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Outpatient Anterior Urethroplasty: Outcome Analysis and Patient Selection Criteria
0022-5347/02/1683-1024/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 168, 1024 –1026, September 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000025400.77578.72
OUTPATIENT ANTERIOR URETHROPLASTY: OUTCOME ANALYSIS AND PATIENT SELECTION CRITERIA JACK B. LEWIS, KELLY A. WOLGAST, JOHN A. WARD
AND
ALLEN F. MOREY*
From the Urology Service, Brooke Army Medical Center, San Antonio, Texas
ABSTRACT
Purpose: We compared the outcomes of anterior urethroplasty for stricture disease performed on an outpatient and an inpatient basis. Materials and Methods: We reviewed the records of 78, 1-stage anterior urethroplasties performed via excision with primary anastomosis, buccal mucosal graft or penile fasciocutaneous skin flap techniques from September 1997 to December 2000 by a single surgeon (A. F. M.). All patients had more than 1 year of followup (range 1 to 4.5). Of the graft procedures only those in the bulbar urethra were included in analysis. Outpatient procedures were defined as those in which the patient was discharged home within 24 hours. Clinical outcome was considered a failure when instrumentation was required postoperatively. Results: Of the 78 anterior urethral repairs 54 (69%) were performed on an outpatient basis, including 50 (93%) in which the outcome was successful compared with 88% (21) of the 24 inpatient procedures. Excision with primary anastomosis had the highest outpatient rate (28 of 31 patients or 90%), followed by penile skin flaps (16 of 25 or 64%) and buccal mucosal grafts (10 of 22 or 45%). Patient characteristics were significantly associated with outpatient procedures, including younger mean age (36 versus 46 years), shorter mean stricture length (3.1 versus 6.6 cm.) and shorter mean operative time (3.2 versus 4.66 hours) (p ⬍0.05). Conclusions: Anterior urethral reconstruction can often be completed safely and effectively on an outpatient basis. KEY WORDS: urethra, urethral stricture, ambulatory surgical procedures, patient selection
In the last 10 years a dramatic increase in outpatient surgery and minimally invasive techniques within all surgical fields has been driven by cost containment efforts of third party payers and patient preference for a shorter hospital stay. Recently data have shown that outpatient surgery costs are 40% to 60% less than those for the same procedure performed with hospitalization, and postoperative recovery and patient satisfaction are enhanced the earlier a patient is discharged from the hospital.1 Concomitantly various urological procedures have been increasingly performed on an outpatient basis. Regardless of cause or previous treatment 1-stage urethroplasty has been refined and is appropriate for the majority of strictures. The success rate of open surgery is 77% to 96%,2, 3 in contrast to endoscopic management via direct vision internal urethrotomy and dilation techniques, for which long-term success rates are reportedly as low as 32%.4, 5 At our institution anterior urethral reconstruction has been performed aggressively instead of repeat endoscopic treatment and on an outpatient basis. With continued experience we have been increasingly impressed with the rapid recovery of most patients postoperatively. We assessed whether outcomes were equivalent in patients who underwent the procedure on an outpatient basis and those who were hospitalized as inpatients after surgery. Furthermore, we identified patient selection criteria that enabled successful outpatient anterior urethral reconstruction.
