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Optimizing Outcomes of Urethroplasty
Editorials
Optimizing Outcomes of Urethroplasty “Success depends upon previous preparation, and without such preparation there is sure to be failure.”
eConfucius MANAGEMENT of urethral strictures is as diverse as the disease itself. Reconstructive urologists often point to the success rates of urethroplasty as being vastly superior to those of endoscopic management.1 However, there is no consensus on definitions of success after urethroplasty. Some argue for cystoscopic confirmation of patency whereas others make a case for uroflowmetry criteria, or simply the presence or absence of symptoms.2 Given the heterogeneity in strictures, approaches to repair, surgical skill and definitions of success, it is almost impossible to reach meaningful conclusions as to what comprises optimal management for affected patients. Nevertheless, at this time our practice patterns are largely guided by the available data from high volume centers. In this issue of The Journal 3 retrospective studies regarding stricture disease provide insight into clinical and tissue based factors potentially relevant to the durability of the repair. Barbagli et al (page 808) combined data from 2 high volume centers to evaluate the long-term success of substitution urethroplasty in anterior strictures with a minimum followup of 6 years.3 They found that skin grafts/flaps had a lower than 60% rate of success (buccal grafts performed better) and that overall success was 73.8%. Most of the failures, defined as need for instrumentation, occurred within the first 5 years. The concept is demonstrated clearly in table 1 in the article, which reports outcomes according to specific descriptions of the surgical technique used.3 Unfortunately the small numbers in several categories highlight the difficulty in drawing conclusions. Surprisingly there were only 54 penile urethroplasties performed at 2 major centers during 13 years, which amounts to approximately 2 cases per center per year. In addition, nearly 18% of patients never had a prior treatment (not even dilation) and the failure rate in this group was about 24%. Patients with prior failed urethroplasties had
0022-5347/14/1923-0636/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
636
j
www.jurology.com
AND
RESEARCH, INC.
better outcomes with a failure rate of only 18%. Thus, the findings from this study need to be viewed in the context of numerical limitations. Ultimately I applaud the attempt to clarify trends in recurrence in order to minimize unnecessary extended followup and associated costs. While the trend among many reconstructive urologists is to approach distal substitution urethroplasties dorsally, some continue to use a ventral approach to save operative time.4 In addition, since the dorsal approach was developed later, failure rates with ventral grafts may appear to be higher due to lead time.5 In an attempt to compensate for deficient spongiosum Cordon et al (page 804) offer an ancillary maneuver they call pseudospongioplasty.6 The concept of using healthy tissue to support a graft is sound, and prior reports have discussed mobilizing true flaps of tunica vaginalis from the scrotum to improve outcomes in the reconstruction of the pendular urethra.7 However, in this case the authors simply mention bringing the lateral tissue of the penis together over the graft. For many of us this maneuver is just a routine multilayered closure of the incision and not a novel procedure, especially since this was described previously.8 It is difficult to determine the impact of the closure since there is no true control group, given that the patients with true spongioplasty had different types of strictures. In addition, most of the strictures in this series were bulbar, with followup and onset to failure as short as 1 month, with only 5% of patients having a history of lichen sclerosus (LS). Treatment of strictures associated with LS can be challenging and our understanding of this condition is limited.9 Liu et al (page 775) reviewed their pathology specimens using a newly proposed set of criteria to see if findings of LS were present in isolated bulbar strictures.10 They found that the proposed criteria allowed more of their patients to be classified as having LS. As some patients had prior urethroplasties or hypospadias repairs, it is conceivable that LS, if present, was not truly isolated. It is unclear whether these data are meaningful, especially since 45% of anastomotic urethroplasties had evidence of LS by the new
http://dx.doi.org/10.1016/j.juro.2014.06.064 Vol. 192, 636-637, September 2014 Printed in U.S.A.
OPTIMIZING OUTCOMES OF URETHROPLASTY
criteria, but the success rates for this procedure are historically very good.11 In fact, among successful operations in this series LS was present more than 40% of the time. The authors routinely send a biopsy of the urethra when performing simple onlay procedures. However, it is unclear if this is taken from the proximal or distal end of the stricture. This may be relevant if there is ongoing injury from hydrodistention at the proximal end of the stricture, which has been used as a rationale for urethral rest.12 In addition, it is not clear that the cost of this pathological evaluation is justified. Nevertheless, the concept of better tissue characterization is well-taken. The changes noted in the spongiosum likely reflect a spectrum within this disease, and development of a discrete grading system could theoretically guide selection of a surgical approach in an effort to optimize outcomes. However, this would require sampling tissue before the repair. Clearly there is still work to be done in improving the management of urethral strictures. We cannot
637
optimize results until we better understand the disease clinically as well as scientifically. We cannot fully improve our understanding until we start comparing the same types of patients using the same types of assessments. The concept of prospective, double-blind trials to compare surgical approaches is exciting, but the reality is that achieving adequate power would necessitate such a large number of patients that it would require multinational and multi-institutional collaboration. Another issue to recognize is that there are those of us investigating clinical applications of engineered tissue to obviate the need to harvest autologous grafts.13 The ultimate goal should be to remove the need for urethroplasty altogether. Ryan Terlecki* Department of Urology Wake Forest University School of Medicine Winston-Salem, North Carolina *Financial interest and/or other relationship with AMS, Allergan and Auxilium.
