Male Urethral Stricture Guideline: Guideline Statements Keith Rourke, MD, FRCSC Associate Professor, University of Alberta

Transcription

1 Male Urethral Stricture Guideline: Guideline Statements Keith Rourke, MD, FRCSC Associate Professor, University of Alberta

2 Statement 17: Surgeons may reconstruct long multisegment strictures with one stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps or a combination of these techniques. (Moderate Recommendation; Evidence Strength Grade C)

3 Pan-urethral Strictures Anterior Strictures that: Involve both the penile and bulbar urethra And are >10-12cm Treatment options: 1) Lifelong endoscopic management/selfcatheterization 2) Urethroplasty* 3) Perineal urethrostomy* *Urethroplasty in these instances is more complicated, time-consuming, and has a higher failure rate.

4 Reconstructive Options for pan-urethral (>10-12cm) strictures 1) One-stage onlay/inlay with Flap 2) One-stage onlay/inlay with multiple BMG s 3) Combination of A & B 4) Staged reconstruction

5 Evidence for Panurethral Urethroplasty One-Stage Urethroplasty Three studies in evidence report (One RCT) 1 Skin Graft (STSG) - 73% success 2 Skin Flap 79% success (Hussein et al.) 3 Oral (Buccal) Mucosal Grafts 84% success (Kulkarni et al) 4 Tunica Vaginalis flap 84% (Mathur & Sharma) Staged Urethroplasty Oral Mucosal Graft (OMG) %

6 When Should you Do a Staged Urethroplasty? Penile/Long Urethral Strictures with: 1. Failed/complex hypospadias 2. Extensive urethral & peri-urethral fibrosis 3. Complete obliteration of lumen 4. Dense Lichen sclerosus (+/- complete excision)

7 Statement 18: Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Strength Grade C)

8 Perineal Urethrostomy (PU): Evidence 173 patients undergoing skin flap PU for complex anterior stricture 50.3% idiopathic strictures; 17.3% LS 52.6% failed prior urethroplasty Outcomes: 70% success rate (121/173) = no need for revision 78% patient satisfaction 16% reported psychological, urinary or sexual dysfunction related to PU

9 Perineal Urethrostomy (PU): Indications Recurrent or complex stricture and: 1. Failed Urethroplasty 2. Extensive Lichen Sclerosus 3. Failed Hypospadias 4. Advanced patient age 5. Medical co-morbidities precluding extended operative time 6. Patient preference

10 BEWARE of the typical versus the actual pan-urethral stricture complicating PU The typical LS pan-urethral stricture The actual LS pan-urethral stricture

11 Statement 19: Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion) When is Tissue Transfer required for Urethroplasty? 1. Longer (>2cm) strictures 2. Penile urethral strictures 3. Inflammatory strictures 4. Re-operative urethroplasty

12 Graft versus Flap? Graft 1. Appropriate graft bed required 2. Readily available 3. Ease of harvest 4. Concealed scar/deformity Flap 1. Preserved blood supply - No graft take required 2. Not always available 3. More dissection required 4. Local visible scar

13 Tissue Transfer Sources for Urethroplasty Grafts: *Buccal mucosa* FTSG/STSG Bladder or colonic epithelial Posterior auricular (Wolfe) Flaps: Penile skin island Scrotal island

14 Oral (Buccal) Mucosa Graft (OMG) Resurgence since 1992 (Burger et al.) Robust take (panlaminar plexus) A wet graft - well suited to the urethra Readily available Easy to handle

15 Statement 20: Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols.(expert Opinion) Use of non-autologous grafts is rarely indicated (except in a patient that has no tissue available for reoperative urethroplasty) Limited experience with unknown long term success Includes: Allograft Xenograft Engineered or synthetic materials

16 Statement 21: Surgeons should not perform a single-stage tubularized graft urethroplasty. (Expert Opinion) Onlay (patch) vs. Tube Onlay has superior outcomes >60% ischemic stenosis with tube (Mundy, 1995) Alternatives to a tube: Combined tissue (graft + flap) Staged Reconstruction