PATIENTS AND METHODS
We retrospectively reviewed the records of 121 consecutive urethroplasties performed by a single surgeon (A. F. M.) from September 1997 to December 2000. Men who underwent posterior urethroplasty, combined procedures or pendulous urethral grafts for reoperative hypospadias were excluded from study. Complete data were analyzed on the 78 cases in which 1-stage anterior urethral reconstruction was performed via excision with primary anastomosis, a buccal mucosa graft or penile skin flap. Many men had been previously treated with endoscopic techniques (dilation in 13% and direct vision internal urethrotomy in 18%), although it was not a prerequisite for open surgery. Previous open urethroplasty had been performed in 20% of the cases and multiple previous procedures had failed in 22%. Preoperative staging was performed in all patients by retrograde urethrography, urinary flow rate measurement and American Urological Association symptom scores. Stricture length, location and severity as well as adverse local factors influenced procedure selection. Of the graft procedures only those performed in the bulbar urethra were included in our analysis and all were applied on the ventral surface. Outpatient procedures were those in which the patient was discharged home within 24 hours of surgery. Patients considered for outpatient procedures were educated in regard to expectations, precautions and postoperative home care requirements before scheduling. Factors influencing outpatient selection included patient age, previous repair, difficulty and duration of planned reconstruction, social considerations, American Society of Anesthesiologists (ASA) class and associated morbidity. Criteria for hospital discharge included stable vital signs, pain well controlled with oral medication and favorable wound characteristics, such as no signs of
Accepted for publication April 5, 2002. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the United States Government. Presented at annual meeting of American Urological Association, Anaheim, California June 2–7, 2001. * Financial interest and/or other relationship with Ortho-McNeil and Pfizer. 1024
1025
OUTPATIENT ANTERIOR URETHROPLASTY
hematoma. Importantly social factors, including the ability to understand hospital discharge instructions and the availability of postoperative care at home, were assessed before the patient was released from the hospital. Statistical analysis of patient selection criteria was performed using univariate and multivariate logistic regression. Padded fishnet shorts were used to compress the genitalia postoperatively, providing hemostasis and immobilization of the surgical site for the first 72 hours after discharge. In addition, for penile flap procedures a bio-occlusive dressing was used to compress the penis. Patients were instructed to minimize activity and change dressings daily for 10 days postoperatively. The catheter remained indwelling for 3 weeks. Oral analgesics, such as oxycodone and acetominophen, were given instead of local or regional anesthetics for postoperative pain control in all cases. Drains were not used, and so additional home health care nursing was not required. All patients had more than 1 year of followup (range 1 to 4.5). Uroflowmetry and urethrography were performed at 3 months and 1 year. Clinical outcome was considered unsuccessful when any postoperative instrumentation was required for recurrent obstructive voiding symptoms. RESULTS
In the 78 patients stricture length was 0.5 to 21 cm. (mean 4.3). Stricture location was bulbar in 70.1% of the cases with a pendulous stricture in 23% and involvement of the whole anterior urethra in 6.3%. On univariate logistic regression younger patient age and stricture length were significantly related to the probability of treatment on an outpatient basis (p ⬍0.05, table 1). Operative time was likewise significantly lower. On multivariate logistic regression analysis age and operative time also remained significantly associated with outpatient management (p ⬍0.05). ASA class, associated morbidity and previous repair were not predictive of outpatient or inpatient management (p ⬎0.05). Overall 54 (69%) of the 78 anterior urethral repairs were performed on an outpatient basis with the rate increasing over the period analyzed (60% in 1997 to 93% in 2000). Excision with primary anastomosis had the highest outpatient rate (28 of 31 cases or 90%), followed by penile skin flaps (16 of 25 or 64%) and buccal mucosal grafts (10 of 22 or 45%). A single patient who underwent primary anastomosis and was initially scheduled as an outpatient remained hospitalized because of postoperative hematoma formation. This condition stabilized with conservative management. He was discharged home on postoperative day 3 and remained stricturefree for 25 months of followup. The success rate was similar in the outpatient (50 of 54 patients or 93%) and hospitalized (21 of 24 or 88%) groups overall and when analyzed by procedure type (table 2). In the outpatient group 1 patient who underwent primary anastomosis had a small recurrent stricture that was managed successfully with internal urethrotomy, penile flap procedures in 2 required intervention (meatotomy in 1, and dilation and a subsequent graft procedure in 1) and a graft required salvage excision and primary anastomosis in 1. In the hospitalized group 2 patients who underwent a graft
TABLE 1. Patient selection for outpatient anterior urethral reconstruction Characteristics
Outpts.
Inpts.
