|Year : 2016 | Volume
| Issue : 2 | Page : 125-132
Impact of anastomotic urethroplasty on urinary continence in men
Ahmed Abed MD , Yasser Osman, Bassem S Wadie, Ahmed B Shehab El-Dein
Department of Urology, Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||03-Apr-2016|
|Date of Acceptance||24-Apr-2016|
|Date of Web Publication||1-Mar-2017|
Department of Urology, Urology and Nephrology Center, Faculty of Medicine, Mansoura University, El Gohoria Street, Mansoura 35516
Source of Support: None, Conflict of Interest: None
The study aimed primarily to evaluate urethral patency and continence following anastomotic urethroplasty, as well as the quality of life of the patient as the secondary outcome.
Materials and methods
A retrospective study was conducted that included 104 adult male patients in whom perineal anastomotic urethroplasty had been performed for post-traumatic urethral stricture with postoperative follow-up for at least 6 months. Ninety-five (91.4%) patients presented with an in-dwelling suprapubic catheter. Thirty-eight (36.6%) patients had heavy pyuria that was adequately treated before the procedure. Escherichia coli was the most frequently isolated organism (36.6%).
The mean age of the patients was 30.85 years (range = 18–71 ± 12 years). Sixty-eight patients had strictures 10–20 mm in length (65.4%) and only four (3.9%) patients had a stricture that was larger than 40 mm. All procedures had been carried out through perineal incision. Fifty-eight (67.4%) patients had normal urethral flow on retrograde urethrogram after the procedure, and the global success rate rose to 93% after a secondary procedure (urethroscopic dilatation under anesthesia or direct visual internal urethrotomy). The stricture with a mean length of 24.7 ± 15.2 mm was the only statistically significant predictor of failure of the procedure (P < 0.001). Only two (2.5%) patients suffered stress urinary incontinence with patent urethra and kept using condoms or pads following the procedure. These patients were managed with a bulbourethral sling and finally were continent.
Stricture length is the only statistically significant predictor of success or failure of anastomotic urethroplasty. Stress urinary incontinence has low incidence following this procedure, whereas bulbourethral sling appears to be a reasonable treatment option. Successful repair of the urethral stricture has a positive impact on the quality of life of the patients following urethroplasty.
Keywords: anastomotic, continence, patency, urethroplasty
|How to cite this article:|
Abed A, Osman Y, Wadie BS, Shehab El-Dein AB. Impact of anastomotic urethroplasty on urinary continence in men. Benha Med J 2016;33:125-32
|How to cite this URL:|
Abed A, Osman Y, Wadie BS, Shehab El-Dein AB. Impact of anastomotic urethroplasty on urinary continence in men. Benha Med J [serial online] 2016 [cited 2022 Jan 25];33:125-32. Available from: http://www.bmfj.eg.net/text.asp?2016/33/2/125/201286
| Introduction|| |
Perineal anastomotic urethroplasty represents the standard of care after a pelvic fracture distraction urethral injury, with satisfactory outcome with respect to urethral patency, minimal negative impact on urinary continence as long as the sphincteric mechanism is preserved, and satisfactory impact on the quality of life of the patient. The current study was conducted to evaluate patency following anastomotic urethroplasty and its impact on the continence status in adult men with post-traumatic urethral strictures. Also it is a trial to evaluate the preoperative predictors of the success of urethroplasty.
| Materials and Methods|| |
This is a retrospective cohort study that included 104 adult male patients (above 18 years) with a history of pelvic trauma and diagnosed with urethral stricture in whom perineal anastomotic urethroplasty had been performed at a single center, at the ‘Urology and Nephrology Center – Mansoura University’, during the period between 1984 and 2013 with a minimum follow-up of 6 months. Patients younger than 18 years, those with malignant urethral strictures or with urethral strictures following orthotopic urinary diversion, or with sexually transmitted diseases were not included in the study. The medical records of all patients were reviewed, besides history taking and clinical examination. Microscopic urine analysis was performed on all patients as well as evaluation of the voiding function and quality of life following urethral reconstruction.
Eighteen patients were lost to follow-up; 12 of them were from outside Egypt (six from Syria, three from Libya, two from Palestine, and one from Iraq) and they were excluded from the follow-up outcome measures following urethroplasty.