REFERENCES 1. Greenwell TJ, Castle C, Andrich DE et al: Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004; 172: 275. 2. Meeks JJ, Erickson BA, Granieri MA et al: Stricture recurrence after urethroplasty: a systematic review. J Urol 2009; 182: 1266. 3. Barbagli G, Kulkarni SB, Fossati N et al: Longterm followup and deterioration rate of anterior substitution urethroplasty. J Urol 2014; 192: 808. 4. Patterson JM and Chapple CR: Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol 2008; 53: 1162. 5. B€urger RA, M€uller SC, el-Damanhoury H et al: The buccal mucosal graft for urethral
reconstruction: a preliminary report. J Urol 1992; 147: 662.
9. Palminteri E, Brandes SB and Djordjevic M: Urethral reconstruction in lichen sclerosus. Curr Opin Urol 2012; 22: 478.
6. Cordon BH, Zhao LC, Scott JF et al: Pseudospongioplasty using periurethral vascularized tissue to support ventral buccal mucosa grafts in the distal urethra. J Urol 2014; 192: 804.
10. Liu JS, Walker K, Stein D et al: Lichen sclerosus and isolated bulbar urethral stricture disease. J Urol 2014; 192: 775.
7. Snow BW, Cartwright PC and Unger K: Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience. J Urol 1995; 153: 472. 8. Jinga V, Hurduc M, Voinescu V et al: Ventral buccal mucosa graft urethroplasty for penile urethral strictures: a predictable failure? Chirurgia (Bucur) 2013; 108: 245.
11. Morey AF, Watkin N, Shenfeld O et al: SIU/ICUD Consultation on Urethral Strictures: anterior urethraeprimary anastomosis. Urology, suppl., 2014; 83: S23. 12. Terlecki RP, Steele MC, Valadez C et al: Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology 2011; 77: 1477. 13. Bhargava S, Patterson JM, Inman RD et al: Tissueengineered buccal mucosa urethroplastyeclinical outcomes. Eur Urol 2008; 53: 1263.
Optimizing Outcomes of Urethroplasty “Success depends upon previous preparation, and without such preparation there is sure to be failure.”
eConfucius MANAGEMENT of urethral strictures is as diverse as the disease itself. Reconstructive urologists often point to the success rates of urethroplasty as being vastly superior to those of endoscopic management.1 However, there is no consensus on definitions of success after urethroplasty. Some argue for cystoscopic confirmation of patency whereas others make a case for uroflowmetry criteria, or simply the presence or absence of symptoms.2 Given the heterogeneity in strictures, approaches to repair, surgical skill and definitions of success, it is almost impossible to reach meaningful conclusions as to what comprises optimal management for affected patients. Nevertheless, at this time our practice patterns are largely guided by the available data from high volume centers. In this issue of The Journal 3 retrospective studies regarding stricture disease provide insight into clinical and tissue based factors potentially relevant to the durability of the repair. Barbagli et al (page 808) combined data from 2 high volume centers to evaluate the long-term success of substitution urethroplasty in anterior strictures with a minimum followup of 6 years.3 They found that skin grafts/flaps had a lower than 60% rate of success (buccal grafts performed better) and that overall success was 73.8%. Most of the failures, defined as need for instrumentation, occurred within the first 5 years. The concept is demonstrated clearly in table 1 in the article, which reports outcomes according to specific descriptions of the surgical technique used.3 Unfortunately the small numbers in several categories highlight the difficulty in drawing conclusions. Surprisingly there were only 54 penile urethroplasties performed at 2 major centers during 13 years, which amounts to approximately 2 cases per center per year. In addition, nearly 18% of patients never had a prior treatment (not even dilation) and the failure rate in this group was about 24%. Patients with prior failed urethroplasties had
0022-5347/14/1923-0636/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
636
j
www.jurology.com
AND
RESEARCH, INC.
