Urethroplasty among Elderly Men, Surgical Techniques and Outcomes ()
1. Introduction
Urethroplasty remains the gold standard for the management of urethral stricture disease, offering the lowest rates of stricture recurrence [1] and in some circumstances proving to be the most cost-effective compared to repeat dilation or endoscopic incision [2] . Recent studies have indicated that strictures not definitively managed by urethroplasty tend to recur after urethrotomy or dilation [3] [4] [5] , further adding to the burden of disease on patients.
However, the treatment of urethral stricture disease in the elderly tends to be less invasive due to the presumption that they are out of reproductive age, have co-morbidities, and might not be able to stand long hours of surgery [6] . The existence of microangiopathy with aging, especially in diabetic and hypertensive elderly men, can be hypothesized to impair wound healing and hence affect the outcome of urethroplasty. Indeed, Mundy reported that, in small numbers of patients requiring posterior anastomotic urethroplasty, age older than 55 was associated with an increased rate of failure, from 7% to 57% [7] .
Although direct vision internal urethrotomy (DVIU) or dilation is less technically demanding than urethroplasty, it is considered by many to have an unacceptably high failure rate (50% failure after the first procedure, 100% failure after the second) [8] [9] .
To the best of our knowledge, there has been no study on the etiology and characteristics of urethral stricture disease and the outcomes of urethroplasty among elderly men in Ghana. We present our experience with the etiology, stricture characteristics, operative techniques, and outcomes of urethroplasty among elderly men seen at the Komfo Anokye Teaching Hospital from January 2012 to December 2021.
2. Materials and Methods
2.1. Study Type
This was a retrospective review of data captured in the urology database on all patients 65 years and above who underwent urethroplasty for urethral strictures at the Komfo Anokye Teaching Hospital between January 2012 and December 2021.
The study involved all urethral strictures irrespective of location, etiology or technique of reconstruction. Those who were treated with only minimally invasive procedures such as DVIU or dilatation were excluded from the study.
A data recording proforma was used to capture information from the urology database on patients’ demographic and clinical data including age, etiology, stricture characteristics, repair technique, and outcome of urethroplasty for all urethral strictures at KATH among elderly men.
2.2. Evaluation of Outcomes
A successful outcome was defined as peak flow rate > 15 mls/s, a patent urethra on retrograde urethrogram (RUG), patient satisfaction with urine stream, or restoration of normal stream of urine with at most one attempt at urethral dilatation or internal urethrotomy postoperatively.
2.3. Statistical Analysis
Extracted data was exported to PASW Statistics for Windows, Version 18.0. Chicago and SPSS Inc. for final analysis. Basic statistics were performed to calculate proportions, means, and corresponding standard deviations on variables such as patients’ age, stricture characteristics, and outcome of surgery. Discrete variables were analyzed by means of frequencies and tables.
Ethical Clearance
Ethical approval for this study was obtained from the Institutional Review Board of Komfo Anokye Teaching Hospital.
All patients with comorbidities were optimized before surgery.
3. Results
Overall, 43 urethroplasties were done over the study period in men aged 65 years and above. The age range was 65 to 87 years and the age distribution is as shown in Table 1. The mean follow-up was 73.09 months. As shown in Table 2, the commonest etiology was catheterization (62.79%) followed by urethritis from sexually transmitted infections (32.56%). One patient developed multiple anterior urethral strictures following external beam radiation therapy for prostate cancer. The length of the urethral strictures ranged from 0.5 cm to 16 cm with a mean of 3.93 cm, with 75% of patients having stricture lengths of 3 cm or less. Most patients (60.46%) had bulbar urethral strictures as shown in Table 3.
The repair methods employed were: anastomotic urethroplasty (62.80%), fasciocutaneous flap (FCF) ventral onlay urethroplasty (13.95%), buccal mucosa graft (BMG) ventral onlay urethroplasty (4.65%), dorsal roof strip BMG augmented anastomotic urethroplasty (4.65%), buccal mucosa graftdorsal onlay urethroplasty (2.33%) and staged urethroplasty (4.65%). Three of the patients (6.98%) had a combination of anastomotic and tissue transfer urethroplasty.
Another 42.9% of patients required treatment for co-existent BPH, of which 33.3% had prostatectomy and 66.7% had pharmacologic treatment following urethroplasty.
The overall success rate for all techniques was 88.37%. Table 4 shows the various techniques employed and their success rates.
Comorbidities included 17 patients with hypertension, 3 with diabetes mellitus, 5 with both hypertension and diabetes mellitus, and one patient who had received radiation therapy for prostate cancer.