Mean age (range) Mean hrs. operative time (range) Mean cm. stricture length (range) Mean ASA class (range) % Co-morbidity % Previous repair
36 (12–83) 3.20 (0.5–5)
46 (17–64) 4.66 (3–7)
3.1 (0.5–10) 1.4 37 37
(1–3)
6.6
(2–21)
1.5 50 56
(1–3)
p Value 0.033 0.001 0.014 ⬎0.05 ⬎0.05 ⬎0.05
TABLE 2. Success rate of inpatient and outpatient surgery based on procedure type Procedure
No. Outpt./ Total No. (%)
No. Inpt./ Total No. (%)
Excision ⫹ primary anastomosis Flap Buccal mucosal graft
27/28 (96) 14/16 (87) 9/10 (90)
3/3 (100) 8/9 (89) 10/12 (83)
50/54 (93)
21/24 (88)
Totals
procedure required reoperation (a penile flap and internal urethrotomy in 1 each), while 1 with balanitis xerotica obliterans awaits reconstruction. DISCUSSION
Our data indicate that a successful outcome is not related to hospital stay and our success rates of 93% for outpatient and 88% for inpatient procedures are comparable to those reported in the literature (77–96%).2, 3 Although more failures may be detected with time, we have observed that the majority are evidenced within the first 6 months as recurrent obstructive symptoms. Which patients are candidates for outpatient urethral surgery? In our experience older patients with longer strictures requiring extensive repair were more likely to be treated on an inpatient basis. Younger patient age and shorter stricture length (and, thus, decreased operative time) were predictive of outpatient surgery. Accordingly excision with primary anastomosis was suitable for outpatient surgery in almost all cases, whereas buccal mucosal grafts and penile flap procedures were less so (45% and 64%, respectively). Graft procedures performed well despite the absence of hospitalization and strict bed rest for the initial postoperative 48 hours. Our data suggest that moderate ambulation in the early postoperative period does not jeopardize long-term graft survival. These results underscore the high reliability of buccal mucosa as a graft source and the stability of the bulbar urethra as a graft bed. Interestingly our analysis revealed that ASA class, associated morbidity and previously attempted repair were not significantly different in the outpatient and inpatient groups. Extensive repairs were often performed successfully on an outpatient basis even in patients with multiple comorbidities, high ASA class and a history of urethroplasty. Others have previously indicated that ASA classification is not uniquely predictive of the necessity of an inpatient procedure.6, 7 We believe that successful reconstruction of complex strictures is related to the performance of a precise, expedient procedure. As we have previously noted, prolonged patient time in the high lithotomy position is associated with increased lower extremity complications and, therefore, it must be limited.8 Accordingly, penile flap procedures at our institution are done with the patient mainly supine and they are reserved primarily for pendulous strictures. Furthermore, we believe that routine moderate penile compression with a bio-occlusive dressing decreases genital edema without compromising flap viability, thus, promoting successful outpatient management. Preoperative assessment of patient willingness, comprehension, reliability, compliance and social support system is vital to successful outpatient surgery. An outpatient care plan concludes just before hospital discharge with reinforcement of postoperative care requirements and followup visit scheduling. Do patients prefer outpatient procedures? Kaye reported that patients in whom a procedure was completed on an outpatient basis tended to manifest significantly better emotional adjustment with fewer psychological distress symptoms than those treated as inpatients.1 The 2 groups noticed
1026
OUTPATIENT ANTERIOR URETHROPLASTY
similar levels of pain, fear, anxiety, health assessment and quality of life but inpatients typically reported longer convalescence than outpatients for the same surgical procedure. Poor hemostasis is the most common cause of hospitalization for all outpatient procedures, accounting for 74% of all re-admissions to outpatient surgery units.7 Although excision with primary anastomosis appears to be uniquely suited to outpatient surgery, care must be taken to ensure meticulous hemostasis intraoperatively, especially when the corpora are divided to facilitate reconstruction.
CONCLUSIONS
Anterior urethral reconstruction done on an outpatient basis appears to be safe and well tolerated. Younger patients with shorter strictures appear to be ideal candidates. Although excision with primary anastomosis is most amenable to outpatient surgery, flaps and grafts may frequently be applied without compromising outcome. Further research is needed to assess patient satisfaction with and cost savings of outpatient urethroplasty.