17 Buccal Mucosal Graft: Graft Placement Ventral vs. Dorsal No clear distinction in outcomes

18 What are the Outcomes of Substitution Urethroplasty? Buccal mucosa most common tissue source Bulbar urethra: No difference in ventral vs. dorsal onlay Limited follow-up of other techniques Penile urethra: Two-stage superior to one-stage LS/BXO likely impacts this

19 Statement 22: Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle) Risks of hair bearing skin: Urethral calculi Recurrent UTI Pain/dysuria LUTS due to hair obstructing the lumen Suspect in patients with previous childhood hypospadias repair or skin flap

20 Statement 23: Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury (PFUI). (Moderate Recommendation; Evidence Strength Grade C)

21 Staging of PFUI Defect: Retrograde Urethrogram Standard urethrography may demonstrate the stricture in PFUIs But only for nonobliterated strictures

22 Staging of PFUI Defect: Combined RUG and VCUG Standard RUG alone is usually not adequate in most cases Complete obliteration Overestimation of defect due to bladder neck competence

23 Staging of PFUI Defect: Antegrade cystoscopy with simultaneous RUG (Up and Down-o-gram)

24 Statement 24: Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury (PFUI). (Expert Opinion) High rate of stricture recurrence Potentially delay and complicate definitive treatment with urethroplasty Significant associated risks

25 Delayed Endoscopic Repair of PFUI: AKA Cut to the Light : Evidence Fluoroscopic incision and resection of fibrosis (Quint & Stanisic, 1993) o 30% transfusion rate o 10% rectal perforation (i.e. Cut to the Rectum ) o 68% stricture recurrence

26 Statement 25: Definitive urethral reconstruction for pelvic fracture urethral injury (PFUI) should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion) Allow healing of orthopedic injuries for lithotomy position Resorption of hematoma, reduction in inflammation and tissue maturation Usually perform urethroplasty at 3-6 months (as early as 6 weeks)

27 Treatment of PFUI It is the urologist who will have to share the burden of the ultimate disability with the patient when the thoracic, abdominal & even the orthopedic aspects are probably long forgotten. Richard Turner-Warwick, 1977 Treatment Goal: A patent continent urethra with maintenance of pre traumatic sexual potency

28 Posterior Urethroplasty for PFUI Lithotomy position Perineal incision Suprapubic access Dissection of bulbospongiosus muscle Dissection of urethra circumferentially Mobilization of perineal body Incision of triangular ligament

29 Posterior Urethroplasty for PFUI Transection of urethra at pelvic floor Control proximal blood supply Resection fibrosis Spatulate prostatic apex Anastomotic Sutures Tension-free anastomosis

30 Ancillary Maneouver: Division of Intra-corporal Space Mundy, 2012

31 Infrapubectomy (22-30%) Mundy, 2012

32 Corporal Rerouting (10-15%) Mundy, 2012

33 Summary: Reconstruction for PFUI 1. ~95% can be approached with single-stage perineal operation % long-term success rate 3. Transpubic approach reserved for: Orthopedic deformities precluding lithotomy Massive defects 4. Erectile dysfunction is common in PFUI s (69%) 5. Urethroplasty increases the rate of de novo ED by 5%

34 Statement 26: Surgeons may perform a dilation, bladder neck incision or transurethral resection for bladder neck contracture after endoscopic prostate procedure (TURP). (Expert Opinion) BNC is very likely to respond to endoscopic treatment Multitude of options Less likely to be complicated by concurrent incontinence or RT

35 Bladder Neck Contracture vs. Vesicourethral Anastomotic Stenosis ICUD Consultation on Urethral Stricture (2011) Bladder neck contracture (BNC) = prostate in situ (i.e after TURP) Vesico-urethral anastomotic stenosis (VUS) = after radical prostatectomy

