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85 URETHRAL RECONSTRUCTION OF LONG-SEGMENT LICHEN SCLEROSUS STRICTURES: COMPARISON OF SURGICAL TECHNIQUES AND OUTCOMES
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THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
84 POOR FOLLOW-UP AND LOW SOCIOECONOMIC STATUS PREDICT CANCER-SPECIFIC MORTALITY IN MEN WITH PROSTATE CANCER Mohummad Siddiqui*, Boston, MA; Alan Paciorek, San Francisco, CA; Mark S. Litwin, Los Angeles, CA; Aria F. Olumi, Boston, MA INTRODUCTION AND OBJECTIVES: Studies suggest that low socioeconomic status (SES) and disparities in prostate cancer care may be determinants of poor outcomes in underserved men. We hypothesize that differential utilization of healthcare resources, including maintaining regular follow-up appointments, may contribute to the poorer outcomes in men of low SES. METHODS: We prospectively identified 3,643 men with prostate cancer diagnosed between 1998 and 2008 in the CaPSURE registry. Median follow-up was 53 months. Participants reported at study entry about household income; low (vs high) SES was set at $30,000 (133% of the federal poverty level for a family of four). We quantified follow-up as the percent of years after prostate cancer diagnosis that the individual had at least one prostate specific antigen (PSA) test checked. We used ordinal linear regression to perform multivariate analysis of follow-up as correlated with SES. We performed Cox proportional hazards models to assess the effects of income and follow-up on prostate cancer-specific mortality. Fifty men died from prostate cancer in the study period. RESULTS: Higher rate of follow-up correlated positively with high SES (p⫽0.003) and prostatectomy (p⬍0.0001) but not with age, Gleason score, stage, or PSA at diagnosis. On univariate analysis, age, Gleason score, stage, PSA at diagnosis, follow-up, and SES were all significant hazards for death from prostate cancer. On multivariate analysis controlling for age, grade, stage, PSA at diagnosis, and treatment modality, low SES was a significant risk for death from prostate cancer (HR⫽2.03, p⫽0.02). When the model was additionally controlled for follow-up, the effect of income was attenuated somewhat by 9% (HR⫽1.89, p⫽0.03). Poor follow-up strongly correlated with prostate cancer-specific death (HR⫽5.6, p⫽0.003). CONCLUSIONS: Men of higher SES maintained better follow-up for their prostate cancer care. Not maintaining regular followup appointments and being of low SES both predicted death from prostate cancer. Source of Funding: CaPSURE is supported by an unrestricted educational gift from Abbott Laboratories (Chicago, IL), by the National Institutes of Health/National Cancer Institute (5RC1CA146596), and by the Agency for Healthcare Research and Quality (1U01CA88160).
Trauma/Reconstruction: Trauma & Reconstructive Surgery II Moderated Poster Saturday, May 19, 2012
3:30 PM-5:30 PM
85 URETHRAL RECONSTRUCTION OF LONG-SEGMENT LICHEN SCLEROSUS STRICTURES: COMPARISON OF SURGICAL TECHNIQUES AND OUTCOMES Keith Rourke*, Adam Kinnaird, Brandon Nadeau, Edmonton, Canada INTRODUCTION AND OBJECTIVES: Lichen sclerosus related urethral strictures provide a unique challenge to reconstructive urologists. Long segments of urethra can be involved, and standard urethroplasty techniques are typically less effective. The purpose of this study was to assess the relative outcomes of three surgical options in the treatment of lichen sclerosus strictures; 1. Staged reconstruction, 2. One-stage onlay reconstruction, and 3. Urethrostomy techniques.
