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Urethral Stricture Score Is Associated with Anterior Urethroplasty Complexity and Outcome

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Urethral Stricture Score Is Associated with Anterior Urethroplasty Complexity and Outcome Urethral Stricture Score is Associated with Anterior Urethroplasty Complexity and Outcome Amjad Alwaal,* Thomas H. Sanford, Catherine R. Harris, E. Charles Osterberg, Jack W. McAninch and Benjamin N. Breyer From the Departments of Urology, King Abdulaziz University (AA), Jeddah, Saudi Arabia, and University of California-San Francisco (AA, THS, CRH, ECO, JWM, BNB), San Francisco, California Purpose: Several surgical techniques are available to treat anterior urethral stricture. The choice of surgical technique largely depends on the severity of Abbreviations and Acronyms stricture disease. The U-score (urethral stricture score) is based on urethral ¼ stricture characteristics, namely length (1 to 3 points), number (1 or 2 points), LS lichen sclerosus location (1 or 2 points) and etiology (1 or 2 points), which are tallied to provide a Accepted for publication December 1, 2015. total score of 4 to 9 points. Our aim was to identify whether the U-score system is No direct or indirect commercial incentive predictive of the surgical complexity and outcome of anterior urethroplasty. associated with publishing this article. Materials and Methods: We retrospectively reviewed the records of all patients The corresponding author certifies that, when applicable, a statement(s) has been included in who underwent anterior urethroplasty from 2002 to 2012 by examining our pro- the manuscript documenting institutional review spectively collected urethroplasty database. We calculated the U-score and looked board, ethics committee or ethical review board for an association with surgical complexity, recurrent stricture and time to study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee recurrence. We defined recurrent stricture as the need for a secondary procedure. approval; institutional animal care and use Results: There were 341 patients who underwent low complexity urethroplasty committee approval; all human subjects provided written informed consent with guarantees of (anastomotic, buccal mucosal graft and augmented anterior urethroplasty) with confidentiality; IRB approved protocol number; a mean U-score of 4.7 while 48 underwent high complexity urethroplasty (double animal approved project number. buccal mucosal graft, flap and graft/flap combination) with a mean score of 6.9. * Correspondence: Department of Urology, < King Abdulaziz University, P.O. Box 80215, Jed- Higher U-score was predictive of higher surgical complexity (p 0.001). U-score dah, Saudi Arabia 21589 (telephone: þ966 was also significantly associated with recurrence. There was a consistent in- 26401000, extension 20222; FAX: þ966 crease in the risk of recurrence with each additional U-score point. However, 26408347; e-mail: [email protected]). there was no association of U-score with time to recurrence. Conclusions: We confirmed the validity of U-score to predict the complexity of surgery for anterior urethral strictures. For the first time to our knowledge we report an association between higher U-score and anterior urethroplasty outcome. The U-score could be used to risk stratify patients and help with perioperative counseling. Key Words: urethral stricture; recurrence; surgical procedures, operative; risk; prognosis URETHRAL stricture disease affects infections due to progressive narrow- almost 300/100,000 men1 and causes a ing of the urethral lumen.2 Several significant burden of illness to those surgical techniques are available to affected. Often mismanagement and treat urethral strictures, which vary in delay in definitive treatment cause complexity and outcomes. The choice men to experience a variety of associ- of treatment is based on preoperative ated symptoms, including a weak and intraoperative assessments, and stream, incomplete emptying, urinary shared decision making between pa- retention and recurrent urinary tract tient and physician. Unfortunately 0022-5347/16/1956-1817/0 http://dx.doi.org/10.1016/j.juro.2015.12.100 THE JOURNAL OF UROLOGY® Vol. 195, 1817-1821, June 2016 www.jurology.com j 1817 Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 1818 URETHRAL STRICTURE SCORE ASSOCIATED WITH URETHROPLASTY COMPLEXITY AND OUTCOME little standardized methodology exists to gauge associations between the U-score and surgical complexity, stricture complexity. recurrent stricture and time to recurrence. We defined The development of a standardized scoring sys- stricture recurrence as the need for a secondary procedure. tem for stricture disease severity would be useful for Statistics patient perioperative counseling regarding surgical Data analysis was performed with STATAÒ, version 14. complexity and