New England Section of the American Urological Association

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Safety of Urethroplasty in the Comorbid Population
Gina N. Tundo, MD1, Andrew Peterson, MD2; Ramiro Madden-Fuentes, MD3
1Dartmouth Hitchcock, Lebanon, NH; 2Duke University, Durham, NC; 3Concord Hospital, Concord, NH

BACKGROUND: It is well recognized that urethroplasty is a more durable treatment for urethral stricture disease than endoscopic management. The AUA guidelines even recommend that urethroplasty be offered to patients as initial treatment of even short strictures, and certainly preferred when a single attempt at endoscopic management has failed. However, many urologists may be hesitant to offer urethroplasty in patients with significant medical comorbidities. The Charlson Comorbidity Index (CCI) and Frailty Index (FI) were used to investigate the relationship between pre-operative comorbidity and immediate complications following urethroplasty with buccal grafting. We hypothesized that even high-risk patients do well with this surgery.
METHODS: Using the National Surgical Quality Improvement Program (NSQIP), patients with CPT codes for urethroplasty with buccal grafting were identified, performed between the years 2007 and 2015. Each patientís CCI was calculated based on ICD 9 codes. A FI score was also calculated for each patient by adding the number of FI conditions the patient had, again based on ICD 9 codes. 30-day complications were identified based on definitions in NSQIP and converted to Clavien-Dindo classification grades. Weighted multivariate logistic regression was utilized to examine the association between post-operative complications and CCI as well as FI.
RESULTS: There were a total of 646 patients identified who underwent urethroplasty with a buccal graft. The average age was 48.7 +/- 16.4 (range 18-90 years). 67.5% of the patients were white. Mean BMI was 30.5 +/- 6.7 (range 17.5-65). 16.4% of patients had smoked within the past year. 97.4% of the patients underwent general anesthesia for the surgery. The average pre-operative CCI was 1.9 +/- 1.8 (range 0-14). 60.2% of patients had no FI conditions, 24.9% had one, and 14.9% had two or more.
Of the 646 patients, 2.9% had a urinary tract infection post-operatively, 0.9% had a superficial surgical site infection, 0.3% had a deep SSI, 0.2% required a transfusion intra- or post-op, 0.5% had a DVT requiring treatment, 0.9% had a wound disruption, 0.3% had an MI, and 0.2% had a PE. Zero patients experienced sepsis, stroke, acute renal failure or death. This constituted an overall complication rate of 6.8%.
As demonstrated above, for each post-operative complication recorded by NSQIP, less than 4% of the population exhibited the complication. Due to the low complication rates, models were only generated for UTI, Clavien-Dindo Grade I, and overall complications.
On multivariate logistic regression, after controlling for anesthesia type and race, there was no association between post-operative UTI (OR=0.99; 95% CI= 0.76, 1.30; p=0.96), Grade I (OR=0.89; 95% CI=0.69, 1.14; p=0.36), or overall complication rate (OR 0.98, 95% CI= 0.82, 1.17, p=0.82) and CCI scores. Similar results were observed for FI.
CONCLUSIONS: Urethroplasty with buccal grafting is a safe procedure with low complication rates, even in the comorbid population, and could therefore be considered a viable treatment option for stricture disease in this demographic.


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