36 Statement 27: Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis (VUS). (Conditional Recommendation; Evidence Strength Grade C) VU Stenosis EUS

37 Vesicourethral Stenosis (VUS): Incidence % of patients post RP Physician outcomes typically 5% incidence Registry reviews 20-30% Often complicated by concurrent sphincteric incontinence Limited series in the literature Elliot et al., JUrol, 2007 Catalona et al., 1999 Gillitzer et al., 1998 Breyer et al., 2010 Borboroglu et al., 2000 Giannarini, 2008

38 Vesicourethral stenosis: Risk Factors Surgical Factors Operative volume Blood loss / Hematoma Urine Leak Postoperative retention Patient factors Prior TURP Prostate Size DM Age Tobacco use Obesity Mundy, 2012; Lange and Reddy, 1987; Davidson et al., 1996; Catalona et al., 1999; Erickson et al., 2009; Gillitzer et al., 1998; Breyer et al., 2010; Borboroglu et al., 2000; Moul et al., 1998

39 VUS: Treatment Options Urethral Dilation % (<30 patients) Cold knife incision 58-80% patency (<20 patients) Hot-knife incision 30-72% patency Holmium Laser incision o 83% patency at 2 years? Urolume Stent

40 1. What are the outcomes of endoscopic management for VUS after RP? 2. What are the predictors of success for the endoscopic management of VUS? 91% (129/142) of patients successfully treated endoscopically Mean Number of Treatments = 2.1 (292 in 142 patients) J Urol, 2015

41 Predictors of Success: Multivariate Analysis Factor p-value Odds Ratio (95% CI) * p<0.05 Treatment modality Number of Treatments <0.001* 0.65 ( ) 0.04* 0.86 ( ) Patient Age ( ) Concurrent radiotherapy ( ) BMI > ( ) Diabetes Mellitus ( ) Tobacco use 0.04* 0.55 ( )

42 Overall Success (%) VUS Success by Number of Treatments p= >3 Number of Treatments

43 VUS: Intralesional Therapy Triamcinolone (Eltahawy et al., 2008) 83% 2 years Uncontrolled holmium laser incision Mitomycin C Inhibits fibroblast proliferation & collagen deposition Used for scar prevention in ophthalmology BUT associated with associated with potentially sightthreatening complications (Mearza & Aslanides, 2007) 58-72% success after x1 treatment for recalcitrant 12 months (Vanni et al., 2011; Redshaw et al. 2015) 7% rate of serious adverse events (Redshaw et al, 2015) Confounding effect of surgical technique and lack of controls

44 Statement 28: Surgeons may perform open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Strength Grade C) Reconstruction for: Recalcitrant (>3 failed treatments) Vesicourethral obliteration Radiation increases complexity and adversely affects outcomes

45 Vesicourethral Obliteration or Recalcitrant VUS: Treatment Approaches 1. Urethral Reconstruction then AUS 2. Long-term Suprapubic drainage 3. Urinary diversion

46 Reconstruction of Vesicourethral Obliteration Do you mobilize the urethra to the defect or the defect to the urethra? Multiple reconstructive approaches: 1. Perineal 2. Abdominoperineal 3. Abdominal/retropubic 65-88% success (small series) Nearly all patients require further treatment for incontinence (65-100%) Technically challenging surgery Mundy, BJUI, 2012 Pfalzgraf et al., J Urol, 2011 Wessells et al., J Urol, 1998 Schlossberg et al., Urology, 1995

47 Poor Candidates for Reconstruction Small bladder capacity <200ml Extensive necrosis Cavitation Osteomyelitis Prostato-symphyseal fistulae

48 Vesicourethral Stenosis: Summary Vesicourethral stenosis after prostate cancer treatment is a significant issue The majority of patients with VUS after radical prostatectomy can be successfully treated with endoscopic modalities But often require several procedures Role of intralesional agents still evolving Reconstruction after >3 attempts Not everyone is a reconstructive candidate