stricture recurrence. A standardized The chi-square and Fisher exact tests were used to assess scoring system would allow for stricture related categorical data (demographics) and the t-test was used to research to be reported in a common language analyze continuous variables (surgical complexity and among centers when comparing surgical techniques time to recurrence). The relationship between U-score and and outcomes. Several scoring systems have proved surgical complexity was determined by the t-test for the successful in urological surgery, including prostate mean U-score in high and low complexity procedures. < cancer scoring systems to predict the outcome after Statistical significance was considered at p 0.05. Uni- variable logistic regression was done to evaluate the asso- surgery3 and renal mass complexity classification.4 ciation of U-score with stricture recurrence. A Cox In 2012 Wiegand and Brandes developed the proportional hazards model and Kaplan-Meier curves were UREThRAL score, a novel scoring method of the used to assess the effect of U-score on time to recurrence. severity of anterior urethral stricture that uses stricture etiology, length, number, location and urinary retention.5 They identified an association of RESULTS the score with surgical complexity. More recently A total of 389 patients underwent anterior ure- Eswara et al further refined and simplified the throplasty and had complete records available during score, renaming it the U-score, and removing the study period. We excluded from study 297 pa- retention from the scoring system.6 They found that tients during this period who underwent posterior the simplified score was associated with the surgical urethroplasty, 2-stage urethral reconstruction, peri- complexity of anterior urethral strictures. neal urethrostomy, urethrocutaneous fistula repair, Our aim was to validate whether the U-score urethrectomy, hypospadias repair, urethral erosion system is predictive of surgical complexity and repair, urethral diverticulum repair, neophallus determine whether it is associated with recurrence urethroplasty, urethroplasty with UroLumeÒ after anterior urethroplasty. removal, meatoplasty or urethroplasty associated with Fournier gangrene. We also excluded 29 pa- tients treated with anterior urethroplasty who were MATERIALS AND METHODS lost to followup after removing the catheter. We retrospectively analyzed our prospectively collected Median age of our patients was 45 years (range institutional database to gather U-score data and de- 14 to 85). Our analysis revealed that 4.9% of pa- mographic factors such as age, etiology and comorbidities, tients had diabetes mellitus, 7% had hypertension specifically diabetes mellitus, chronic obstructive pulmo- and 1.8% had chronic obstructive pulmonary dis- nary disease and hypertension. We included in study pa- tients who underwent anterior urethroplasty from 2002 to ease. Median followup was 12 months (range 6 to 2012 and had complete data available. Two surgeons (JWM 156). Table 1 shows a distribution of our patients and BNB) performed all urethroplasties. We obtained Table 1. Patient U-score characteristics institutional review board approval from our institution. No. Recurrence No. No (%) Recurrence (%) p Value U-Score The U-score is based on urethral stricture characteristics, U-score: namely length (1 to 3 points), number (1 or 2 points), location 4 10 (14) 141 (44) e 5 27 (39) 141 (44) e (1 or 2 points) and etiology (1 or 2 points), which are tallied to e 6 6 9 (13) 18 (6) provide a total score of 4 to 9 points. Stricture length was 7 16 (23) 14 (4) e measured by perioperative sonourethrogram and in the 8 8 (11) 5 (2) e operating suite with a ruler by the surgeon. Stricture 900<0.001 Stricture cm length (points): number and location were determined by preoperative e 7 2 or Greater (1) 16 (23) 157 (48) retrograde urethrogram performed in standard fashion Greater than 2e5 or less (2) 29 (41) 132 (42) e and later verified at surgery. Stricture etiology was deter- Greater than 5 (3) 25 (36) 30 (10) <0.001 mined by patient history and comprised trauma/idiopathic/ No. strictures (points): iatrogenic (1 point) or inflammatory/hypospadias (2 points). 1 (1) 58 (83) 313 (98) e 6 Greater than 1 (2) 12 (17) 6 (2) <0.001 We used criteria defined by Eswara et al to classify Location (points): surgical complexity into low complexitydanastomotic, Bulbar urethra (1) 40 (57) 283 (89) e buccal mucosal graft and augmented anterior urethroplasty, Penile urethra (2) 30 (43) 36 (11) <0.001 and high complexityddouble buccal mucosal graft, flap and Etiology (points): e graft/flap combination. We calculated the U-score of all pa- Trauma, idiopathic, iatrogenic (1) 64 (91) 309 (97) Inflammatory, hypospadias (2) 6 (9) 10 (3) 0.08 tients who underwent those procedures and looked for URETHRAL STRICTURE SCORE ASSOCIATED
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