REFERENCES
1. Kaye, K. W.: Changing trends in urology practice: increasing outpatient surgery. Aust N Z J Surg, 65: 31, 1995 2. Roehrborn, C. G. and McConnell, J. D.: Analysis of factors contributing to the success or failure of 1-stage urethroplasty for urethral stricture disease. J Urol, 151: 869, 1994 3. Webster, G. D., Koefoot, R. B. and Sihelnik, S. A.: Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection. J Urol, 134: 892, 1985 4. Charbit, L., Mersel, A., Beurton, D. and Cukier, J.: [5-Year treatment results of urethral stenosis using internal urethrotomy in adults.] Ann Urol, 24: 66, 1990 5. Pansadoro, V. and Emiliozzi, P.: Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J Urol, 156: 73, 1996 6. Birch, B. R.: Day case surgery and urology: present practice and future trends. Br J Urol, 74: 2, 1994 7. Crew, J. P., Turner, K. J., Millar, J. and Cranston, D. W.: Is day case surgery in urology associated with high admission rates? Ann R Coll Surg Engl, 79: 416, 1997 8. Anema, J. G., Morey, A. F., McAninch, J. W., Mario, L. A. and Wessells, H.: Complications related to the high lithotomy position during urethral reconstruction. J Urol, 164: 360, 2000
Vol. 168, 1024 –1026, September 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000025400.77578.72
OUTPATIENT ANTERIOR URETHROPLASTY: OUTCOME ANALYSIS AND PATIENT SELECTION CRITERIA JACK B. LEWIS, KELLY A. WOLGAST, JOHN A. WARD
AND
ALLEN F. MOREY*
From the Urology Service, Brooke Army Medical Center, San Antonio, Texas
ABSTRACT
Purpose: We compared the outcomes of anterior urethroplasty for stricture disease performed on an outpatient and an inpatient basis. Materials and Methods: We reviewed the records of 78, 1-stage anterior urethroplasties performed via excision with primary anastomosis, buccal mucosal graft or penile fasciocutaneous skin flap techniques from September 1997 to December 2000 by a single surgeon (A. F. M.). All patients had more than 1 year of followup (range 1 to 4.5). Of the graft procedures only those in the bulbar urethra were included in analysis. Outpatient procedures were defined as those in which the patient was discharged home within 24 hours. Clinical outcome was considered a failure when instrumentation was required postoperatively. Results: Of the 78 anterior urethral repairs 54 (69%) were performed on an outpatient basis, including 50 (93%) in which the outcome was successful compared with 88% (21) of the 24 inpatient procedures. Excision with primary anastomosis had the highest outpatient rate (28 of 31 patients or 90%), followed by penile skin flaps (16 of 25 or 64%) and buccal mucosal grafts (10 of 22 or 45%). Patient characteristics were significantly associated with outpatient procedures, including younger mean age (36 versus 46 years), shorter mean stricture length (3.1 versus 6.6 cm.) and shorter mean operative time (3.2 versus 4.66 hours) (p ⬍0.05). Conclusions: Anterior urethral reconstruction can often be completed safely and effectively on an outpatient basis. KEY WORDS: urethra, urethral stricture, ambulatory surgical procedures, patient selection
In the last 10 years a dramatic increase in outpatient surgery and minimally invasive techniques within all surgical fields has been driven by cost containment efforts of third party payers and patient preference for a shorter hospital stay. Recently data have shown that outpatient surgery costs are 40% to 60% less than those for the same procedure performed with hospitalization, and postoperative recovery and patient satisfaction are enhanced the earlier a patient is discharged from the hospital.1 Concomitantly various urological procedures have been increasingly performed on an outpatient basis. Regardless of cause or previous treatment 1-stage urethroplasty has been refined and is appropriate for the majority of strictures. The success rate of open surgery is 77% to 96%,2, 3 in contrast to endoscopic management via direct vision internal urethrotomy and dilation techniques, for which long-term success rates are reportedly as low as 32%.4, 5 At our institution anterior urethral reconstruction has been performed aggressively instead of repeat endoscopic treatment and on an outpatient basis. With continued experience we have been increasingly impressed with the rapid recovery of most patients postoperatively. We assessed whether outcomes were equivalent in patients who underwent the procedure on an outpatient basis and those who were hospitalized as inpatients after surgery. Furthermore, we identified patient selection criteria that enabled successful outpatient anterior urethral reconstruction.
