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Introduction and objectivesSeveral factors influence recurrence after urethral stricture repair. The impact of socioeconomic factors on stricture recurrence after urethroplasty is poorly understood. This study aims to assess the impact that social deprivation, an area-level measure of disadvantage, has on urethral stricture recurrence after urethroplasty.MethodsWe performed a retrospective review of patients undergoing urethral reconstruction by surgeons participating in a collaborative research group. Home zip code was used to calculate Social Deprivation Indices (SDI; 0-100), which quantifies the level of disadvantage across several sociodemographic domains collected in the American Community Survey. Patients without zip code data were excluded from the analysis. The Cox Proportional Hazards model was used to study the association between SDI and the hazard of functional recurrence, adjusting for stricture characteristics as well as age and body mass index.ResultsMedian age was 46.0 years with a median follow up of 367 days for the 1452 men included in the study. Patients in the fourth SDI quartile (worst social deprivation) were more likely to be active smokers with traumatic and infectious strictures compared to the first SDI quartile. Patients in the fourth SDI quartile had 1.64 times the unadjusted hazard of functional stricture recurrence vs patients in the first SDI quartile (95% CI 1.04-2.59). Compared to anastomotic ± excision, substitution only repair had 1.90 times the unadjusted hazard of recurrence. The adjusted hazard of recurrence was 1.08 per 10-point increase in SDI (95% CI 1.01-1.15, P = .027).ConclusionsPatient social deprivation identifies those at higher risk for functional recurrence after anterior urethral stricture repair, offering an opportunity for preoperative counseling and postoperative surveillance. Addressing these social determinants of health can potentially improve outcomes in reconstructive surgery.

ObjectiveTo describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort.MethodsData were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups.ResultsOne thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6 cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P = .3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P = .003, S2a, P = .001, S2b, P = .01 and S2c, P = .02 and E classifications: E3a, P = .004 and E6, P = .03, were associated with increased odds of functional failure.ConclusionRepair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.

ObjectiveTo clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S).MethodsThe Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed.ResultsThe final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques.ConclusionThe PAS classification schema adequately describes AABP heterogeneity, is reproducible among observers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.

PurposeThere are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates.Materials and methodsWe prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors.ResultsThe mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections.ConclusionsThe use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

PurposeA successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort.Materials and methodsData were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate

PurposePostoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure.Materials and methodsWe evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (

ObjectiveTo determine surgical site infection and urinary tract infection (UTI) rates in the setting of urethroplasty. Given significant variation in the utilization of antibiotics, there is an opportunity to improve antibiotic stewardship. This study aims to elucidate the rate of both UTI and surgical site infection after urethroplasty on a standardized perioperative antibiotic regimen, and to obtain patient and operative characteristics that may predict infection.MethodsWe prospectively treated 390 patients undergoing urethroplasty at 11 centers with a standardized perioperative antibiotic protocol. Patients had a urine culture or urine analysis within 3 weeks of surgery. After surgery, patients were discharged with an indwelling catheter, removed per usual surgeon practice. All were given nitrofurantoin from discharge until catheter removal. Logistic regression analyses were performed to determine the correlation between patient characteristics or operative categories with post-operative infection.ResultsThe rates of postoperative UTI and wound infection within 30 days were 6.7% and 4.1%, respectively. On multivariate analysis of demographics, comorbidities, and stricture characteristics and repair, only preoperative UTI (P = .012), history of cardiovascular disease (P = .015), and performing a membranous urethroplasty (0.018) were significant predictors of a UTI within 30 days postoperatively. Location of repair nor graft use increased the risk of UTI. There were no factors predictive of postoperative wound infection.ConclusionA standardized antibiotic protocol was created to narrow and limit excess antibiotic use. This protocol, with clear definitions of UTI and wound infection, allowed determination of accurate infection rates in urethroplasties. Preoperative UTI, even when properly treated, increases the risk of postoperative UTI.

PURPOSE:Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS:A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS:Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS:Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

PurposeTo analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success.MethodsPatients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated.ResultsOf the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure.ConclusionsPosterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

PURPOSE:To assess the functional Queryoutcome of patients with cystoscopic recurrence of stricture post-urethroplasty and to evaluate the role of cystoscopy as initial screening tool to predict future failure. METHODS:Cases with cystoscopy data after anterior urethroplasty in a multi-institutional database were retrospectively studied. Based on cystoscopic evaluation, performed within 3-months post-urethroplasty, patients were categorized as small-caliber (SC) stricture recurrence: stricture unable to be passed by standard cystoscope, large-caliber (LC) stricture accommodating a cystoscope, and no recurrence. We assessed the cumulative probability of intervention and the quality of life scores in association with cystoscopic recurrence 1-year post-urethroplasty. Patients with history of hypospadias, perineal urethrostomy, urethral fistula, and meatal pathology were excluded. RESULTS:From a total of 2630 men in our cohort, 1054 patients met the inclusion criteria: normal (n = 740), LC recurrence (n = 178), and SC recurrence (n = 136) based on the first cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121-617) after urethroplasty. Cystoscopic recurrence was significantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically significantly different among the three study groups. CONCLUSIONS:Many patients with cystoscopic recurrence do not need an intervention after initial urethroplasty. Despite good negative predictive value, cystoscopy alone may be a poor screening test for stricture recurrence defined by patient symptoms and need for secondary interventions.