Primary outcomes included both urethral patency and continence status. Secondary outcome was the impact of surgery on the quality of life of the patient. Functional evaluation of voiding (patency) following urethroplasty was done using the American Urological Association Symptom Index (AUASI), noninvasive uroflowmetry, estimation of the postvoiding residual urine, and an ascending urethrogram. Continence as a primary outcome was assessed using stress and pad tests on all patients. Pressure flow study was conducted with positive stress and pad tests with patent urethral flow. Quality of life of the patient following urethroplasty was evaluated in the second section of the AUASI using a score starting from ‘0’ for the delighted patient to ‘6’ for the most terrible results.
Statistical analysis of the collected data was performed using SPSS Statistics, version 16.0 (SPSS Inc., Chicago, Illinois, USA) software. The values of continuous variables were demonstrated as mean ± SD. Analysis of categorical variables was done using the χ2-test. P-values less than 0.05 were considered statistically significant.
Eighty-two (78.9%) patients had stricture after road traffic accidents, eight (7.7%) after falling astride, seven (6.7%) after falling from a height, and seven (6.7%) after blunt pelvic trauma. Ascending urethrogram or combined cystogram in patients with an in-dwelling suprapubic catheter was carried out to evaluate the site and length of the urethral stricture. Membranous urethra was the most frequently affected segment in this cohort, being evident in 57 (54.8%) patients, whereas stricture of the bulbar segment was found in 44 (42.3%) patients. Multiple segment strictures were evident in another three patients.
Eight patients presented initially with difficulty and obstructive lower urinary tract symptoms (7.7% of patients); one patient had an in-dwelling urethral catheter (0.9%) and 95 patients had an in-dwelling suprapubic catheter (91.4% of patients). Twenty-three (22.1%) patients had undergone urgent abdominal exploration at the time of trauma for internal hemorrhage or other concomitant injury. Splenectomy had been carried out on three of them, and colostomy for rectal injury in one patient. Forty-six (44.2%) patients had suffered a pelvic fracture. Only 11 (10.6%) of them had undergone orthopedic surgery; eight patients had plate and internal fixation of the pelvic bone, two needed fixation using plates and screws of the spinal cord, and the last one had an intramedullary nail in his right femur.
Mean preoperative serum creatinine was 0.8 mg/dl (range = 0.4–1.5 ± 0.17 mg/dl). Pyuria was a universal finding in the preoperative urinalysis in our series because of the presence of a catheter in most of them, making urine always infected. Thirty-eight (36.6%) patients had heavy pyuria (more than 100 white blood cells/high-power field). Escherichia More Details coli was the most frequently isolated organism in 38 (36.6%) patients, followed by Klebsiella pneumonia in 18 (17.3%) patients and Pseudomonas aeruginosa in 11 (10.6%) patients. No organisms were isolated in 11 (10.6%) patients. Pyuria had been adequately treated before surgical intervention. Adequate antibiotic coverage had been maintained during the day of the surgery and during the early postoperative period.
| Results|| |
The mean age of the patients at the time of anastomosis was 30.85 years (range = 18–71 ± 12 years). Urethroplasty had been performed a median of 10 months (range = 3–120 months) after the initial trauma. The length of the urethral stricture assessed by retrograde urethrogram was found to range between 6 and 50 mm: 16 (15.4%) patients had urethral stricture below 10 mm, 68 (65.4%) patients had strictures ranging from 10 mm to less that 20 mm, and 13 (12.6%) patients had strictures ranging from 20 mm to less than 40 mm. Only four (3.9%) patients had perineal anastomotic urethroplasty for urethral strictures more than 40 mm in length.
All anastomotic procedures had been carried out through perineal incision. The most frequently used incision was the inverted-U-shaped incision in 65 (62.5%) patients, followed by inverted Y-shaped incision in 30 (28.8%) patients, and midline vertical incision in nine patients (8.7% of patients). Suprapubic incision had been used in 72 (69.2%) patients. Pubectomy had been carried out in four patients only. Redoanastomotic urethroplasty had been performed in 16 (15.4%) patients following previous urethroplasty procedures. Eleven (10.6%) anastomotic procedures had been carried out for recurrent strictures following direct visual internal urethrotomy (DVIU). Two catheters are always left for all patients postoperatively, a urethral one to stent the anastomosis and another one through the suprapubic area for urine drainage. The urethral catheter is kept in place for 21–30 days postoperatively, but can be kept for longer in the presence of urinary leakage. The suprapubic one is then kept closed until the patient voids normally for 24 h and is then removed.
