Hypothesis / aims of study
First-line treatment of bulbar urethral strictures in men consists of minimal-invasive endoluminal procedures: dilatation or direct visual internal urethrotomy (DVIU). Recurrence rate at two years after first DVIU is 30 to 60% and increases to 50 to 100% after second urethrotomy (1). Furthermore, repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration (2). Therefore, both the recent European (European Association of Urology) and American (American Urological Association) guidelines recommend to not perform repetitive endoluminal treatments for anterior urethral strictures in men if urethroplasty is a viable option.
Urethroplasty with (transecting or non-transecting) anastomotic repair or free graft urethroplasty have emerged as the standard management for most anterior urethral strictures in men, offering high success rate (up to 90%) (1). Multivariate analyses of risk factors predictive for failure after urethroplasty (such as etiology, stricture length or previous treatments) show conflicting evidence (3). Furthermore, intermittent self-dilatation (ISD), which is also a (repetitive) transurethral manipulation, has not been evaluated as a (independent) risk factor for stricture recurrence after urethroplasty. The aim of this study is to evaluate the relation between the presence and number of prior endoluminal treatments (dilatation, DVIU) and / or ISD, and clinically relevant stricture recurrence after first urethroplasty in men with (peno-) bulbar urethral strictures.
Study design, materials and methods
This is a retrospective evaluation of prospectively gathered data. All male patients with urethral strictures treated with urethroplasty between 2011 and 2019 were evaluated, treated and followed in a standardized protocol, and were included in a prospective database. Only patients with bulbar or penobulbar strictures with short penile extension who underwent their first urethroplasty were included in this study. Penobulbar strictures with a penile approach during urethroplasty, and patients with a history of hypospadias and pelvic fracture urethral distraction injury were excluded to acquire a more homogenous patient population.
Stricture recurrence was defined as any need for re-intervention (indicated by both patient symptoms and diagnostic findings) after first urethroplasty, including outpatient dilatation, endoscopic re-intervention and redo urethroplasty.
Primary outcome was the analysis of recurrence risk after first urethroplasty in relation with the number of prior endoscopic treatments or performance of ISD.
Secondary the relation between age at surgery, stricture length, location, etiology, surgical technique [(non-) transecting excision and primary anastomosis and free graft (dorsal buccal mucosa) urethroplasty], and stricture recurrence after first urethroplasty was evaluated. Univariate [Mann-Whitney U and Chi-square (post-hoc Bonferroni)] and multivariate analysis was performed. Statistical significance was set at <0.05.
Results
Overall, 106 patients were included in the study with a median follow-up of 12 months [IQR 8-13]. Seventeen (16%) patients had no prior endoluminal treatment for their bulbar urethral stricture, 28 (26%) had one, 25 (24%) had two, and 36 (34%) had three or more. Thirty-two patients (30%) routinely performed ISD before first anterior urethroplasty. Patient and stricture characteristics in relation to recurrence after first urethroplasty are presented in table 1.
Re-intervention was necessary in 16 patients (15%) and was related to the presence and number of prior endoluminal treatments: recurrence was more prevalent in patients with ≥3 prior endoscopic treatments (28%, p=0.009), while no increased risk was found in patients with one or two prior endoscopic treatments (compared to no prior endoluminal treatment). The prevalence of prior ISD was twice as high in the stricture recurrence group (56% vs. 26%, p=0.014), and ISD was performed in 61% of the patients with ≥3 prior endoscopic treatments (p=<0.001). Multivariate analysis showed that the number of prior endoluminal interventions [2: OR 0.6 (0.1-3.6), >3: OR 1.3 (0.2-7.8)] and performance of ISD [OR 2.3 (0.6 – 9.2)] were no independent predictors for recurrence.
Interpretation of results
This is the first study to evaluate ISD as a risk factor for stricture recurrence after first urethroplasty for (peno-) bulbar urethral strictures in a homogenous male cohort. Although there was a strong relation between pre-operative ISD and stricture recurrence after first urethroplasty, multivariate analysis did not identify it as an independent risk factor. This can be explained by the high prevalence of ISD in patients who had three or more prior endoscopic treatments before urethroplasty.
The number of prior endoscopic treatments was also related to stricture recurrence after first urethroplasty. In contrast to what the recent European and American guidelines recommend, our study suggests that there is room for a second attempt at endoscopic treatment of (peno-) bulbar urethral stricture in men as it did not relate to recurrence after first urethroplasty in our patient cohort. Nevertheless, patients should be well informed about the known high recurrence risk after repeat endoluminal treatment as opposed to the high success chance of the more invasive treatment with urethroplasty. Based on our findings we would strongly advise against a third (or more) endoluminal treatment for recurrent bulbar strictures, as success chance is very low and as it may lead to a higher recurrence risk after subsequent urethroplasty.