PATIENTS AND METHODS
We retrospectively reviewed the records of 121 consecutive urethroplasties performed by a single surgeon (A. F. M.) from September 1997 to December 2000. Men who underwent posterior urethroplasty, combined procedures or pendulous urethral grafts for reoperative hypospadias were excluded from study. Complete data were analyzed on the 78 cases in which 1-stage anterior urethral reconstruction was performed via excision with primary anastomosis, a buccal mucosa graft or penile skin flap. Many men had been previously treated with endoscopic techniques (dilation in 13% and direct vision internal urethrotomy in 18%), although it was not a prerequisite for open surgery. Previous open urethroplasty had been performed in 20% of the cases and multiple previous procedures had failed in 22%. Preoperative staging was performed in all patients by retrograde urethrography, urinary flow rate measurement and American Urological Association symptom scores. Stricture length, location and severity as well as adverse local factors influenced procedure selection. Of the graft procedures only those performed in the bulbar urethra were included in our analysis and all were applied on the ventral surface. Outpatient procedures were those in which the patient was discharged home within 24 hours of surgery. Patients considered for outpatient procedures were educated in regard to expectations, precautions and postoperative home care requirements before scheduling. Factors influencing outpatient selection included patient age, previous repair, difficulty and duration of planned reconstruction, social considerations, American Society of Anesthesiologists (ASA) class and associated morbidity. Criteria for hospital discharge included stable vital signs, pain well controlled with oral medication and favorable wound characteristics, such as no signs of
Accepted for publication April 5, 2002. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the United States Government. Presented at annual meeting of American Urological Association, Anaheim, California June 2–7, 2001. * Financial interest and/or other relationship with Ortho-McNeil and Pfizer. 1024
1025
OUTPATIENT ANTERIOR URETHROPLASTY
hematoma. Importantly social factors, including the ability to understand hospital discharge instructions and the availability of postoperative care at home, were assessed before the patient was released from the hospital. Statistical analysis of patient selection criteria was performed using univariate and multivariate logistic regression. Padded fishnet shorts were used to compress the genitalia postoperatively, providing hemostasis and immobilization of the surgical site for the first 72 hours after discharge. In addition, for penile flap procedures a bio-occlusive dressing was used to compress the penis. Patients were instructed to minimize activity and change dressings daily for 10 days postoperatively. The catheter remained indwelling for 3 weeks. Oral analgesics, such as oxycodone and acetominophen, were given instead of local or regional anesthetics for postoperative pain control in all cases. Drains were not used, and so additional home health care nursing was not required. All patients had more than 1 year of followup (range 1 to 4.5). Uroflowmetry and urethrography were performed at 3 months and 1 year. Clinical outcome was considered unsuccessful when any postoperative instrumentation was required for recurrent obstructive voiding symptoms. RESULTS
In the 78 patients stricture length was 0.5 to 21 cm. (mean 4.3). Stricture location was bulbar in 70.1% of the cases with a pendulous stricture in 23% and involvement of the whole anterior urethra in 6.3%. On univariate logistic regression younger patient age and stricture length were significantly related to the probability of treatment on an outpatient basis (p ⬍0.05, table 1). Operative time was likewise significantly lower. On multivariate logistic regression analysis age and operative time also remained significantly associated with outpatient management (p ⬍0.05). ASA class, associated morbidity and previous repair were not predictive of outpatient or inpatient management (p ⬎0.05). Overall 54 (69%) of the 78 anterior urethral repairs were performed on an outpatient basis with the rate increasing over the period analyzed (60% in 1997 to 93% in 2000). Excision with primary anastomosis had the highest outpatient rate (28 of 31 cases or 90%), followed by penile skin flaps (16 of 25 or 64%) and buccal mucosal grafts (10 of 22 or 45%). A single patient who underwent primary anastomosis and was initially scheduled as an outpatient remained hospitalized because of postoperative hematoma formation. This condition stabilized with conservative management. He was discharged home on postoperative day 3 and remained stricturefree for 25 months of followup. The success rate was similar in the outpatient (50 of 54 patients or 93%) and hospitalized (21 of 24 or 88%) groups overall and when analyzed by procedure type (table 2). In the outpatient group 1 patient who underwent primary anastomosis had a small recurrent stricture that was managed successfully with internal urethrotomy, penile flap procedures in 2 required intervention (meatotomy in 1, and dilation and a subsequent graft procedure in 1) and a graft required salvage excision and primary anastomosis in 1. In the hospitalized group 2 patients who underwent a graft
TABLE 1. Patient selection for outpatient anterior urethral reconstruction Characteristics
Outpts.
Inpts.