Voiding function (patency)
Fifty-eight (67.4%) patients had normal urethral flow on retrograde urethrogram after the anastomotic procedure with no need for a secondary procedure ([Figure 1]). One patient had needed urethroscopic dilatation under anesthesia following urethroplasty to have a normal urethra flow (1.2%). Twenty-three patients had needed DVIU as a secondary procedure 1 month after anastomotic urethroplasty when the retrograde urethrogram had revealed the presence of recurrent short-segment stricture at the site of anastomosis; the procedure had been successful in 21 (25.6%) patients. Hence, the global success rate after the secondary procedures was 93%. The other two patients with failed DVIU had undergone redoanastomotic urethroplasty; one of them 6 months and the other 9 months after the primary procedure. The procedure of anastomotic urethroplasty failed to achieve patent urethral flow in six (7%) patients who needed urinary diversion using a suprapubic catheter.
|Figure 1 (a) Preoperative combined cystourethrogram in an 18-year-old male patient. (b) Postoperative retrograde urethrogram in an 18-year-old male patient.|
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Noninvasive uroflowmetry and postvoid residual urine volume
Noninvasive uroflowmetry had been performed postoperatively on all patients with patent urethral voiding, and the maximum flow rate (Qmax) had been 15 ml/s or more in 21 (26.25%) patients, 10 ml/s or less in 20 (25%) patients, and between 10 and 15 ml/s in 39 (48.75%) patients. Postvoid residual urine volume had been estimated to be less than 50 ml in 54 patients with patent urethral flow on the retrograde urethrogram (67.5%), and between 50 and 100 ml in 26 (32.5%) patients.
American Urological Association Symptom Index
AUASI was calculated postoperatively for all patients with patent urethral voiding, revealing a score between 0 and 7 in 21 (26.25%) patients, 8–19 in 51 (63.75%) patients, and 20–35 in eight (10%) patients.
In our series, only two of 80 patients with urethral voiding available for follow-up (2.5%) had suffered stress urinary incontinence and kept using condoms or pads following anastomotic urethroplasty with patent urethra. Both underwent a positive stress test and 1-h pad test (90 and 150 g) after urethroplasty. On performing filling cystometry, detrusor overactivity was infrequent, with cystometric bladder capacity 230 and 280 ml, whereas abdominal leak-point pressure was elicited at 75 cmH2O in one patient and at 87 cmH2O in the other patient. Both were managed with a bulbourethral sling (BUS); a urethral catheter had been kept postoperatively for 2 days in one patient (as usually followed in patients with postprostatectomy incontinence), whereas urethral catheterization had been prolonged for 14 days in the patient who had undergone concomitant diverticulectomy. One of the two patients is totally continent after the sling procedure, whereas the other showed initial improvement in a 1-h pad test from 150 to 30 g, and required retightening of the sling 1 year after the initial sling procedure and is currently socially dry (not using pads at all).
Quality of life
Quality of life of the patient as the secondary outcome following urethroplasty was evaluated in the second section of the AUASI. All the patients either with successful or failed urethroplasty were asked how they would feel if they had to spend the rest of their life with the current urinary condition. Their response was stratified on a scale starting with score ‘0’ for the delighted patient up to score ‘6’ for the most terrible course. The results are illustrated in [Table 1].
Predictors of success of urethroplasty
The length of post-traumatic urethral stricture was found to be the only statistically significant factor compromising the success of anastomotic urethroplasty. Strictures with a mean length of 24.7 mm with an SD of ± 15.2 were the only predictors of failure of the procedure (P < 0.001). The following factors on univariate analysis were found to have a nonstatistically significant effect on the outcome: age at the time of the anastomotic procedure (P = 0.2), site of the stricture (P = 0.2), surgeon's capability (whether he has done at least a series of 10 procedures) (P = 0.2), duration between initial trauma and time of surgery (P = 0.4), presence of an in-dwelling suprapubic catheter or its duration preceding the procedure (P = 0.5), and history of endoscopic or open surgical management carried out for the stricture preceding the current procedure (P = 0.8). The results of the statistical analysis are illustrated in [Table 2].
| Discussion|| |
Pelvic fracture-related urethral injuries are considered mainly distraction defects rather than actual strictures, most probably caused by the shearing force distracting the membranous from the bulbar urethral segments. Treatment for urethral stricture ranges from simple procedure such as urethral dilatation, DVIU, to anastomotic urethroplasty for longer strictures with more fibrosis. Treatment ideally aims at preservation of the urethral sphincter mechanism. Stress urinary incontinence following urethral injury may follow either early urethral realignment or delayed anastomotic urethroplasty.
