UCSF UC San Francisco Previously Published Works Title Clinical significance of cystoscopic urethral stricture recurrence after anterior urethroplasty: a multi-institution analysis from Trauma and Urologic Reconstructive Network of Surgeons (TURNS). Permalink https://escholarship.org/uc/item/3f57n621 Journal World journal of urology, 37(12) ISSN 0724-4983 Authors Baradaran, Nima Fergus, Kirkpatrick B Moses, Rachel A et al. Publication Date 2019-12-01 DOI 10.1007/s00345-019-02653-6 Peer reviewed eScholarship.org Powered by the California Digital Library University of California World Journal of Urology https://doi.org/10.1007/s00345-019-02653-6 ORIGINAL ARTICLE Clinical signifcance of cystoscopic urethral stricture recurrence after anterior urethroplasty: a multi‑institution analysis from Trauma and Urologic Reconstructive Network of Surgeons (TURNS) Nima Baradaran1 · Kirkpatrick B. Fergus2 · Rachel A. Moses3 · Darshan P. Patel3 · Thomas W. Gaither2 · Bryan B. Voelzke4 · Thomas G. Smith III5 · Bradley A. Erickson6 · Sean P. Elliott7 · Nejd F. Alsikaf8 · Alex J. Vanni9 · Jill Buckley10 · Lee C. Zhao11 · Jeremy B. Myers3 · Benjamin N. Breyer2 Received: 13 December 2018 / Accepted: 24 January 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract 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 fstula, 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 frst cystoscopic evaluation performed at median 111 days postoperatively. Median follow-up was 350 days (IQR 121–617) after urethroplasty. Cystoscopic recurrence was signifcantly associated with secondary interventions (2.7%, 6.2%, 33.8% in normal, LC, and SC groups, respectively). Quality of life variables were not statistically signifcantly diferent 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 defned by patient symptoms and need for secondary interventions. Keywords Urethra · Lower urinary tract symptoms · Urethral stricture · Cystoscopy · Self report · Treatment outcome * Benjamin N. Breyer 6 Department of Urology, University of Iowa, Iowa City, IA, [email protected] USA 7 Department of Urology, University of Minnesota, 1 Department of Urology, Ohio State University, Columbus, Minneapolis, MN, USA OH, USA 8 Uropartners, Gurnee, IL, USA 2 Department of Urology, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San 9 Department of Urology, Lahey Hospital and Medical Center, Francisco, 1001 Potrero Suite 3A, San Francisco, CA 94110, Burlington, MA, USA USA 10 Department of Urology, University of California San Diego, 3 Division of Urology, University of Utah, Salt Lake City, UT, San Diego, CA, USA USA 11 New York University School of Medicine, New York, NY, 4 Department of Urology, University of Washington, Seattle, USA WA, USA 5 Department of Urology, Baylor College of Medicine, Houston, TX, USA Vol.:(0123456789)1 3 World Journal of Urology Introduction stricture recurrence which could accommodate the stand- ard cystoscope; and small-caliber (SC) stricture where a Urethral stricture disease (USD) occurs in 0.6% of the standard cystoscope could not be easily passed. male population and is associated with signifcant uro- logic morbidities if left untreated [1, 2]. There has been Urethroplasty failure and patient‑reported outcome a paradigm shift in treatment algorithm of USD favoring measures (PROM) urethroplasty over less efective endoscopic approaches in recent years. This change is refected in the most recent The primary outcome was failure after anterior urethro- update of American Urological Association guideline for plasty, which was classifed as the need for re-intervention treatment of USD [3]. such as internal urethrotomy, dilation, fstula excision, per- The defnition of “success” after urethroplasty is a point ineal urethrostomy or repeated urethroplasty. The secondary of controversy in the literature [4]. Historically, success outcome was PROMs which were assessed during the same has been defned as the absence of secondary interven- follow-up visit for cystoscopy and again > 8 months after tions after urethroplasty. However, multiple publications urethroplasty. Questionnaires were mailed prior to clinic have afrmed the importance of patients’ perspective when visit or flled during the same visit but prior to cystoscopy. urethroplasty success is being evaluated [5, 6]. In addition For patients with primary failure of urethroplasty, the most there is no consensus on the optimal surveillance protocol recent available PROM before re-intervention is reported. after urethroplasty, which has led to signifcant variabil- Measures included the International Prostate Symptom ity in practice patterns among experts and increased cost Score (IPSS), Sexual Health Inventory for Men (SHIM), [7–9]. Surprisingly the utility of cystoscopy, as the pre- Male Sexual Health Questionnaire (MSHQ), and Core sumed gold standard for diagnosing USD, has never been Lower Urinary Tract Symptom Score (CLSS). critically studied as a surveillance tool after urethroplasty. The present study aimed to evaluate the association Statistical analysis between cystoscopic recurrence of USD and the need for secondary intervention as a primary outcome. Secondary All analyses were conducted using STATA, version 15, with goal was to study the association between cystoscopic statistical signifcance set at p < 0.05. We provide descrip- recurrence and patients’ symptoms assessed by standard- tive statistics to present patient demographics, as well as ized questionnaires. one-way ANOVA, Kruskal–Wallis, and Chi squared tests to compare patient characteristics according to cystoscopy result. Non-parametric tests were used when the data were not normally distributed. Survival analysis for anterior ure- Materials and methods throplasty failure included a Kaplan–Meier curve reporting cumulative incidence of re-intervention (failure) with an Subjects accompanying log-rank test for equality. Cox proportional hazards test was used to calculate unadjusted and adjusted We retrospectively reviewed a cohort of 2630 men in the hazard ratios (adjusting for age, stricture length, location and Trauma and Urologic Reconstruction Network of Sur- etiology). We used descriptive statistics to report PROMs geons (TURNS) that underwent anterior urethroplasty at and Kruskal–Wallis test to compare PROMs. ten institutions between December of 2006 and May of 2017. Details regarding the study design and database are available in other publications [10]. Patients with history Results of hypospadias, perineal urethrostomy, urethral fstula, and meatal pathology were excluded (n = 321). All postopera- Demographic and clinical characteristics tive cystoscopic evaluations were performed using stand- ard fexible 17 french (f) cystoscope to the level of stric- In our cohort, 1054 patients met the inclusion criteria with ture. No attempts to pass the cystoscope beyond the area a mean age of 46.21 (SD = 16.48). Total follow-up time of urethroplasty (regardless of caliber) are routinely per- for all participants was a median of 350 days after anterior formed unless clinically indicated. Total of 1054 patients urethroplasty (IQR 121–617). Baseline comorbidities are who had their initial postoperative cystoscopic evaluation presented in Table 1. In total, 18.3% of patients had a pre- between 3 and 6 months after urethroplasty were included. vious urethroplasty (n = 180). Postoperative cystoscopic Subjects were classifed into three groups according to evaluation occurred a median of 111 days post-urethro- their frst cystoscopy result: normal; large-caliber (LC) plasty (IQR 99–125). 740 (70.2%) patients had a normal lumen, 136 (12.9%) had SC recurrence, and 178 (16.9%) 1 3 World Journal of Urology Table 1 Baseline demographic and clinical characteristics of patients undergoing urethroplasty according to postoperative surveillance cysto- scopic evaluation Normal lumen > 17 French stricture < 17 French stricture p value Number variable 740 178 136 Age mean (SD) 45.6 (16.6) 48.9 (16.0) 45.9 (16.0) 0.05 BMI (SD) 29.5 (6.7) 30.3 (6.6) 30.7 (7.0) 0.09 Diabetes n (%) 88 (11.9) 21 (11.8) 9 (6.6) 0.19 Hypertension n (%) 211 (28.5) 50 (28.1) 52 (38.2) 0.07 Hyperlipidemia n (%) 155 (21.0) 31 (17.4) 29 (21.3) 0.55 CAD n (%) 7 (1.0) 1 (0.6) 1 (0.7) 1.00 COPD n (%) 9 (1.2) 3 (1.7) 5 (3.7) 0.10 Smoking history n (%) 0.97 Never smoked 484 (65.4) 117 (65.7) 76 (55.9) Current