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Impact of Cardiovascular and Metabolic Risk Factors on Stricture Recurrence After Anterior One-stage Buccal Mucosal Graft Urethroplasty

  • Author Footnotes
    ⁎ Equal contribution.
    Christian P. Meyer
    Correspondence
    Address correspondence to Christian P. Meyer, M.D., FEBU, Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
    Footnotes
    ⁎ Equal contribution.
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Author Footnotes
    ⁎ Equal contribution.
    Jule Lamp
    Footnotes
    ⁎ Equal contribution.
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Author Footnotes
    § On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU).
    Malte W. Vetterlein
    Footnotes
    § On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU).
    Affiliations
    Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany
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  • Armin Soave
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Oliver Engel
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Roland Dahlem
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Margit Fisch
    Affiliations
    Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Author Footnotes
    § On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU).
    Luis A. Kluth
    Footnotes
    § On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU).
    Affiliations
    Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany
    Search for articles by this author
  • Author Footnotes
    ⁎ Equal contribution.
    § On behalf of the Trauma and Reconstructive Urology Working Party of the European Association of Urology (EAU) Young Academic Urologists (YAU).
Published:September 17, 2020DOI:https://doi.org/10.1016/j.urology.2020.07.073

      Objectives

      To evaluate the impact of cardiovascular, metabolic and smoking related risk factors on recurrence in patients with buccal mucosal graft urethroplasty for anterior urethral strictures.

      Patients and Methods

      Retrospective single-center analysis between 2009 and 2016. Covariates included American Society of Anesthesiology (ASA) score, body mass index, and smoking status (never vs ever), coronary artery disease, arterial hypertension, diabetes mellitus, change in hemoglobin, creatinine, c-reactive protein, and leucocyte count. Descriptive and survival analyses evaluated the association with stricture recurrence.

      Results

      Overall, 1039 patients had buccal mucosal graft urethroplasty of which 517 remained for final analysis. Patients with stricture recurrence (n = 76) were significantly older (P < .001), had a higher American Society of Anesthesiology score (P = .006), higher proportion coronary artery disease (P = .011), and hypertension (P = .003) compared to those patients without stricture recurrence. Patients without stricture recurrence had a significantly larger drop in hemoglobin (1.5 [0.9, 2.1] vs 1.2 [0.7, 1.8]) mg/dl ( = .005).Overall stricture-free recurrence rate was 86%, with a median follow-up of 32 (95% confidence interval: 26-30) months. In multivariable analysis, a larger drop of hemoglobin remained the only independent, statistically significant negative predictor of stricture recurrence (Hazard ratio, 95% confidence interval: 0.74, 0.57-0.97, P = .03).

      Conclusion

      A larger drop of hemoglobin is independently associated with recurrence free survival. This may be considered as a surrogate marker for good microvascular circulation of the corpus spongiosum and therefore neovascularization of the graft. Contrary to the existing and mostly heterogenous previous studies, our findings suggest that stricture recurrence is largely independent of cardiovascular and metabolic risk factors.
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      References

