The evolution of urethral stricture and urethroplasty practice over 15 years: A single-center, single-surgeon 1319 urethroplasty analysis

Abstract

Introduction: The management of urethral stricture has evolved over the last several decades. We sought to analyze urethral stricture and urethroplasty trends at a tertiary referral center over a 15-year period. Methods: Patients undergoing urethroplasty by a single surgeon from August 2003 to July 2018 were analyzed. Patient demographics, urethroplasty techniques, and outcomes were collected in a prospectively maintained database and were categorized into three five-year tertiles based on date of surgery. These tertiles were subsequently retrospectively analyzed for trends and changes in practice. Results: A total of 1319 urethroplasties were completed over the study period. During the first five years (T1), 299 urethroplasties were performed, with 431 and 589 performed in T2 and T3 respectively. Mean overall patient age was 46.8 years, which increased significantly over time (p<0.001). Idiopathic strictures were most common (n=516, 39.1%) and unchanged over time, while proportionately radiation-induced strictures increased (n=9, 3.0% [T1], n=22, 5.1% [T2], n=51, 8.7% [T3]; p=0.001) as did iatrogenic and lichen sclerosus strictures. Mean stricture length (4.7 cm [T1], 4.8 cm [T2], 4.0 cm [T3]; p<0.001) and the mean number of prior endoscopic procedures (3.4 [T1], 3.9 [T2], and 2.5 [T3]; p<0.001] decreased over time. Single-stage urethroplasty with buccal mucosa was the most common technique performed (n=656, 49.7%) that increased in prevalence (p=0.009), while both flap and staged techniques decreased (p=0.008, p=0.004, respectively). Overall success rate was 90.1% (n=1106), which improved significantly with time (n=248, 86.7% [T1], n=359, 90.0% [T2], n=499, 93.4% [T3]; p=0.001). Conclusions: We observed that patients and treatment of urethral stricture evolved over 15 years in practice with an increase in patient age, radiation, and iatrogenic and lichen sclerosus strictures, while demonstrating a decrease in stricture length and the number of prior endoscopic procedures performed. An increased use of single-stage urethroplasty using buccal mucosa was observed, which may have contributed to an increase in urethroplasty success over time.

Affirming Long-Term Outcomes After Contemporary Urethroplasty: The Adverse Impact of Increasing Stricture Length, Lichen Sclerosus, Radiation, and Infectious Strictures

“…Other explanations for improved contemporary success of urethroplasty may also be related to improved patient selection, enhanced perioperative care, and earlier operative intervention which may limit the number of failed endoscopic treatments prior to urethroplasty and create a more favorable milieu for urethroplasty. 10,15…”

“…8 However, urethroplasty techniques and selection have evolved greatly over the last 15 to 20 years, and a more contemporary assessment is required in order to accurately counsel patients regarding long-term success and satisfaction. 10,11 In this context, our objective is to determine the long-term success (100 months) of contemporary urethroplasty and identify clinical factors associated with stricture recurrence. We hypothesize that there will be deterioration in urethroplasty success over time but not to the same degree as reported previously due to advances in surgical technique and patient selection.…”