METHODS: A retrospective analysis was performed on a database containing all urethral reconstructions performed by a single urologist from August 2003 to March 2011. Forty-two male patients (mean age 52.4 years) were identified with lichen sclerosus as the stricture etiology with 39 having sufficient follow-up for analysis. Patients were divided into those who received staged reconstruction (14), one-stage onlay (13), or urethrostomy (12). Of the 12 urethrostomies performed, 11 were of the “augmented” variety requiring buccal mucosa in patients with panurethral stricture extending to the proximal bulbar urethra. The primary outcomes measures were the need for additional procedures, presence of persisting lower urinary tract symptoms, and urethral patency at follow-up cystoscopy. Statistical significance of success rates were determined by twotailed Chi-square analysis (p⬍0.05). RESULTS: Of the 39 patients with available follow-up, mean stricture length was 11.7 cm with a mean follow-up of 39.7 months. The overall success rates (those not requiring additional procedures) were 92% for urethrostomy techniques, 79% for two-stage reconstruction, and 54% for one-stage onlay. Urethrostomy techniques were found to offer better success rates than one-stage onlay (p⫽0.04). At 6 month cystoscopy, 100% of urethrostomies were patent, compared with 92% of two-stage reconstructions, and 83% of one-stage onlays. Finally, the rates of persisting post-operative LUTS were 8% for urethrostomy, 21% in two-stage reconstructions, and 62% in one-stage onlay (p⫽0.04). CONCLUSIONS: Urethrostomy techniques appear to offer the best outcomes when treating urethral strictures secondary to lichen sclerosis, particularly when compared to onlay techniques. In patients with true panurethral strictures, an “augmented” urethrostomy using buccal mucosa to treat select segments is a viable option. Onlay techniques alone exhibit poor outcomes, while staged reconstruction in select patients with penile urethral stricture seems a reasonable alternative when a urethrostomy is unwanted. Source of Funding: None
86 LONG TERM RESULTS OF LINGUAL MUCOSAL GRAFTS FOR REPAIRING LONG ANTERIOR URETHRAL STRICTURES Samir Elgamal*, Mohamed Abu Farha, Ahmed El-abd, Ahmed Tawfik, Mohamed Soliman, Tanta, Egypt INTRODUCTION AND OBJECTIVES: The lingual mucosal graft is widely used as an effective option for urethral reconstruction, however, the long term outcome of these patients remain unclear. The aim of this study is to report the long term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts. METHODS: This study included 23 patients who underwent lingual mucosa onlay graft for management of long anterior urethral stricture and were followed for at least 5 years. A free graft of lingual mucosa was used as a ventral onlay in 8 patients and as a dorsal onlay in the remaining 15 patients. Mean stricture length was 4.6 cm (range 3 to 11.5). International Prostate Symptom Score and uroflowmetry were obtained preoperatively, at 3, 6 and 12 months postoperatively, and annually thereafter. A retrograde urethrogram with a voiding cystourethrogram was taken preoperatively, at catheter removal, after 3 and 6 months postoperatively and selectively thereafter. A successful outcome was defined as normal voiding with no stricture on the urethrogram and no need for subsequent instrumentation. RESULTS: The mean age of the patients was 36.3 years (range 21-62). The mean follow-up was 66 months (range 60 to 72). Etiology of the strictures was trauma (in 9),instrumentation (in 7), idiopathic (in 4), urethritis (in 2) and prior hypospadias repair (in 1). Success was achieved in 20 of 23 patients (87%). Recurrent stricture was developed in the remaining 3 patients. All failures occurred within the first year and were managed successfully by internal urethrotomy. There were no fistulas or clinically perceptible graft sacculations. Also, there were no long term donor site complications. CONCLUSIONS: With long-term follow-up our series confirms the durability of lingual mucosal onlay grafts for the treatment of long
THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
84 POOR FOLLOW-UP AND LOW SOCIOECONOMIC STATUS PREDICT CANCER-SPECIFIC MORTALITY IN MEN WITH PROSTATE CANCER Mohummad Siddiqui*, Boston, MA; Alan Paciorek, San Francisco, CA; Mark S. Litwin, Los Angeles, CA; Aria F. Olumi, Boston, MA INTRODUCTION AND OBJECTIVES: Studies suggest that low socioeconomic status (SES) and disparities in prostate cancer care may be determinants of poor outcomes in underserved men. We hypothesize that differential utilization of healthcare resources, including maintaining regular follow-up appointments, may contribute to the poorer outcomes in men of low SES. METHODS: We prospectively identified 3,643 men with prostate cancer diagnosed between 1998 and 2008 in the CaPSURE registry. Median follow-up was 53 months. Participants reported at study entry about household income; low (vs high) SES was set at $30,000 (133% of the federal poverty level for a family of four). We quantified follow-up as the percent of years after prostate cancer diagnosis that the individual had at least one prostate specific antigen (PSA) test checked. We used ordinal linear regression to perform multivariate analysis of follow-up as correlated with SES. We performed Cox proportional hazards models to assess the effects of income and follow-up on prostate cancer-specific mortality. Fifty men died from prostate cancer in the study period. RESULTS: Higher rate of follow-up correlated positively with high SES (p⫽0.003) and prostatectomy (p⬍0.0001) but not with age, Gleason score, stage, or PSA at diagnosis. On univariate analysis, age, Gleason score, stage, PSA at diagnosis, follow-up, and SES were all significant hazards for death from prostate cancer. On multivariate analysis controlling for age, grade, stage, PSA at diagnosis, and treatment modality, low SES was a significant risk for death from prostate cancer (HR⫽2.03, p⫽0.02). When the model was additionally controlled for follow-up, the effect of income was attenuated somewhat by 9% (HR⫽1.89, p⫽0.03). Poor follow-up strongly correlated with prostate cancer-specific death (HR⫽5.6, p⫽0.003). CONCLUSIONS: Men of higher SES maintained better follow-up for their prostate cancer care. Not maintaining regular followup appointments and being of low SES both predicted death from prostate cancer. Source of Funding: CaPSURE is supported by an unrestricted educational gift from Abbott Laboratories (Chicago, IL), by the National Institutes of Health/National Cancer Institute (5RC1CA146596), and by the Agency for Healthcare Research and Quality (1U01CA88160).
