Urethra ppt

1. AHMED ABDELRAHIM, MD
LECTURER OF UROLOGY AT KASR ALAINY
CAIRO UNIVERSITY
Definition of Successful Treatment and
Optimal Follow-up after Urethral
Reconstruction for Urethral Stricture
Disease

2. Successful Treatment
 Historically, endoscopic approaches have success
rates 0-50%, and open repairs have much higher
success rates of 50-98%.
 Recent increase in Urethroplasty utilization:*
 2.3% - 2004
 7.6% - 2012
* Liu JS, Hofer MD, Oberlin DT, et al. Practice Patterns in the Treatment of Urethral Stricture
Among American Urologists: A Paradigm Change? Urology 2015;86(4):830–4

3.  Hence, the emerging need for a clear definition for
standardization:
 What defines a successful treatment?

4. Successful Treatment
 Anecdotally, the academic definition of a successful
urethroplasty has been defined as the lack of need
for a secondary procedure.
 Pros:
 easily definable
 easy to quantitate using retrospective methodologies

5. Successful Treatment
 Cons: inherently subjective “assumption”
 Patient with recurrent symptoms will seek care at the center in
which the urethroplasty was performed
 equal utilization (both patient and provider) of secondary
procedures for postoperative strictures
 does not account for asymptomatic recurrences, up to 35%*
* Erickson BA, Elliott SP, Voelzke BB, et al. Multi-institutional 1-year bulbar urethroplasty outcomes
using a standardized prospective cystoscopic follow-up protocol. Urology 2014;84(1):213–6.

6. Absence of secondary procedures
 75% of the academic literature on urethral
reconstruction published between 2000 and 2008.*
 This definition says very little about what is actually
happening inside the urethral lumen
* Meeks JJ, Erickson BA, Granieri MA, et al. Stricture recurrence after urethroplasty: a
systematic review. J Urol 2009;182(4):1266–70

7. Objective measurements
 Cystoscopy & Retrograde urethrogram (RUG)
 Considered gold standard
 Flexible Cystoscopy:
 Flexible cystoscopy is easy to perform,
 relatively safe
 perhaps the most reliable way to compare the anatomy of a
reconstructed urethra

8. Flexible cystoscopy
 The Trauma and Urologic Reconstruction Network
of Surgeons (TURNS; www.turnsresearch.org); a
network of 13 urologic reconstructive centers (and
14 surgeons) across the United States
 uses cystoscopy at 3 and 12 months to determine anatomic
success, using the “inability to traverse the reconstructed
urethra without force” as the definition of failure.*
* Erickson BA, Elliott SP, Voelzke BB, et al. Multi-institutional 1-year bulbar urethroplasty outcomes
using a standardized prospective cystoscopic follow-up protocol. Urology 2014;84(1):213–6

9. Flexible cystoscopy “TURNS study”
 Using this protocol:
 1-year success rates were significantly lower than had
previously been reported (88.5% and 77.5% for excisional and
substitutional repairs, respectively).
 Likely due in large part to the nearly 35% of subjects
with failure that were asymptomatic.
 These are subjects with anatomic recurrences that
would have been missed had the traditional
definition of failure, secondary operations, been
used, and thus reported success rates would have
been much higher.

10.  RUG:
Few advantages compared with cystoscopy
 visualize the entire urethra simultaneously,
 May be able to more easily diagnose diverticula and fistulas,
 and is easier to compare to preoperative to postoperative
objective findings.

11.  RUG:
However, logistically difficult to perform in a
standardized fashion and thus its interpretation can
be considered subjective.

12. Noninvasive Objective Measurements
 Uroflowmetry:
 Non invasive
 May be used to screen for patients who need further
assessment with cysto or RUG
 PVR:
 Usually used as an adjunct to other non invasive tools.

13. Voiding Patient-Reported Outcomes Measures
 Patient Reported Outcomes Measures (PROMS)
 AUASI/IPSS
 Disease-specific validated Questionnaires
 However, many men with anatomic recurrence will
be asymptomatic*
* Erickson BA, Elliott SP, Voelzke BB, et al. Multi-institutional 1-year bulbar urethroplasty outcomes using a
standardized prospective cystoscopic follow-up protocol. Urology 2014;84(1):213–6.

