A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures

Warner, Jonathan N.; Malkawi, Ibraheem; Dhradkeh, Mohammad; Joshi, Pankaj; Kulkarni, Sanjay; Lazzeri, Massimo; Barbagli, Guido; Mori, Ryan; Angermeier, Kenneth W.; Storme, O.; Campos, Rodrigo; Velarde, Laura; Gómez, Reynaldo; Han, Jiayu; Gonzalez, Christopher; Martinho, David; Sandul, A.; Martins, Francisco E.; Santucci, Richard A.

doi:10.1016/j.urology.2015.01.041

Cited by 52 publications

(37 citation statements)

References 14 publications

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“…A number of different tissue typesincluding penile skin, scrotal skin, extragenital skin, bladder mucosa, intestinal mucosa and oral mucosahave been used as urethral substitutes, and in contemporary practice, penile skin (as a pedicled flap or free graft) and oral mucosa (as a free graft) are the tissues most commonly used for urethral substitutes. [18][19][20][21][22][23] Penile skin flaps had been popular for urethroplasty until several decades ago, but have gradually been replaced by oral mucosa grafts because of their simplicity and little potential for morbidity. Harvesting a penile skin flap is fastidious, and has to be prepared carefully, which takes time.…”

Section: Oral Mucosa As a Urethral Substitutementioning

confidence: 99%

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Horiguchi

2017

Int J of Urology

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Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two-sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one-stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one-sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.

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Section: Oral Mucosa As a Urethral Substitutementioning

confidence: 99%

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Horiguchi

2017

Int J of Urology

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“…It is well known that stricture etiology such as lichen sclerosis, reoperative strictures, or longer stricture length are preoperative factors associated with complex flap/graft urethroplasty and increased complication rates and hospital stay. [24–27] Second, the NIS data is limited to the immediate inpatient stay after urethroplasty. Outpatient or short-stay related procedures may not be captured by this dataset depending on coding differences across hospitals.…”

Section: Discussionmentioning

confidence: 99%

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications

Harris

Osterberg

Sanford

et al. 2016

Urology

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Objective To determine which factors are associated with higher urethroplasty procedural costs and whether they have been increasing or decreasing over time. Identification of determinants of extreme costs may help reduce cost while maintaining quality. Materials and Methods We conducted a retrospective analysis using the 2001–2010 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS). The HCUP-NIS captures hospital charges which we converted to cost using the HCUP Cost-to-Charge Ratio. Log cost linear regression with sensitivity analysis was used to determine variables associated with increased costs. Extreme cost was defined as the top 20th percentile of expenditure, analyzed with logistic regression and expressed as Odds Ratios (OR). Results A total of 2298 urethroplasties were recorded in NIS over the study period. The median (interquartile range) calculated costs was $7321 ($5677–$10000). Patients with multiple comorbid conditions were associated with extreme costs (OR 1.56 95% CI 1.19–2.04, p=0.02) compared to patients with no comorbid disease. Inpatient complications raised the odds of extreme costs OR 3.2 CI 2.14–4.75, p<0.001). Graft urethroplasties were associated with extreme costs (OR 1.78 95% CI 1.2–2.64, p=0.005). Variation in patient age, race, hospital region, bed size, teaching status, payer type, and volume of urethroplasty cases were not associated with extremes of cost. Conclusion Cost variation for perioperative inpatient urethroplasty procedures is dependent on preoperative patient comorbidities, postoperative complications and surgical complexity related to graft usage. Procedural cost and cost variation are critical for understanding which aspects of care have the greatest impact on cost.

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“…This optimized procedure is very satisfactory for the treatment of the worst sorts of strictures and supplants the former use of highly morbid, staged urethroplasty or fasciocutaneous flaps. This technique yields an 80 – 83% long-term success rate despite being used in patients with features that might increase failure: very long strictures, lichen sclerosus, or failed previous urethroplasty 42– 45 .…”

Section: Managementmentioning

confidence: 99%

“…The buccal graft is sutured to the lateral edges of the urethral plate, effectively widening the circumference. The second stage is closing or tubularizing the previously opened urethra 45 . This technique is best used when previous hypospadias surgery was performed, when obliterated strictures are present, or severe lichen sclerosus is present 45 .…”

Section: Managementmentioning

confidence: 99%

“…The second stage is closing or tubularizing the previously opened urethra 45 . This technique is best used when previous hypospadias surgery was performed, when obliterated strictures are present, or severe lichen sclerosus is present 45 . The utilization of buccal graft increases the success rate of this procedure from 33 to 85% and should be considered 45, 47– 49 .…”

Section: Managementmentioning

confidence: 99%

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Advances in urethral stricture management

Gallegos

Santucci

2016

F1000Res

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Urethral stricture/stenosis is a narrowing of the urethral lumen. These conditions greatly impact the health and quality of life of patients. Management of urethral strictures/stenosis is complex and requires careful evaluation. The treatment options for urethral stricture vary in their success rates. Urethral dilation and internal urethrotomy are the most commonly performed procedures but carry the lowest chance for long-term success (0–9%). Urethroplasty has a much higher chance of success (85–90%) and is considered the gold-standard treatment. The most common urethroplasty techniques are excision and primary anastomosis and graft onlay urethroplasty. Anastomotic urethroplasty and graft urethroplasty have similar long-term success rates, although long-term data have yet to confirm equal efficacy. Anastomotic urethroplasty may have higher rates of sexual dysfunction. Posterior urethral stenosis is typically caused by previous urologic surgery. It is treated endoscopically with radial incisions. The use of mitomycin C may decrease recurrence. An exciting area of research is tissue engineering and scar modulation to augment stricture treatment. These include the use of acellular matrices or tissue-engineered buccal mucosa to produce grafting material for urethroplasty. Other experimental strategies aim to prevent scar formation altogether.

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A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures

Cited by 52 publications

References 14 publications

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

National Variation in Urethroplasty Cost and Predictors of Extreme Cost: A Cost Analysis With Policy Implications

Advances in urethral stricture management

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