This cohort study was conducted to evaluate the urethral patency and incidence of recurrent stricture as well as the incidence of urinary incontinence following anastomotic urethroplasty for traumatic posterior urethral strictures in men, as well as further management of cases of recurrent strictures and urinary incontinence following anastomotic urethroplasty.
A retrograde urethrogram with or without an antegrade cystogram had been taken preoperatively in all patients to evaluate the site and length of the urethral stricture. However, defects look longer than the actual length when the bladder neck does not open during the examination, resulting in failure of visualization of the prostatic urethra. In our series, 68 patients had strictures ranging from 10 to 20 mm (65.4%), and only four (3.9%) patients had undergone perineal anastomotic urethroplasty for urethral stricture between 40 and 50 mm in length. This agrees with the observations made in most of the large series, such as that of Santucci et al. , who reported an average stricture length of 1.7 cm in 162 patients with bulbar urethral strictures with a maximum length of 4.5 cm . Previously, anastomotic urethroplasty was advocated for urethral strictures not more than 3 cm. However, Morey and Kizer  reported that strictures up to 5 cm in length can be repaired, depending on the distal urethral segment elasticity. In another series of 61 patients reviewed by Lumen and colleagues, the mean stricture length was 3.5 cm. The long defect was bridged by urethral mobilization (100% of patients), separation of corporeal bodies (52.5%), and inferior pubectomy (6.6%), with recurrence of urethral stricture only in nine  patients (14.8%).
Regarding the surgical procedure, urethroplasty had been delayed for at least 3 months after the injury in all patients in our series. A suprapubic catheter had been placed initially at the time of trauma (91.4%) providing a chance for resolution of the pelvic hematoma and complete healing of the local pathology and any associated injuries. Sometimes delay can be for up to 6 months in case of large pelvic hematoma; otherwise, the chance of successful results following anastomotic urethroplasty will be much lower ,. The same standards were followed before redo surgeries that were postponed for at least 3 months after failure of the first procedure to achieve better delineation of the recurrence and to avoid insufficient resection of the fibrotic segment to decrease the risk for further recurrence. The median time interval between the initial trauma and the urethroplasty procedure in our series was 10 months, which was slightly longer than the expected ‘6 months’. This mainly returns to previous trials of DVIU, anastomotic urethroplasty, or both (12, five, and 10 patients in that order), representing 26% of the patients in our series.
Some authors reported that early management adds to the direct urethral injury following trauma, thus compromising urinary incontinence, especially as early realignment was being carried out as an open procedure with greater risk for subsequent incontinence ,. Currently, immediate endoscopic realignment is followed with low risk for urinary continence, and open realignment is reserved only for cases of concomitant injury of the bladder, bladder neck, or the rectum to guard against pelvic sepsis from urinary leakage .
The perineal approach was employed in all urethroplasties regardless of the type of incision [the most frequently used was the inverted-U-shaped incision (62.5%), followed by the inverted-Y-shaped incision (28.8%) and the midline vertical incision (8.7% of patients)]. Suprapubic incision was used in 72 (69.2%) patients. Efforts were made in every repair to achieve complete excision of the fibrotic tissue with a tension-free mucosa-to mucosa anastomosis aiming at the most optimum chances of success, even when these conditions were difficult to attain in the redo urethroplasty.
