87 The evolution of urethroplasty for bulbar urethral stricture disease; more options, better outcomes

87

The evolution of urethroplasty for bulbar urethral stricture disease; more options, better outcomes Eur Urol Suppl 2014;13;e87          

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Granieri M.A., Webster G.D., Fraser M.O., Peterson A.C. Duke University, Dept. of Surgery and Urology, Durham, United States of America INTRODUCTION & OBJECTIVES: The past fifteen years have brought dramatic changes to the surgical options for treating bulbar urethral stricture disease (USD). We present a single centre experience describing the evolution of procedure selection and outcomes for bulbar USD over this time period. MATERIAL & METHODS: We performed an IRB approved retrospective review of our institution’s database. Patient demographics, stricture details including etiology, length and location, as well as intraoperative and post-operative information were collected.  One-way ANOVA was used to detect differences in age and stricture length, Fisher’s Exact Test was used to detect differences in recurrence rate, and t-test and chi-square test with Bonferroni correction was used for sub-group analysis. RESULTS: We identified 429 men who underwent urethroplasty for bulbar USD by two surgeons (GDW, ACP) from 1/1/1996 to 8/31/2011.  Of these 429 men, 384 (90%) had available follow up data.  Table 1 provides a detailed description by repair type.  Figure 1 demonstrates a significant change in procedures selection for the period reviewed, specifically in the replacement of penile skin by buccal mucosa for augmented anastomotic repair (AAR).  Table 1 shows changes in outcomes. AAR with buccal mucosa had a significantly improved recurrence rate when compared to AAR with penile skin (21.6% vs 5.8%, p=0.002).  While there was a statistically significant increase in the median length of strictures treated with excision and primary anastomosis (EPA) after 2004 (1.32cm vs. 1.54cm, p=0.05), it was not associated with any significant change in recurrence rate (6.9% vs 3.0%, p = 0.27).  Table 1:

Repair Type

N (%)

Age (Yrs) +/- SD Stricture length (cm) +/- SD Recurrence Rate

ALL

384

43.2+/-15

2.0 +/- 1.2

6.8%

Onlay

20 (5.2%)

36 +/- 11 a

2.5 +/- 0.9 b

0%

AAR Penile Skin

37 (9.6%)

43.0 +/-13 a

2.1+/- 1.1 b

21.6%

AAR Buccal

103 (26.8%) 41.2 +/- 13 a

2.8+/- 1.6 b

5.8% c

EPA

202 (52.6%) 43.3 +/-16 a

1.4 +/- 0.8

5.5% c

Staged

2 (0.5%)

43.3 +/-15

4 +/- 1.7

0%

Perineal Urethrostomy 16 (4.2%)

56.6+/-18

2.75 +/-1.5

6.3%

Flap Based

4 (1%)

52 +/-17

2.5 +/- 0.6

0%

P value

 

0.01*

<0.01*

0.05*

*= significance for ANOVA/Fisher’s Exact Test (p<0.05) a=significant difference when compared to perineal urethrostomy (p<0.0024) b= significant difference when compared to EPA (p<0.0024) c=significant difference when compared to AAR Penile skin (p<0.0024)

Figure 1:

CONCLUSIONS: While the transition from the use of penile skin to buccal mucosa for AAR at our institution was relatively abrupt it was associated with an overall decrease in recurrence rates. Furthermore, the rates of EPA have increased significantly since 2004. This is likely because we have become more aggressive with respect to stricture length, performing the EPA in longer diseased segments. Despite this, we have not seen an increase recurrence rates after this procedure.