Complications included 3 cases of surgical site infection, two of urethral diverticulum and one of glans dehiscence after undergoing FCF urethroplasty on account of pan-urethral stricture. Two needed single dilatations post-urethroplasty to restore normal flow of urine. Five patients had failed repair and needed further procedures. Of these, 3 had extensive stricture disease requiring more than one procedure at a single stage. There were no peri-operative mortality nor neurological deficits related to prolonged lithotomy positioning.
Table 5 shows the distribution of patient age, number of strictures, and number of procedures versus outcome. There was no correlation between patient age group and outcome (p = 0.446), outcome and number of strictures (p = 0.126), nor outcome and technique of urethroplasty (p = 0.151). However, there was a significant correlation between outcome and number of procedures (p = 0.005).
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Table 4. Surgical techniques employed and outcomes.
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Table 5. Outcome versus age, number of procedures and number of strictures.
4. Discussion
According to the World Health Organization, age 65 and older is chronologically considered elderly. In old age, the interaction between genetic structure and the environment is observed at the highest level and may affect diseases and their treatment outcomes [10] . The effect of age on urethroplasty outcomes has been researched by many investigators [11] [12] [13] . Breyer et al. demonstrated that age above 65 years was not predictive for urethroplasty failure [13] . The surgical approaches most commonly used in their study cohort were anastomotic, BMG, and fascio-cutaneous flap urethroplasties. Similar findings were reported by Levy et al. in patients over 60 years of age who underwent anastomotic urethroplasty and buccal mucosa graft urethroplasty [11] . In a study comparing the impact of age on urethroplasty outcomes, Pazir et al. did not find a correlation in patients treated with anastomotic and buccal mucosa graft urethroplasty between age and urethroplasty failure, consistent with the findings of the aforementioned studies [14] .
In contrast, Viers et al. reported that advancing age per decade beyond 50 years was independently associated with the risk of urethroplasty failure in patients who underwent anastomotic and substitution urethroplasty [12] . However, they found that although the failure rate increased with age, about 75% - 80% of men over the age of 60 years remained stricture-free for 5 years and therefore concluded that advanced age alone should not be a contraindication to urethroplasty.
Aging is known to promote wound healing at the microlevel structure of the urethra through matrix metalloprotein (MMP) enzymes, which increase with aging [15] . These extracellular matrixes play an essential role in the healing process [16] . It is known that even the urethral plaques of hypospadias in childhood show significant age-related structural changes, and these changes may play a role in urethral healing after hypospadias repair [17] .
However, Hoffer et al. found a significant increase in urethral atrophy risk due to a decrease in serum testosterone [18] . For this reason, it has been suggested that there may be an increase in urethral stenosis and an inability to achieve good post-urethroplasty outcomes due to a decrease in androgen, which develops secondarily in the elderly [19] .
In this study, the overall success rate for all techniques was 88.37% with an insignificant failure rate, consistent with the findings of other researchers as discussed above. This suggests that urethroplasty with various surgical techniques is well tolerated by elderly men.
Globally, urethral strictures in elderly patients occur most frequently secondary to urological instrumentation [20] . This is as a result of the high number of elderly patients who undergo transurethral resection of prostate. It is therefore not surprising that the incidence of urethral stricture is increasing in the elderly population [21] . In this studyhowever, urethral catheterization was the commonest cause of urethral stricture in the elderly, 62.79% (Table 2). These were men on regular catheter changes for urine retention from prostatic diseases while waiting for definitive treatment due to long waiting times, poor quality catheter material, or poor catheterization techniques by poorly trained staff.
Although optical urethrotomy is known to have inferior success rates compared with open urethroplasty, it was still suggested by urologists for elderly men with urethral strictures due to their limited life expectancy [22] . Despite their advanced age, all patients in this study had urethroplasty with a high success rate with no peri-operative mortality.
The findings in this study suggest that elderly men tolerate urethroplasty with satisfactory outcomes and if indicated, the procedure should not be denied on account of their advanced age. Similar to findings in urethroplasty for younger men, our study found no correlation between patient age group and outcome (p = 0.446), outcome and number of strictures (p = 0.126) nor outcome and technique of urethroplasty (p = 0.151) [11] [12] [13] . However, as expected, there was a significant relation between the outcome and number of procedures performed (p = 0.004849).
5. Limitation
This study is limited by the relatively small sample size.
6. Conclusion
Elderly men appear to tolerate urethroplasty well and these findings show that urethroplasty should not be denied solely on the basis of age unless there is an absolute contraindication to the procedure. Bladder outlet obstruction from prostatic enlargement must be considered in those patients who have decreased stream after a successful urethroplasty.
Acknowledgments
The abstract of this manuscript was presented at the West African College of Surgeons Congress in Kumasi, Ghana in 2014.
Data Availability
The data supporting the conclusions of the study are available and can be accessed by an email request to the corresponding author.
Funding Statement
This research was self-funded by the authors.