better outcomes with a failure rate of only 18%. Thus, the findings from this study need to be viewed in the context of numerical limitations. Ultimately I applaud the attempt to clarify trends in recurrence in order to minimize unnecessary extended followup and associated costs. While the trend among many reconstructive urologists is to approach distal substitution urethroplasties dorsally, some continue to use a ventral approach to save operative time.4 In addition, since the dorsal approach was developed later, failure rates with ventral grafts may appear to be higher due to lead time.5 In an attempt to compensate for deficient spongiosum Cordon et al (page 804) offer an ancillary maneuver they call pseudospongioplasty.6 The concept of using healthy tissue to support a graft is sound, and prior reports have discussed mobilizing true flaps of tunica vaginalis from the scrotum to improve outcomes in the reconstruction of the pendular urethra.7 However, in this case the authors simply mention bringing the lateral tissue of the penis together over the graft. For many of us this maneuver is just a routine multilayered closure of the incision and not a novel procedure, especially since this was described previously.8 It is difficult to determine the impact of the closure since there is no true control group, given that the patients with true spongioplasty had different types of strictures. In addition, most of the strictures in this series were bulbar, with followup and onset to failure as short as 1 month, with only 5% of patients having a history of lichen sclerosus (LS). Treatment of strictures associated with LS can be challenging and our understanding of this condition is limited.9 Liu et al (page 775) reviewed their pathology specimens using a newly proposed set of criteria to see if findings of LS were present in isolated bulbar strictures.10 They found that the proposed criteria allowed more of their patients to be classified as having LS. As some patients had prior urethroplasties or hypospadias repairs, it is conceivable that LS, if present, was not truly isolated. It is unclear whether these data are meaningful, especially since 45% of anastomotic urethroplasties had evidence of LS by the new
http://dx.doi.org/10.1016/j.juro.2014.06.064 Vol. 192, 636-637, September 2014 Printed in U.S.A.
OPTIMIZING OUTCOMES OF URETHROPLASTY
criteria, but the success rates for this procedure are historically very good.11 In fact, among successful operations in this series LS was present more than 40% of the time. The authors routinely send a biopsy of the urethra when performing simple onlay procedures. However, it is unclear if this is taken from the proximal or distal end of the stricture. This may be relevant if there is ongoing injury from hydrodistention at the proximal end of the stricture, which has been used as a rationale for urethral rest.12 In addition, it is not clear that the cost of this pathological evaluation is justified. Nevertheless, the concept of better tissue characterization is well-taken. The changes noted in the spongiosum likely reflect a spectrum within this disease, and development of a discrete grading system could theoretically guide selection of a surgical approach in an effort to optimize outcomes. However, this would require sampling tissue before the repair. Clearly there is still work to be done in improving the management of urethral strictures. We cannot
637
optimize results until we better understand the disease clinically as well as scientifically. We cannot fully improve our understanding until we start comparing the same types of patients using the same types of assessments. The concept of prospective, double-blind trials to compare surgical approaches is exciting, but the reality is that achieving adequate power would necessitate such a large number of patients that it would require multinational and multi-institutional collaboration. Another issue to recognize is that there are those of us investigating clinical applications of engineered tissue to obviate the need to harvest autologous grafts.13 The ultimate goal should be to remove the need for urethroplasty altogether. Ryan Terlecki* Department of Urology Wake Forest University School of Medicine Winston-Salem, North Carolina *Financial interest and/or other relationship with AMS, Allergan and Auxilium.
REFERENCES 1. Greenwell TJ, Castle C, Andrich DE et al: Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004; 172: 275. 2. Meeks JJ, Erickson BA, Granieri MA et al: Stricture recurrence after urethroplasty: a systematic review. J Urol 2009; 182: 1266. 3. Barbagli G, Kulkarni SB, Fossati N et al: Longterm followup and deterioration rate of anterior substitution urethroplasty. J Urol 2014; 192: 808. 4. Patterson JM and Chapple CR: Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol 2008; 53: 1162. 5. B€urger RA, M€uller SC, el-Damanhoury H et al: The buccal mucosal graft for urethral
reconstruction: a preliminary report. J Urol 1992; 147: 662.
9. Palminteri E, Brandes SB and Djordjevic M: Urethral reconstruction in lichen sclerosus. Curr Opin Urol 2012; 22: 478.
6. Cordon BH, Zhao LC, Scott JF et al: Pseudospongioplasty using periurethral vascularized tissue to support ventral buccal mucosa grafts in the distal urethra. J Urol 2014; 192: 804.
10. Liu JS, Walker K, Stein D et al: Lichen sclerosus and isolated bulbar urethral stricture disease. J Urol 2014; 192: 775.
7. Snow BW, Cartwright PC and Unger K: Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience. J Urol 1995; 153: 472. 8. Jinga V, Hurduc M, Voinescu V et al: Ventral buccal mucosa graft urethroplasty for penile urethral strictures: a predictable failure? Chirurgia (Bucur) 2013; 108: 245.
11. Morey AF, Watkin N, Shenfeld O et al: SIU/ICUD Consultation on Urethral Strictures: anterior urethraeprimary anastomosis. Urology, suppl., 2014; 83: S23. 12. Terlecki RP, Steele MC, Valadez C et al: Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology 2011; 77: 1477. 13. Bhargava S, Patterson JM, Inman RD et al: Tissueengineered buccal mucosa urethroplastyeclinical outcomes. Eur Urol 2008; 53: 1263.