OBJECTIVE:To analyze contemporary urethroplasty trends and urethral stricture etiologies over a 7-year study period among urologists from a large multi-institutional surgical outcomes group. METHODS:Review of a multi-institutional, prospectively maintained urethroplasty database was performed on 2098 anterior urethroplasties done between 2010 and 2017 by 10 surgeons. Stricture characteristics, including etiology, length, and anatomic location were analyzed and compared to urethroplasty type over the study period using chi-squared analysis to assess for linear trends within the group and by surgeon. RESULTS:Average stricture lengths for bulbar (2.8 ± 1.8 cm), penile (3.6 ± 2.6 cm), and penile-bulbar strictures (8.7 ± 5.0) remained stable. The most common stricture etiology was idiopathic/unknown in all study years (63%). In the bulbar urethra, the group performed significantly (1) fewer excisional repairs (-31%) and more substitutional repairs (+78%); (2) of substitutional repairs, more grafts are being placed dorsally (+95%) vs ventrally (-75%) (3) of the bulbar excisional repairs, more are being performed without transection of the bulbar urethra (+430%); and in the penile urethra (4) the fasciocutaneous flap is in decline (-86%), while single-stage dorsal repairs are increasing (+280%). CONCLUSION:Anterior urethroplasty techniques continue to evolve in the absence of robust clinical data or randomized controlled trials, with a general movement in this cohort toward an initial dorsal approach for most strictures. Inter- and intrasurgeon variability in the surgical management of similar strictures was noted, and the feasibility of any future randomized controlled trials, without apparent surgical equipoise, must be questioned.

PurposeWe report multi-institutional outcomes in patients who underwent urethroplasty with a rectal mucosa graft.Materials and methodsWe used the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database to identify patients who underwent urethral reconstruction with transanal harvest of a rectal mucosa graft. We reviewed preoperative demographics, stricture etiology, previous management and patient outcomes.ResultsWe identified 13 patients from April 2013 to June 2017. Median age at surgery was 54 years. The stricture etiology was lichen sclerosus in 6 of 13 patients (46%), idiopathic in 2 (15%), hypospadias in 1 (7%), prior gender confirming surgery in 3 (23%) and rectourethral fistula after radiation for prostate cancer in 1 (7%). Prior procedures included failed urethroplasty with a buccal mucosa graft in 9 of 13 patients (69%), direct vision internal urethrotomy in 2 (15%) and none in 2 (15%). Median stricture length was 13 cm. Stricture location in the 9 cisgender patients was panurethral in 5 (56%), bulbopendulous in 2 (22%) and bulbar in 2 (22%). It was located at the junction of the fixed urethra extending into the neophallus in all 3 patients (100%) who underwent prior gender confirming surgery. Mean rectal mucosa graft length for urethroplasty was 10.6 cm (range 3 to 16). Repair types included dorsal or ventral onlay, or 2-stage repair. Stricture recurred at a median followup of 13.5 months in 2 of 13 patients (15%). Postoperative complications included glans dehiscence, urethrocutaneous fistula and compartment syndrome in 1 patient each (7%). No rectal or bowel related complications were reported.ConclusionsUrethral reconstruction with a transanal harvested rectal mucosa graft is a safe technique when a buccal mucosa graft is unavailable or not indicated.

ObjectiveTo compare the utility of generic health quality of life (QOL) and condition specific indicators as patient reported outcomes measures for urethral stricture surgery.Materials and methodsPatient data were obtained from the Trauma and Urologic Reconstructive Network of Surgeons collaborative database. Patients who underwent any successful urethroplasty and completed both pre- and postoperative generic and condition-specific questionnaires were included.ResultsA total of 201 patients met inclusion criteria. Urethral-stricture specific measures improved after surgery: mean LUTS score (13.1-4.0, p

Introduction: To investigate preoperative predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for management of distal ureteral strictures. Methods: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for surgical repair of distal ureteral strictures between 04/2012 and 12/2022. Procedures included refluxing reimplant (58.5%), side to side reimplant (18.0%), ureteroureterostomy (12.7%), non-refluxing reimplant (6.3%), buccal mucosa ureteroplasty (2.8%), and appendiceal bypass ureteroplasty (1.7%). Patients were grouped according to whether they were surgically successful. Preoperative variables between both groups were compared using chi-square tests. All variables with associations of p < 0.2 underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p ≤ 0.05 considered statistically significant). Results: Overall, 284 patients met inclusion criteria. Univariate analysis showed obesity (p = 0.03), smoking history (p = 0.10), abdominopelvic radiation history (p = 0.14), immunocompromised state (p = 0.12), and ureteral rest (p = 0.01) were notable preoperative factors (p < 0.2). Binary logistic regression analysis further revealed the odds of surgical success in patients with obesity was 0.32 times (CI: 0.12–0.83, p = 0.02) the odds of success for patients without obesity. The odds of surgical success in patients who underwent preoperative ureteral rest was 4.2 times (CI: 1.51–11.77, p < 0.01) the odds of success for patients who did not undergo preoperative ureteral rest. Conclusion: Preoperative factors including obesity and ureteral rest may affect surgical success of RUR for management of distal ureteral strictures. [ABSTRACT FROM AUTHOR]

PurposeIn this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence.Materials and methodsWe retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities.ResultsPreoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%.ConclusionsThe prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

ObjectiveTo review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates.Materials and methodsPatients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence.ResultsBetween 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement.ConclusionRBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.

INTRODUCTION:Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist. MATERIALS AND METHODS:All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease. RESULTS:There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007). CONCLUSIONS:There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.