49 Statement 29: In men who require chronic selfcatheterization (e.g. neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion) Pathology Arising from a neurogenic bladder & CIC Stricture Diverticulum Fistula False passage Erosion

50 Urethral Reconstruction & Neurogenic Bladder Consider the cause of the problem and bladder function Reconstruction for stricture appears acceptable Unclear how CIC affects stricture recurrence Urethral rest prior with a SPC may be useful to better delineate the stricture Reconstructive outcomes for posterior urethral false passage is quite poor Secrest et al., 2003 Casey et al., 2008

51 Statement 30: Clinicians may perform biopsy for suspected lichen sclerosus (LS), and must perform biopsy if urethral cancer is suspected. (Clinical Principle)

52 Lichen Sclerosus et atrophicus (LS) (aka BXO) A chronic inflammatory, lymphocyte mediated skin disease with a predilection for the anogenital area Symptoms: Leucoderma Ecchymosis Itching Pain Phimosis Glans adhesions 30% have urethral involvement/stricture ~2-8% lifetime risk of malignancy (SCC)

53 GOALS Lichen Sclerosus: Initial Treatment Alleviate patient symptoms Prevent development of stenosis or stricture Prevent progression or transformation to squamous cell carcinoma (2-8%) Initial treatment Potent topical corticosteroids (clobetasol 0.05%) +/- Cystoscopy, Urethral dilation,? Urethroplasty Second line: Topical Testosterone or Tacrolimus (0.1%) LS strictures are a reconstructive challenge

54 31. In lichen sclerosus (LS) proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Strength Grade B) Beware of Lichen Sclerosus! And failed urethroplasty

55 One-stage: The One-Stage Penile Flap has Poor outcomes in Lichen Sclerosus Penile island flap onlay vs. Two-stage: Stricture excision Non-genital skin graft 20 (Mundy, 1998) 0 % One-Stage Outcome One or two stage free-graft urethroplasty preferred over a penile flap for LS 87 Two-Stage

56 Statement 32: Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy (DVIU) or urethroplasty. (Expert Opinion) Stricture recurrence may develop anytime after treatment

57 Risk Factors for Stricture Recurrence Risk Factors for Stricture Recurrence: 1) Increasing Stricture Length (>5cm) 2) Lichen Sclerosus 3) Infectious and Iatrogenic Strictures 4) Previous urethroplasty 5) Previous DVIU 6) Smoking

58 Detection of Recurrent Stricture Multitude of tests available Same as for diagnosis (Statements 1 & 2) Most definitive tests for detecting recurrence are: Urethrocystoscopy Urethral ultrasound Retrograde Urethrogram No accepted definition of stricture recurrence Specific urethral lumen diameter Endoscopic, radiographic or symptomatic

59 Patient Reported Outcome Measures (PROM) Questionnaire focusing on: LUTS Pain Satisfaction/QOL Based on: Focus groups Expert opinion Existing HRQoL surveys An emerging area in reconstructive urology

60 MCQ 1: A 65 year old gentleman post- RARP develops a recurrent VUS despite 2 separate urethral dilations. What would be the most appropriate treatment option? A. Urolume endoprosthesis B. Posterior Urethroplasty C. Indwelling suprapubic catheter D. Repeat endoscopic procedure with another modality Answer = D

61 MCQ 2: A 65-year old male develops a recurrent urethral stricture despite 3 urethral dilations. On urethrogram he has a 6cm penile urethral stricture caused by lichen sclerosus. Which of the following is NOT an appropriate treatment option? A. Perineal urethrostomy B. Two-stage urethroplasty with buccal mucosa C. One-stage urethroplasty with buccal mucosa D. One-stage urethroplasty with penile fasciocutaneous flap Answer = D

62 MCQ 3: Which of the following is most likely to be a risk factor for urethral stricture recurrence after urethroplasty A. Advanced patient age B. Increased stricture length C. Trauma etiology D. Obesity Answer = B