A urethral catheter was always left to stent the anastomosis postoperatively, together with a suprapubic catheter for urine drainage, in all patients. It was kept in mind that the catheter did not fit tightly into the urethral lumen to enable the discharge and inflammatory exudate to drain around the catheter if the lumen had been obstructed. A suprapubic catheter is usually fixed through the previous preoperative track and is closed shortly after surgery unless the urethral catheter is obstructed. In our series the urethral catheter was not removed earlier than 21–30 days postoperatively to guarantee the best possible anastomosis and to allow radiographic monitoring of the process of healing before removal of the catheter using a retrograde urethrogram. The urethral drainage could be prolonged if leakage was noted in the postoperative retrograde urethrogram. The suprapubic catheter is then kept closed and not removed until the patient voids normally for 24 h; otherwise it is left in place and further assessment is carried out.
Upon reviewing the literature for the definition of a successful urethroplasty, multiple clinical or radiological terms were found, including postoperative evaluation of patency using diagnostic cystourethroscopy . However, there is no clear definition of success that has got unanimous approval. In the current study, a retrograde urethrogram was considered the main tool to define the patency of the urethra and to detect the common complications, including stricture recurrence. This is commensurate with many series that used a retrograde urethrogram to judge the success of urethroplasty.
The initial success rate after primary anastomotic urethroplasty in our series was 67.4%, which is lower than that reported in a similar series of 134 patients who underwent posterior urethroplasty, which represents a 25-year study by Cooperberg and colleagues, who defined success by the absence of restenosis. Cooperberg et al.  reported an initial success rate of 84%, which increased to a global success rate of 93% of patients after an additional single internal urethrotomy. The global success rate of our study (93% of patients) after urethroplasty approaches what is frequently cited in the literature, which ranges from 90 to 98% ,,,. The failure of urethroplasty due to repeated obstruction at the anastomotic site was reported mainly to be due to incomplete scar excision or failure to achieve a mucosa-to-mucosa anastomosis , and these factors were avoided whenever possible in our series as mentioned before. In a series of 250 patients treated by perineal or perineoabdominal urethroplasty, Koraitim  reported recurrent stricture in 20 (8%) patients. Hussain et al.  reported recurrent stricture in 18% of their series (seven of 40 cases).
Noninvasive uroflowmetry alone has not been found to be an accurate predictor of restenosis as it has a sensitivity of only 54% to detect recurrence when compared with cystoscopy. Uroflowmetry has high sensitivity and negative predictive values (both >99%) when maximum flow rate is below 10 ml/s and should be combined with obstructive symptoms . However, it was not representative in our series because of the lack of comparison with preoperative data as 91.4% of patients had in-dwelling catheters. The same also for AUASI, although it has more than has 93% sensitivity and 78% specificity in detecting urethral stricture recurrence , it was not representative in our series because it could not be applied preoperatively because of the in-dwelling suprapubic catheter.
Recurrent urethral stricture after urethroplasty depends on the time of recurrence and the extent of narrowing. DVIU can be satisfactory for short-segment recurrent strictures with minimal or no fibrosis. In our series, 23 patients needed DVIU following urethroplasty and it was successful in 21 (91.3%) patients. On a review of the literature, the success possibility after a single DVIU is high because the scarred tissue has been already excised during urethroplasty ,; otherwise, redo anastomotic urethroplasty is recommended, especially in the presence of a large amount of fibrosis. Redo procedure was carried out in 16 (15.39%) patients following previous urethroplasty procedures.
The incontinence rate in our series (2.5%) is slightly lower than that reported in most of the published series on incontinence: Koraitim  reported incontinence in 4% of patients following delayed repair, and Morey and McAninch  reported incontinence in 5% of 82 patients treated with delayed urethroplasty. In a published series of 103 men by Cooperberg et al. , only 10% had symptoms of incontinence, but only one patient had significant incontinence that required placement of an artificial sphincter. The incontinence rate in our series is not the lowest when compared with the published literature. Ennemoser et al.  reported no incontinence in 42 patients with a mean follow-up of 8.6 years, and the same was reported in another series of 172 patients following urethroplasty .
Both patients with stress urinary incontinence following urethroplasty in our study were managed with a BUS similar to what has been done for postprostatectomy urinary incontinence as a reasonable management, as it is cost-effective and has the advantage of being adjustable by retightening of the suprapubic knot. Urethral diverticulectomy was performed in one patient before applying the sling.