Trauma/Reconstruction: Trauma & Reconstructive Surgery II Moderated Poster Saturday, May 19, 2012
3:30 PM-5:30 PM
85 URETHRAL RECONSTRUCTION OF LONG-SEGMENT LICHEN SCLEROSUS STRICTURES: COMPARISON OF SURGICAL TECHNIQUES AND OUTCOMES Keith Rourke*, Adam Kinnaird, Brandon Nadeau, Edmonton, Canada INTRODUCTION AND OBJECTIVES: Lichen sclerosus related urethral strictures provide a unique challenge to reconstructive urologists. Long segments of urethra can be involved, and standard urethroplasty techniques are typically less effective. The purpose of this study was to assess the relative outcomes of three surgical options in the treatment of lichen sclerosus strictures; 1. Staged reconstruction, 2. One-stage onlay reconstruction, and 3. Urethrostomy techniques.
METHODS: A retrospective analysis was performed on a database containing all urethral reconstructions performed by a single urologist from August 2003 to March 2011. Forty-two male patients (mean age 52.4 years) were identified with lichen sclerosus as the stricture etiology with 39 having sufficient follow-up for analysis. Patients were divided into those who received staged reconstruction (14), one-stage onlay (13), or urethrostomy (12). Of the 12 urethrostomies performed, 11 were of the “augmented” variety requiring buccal mucosa in patients with panurethral stricture extending to the proximal bulbar urethra. The primary outcomes measures were the need for additional procedures, presence of persisting lower urinary tract symptoms, and urethral patency at follow-up cystoscopy. Statistical significance of success rates were determined by twotailed Chi-square analysis (p⬍0.05). RESULTS: Of the 39 patients with available follow-up, mean stricture length was 11.7 cm with a mean follow-up of 39.7 months. The overall success rates (those not requiring additional procedures) were 92% for urethrostomy techniques, 79% for two-stage reconstruction, and 54% for one-stage onlay. Urethrostomy techniques were found to offer better success rates than one-stage onlay (p⫽0.04). At 6 month cystoscopy, 100% of urethrostomies were patent, compared with 92% of two-stage reconstructions, and 83% of one-stage onlays. Finally, the rates of persisting post-operative LUTS were 8% for urethrostomy, 21% in two-stage reconstructions, and 62% in one-stage onlay (p⫽0.04). CONCLUSIONS: Urethrostomy techniques appear to offer the best outcomes when treating urethral strictures secondary to lichen sclerosis, particularly when compared to onlay techniques. In patients with true panurethral strictures, an “augmented” urethrostomy using buccal mucosa to treat select segments is a viable option. Onlay techniques alone exhibit poor outcomes, while staged reconstruction in select patients with penile urethral stricture seems a reasonable alternative when a urethrostomy is unwanted. Source of Funding: None
86 LONG TERM RESULTS OF LINGUAL MUCOSAL GRAFTS FOR REPAIRING LONG ANTERIOR URETHRAL STRICTURES Samir Elgamal*, Mohamed Abu Farha, Ahmed El-abd, Ahmed Tawfik, Mohamed Soliman, Tanta, Egypt INTRODUCTION AND OBJECTIVES: The lingual mucosal graft is widely used as an effective option for urethral reconstruction, however, the long term outcome of these patients remain unclear. The aim of this study is to report the long term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts. METHODS: This study included 23 patients who underwent lingual mucosa onlay graft for management of long anterior urethral stricture and were followed for at least 5 years. A free graft of lingual mucosa was used as a ventral onlay in 8 patients and as a dorsal onlay in the remaining 15 patients. Mean stricture length was 4.6 cm (range 3 to 11.5). International Prostate Symptom Score and uroflowmetry were obtained preoperatively, at 3, 6 and 12 months postoperatively, and annually thereafter. A retrograde urethrogram with a voiding cystourethrogram was taken preoperatively, at catheter removal, after 3 and 6 months postoperatively and selectively thereafter. A successful outcome was defined as normal voiding with no stricture on the urethrogram and no need for subsequent instrumentation. RESULTS: The mean age of the patients was 36.3 years (range 21-62). The mean follow-up was 66 months (range 60 to 72). Etiology of the strictures was trauma (in 9),instrumentation (in 7), idiopathic (in 4), urethritis (in 2) and prior hypospadias repair (in 1). Success was achieved in 20 of 23 patients (87%). Recurrent stricture was developed in the remaining 3 patients. All failures occurred within the first year and were managed successfully by internal urethrotomy. There were no fistulas or clinically perceptible graft sacculations. Also, there were no long term donor site complications. CONCLUSIONS: With long-term follow-up our series confirms the durability of lingual mucosal onlay grafts for the treatment of long