJECTIVES: While repeat urethroplasty following primary treatment failure is often successful, limited data exist describing outcomes among men requiring additional urethral surgeries. We aim to describe the characteristics and outcomes among men undergoing tertiary urethroplasty compared to primary and secondary repairs. METHODS: A retrospective review of over 1000 urethroplasty cases by a single surgeon from 2007-2014 was performed to identify men undergoing primary, secondary, and tertiary urethroplasty procedures. Tertiary urethroplasty was defined as urethral reconstruction following two or more previous urethroplasty failures. Clinical characteristics and outcomes were compared between groups. Mutivariable logistic regression models evaluated the association between number of previous urethral surgeries and treatment success. RESULTS: Among 573 urethroplasty cases having complete data available, 46 (8%) tertiary procedures were compared with 87 (15%) secondary and 440 (77%) primary procedures. Tertiary strictures were more often located in the penile urethra (50% vs 29% vs 17%, p<0.0001), and underwent substitution urethroplasty (61% vs 41% vs 23%, p<0.0001). Failure rates were higher for tertiary cases (37%) vs 20% and 13 % for secondary and primary procedures (p¼0.0001) during follow up (mean 17 months). The estimated 24-month stricture recurrence-free survival was lower for tertiary cases (44% vs 75% vs 75%, p¼0.07), but success rates of perineal urethrostomy (100%) and excision primary anastomosis (90%) were far greater than substitution urethroplasty (50%). Tertiary repairs were more likely to have a history of hypospadias (58% vs 20% vs 2%, p<0.001) and chronic kidney disease (17% vs 5% vs 9%, p¼0.003). No difference was noted in age, medical comorbidities, nor frequency of <90 day complications. On multivariable analysis controlling for history of hypospadias, stricture location, and type of surgery, tertiary urethroplasty was associated with an increased risk of treatment failure relative to primary (OR 2.88, 95% CI 1.29-6.65; p¼0.02) and secondary (OR 2.11, 95%CI 0.87-5.14; p¼0.09) urethroplasty. CONCLUSIONS: While tertiary urethroplasty is associated with an increased risk of treatment failure relative to primary and secondary urethroplasty, many patients can expect to experience durable resolution of obstructive voiding symptoms.