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Standardized Routines and Variations the Key to Making Urethral Surgery a Success


Surgical intervention for urethral stricture - a condition that affects mainly men - is going to require more and more expertise and standardized surgical procedures to ensure success, according to research done at the Sahlgrenska Academy, in which a total of 569 surgical procedures were studied.

“We wanted to look at the surgical procedures that were successful and at the patients that experience urethral stricture again after the operation to work out what could have been done differently and try to spot any patterns,” says Teresa Olsen Ekerhult, a postdoctoral researcher and urology specialist.

Urethral stricture may occur as a result of scar formation following “straddling” accidents, for example a blow between the legs from a bicycle bar, or following an infection. More often than not, however, it is not known what causes the condition.

The risks increase with advancing age, with roughly one in a hundred men affected. Between 50 and 60 operations to treat the condition are carried out in Sweden every year.

“This particular group of patients are not given high priority. Often they end up walking around with a catheter through their abdominal wall for several months, resulting in them not being able to work; it can be painful sometimes too. Not being able to pee is a cruel fate, so patients really appreciate the surgery once it has been completed,” says Teresa Olsen Ekerhult.

Routines Crucial

The research carried out looked at operations performed in Sweden between 1999 and 2014 to treat strictures in the section of the urethra located in the shaft of the penis (the penile urethra), and strictures located higher up, at the point where the urethra continues into the body before the prostate (the bulbar urethra). The findings confirmed the pattern that had been expected i.e. that surgical procedures closer to the prostate, where there is more tissue to work with, delivered good results for a larger number of patients.

Nine in ten operations on the bulbar urethra, removing all of the stricture, were successful. In the cases where replacement tissue was inserted, seven in ten of the operations had successful outcomes.

Operations on the penile urethra delivered acceptable results in 65 percent of cases when a “one-step procedure” was used, and in 72 percent of cases when replacement tissue was also used. Obesity and “earlier” surgery were revealed as significant risk factors with regard to relapse, i.e. of the stricture being experienced again.

Another striking finding of the research was that the operations carried out towards the end of the period studied had far more successful outcomes, with far fewer relapses, interpreted as meaning that there is a clear and decisive learning curve involved when it comes to performing this type of surgery.

Important Toolkit

“Urethral plastic surgery emerged as a technique in the 1950s, and has evolved over the years, but only in the past twenty years have we figured it out completely. It’s not a case of saying that is one type of surgery is better than the other, but rather it must be decided in each case which surgical procedure is best for that particular patient,” says Teresa Olsen Ekerhult.

She believes that the fact that surgical routines constitute such an important variable should have consequences, and questions the current structure in place, which sees the surgical procedures performed at a handful of units around the country.

“We should concentrate the operations around, say, two to three centers. It takes a while to get to grips with and learn how to proceed, and takes time to learn all the techniques. it is important to master the many different surgical techniques involved so that you can develop your “toolbox” and make the right choices,” says Teresa Olsen Ekerhult.

Link to thesis. Principal researcher: Teresa Olsen Ekerhult.