        • Anger JT
        • Buckley JC
        • Santucci RA
        • Elliott SP
        • Saigal CS
        Urologic diseases in America P. Trends in stricture management among male medicare beneficiaries: underuse of urethroplasty?.
        Urology. 2011; 77: 481-485
        • Vetterlein MW
        • Loewe C
        • Zumstein V
        • et al.
        Characterization of a standardized postoperative radiographic and functional voiding trial after 1-stage bulbar ventral onlay buccal mucosal graft urethroplasty and the impact on stricture recurrence-free survival.
        J Urol. 2019; 201: 563-572
        • Barbagli G
        • Kulkarni SB
        • Fossati N
        • et al.
        Long-term followup and deterioration rate of anterior substitution urethroplasty.
        J Urol. 2014; 192: 808-813
        • Cavalcanti AG
        • Costa WS
        • Baskin LS
        • McAninch JA
        • Sampaio FJ
        A morphometric analysis of bulbar urethral strictures.
        BJU Int. 2007; 100: 397-402
        • Borboroglu PG
        • Sands JP
        • Roberts JL
        • Amling CL
        Risk factors for vesicourethral anastomotic stricture after radical prostatectomy.
        Urology. 2000; 56: 96-100
        • Breyer BN
        • McAninch JW
        • Whitson JM
        • et al.
        Multivariate analysis of risk factors for long-term urethroplasty outcome.
        J Urol. 2010; 183: 613-617
        • Chapman D
        • Kinnaird A
        • Rourke K
        Independent predictors of stricture recurrence following urethroplasty for isolated bulbar urethral strictures.
        J Urol. 2017; 198: 1107-1112
        • Han JS
        • Liu J
        • Hofer MD
        • et al.
        Risk of urethral stricture recurrence increases over time after urethroplasty.
        Int J Urol. 2015; 22: 695-699
        • Kinnaird AS
        • Levine MA
        • Ambati D
        • Zorn JD
        • Rourke KF
        Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties.
        Can Urol Assoc J. 2014; 8: E296-E300
        • Vetterlein MW
        • Stahlberg J
        • Zumstein V
        • et al.
        The impact of surgical sequence on stricture recurrence after anterior 1-stage buccal mucosal graft urethroplasty: comparative effectiveness of initial, repeat and secondary procedures.
        J Urol. 2018;
        • Asopa HS
        • Garg M
        • Singhal GG
        • Singh L
        • Asopa J
        • Nischal A
        Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach.
        Urology. 2001; 58: 657-659
        • Riechardt S
        • Pfalzgraf D
        • Dahlem R
        • Fisch M
        Surgery illustrated–focus on details: dorsal buccal mucosal inlay for penile urethroplasty.
        BJU Int. 2009; 103: 1444-1447
        • Rosenbaum CM
        • Schmid M
        • Ludwig TA
        • et al.
        Internal urethrotomy in patients with recurrent urethral stricture after buccal mucosa graft urethroplasty.
        World J Urol. 2015; 33: 1337-1344
        • Rosenbaum CM
        • Schmid M
        • Ludwig TA
        • et al.
        Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes.
        BJU Int. 2016; 118: 797-803
        • Kluth LA
        • Dahlem R
        • Reiss P
        • et al.
        Short-term outcome and morbidity of different contemporary urethroplasty techniques–a preliminary comparison.
        J Endourol. 2013; 27: 925-929
        • Soave A
        • Dahlem R
        • Pinnschmidt HO
        • et al.
        Substitution urethroplasty with closure versus nonclosure of the buccal mucosa graft harvest site: a randomized controlled trial with a detailed analysis of oral pain and morbidity.
        Eur Urol. 2018; 73: 910-922
        • Erickson BA
        • Breyer BN
        • McAninch JW
        The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery.
        J Urol. 2010; 184: 1386-1390
        • Meeks JJ
        • Erickson BA
        • Granieri MA
        • Gonzalez CM
        Stricture recurrence after urethroplasty: a systematic review.
        J Urol. 2009; 182: 1266-1270
        • Blaschko SD
        • Harris CR
        • Zaid UB
        • et al.
        Trends, utilization, and immediate perioperative complications of urethroplasty in the United States: data from the national inpatient sample 2000-2010.
        Urology. 2015; 85: 1190-1194
        • Wessells H
        • Angermeier KW
        • Elliott S
        • et al.
        Male urethral stricture: American Urological Association Guideline.
        J Urol. 2017; 197: 182-190
        • Desai N
        • Schofield N
        • Richards T
        Perioperative patient blood management to improve outcomes.
        Anesth Analg. 2018; 127: 1211-1220
        • Thiel DD
        • Igel TC
        • Brisson TE
        • Heckman MG
        Outcomes with an alternative anastomotic technique after radical retropubic prostatectomy: 10-year experience.
        Urology. 2006; 68: 132-136
        • Mucke T
        • Wolff KD
        • Rau A
        • Kehl V
        • Mitchell DA
        • Steiner T
        Autonomization of free flaps in the oral cavity: a prospective clinical study.
        Microsurgery. 2012; 32: 201-206
        • Gordillo GM
        • Sen CK
        Revisiting the essential role of oxygen in wound healing.
        Am J Surg. 2003; 186: 259-263
        • Plock JA
        • Rafatmehr N
        • Sinovcic D
        • et al.
        Hemoglobin vesicles improve wound healing and tissue survival in critically ischemic skin in mice.
        Am J Physiol Heart Circ Physiol. 2009; 297: H905-H910
      1. Aksamitiene E, Bryant L, Stanczak M, Eisenbrey JR, Hoek JB, Pribitkin EA. Prognostic significance of tissue oxygenation changes and early signaling responses in fasciocutaneous advancement flap healing. 2016;30:444.410-444.410.

        • Fawcett A
        • Shembekar M
        • Church JS
        • Vashisht R
        • Springall RG
        • Nott DM
        Smoking, hypertension, and colonic anastomotic healing; a combined clinical and histopathological study.
        Gut. 1996; 38: 714-718
        • Levy M
        • Gor RA
        • Vanni AJ
        • et al.
        The Impact of Age on Urethroplasty Success.
        Urology. 2017; 107: 232-238
      2. Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), editor. S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen [Internet]. AWMF-Institut für Medizinisches Wissensmanagement (AWMF-IMWi); [cited 2019 Nov 26]. Available from: https://www.oegari.at/web_files/dateiarchiv/editor/s3-leitlinie_intraversale_volumentherapie_dgai.pdf

        • Rehm M
        • Hulde N
        • Kammerer T
        • Meidert AS
        • Hofmann-Kiefer K
        State of the art in fluid and volume therapy: A user-friendly staged concept. English version.
        Anaesthesist. 2019; 68: 1-14
        • Wilson PW
        • D'Agostino RB
        • Levy D
        • Belanger AM
        • Silbershatz H
        • Kannel WB
        Prediction of coronary heart disease using risk factor categories.
        Circulation. 1998; 97: 1837-1847
        • Conroy RM
        • Pyorala K
        • Fitzgerald AP
        • et al.
        Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project.
        Eur Heart J. 2003; 24: 987-1003