The Impact of Age on Urethroplasty Success

Levy, Mya E.; Gor, Ronak A.; Vanni, Alex J.; Stensland, Kristian; Erickson, Beth; Myers, Jeremy B.; Voelzke, Bryan B.; Smith, Thomas G.; Breyer, Benjamin N.; McClung, Christopher; Alsikafi, Nejd F.; Fan, Yunshan; Elliott, Sean P.

doi:10.1016/j.urology.2017.03.066

Cited by 32 publications

(16 citation statements)

References 21 publications

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“…We recently identified that older men have a higher risk of recurrence after urethroplasty and this may be related to decreased testosterone levels and resulting decreased angiogenesis with subsequently decreased degenerative potential ( 17 ). It should be noted that Levy et al have reported equal success in younger and older patients undergoing urethroplasty, however, although in this study patients were only dichotomized as younger or older than 60 years ( 18 ) and not analyzed as a continuum of decades as in our study. An often utilized approach in pediatric urology is administration of preoperative testosterone to prepubertal boys with hypospadias to improve tissue vascularization and healing after hypospadias repair ( 18 ).…”

Section: Discussionmentioning

confidence: 90%

“…It should be noted that Levy et al have reported equal success in younger and older patients undergoing urethroplasty, however, although in this study patients were only dichotomized as younger or older than 60 years ( 18 ) and not analyzed as a continuum of decades as in our study. An often utilized approach in pediatric urology is administration of preoperative testosterone to prepubertal boys with hypospadias to improve tissue vascularization and healing after hypospadias repair ( 18 ). We have found that adult hypogonadal men with AUS cuff erosions appear to be eager to undergo testosterone replacement therapy prior to AUS replacement when offered this option.…”

Section: Discussionmentioning

confidence: 90%

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Role of androgens for urethral homeostasis

Hofer¹,

Morey²

2018

Transl. Androl. Urol.

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BackgroundWe observed that patients with hypogonadism are at higher risk to experience artificial urinary sphincter cuff erosion. Sphincter erosions have been found to be associated with urethral atrophy or compromised urethras subsequent to events limiting its blood supply. We therefore analyzed possible mechanisms how a decrease in testosterone serum levels can result decreased urethral blood flow.MethodsIn a cohort of >1,200 urethroplasties, tissue specimens obtained during surgeries were analyzed for expression of androgen receptor (AR), AR-responsive TIE-2 associated with angiogenesis, and the endothelial cell marker CD31 for determination of vessel counts were analyzed immunohistochemically. A total of 11 patients were included in whom both tissue and serum testosterone levels within 2 years of the urethroplasty was available. Low serum testosterone level defined as <280 ng/dL. Image J software was used to analyze expression profiles.ResultsMean serum testosterone level was significant lower in hypogonadal patients (179.4 ng/dL) compared to eugonadal patients (375.0 ng/dL, P=0.003). Urethral tissue of hypogonadal patients showed decreased AR expression [1.11% high power field (HPF)] compared to eugonadal patients (1.62%, P=0.016), decreased TIE-2 expression (1.84% HPF vs. 3.08%, P=0.006), and also decreased vessel counts (44.47 vessels/HPF vs. 98.33, P=0.004). There was a direct correlation of AR and TIE-2 expression levels with serum testosterone levels (rho 0.685, P=0.029, and rho 0.773, P=0.005, respectively). Of note, we did not detect a difference in age, prior radiation, coronary artery disease or hypertension among hypo- or eugonadal patient. However, higher body mass index was associated with low serum testosterone levels.ConclusionsHypogonadal status is associated with decreased expression of AR and TIE-2 and also reduced vessel count in urethral tissue. We believe that the resulting decreased urethral vascularity subsequent to a hypogonadal state may be an important risk factor for complications of urethral surgery.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 90%

Role of androgens for urethral homeostasis

Hofer¹,

Morey²

2018

Transl. Androl. Urol.

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“…Specific to urethroplasty, avoiding surgical infection is a primary concern as infection is a well-known cause for surgical failure ( 7 ). Further, given that a successful urethroplasty requires a well-vascularized urethra [excision and primary anastomosis (EPA)] or graft bed (buccal), the presence of cardiac or vascular disease may, in theory, deleteriously impact recurrence rates following repair ( 9 ). Given the previously described association of BMI with both infection and vascular disease, BMI itself is a potential risk factor of surgical failure following urethroplasty.…”

Section: Discussionmentioning

confidence: 99%

Effect of body mass index on recurrence following urethroplasty

Rapp

Mills

Smith‐Harrison

et al. 2018

Transl. Androl. Urol.

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BackgroundLimited investigation exists to understand whether obesity affects outcomes of urethral reconstruction. We sought to assess whether body mass index (BMI) is an independent predictor for stricture recurrence following urethroplasty.MethodsWe performed a retrospective review of patients undergoing urethroplasty between 2007–2014, identifying 137 patients for study inclusion. Data collected included BMI and patient demographic and surgical characteristics, including age, stricture length and location, etiology, and urethroplasty technique. Stricture-free survival analysis was performed using Kaplan-Meier method. Logistic regression was performed to assess predictors for stricture recurrence using both univariate and multivariate models.ResultsMean patient age and follow-up was 46.7 (±16.4) years and 91.8 (±30.5) months, respectively. A recurrence rate of 17% was identified, with a mean time to recurrence of 29 months. There was no difference when comparing the mean BMI in patients with and without recurrence (28.9 vs. 30.4 kg/m2, respectively) (P=0.4). A higher rate of stricture recurrence was seen when comparing the cohort with a BMI <25 kg/m2 versus remaining cohorts (BMI: 25–30 kg/m2; BMI >30 kg/m2). However, in univariate and multivariate analysis, BMI failed to demonstrate statistical significance as a predictor for urethroplasty outcome. On multivariate analysis, fasciocutaneous repair type was predictive of stricture recurrence. No additional potential predictors assessed were found to be significant.ConclusionsIn the present study, BMI did not independently predict for stricture recurrence following urethroplasty.

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“…13 Likewise, advanced patient age has also been shown to be associated with stricture recurrence after urethroplasty particularly in the elderly although this association is less consistently established. 14,15 While multimodal radiation treatment was associated with recurrent stenosis on univariate analysis, it was not associated on multivariate assessment. Additional factors including body mass index and use of a gracilis muscle flap were also not associated with surgical failure.…”

Section: Discussionmentioning

confidence: 99%

Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment

Voelzke

Leddy

Myers

et al. 2021

Urology

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for the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) OBJECTIVETo evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODSAn IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/ 2007−6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTSOne hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONSEPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentationfree voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.

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The Impact of Age on Urethroplasty Success

Abstract: Urethroplasty success may be affected by comorbidities but not age. Age alone should not be used as an absolute exclusion criterion for men needing urethral reconstruction.

Cited by 32 publications

References 21 publications

Role of androgens for urethral homeostasis

Role of androgens for urethral homeostasis

Effect of body mass index on recurrence following urethroplasty

Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment

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