JS HAN ET AL.

Editorial Comment Editorial Comment from Dr Horiguchi to Risk of urethral stricture recurrence increases over time after urethroplasty Although the management of male urethral stricture disease has a wide variety of therapeutics, urethroplasty remains the gold standard that offers the lowest rates of stricture recurrence.1 However, there is no consensus about the follow-up strategies or the optimal intervals between and durations of follow up after urethroplasty. The present study describes the long-term follow up of 347 patients who underwent urethroplasty, evaluates the potential risks for stricture recurrence and concludes that the durations of follow up are an independent predictor of recurrence.2 The authors advocate that patients should be counseled appropriately on the potential risks of late stricture recurrence after urethroplasty, regardless of surgical procedures. Most stricture recurrences generally occur in the first year after urethroplasty and rise slightly in the subsequent 4 years of follow-up examinations, followed by relative stability.3–5 Lifelong follow up is necessary after substitution urethroplasty, because stricture recurrences can increase with time and occur even after 15 years as a result of the contracture of grafts or flaps.6 I agree with the authors that stricture recurrence increases with time in patients who undergo substitution urethroplasty. However, I was surprised by the results that show late recurrence occurring at an increased rate over time in patients who undergo anastomotic urethroplasty. It is evident from the literature that anastomotic urethroplasty is highly successful and has sustained durable results.4 I understand that scar formation at anastomotic sites stabilizes within 12 months after anastomotic urethroplasty, and that stricture recurrence after 12 months is rare. Santucci et al. reported a long-term (mean of 70 months postoperatively) outcome of anastomotic urethroplasty for 168 bulbar urethral strictures with a high recurrence-free rate (95%) and recurrences in just eight patients (the mean time to recurrence was 15 months).4 Notably, six out of eight patients (75%) experienced recurrences within 12 months, and only one experienced a late

recurrence (at 80 months postoperatively).4 The recurrence rate according to Andrich et al. also appears to be stable at 5, 10 and 15 years after anastomotic urethroplasty.5 In accordance with the authors’ findings, I suppose these differences might be due to the number of patients who did not participate in follow-up examinations and could have experienced recurrences. Patients should be carefully monitored continually after urethroplasty irrespective of the type of procedure carried out, and surveillance protocols should be standardized. Akio Horiguchi M.D., Ph.D. Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan [email protected] DOI: 10.1111/iju.12790

Conflict of interest None declared.

References 1 Meeks JJ, Erickson BA, Granieri MA, Gonzalez CM. Stricture recurrence after urethroplasty: a systematic review. J. Urol. 2009; 182: 1266–70. 2 Han JS, Liu J, Hofer MD et al. Risk of urethral stricture recurrence increases over time after urethroplasty. Int. J. Urol. 2015; 22: 695–9. 3 Barbagli G, Kulkarni SB, Fossati N et al. Long-term followup and deterioration rate of anterior substitution urethroplasty. J. Urol. 2014; 192: 808–13. 4 Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J. Urol. 2002; 167: 1715–9. 5 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: e296–300. 6 Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J. Urol. 2003; 170: 90–2.

Editorial Comment Editorial Comment from Dr Rourke to Risk of urethral stricture recurrence increases over time after urethroplasty Although urethroplasty is well established as the most efficacious treatment for urethral stricture, it (like everything else in the world) is not perfect. Stricture recurrence after urethroplasty is a reality, even in the most experienced and capable hands. The present article by Han et al. examines risk factors for stricture recurrence in a cohort of 227 patients undergoing anterior urethroplasty with a mean follow up of 62 months.1 Patients with radiation or pelvic facture‐related stenosis as well as panurethral strictures were excluded from the study. In this series, 26% of 700

patients experienced stricture recurrence during follow up. Multivariate analysis identified prior urethroplasty and follow up greater than 48 months as risk factors for stricture recurrence. Strictures associated with lichen sclerosus were additionally very close to achieving significance as a risk factor. The exclusion of “panurethral” strictures involving portions of both the penile and bulbar urethra could have unintentionally contributed to the underestimation of stricture length and lichen sclerosus as a risk factor for stricture recurrence. © 2015 The Japanese Urological Association

Long‐term recurrence after urethroplasty

The underlying basis for stricture recurrence after urethroplasty remains poorly understood. This is in part related to a lack of literature on the subject. However, there has been inconsistency regarding which factors are associated with stricture recurrence after urethroplasty, even in studies carrying out multivariate analysis. The factors most often associated with stricture recurrence (in descending order) are prior procedures (urethroplasty or endoscopic), stricture length, smoking and lichen sclerosus.2–4 These risk factors, however, are found in less than half of the studies on the subject. Other occasionally identified factors include diabetes, the use of penile skin grafts, surgical technique (anastomotic urethroplasty), hypospadias, poor oral hygiene and surgeon experience.5,6 Some of the inconsistency can be explained by the fact that no studies have examined a comprehensive list of all known potential confounding variables, which increases the risk of underestimating or overestimating the association between a given variable and treatment outcome. Additionally, many studies are simply not statistically powered to examine all potential risk factors, and a significant association with more factors might have been found if studies had greater statistical power. Inconsistencies in the literature could also be related to surgeon preference for variations in urethroplasty technique, discrepancies in stricture etiology related to regional patterns and the duration of follow up preferred by the surgeon. Although many surgeons feel that the majority of stricture recurrences occur within 2 years of surgery, this might be an artifact of limited or inconsistent patient follow up. If patients are followed over a longer time‐period, it is likely that more recurrences will be detected. It makes intuitive sense that stricture recurrence can occur at any time‐point after urethroplasty.

© 2015 The Japanese Urological Association

This study by Han et al. further emphasizes this logic. Patients at increased risk for stricture recurrence after urethroplasty should be counseled accordingly and every effort should be made to achieve regular follow up for these patients. Keith Francis Rourke B.Sc., M.D., F.R.C.S.C. Division of Urology, University of Alberta, Edmonton, Alberta, Canada [email protected] DOI: 10.1111/iju.12798

Conflict of interest None declared.

References 1 Han JS, Liu J, Hofer MD et al. Risk of urethral stricture recurrence increases over time after urethroplasty. Int. J. Urol. 2015; 22: 695–9. 2 Breyer BN, McAninch JW, Whitson JM et al. Multivariate analysis of risk factors for long‐term urethroplasty outcome. J. Urol. 2010; 183: 613–17. 3 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: 296–300. 4 Gimbernat H, Arance I, Redondo C, Meilan E, Ramon de Fata F, Angulo JC. Analysis of the factors involved in the failure of urethroplasty in men. Actas Urol. Esp. 2014; 38: 96–102. 5 Barbagli G, Kulkarni SB, Fossati N et al. Long–term followup and deterioration rate of anterior substitution urethroplasty. J. Urol. 2014; 192: 808–13. 6 Fall B, Sow Y, Diallo Y et al. Urethroplasty for male urethral strictures: Experience from a national teaching hospital in Senegal. Afr. J. Urol. 2014; 20: 76–81.

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Editorial Comment from Dr Rourke to Risk of urethral stricture recurrence increases over time after urethroplasty.

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