14.  In a TURNS study of 213 men, only 13 of 20
recurrences (65%) presented with urinary
symptoms*
 Comparing IPSS to cystoscopy, IPSS was only 50%
sensitive in detecting anatomic recurrences when
using an IPSS total score cutoff of 10.19
* Tam CA, Elliott SP, Voelzke BB, et al. The International Prostate Symptom Score (IPSS) Is an Inadequate
Tool to Screen for Urethral Stricture Recurrence After Anterior Urethroplasty. Urology 2016;95:197–201.

15. Non-voiding Patient-Reported Outcomes Measures
 PO sexual dysfunction, Pain, Voiding pattern
 Rates of permanent, de novo sexual dysfunction are
likely around 1%*
 With such low rates of expected long-term ED, does
it even need to be routinely assessed?!
* Blaschko SD, Sanford MT, Cinman NM, et al. De novo erectile dysfunction after anterior
urethroplasty: a systematic review and meta-analysis. BJU Int 2013;112(5):655–63

16. Non-voiding PROMS
 A study evaluated satisfaction after anterior
urethroplasty depended on 3 factors: independent of
anatomic success:
 Erectile function,
 pain, and
 voiding symptoms
 So, even if we created a widely patent urethra, if the
patient had ED (even transient), new pain, or they
did not perceive their urinary function to be
improved, they were unhappy!
* Erickson BA, Wysock JS, McVary KT, et al. Erectile function, sexual drive, and ejaculatory function
after reconstructive surgery for anterior urethral stricture disease. BJU Int 2007;99(3):607–11

17. Non-voiding PROMS
 Thus, these nonvoiding parameters should be a
standard part of any complete urethroplasty follow-
up to allow for assessment of the entire postoperative
outcome.
 However, currently available validated
questionnaires assess only voiding and quality of life
measures.

18. WHAT IS A SUCCESSFUL URETHROPLASTY?
 Both the anatomic findings and patient-reported
findings should be reported separately, and
simultaneously, for all urethroplasties.

19.  The traditional academic definition of a successful
urethroplasty, lack of need for a secondary
procedure, is outdated and should be amended to
incorporate both:
 objective (anatomic) and
 subjective (functional) outcomes measures.

20. Assigning anatomic success
 Anatomic success is assigned if a flexible cystoscope
is able to traverse the reconstructed urethra without
force during postoperative cystoscopy.
 RUG can be an altenative

21.  Objective uroflowmetry combined with PROMs
and/or an obstructive voiding curve has high
sensitivity and specificity for detecting recurrences
and can be used as a surrogate for anatomic
evaluation over time.

22. Assigning functional success
 Functional success is assigned if analysis of patient-
reported outcome measures (PROMs) reveals
improvement in voiding symptoms and urinary
quality of life, without de novo sexual dysfunction or
genitourinary pain.

23. Follow up
 The optimal follow-up strategy must allow for
 determination of both anatomic and functional outcomes,
 protect patients’ genitourinary health, and
 prevent patients from undergoing excessive invasive testing
that leads to unnecessary cost, discomfort, anxiety, and risk.

24. Follow up

25.  A decrease in the Qm or Qm – Qa (generally 20%–
30%) should prompt an evaluation of the urethra
with or without voiding symptoms.

26. Algorithm for determination of functional and anatomic success or failure

27. In conclusion
 Urethral reconstruction has firmly established itself
as the preferred method for the durable treatment of
male USD.
 Although there are a multitude of techniques
available for reconstruction, the ability to compare
outcomes between the techniques has been hampered
by the lack of a standardized definition of success
and a standardized follow-up regimen.

28. In conclusion
 The proposed 2-tiered definition of success that
considers both anatomic and functional factors, and
offers a personalized follow-up strategy that will
improve the ability to report success, detect
recurrence, and minimize unnecessary invasive
testing.

29. In conclusion
 Historical success rates have effectively concluded
that all urethroplasties are created equal.*
* Chen ML, Odom BD, Santucci RA. Substitution urethroplasty is as successful as anastomotic
urethroplasty for short bulbar strictures. Can J Urol 2014; 21(6):7565–9

30. In conclusion
 However, there is current strongly belief that
utilization of this second functional outcome
measure will reveal differences in the techniques
that will help guide reconstructive urologists toward
improved overall outcomes.

31. Thank You