Trauma/Reconstruction/Diversion Urinary and Sexual Function after Perineal Urethrostomy for Urethral Stricture Disease: An Analysis from the TURNS Gregory P. Murphy,* Kirkpatrick B. Fergus, Thomas W. Gaither, Nima Baradaran, Bryan B. Voelzke, Jeremy B. Myers, Bradley A. Erickson, Sean P. Elliott,† Nejd F. Alsikafi, Alex J. Vanni, Jill C. Buckley and Benjamin N. Breyer From the Division of Urology, Washington University (GPM), St. Louis, Missouri, and University of Utah (JBM), Salt Lake City, Utah, Departments of Urology, University of California-San Francisco (KBF, TWG, NB, BNB), San Francisco and University of California-San Diego Health System (JCB), San Diego, California, University of Washington (BBV), Seattle, Washington, University of Iowa (BAE), Iowa City, Iowa, University of Minnesota (SPE), Minneapolis, Minnesota, and Lahey Hospital and Medical Center (AJV), Burlington, Massachusetts, and UroPartners (NFA), Gurnee, Illinois Purpose: Perineal urethrostomy is a viable option for many complex urethral Abbreviations strictures. However, to our knowledge no comparison with anterior urethroplasty and Acronyms regarding patient reported outcome measures has been published. We compared [ AU anterior urethroplasty these groups using a large multi-institution database. [ CLSS Core Lower Urinary Tract Materials and Methods: We performed a retrospective study of anterior ure- Symptom Score throplasty in the TURNS (Trauma and Urologic Reconstructive Network of I-PSS [ International Prostate Surgeons) database. The anterior urethroplasty cohort was defined by long Symptom Score strictures greater than 6 cm. We compared demographic, clinical, urinary and MSHQ [ Men's Sexual Health sexual characteristics using validated patient reported outcome measures Questionnaire between patients treated with long stricture anterior urethroplasty and those PROM [ patient reported who underwent perineal urethrostomy. outcome measure Results: Of the 131 patients 92 treated with long stricture anterior urethroplasty SHIM [ Sexual Health Inventory and 39 treated with perineal urethrostomy met study inclusion criteria. The for Men cumulative incidence of failure at 2 years was 30.2% (95% CI 18.3e47.3) for long TURNS [ Trauma and Urologic stricture anterior urethroplasty and 14.5% (95% CI 4.8e39.1) for perineal ure- Reconstructive Network of throstomy (p [ 0.09). Compared to baseline metrics, patients who underwent Surgeons long stricture anterior urethroplasty and perineal urethrostomy had similar improvements in urinary function and stable sexual function after surgery. Conclusions: Patients reported improvement in urinary function after perineal urethrostomy with no deleterious effect on sexual function. These patient re- ported outcome measures were comparable to those of long stricture anterior urethroplasty. Perineal urethrostomy failure rates were similar to those of long stricture anterior urethroplasty. Key Words: urethral stricture, patient reported outcome measures, quality of life, erectile dysfunction, urination Accepted for publication November 30, 2018. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with gua- rantees of confidentiality; IRB approved protocol number; animal approved project number. No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. * Correspondence: Division of Urologic Surgery, Washington University School of Medicine, 4960 Children's Pl., Suite 216, Wohl Hospital, St. Louis, Missouri 63110 (telephone: 314-273-1597; e-mail: [email protected]). † Financial interest and/or other relationship with Boston Scientific, PercuVision and Urotronic. Editor’s Note: This article is the fifth of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1018 and 1019. 0022-5347/19/2015-0956/0 https://doi.org/10.1097/JU.0000000000000027 THE JOURNAL OF UROLOGY® Vol. 201, 956-961, May 2019 Ó 2019 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 956 j www.auajournals.org/jurology Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited. URINARY AND SEXUAL FUNCTION AFTER URETHROSTOMY 957 URETHRAL reconstruction in experienced hands surgery and 9 who underwent a prior perineal ure- achieves a greater than 90% success rate for sim- throstomy. For AU we included only patients with stric- ple short bulbar strictures with anastomotic ure- tures greater than 6 cm and defined this as long stricture throplasty.1 AU failure requiring a repeat procedure is AU. Finally, we selected patients with at least 1 baseline