Urethroplasty with flaps or grafts is safe in current male smokers
Ellen M. Cahill, BA1, Kevin J. Chua, MD1, Vasundhara Balraj, BA1, Joseph J. Boyle, BS1, Hiren V. Patel, MD PhD1, Alain Kaldany, MD1, Sai Krishnaraya Doppalapuddi, MD1, Danielle Velez, MD1, Hari Tunuguntla, MD1, Joshua Sterling, MD2.
1Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA, 2Department of Urology, Yale University School of Medicine, New Haven, CT, USA.
Title: Urethroplasty with flaps or grafts is safe in current male smokers Authors:Ellen M. Cahill BA1, Kevin J. Chua MD1, Vasundhara Balraj BA1, Joseph J. Boyle BS1, Hiren V. Patel MD PhD1, Alain Kaldany MD1, Sai Krishnaraya Doppalapudi MD1, Danielle Velez MD1, Hari Tunuguntla MD1, Joshua Sterling MD2 Affiliations: 1Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ2Department of Urology, Yale University School of Medicine, New Haven, CT
Funding: None
Introduction: Urethroplasty is an effective treatment for male urethral strictures, which may be completed with or without flaps or grafts. Since smoking can impair microvasculature, patients are recommended to quit prior to surgery. However, given the difficulty of smoking cessation, this may delay patients from surgical treatment indefinitely. We aimed to determine if current smoking history was associated with increased risk of wound complication in men undergoing urethroplasty with or without a flap or graft. Methods: The National Surgical Quality Improvement Program database from 2006-2018 was queried for male patients undergoing urethroplasty with or without a flap or graft. Thirty-day wound complications were identified and categorized (superficial/deep/organ-space surgical site infections and dehiscence). Multivariable logistic regression was performed to determine risk factors associated with wound complications. Smoking history was defined as current smoker within the past year.
Results:Urethroplasty was performed in 2251 males, with 29.90% (n=673) using a flap or graft. There was no significant difference in wound complications for patients undergoing urethroplasty with (n=19, 2.82%) or without a flap or graft (n=43, 2.73%). Patients with a flap or graft had a higher BMI, longer operative time, and longer length of stay (Table 1). On multivariable logistic regression, risk factors associated with wound complications for patients undergoing urethroplasty without a flap or graft were diabetes (OR 2.56, p=0.03) and smoking (OR 2.32, p=0.02) (Table 2). However, these factors were not associated with wound complications in patients undergoing urethroplasty with a flap or graft.
Conclusions: Smoking and diabetes were associated with increased wound complications for men undergoing urethroplasty without a flap or graft, but not in patients with a flap or graft. Current male smokers may safely undergo urethroplasty with a flap or graft, and usage of a flap or graft may be preferable to excision and primary anastomosis in such patients.
Table 1: Patient/Operative Characteristics and Complication Rates for Patients Undergoing Urethroplasty (n=2251).
| Patient/Operative Characteristic | No Graft/Flap (n=1578)Median (IQR)/n (%) | Graft/Flap (n=673)Median (IQR)/n (%) | p-value |
| Age | 48.50 (34-62) | 49 (34-60) | 0.58 |
| BMI | 28.69 (25.40-32.89) | 29.83 (26.40-35) | <0.01* |
| ASA ≥3 | 432 (27.39%) | 201 (29.87%) | 0.23 |
| Operative Time (mins) | 139 (87-193) | 188 (146-241) | <0.01* |
| Length of Stay (days) | 1 (0-2) | 1 (1-2) | <0.01* |
| Diabetes | 196 (12.42%) | 98 (14.56%) | 0.168 |
| Smoking | 263 (16.67%) | 90 (13.37%) | 0.05 |
| Wound Complications | 43 (2.73%) | 19 (2.82%) | 0.90 |
| Reoperation | 21 (1.33%) | 4 (0.59%) | 0.13 |
| Readmission | 53 (3.36%) | 18 (2.67%) | 0.40 |
BMI = body mass index, ASA = American Society of Anesthesiologists physical status classification.
Table 2: Multivariable logistic regression of risk factors associated with wound complications comparing those who underwent graft/flap and those who did not (n=2251).
| No Graft/Flap (n=1578) | Graft/Flap (n=673) | |||||||
| Patient/Operative Characteristic | OR | 95% CI | p-value | OR | 95% CI | p-value | ||
| Age | 1.01 | 0.98 | 1.03 | 0.64 | 0.99 | 0.96 | 1.02 | 0.42 |
| BMI | 1.02 | 0.97 | 1.07 | 0.44 | 0.96 | 0.89 | 1.04 | 0.31 |
| Smoking | 2.32 | 1.15 | 4.70 | 0.02* | 1.06 | 0.30 | 3.77 | 0.93 |
| DM | 2.56 | 1.11 | 5.92 | 0.03* | 2.83 | 0.83 | 9.68 | 0.10 |
| ASA ≥3 | 0.70 | 0.32 | 1.57 | 0.39 | 1.04 | 0.32 | 3.39 | 0.94 |
| OR time | 1.00 | 1.00 | 1.00 | 0.88 | 1.00 | 1.00 | 1.01 | 0.36 |
BMI = body mass index, ASA = American Society of Anesthesiologists physical status classification.
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