Mean age (range) Mean hrs. operative time (range) Mean cm. stricture length (range) Mean ASA class (range) % Co-morbidity % Previous repair
36 (12–83) 3.20 (0.5–5)
46 (17–64) 4.66 (3–7)
3.1 (0.5–10) 1.4 37 37
(1–3)
6.6
(2–21)
1.5 50 56
(1–3)
p Value 0.033 0.001 0.014 ⬎0.05 ⬎0.05 ⬎0.05
TABLE 2. Success rate of inpatient and outpatient surgery based on procedure type Procedure
No. Outpt./ Total No. (%)
No. Inpt./ Total No. (%)
Excision ⫹ primary anastomosis Flap Buccal mucosal graft
27/28 (96) 14/16 (87) 9/10 (90)
3/3 (100) 8/9 (89) 10/12 (83)
50/54 (93)
21/24 (88)
Totals
procedure required reoperation (a penile flap and internal urethrotomy in 1 each), while 1 with balanitis xerotica obliterans awaits reconstruction. DISCUSSION
Our data indicate that a successful outcome is not related to hospital stay and our success rates of 93% for outpatient and 88% for inpatient procedures are comparable to those reported in the literature (77–96%).2, 3 Although more failures may be detected with time, we have observed that the majority are evidenced within the first 6 months as recurrent obstructive symptoms. Which patients are candidates for outpatient urethral surgery? In our experience older patients with longer strictures requiring extensive repair were more likely to be treated on an inpatient basis. Younger patient age and shorter stricture length (and, thus, decreased operative time) were predictive of outpatient surgery. Accordingly excision with primary anastomosis was suitable for outpatient surgery in almost all cases, whereas buccal mucosal grafts and penile flap procedures were less so (45% and 64%, respectively). Graft procedures performed well despite the absence of hospitalization and strict bed rest for the initial postoperative 48 hours. Our data suggest that moderate ambulation in the early postoperative period does not jeopardize long-term graft survival. These results underscore the high reliability of buccal mucosa as a graft source and the stability of the bulbar urethra as a graft bed. Interestingly our analysis revealed that ASA class, associated morbidity and previously attempted repair were not significantly different in the outpatient and inpatient groups. Extensive repairs were often performed successfully on an outpatient basis even in patients with multiple comorbidities, high ASA class and a history of urethroplasty. Others have previously indicated that ASA classification is not uniquely predictive of the necessity of an inpatient procedure.6, 7 We believe that successful reconstruction of complex strictures is related to the performance of a precise, expedient procedure. As we have previously noted, prolonged patient time in the high lithotomy position is associated with increased lower extremity complications and, therefore, it must be limited.8 Accordingly, penile flap procedures at our institution are done with the patient mainly supine and they are reserved primarily for pendulous strictures. Furthermore, we believe that routine moderate penile compression with a bio-occlusive dressing decreases genital edema without compromising flap viability, thus, promoting successful outpatient management. Preoperative assessment of patient willingness, comprehension, reliability, compliance and social support system is vital to successful outpatient surgery. An outpatient care plan concludes just before hospital discharge with reinforcement of postoperative care requirements and followup visit scheduling. Do patients prefer outpatient procedures? Kaye reported that patients in whom a procedure was completed on an outpatient basis tended to manifest significantly better emotional adjustment with fewer psychological distress symptoms than those treated as inpatients.1 The 2 groups noticed
1026
OUTPATIENT ANTERIOR URETHROPLASTY
similar levels of pain, fear, anxiety, health assessment and quality of life but inpatients typically reported longer convalescence than outpatients for the same surgical procedure. Poor hemostasis is the most common cause of hospitalization for all outpatient procedures, accounting for 74% of all re-admissions to outpatient surgery units.7 Although excision with primary anastomosis appears to be uniquely suited to outpatient surgery, care must be taken to ensure meticulous hemostasis intraoperatively, especially when the corpora are divided to facilitate reconstruction.
CONCLUSIONS
Anterior urethral reconstruction done on an outpatient basis appears to be safe and well tolerated. Younger patients with shorter strictures appear to be ideal candidates. Although excision with primary anastomosis is most amenable to outpatient surgery, flaps and grafts may frequently be applied without compromising outcome. Further research is needed to assess patient satisfaction with and cost savings of outpatient urethroplasty.
REFERENCES
1. Kaye, K. W.: Changing trends in urology practice: increasing outpatient surgery. Aust N Z J Surg, 65: 31, 1995 2. Roehrborn, C. G. and McConnell, J. D.: Analysis of factors contributing to the success or failure of 1-stage urethroplasty for urethral stricture disease. J Urol, 151: 869, 1994 3. Webster, G. D., Koefoot, R. B. and Sihelnik, S. A.: Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection. J Urol, 134: 892, 1985 4. Charbit, L., Mersel, A., Beurton, D. and Cukier, J.: [5-Year treatment results of urethral stenosis using internal urethrotomy in adults.] Ann Urol, 24: 66, 1990 5. Pansadoro, V. and Emiliozzi, P.: Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J Urol, 156: 73, 1996 6. Birch, B. R.: Day case surgery and urology: present practice and future trends. Br J Urol, 74: 2, 1994 7. Crew, J. P., Turner, K. J., Millar, J. and Cranston, D. W.: Is day case surgery in urology associated with high admission rates? Ann R Coll Surg Engl, 79: 416, 1997 8. Anema, J. G., Morey, A. F., McAninch, J. W., Mario, L. A. and Wessells, H.: Complications related to the high lithotomy position during urethral reconstruction. J Urol, 164: 360, 2000