associated with longer strictures, prior urethroplasty, and 1 followup PROM. A total of 131 patients met inclusion e criteria. failed hypospadias and lichen sclerosus.2 5 While In our study population we compared demographic and urethral reconstruction techniques can be successful clinical characteristics, including patient age, body mass for complex strictures, they are difficult cases with index, diabetes, hypertension and stricture length, loca- 2e7 higher recurrence and complication rates. The best tion and etiology. Stricture location and etiology were not reconstruction method for complex strictures is not mutually exclusive categories. always clear. An underused and under studied technique for Exposures and Outcomes recurrent and complex anterior strictures which Exposures consisted of 2 surgical procedures, that is AU spares the posterior and proximal anterior urethra and perineal urethrostomy. We defined AU to include is perineal urethrostomy.8 The AUA (American graft urethroplasty, and excision and primary anasto- Urological Association) guidelines on male urethral mosis. Long stricture AU was defined as a stricture strictures recommend perineal urethrostomy as an greater than 6 cm. PROMs for urinary and sexual func- tion were our primary study outcome. We administered option in patients with “recurrent or primary com- 13 14 plex anterior stricture, advanced age, medical co- validated PROMs, including the I-PSS, the CLSS, the SHIM15 and the MSHQ,16 preoperatively and at the most morbidities precluding extended operative time, recent postoperative followup. extensive lichen sclerosus, numerous failed at- tempts at urethroplasty and patient choice.”9 Statistical Analysis Upon initial consideration perineal urethrostomy We provide descriptive statistics of demographic variables often is not well received by patients. However, with long stricture AU and perineal urethrostomy in pa- Barbagli et al retrospectively reviewed an Italian tients compared by the Mann-Whitney test for non- cohort of 173 patients treated with perineal ure- normally distributed continuous variables (total followup) throstomy and found a 70% success rate and a 97% and a simple t-test for normally distributed continuous patient satisfaction rate using a nonvalidated ques- variables (age and body mass index). We performed Cox tionnaire.10 Of the patients 78% were satisfied and proportional hazards survival analysis to identify the 2- 19.1% were very satisfied. A smaller case series year cumulative incidence of failure for each procedure demonstrated a lower revision rate for perineal ure- and used the log rank test of difference. We applied the throstomy in patients with lichen sclerosus than for Wilcoxon matched pairs signed ranks test to compare anterior urethroplasty, although patient quality of preprocedure and post-procedure urinary and sexual function scores for long stricture AU and perineal ure- life outcomes were not discussed.11 To our knowledge throstomy. All p value alphas were 2-sided with statistical no group has compared the functional and quality of significance considered at p <0.05. All analyses were life outcomes in men after perineal urethrostomy performed with StataÒ, release 15. compared to AU. In this study we evaluated sexual and urinary function in men with longer urethral stricture disease RESULTS when comparing perineal urethrostomy surgery to Of the 131 patients who met study inclusion criteria AU. We hypothesized that men treated with perineal 92 underwent long stricture AU and 39 underwent urethrostomy would have quality of life outcomes perineal urethrostomy. Median followup in our similar to those in men with longer strictures. cohort was 390 days (IQR 132e771). There was no statistically significant difference in followup be- tween the 2 groups. The 2 patient groups were MATERIALS AND METHODS remarkably similar and the only significant differ- Study Population ence was the proportion with hypertension (see This is a retrospective cohort study of 2,484 patients with table). urethral stricture disease who were recorded in the The 2-year cumulative incidence of failure, TURNS database. The TURNS is a research group of 13 12 defined by the re-intervention rate, was 30.23% reconstructive surgeons from across the United States. (95% CI 18.32e47.30) for long stricture AU and Excluded from study were 122 patients who underwent 14.50% (95% CI 4.83e39.1) for perineal ure- fistula repair, direct vision internal