63 Cases

64 Case 1: Mr. HC A 58 year old healthy male PSA 9.2, Small Lt mid-nodule Biopsy - Gleason 3+4 4/12 cores positive (Left, 10-15%) Undergoes RARP Stage T2b, Gl 3+4 Negative margins No adjuvant EBRT

65 3-months Postoperatively PSA <0.1 Severe LUTS IPSS 22 Hesistancy, Frequency, Decreased force of stream Wears 1-2 pads/day Minimal Erectile Function

66 Evaluation Urinalysis 5-10 RBC/HPF Urine C&S 10x6 mixed growth Cystoscopy Stenosis at Bladder Neck

67 Vesicourethral Stenosis What is your preferred initial treatment? A. Urethral dilation B. Hot-knife transurethral incision C. Cold-knife transurethral incision D. Holmium laser transurethral incision E. Other

68 8 weeks post endoscopic treatment: Recurrent LUTS & recurrent stenosis How would you treat this patient? A. Endoscopic treatment with same modality B. Endoscopic treatment with different modality C. Endoscopic treatment with intralesional mitomycin C D. Endoscopic treatment with selfcatheterization E. Urethroplasty (perform or refer)

69 Case 2: A 47 year old male Presents with progressive LUTS of 9 years duration: Urinary hesitancy Intermittency Double voiding Nocturia x 4 Recurrent UTI x3 (cystitis) E Coli Sensitive to ciprofloxacin Past Medical History: o Mosaic mild Down s syndrome

70 Laboratory Evaluation and Imaging Serum Creatinine 297 umol/l (3.3 mg/dl) Renal and Bladder Ultrasound: PVR urine 350mL Thickened/trabeculated bladder wall Moderate bilateral hydronephrosis Urologist: Identifies dense penile urethral stricture Cystoscopy Unable to dilate acutely Suprapubic catheter (SPC) placed

71 Referral and Physical Examination Creatinine normalizes with SP catheter 107 umol/l (=1.2 mg/dl) Examination: Circumcised previously Obvious LS involving glans + meatus Cystoscopy (pediatric) - <6Fr penile urethral stricture

72 Retrograde Urethrogram What is your approach to this patient?

73 URETHROPLASTY for PANURETHRAL Lichen Sclerosus (LS) strictures Penile skin flap urethroplasty have very poor outcomes (0%) (Venn and Mundy, 1998) Current literature favours either a one-stage onlay reconstruction or staged approach (Dubey et al., 20005, Kulkarni et al., 2008, Kulkarni et al., 2012) BUT: Stricture length >4-5cm is a strong risk factor for stricture recurrence after urethroplasty (Breyer, et al, 2010; Kinnaird & Rourke, CUAJ 2014) AND: Lichen Sclerosus is an undeniable risk factor for stricture recurrence after urethroplasty (p<0.001) (Kinnaird and Rourke, CUAJ 2014)

74 URETHROSTOMY for Lichen Sclerosus (LS) related PAN-URETHRAL stricture Patients with LS and complex urethral stricture treated with a urethrostomy enjoy an excellent quality of life (>97%)(Peterson et al, 2004, Barbagli et al., 2009) BUT: Patency rates of urethrostomies in LS are suboptimal (~70%) (Kulkarni et al., 2008, Barbagli et al., 2009) IT IS POSSIBLE to use buccal mucosa to reconstruct a perineal urethrostomy in patients with LS-related pan-urethral stricture?

75 The Augmented Urethrostomy Preparation of broad based lambda -shaped perineal incision

76 The Augmented Urethrostomy Exposure and mobilization of bulbar urethra/corpus spongoisum.

77 The Augmented Urethrostomy Transection of bulbar urethra and dorsal onlay grafting with buccal mucosa.

78 The Augmented Urethrostomy Creation of the augmented urethrostomy by advancing skin flaps to urethra and buccal mucosa