The BUS is used with sterile urine culture under spinal anesthesia in an extended lithotomy position, with minimal employment of a mesh made of knitted polypropylene suspended to the anterior abdominal wall by three pairs of size-zero nylon sutures transferred through the retropubic approach on each side using a modified Stamey needle passing in an antegrade course. The procedure is done through an inverted U-shaped perineal incision with creation of a space between bulbospongiosus and ischiocavernosus muscles where the sling is set to cover the bulbar urethra within its covering muscles, and then the sutures are tied in front of the rectus sheath. Thus, the mesh completely covers the bulb of the urethra to its side walls. It is mandatory before the procedure to perform a cystourethroscopy to exclude the presence of urethral strictures or bladder neck pathology. Cystourethroscopy should also be carried out after each passage of the needle to exclude urethral or bladder neck perforation ,.
One of both patients is totally continent after the sling procedure while the other showed an initial improvement in the 1-h pad test from 150 to 30 g (the same patient needed urethral diverticulectomy), and required retightening of the sling under local anesthesia one year after the initial sling procedure through a short (2 cm) Pfannenstiel incision over the knot of the nylon suture. Afterwards he too became totally continent. The final postoperative pressure flow study for both was satisfactory with normal cystometric bladder capacity (350 and 420 ml), infrequent detrusor overactivity, and no leakage during cystometry.
The BUS proved to be cost-effective especially when compared with artificial urinary sphincter. In addition, it eliminated the occurrence of mechanical problems. This procedure also avoids the risk of fixation of bone screws used in bone anchored slings or urethral compression by Dacron tube bolsters used previously in other sling procedures tried for postprostatectomy incontinence. The need to retighten the sling should not be considered a drawback, but in fact a potential advantage, as it is a simple outpatient procedure using local anesthesia .
On evaluation of the quality of life of the patient following urethroplasty as a secondary outcome using the private section of the AUASI, it was no surprise that all six patients after failed urethroplasty expressed their feelings as ‘terrible’ because of the in-dwelling suprapubic catheter (7%), whereas another two were unhappy about their continence status. Five patients were dissatisfied and another one unhappy owing to frequent, weak, or interrupted urinary stream, or associated erectile dysfunction.
Multiple trials were conducted to identify the preoperative predictors of success or failure of the urethroplasty. However, there are no fixed predictors or cutoff values until now. In a study carried out by Breyer et al. , smoking, prior urethroplasty, and failed endoscopic therapy were statistically significant predictors (P < 0.05), whereas urethral strictures of 4 cm length or more and diabetes mellitus lacked this statistical significance (P = 0.18 and 0.14, respectively).
On the other side, age above 65 years was not found to be a predictor of failure of urethroplasty. However, benign prostatic hyperplasia may contribute to a decreased stream after stricture repair in men older than 65 years .
Multivariate analysis of 651 patients with urethral stricture of various etiologies identified Lichen sclerosus, iatrogenic causes (such as transurethral resection of the prostate, laser prostatectomy, cryosurgery, and radical prostatectomy), and infections as independent factors of recurrence of urethral stricture (P < 0.05). Stricture length of 5 cm or more had a higher possibility of recurrence (P ≤ 0.01), whereas old age, smoking, medical morbidity, and prior failed endoscopic or open management had no statistically significant effect on the outcome of urethroplasty. However, the incidence of post-traumatic urethral stricture in this study did not exceed 26% of all patients .
In our series, all cases had suffered a previous pelvic trauma, with no postinflammatory or iatrogenic strictures. Post-traumatic urethral stricture with a mean length of 24.7 mm with an SD of ± 15.2 was identified as the only predictor of failure of urethroplasty (P < 0.001).
The results of the current series agree with the published literature that other than the length of the urethral stricture other factors were all statistically nonsignificant, such as the age of the patient and location of the urethral stricture. Also, history of prior endoscopic or open surgical management carried out for the stricture preceding the current procedure does not affect the outcome. Other factors that were studied in our series and not found to be predictors of success or failure include surgeon capability, duration between initial trauma and surgery, presence of in-dwelling suprapubic catheter, or its duration preceding the procedure.
| Summary and conclusion|| |
Patent urethral flow on retrograde urethrogram remains the primary tool for assessing the success of the procedure. The length of the post-traumatic urethral stricture is the only statistically significant predictor of success or failure of the procedure. Stress urinary incontinence following anastomotic perineal urethroplasty is a rare condition in a cohort of patients with heterogenous etiology. The BUS appears to be a reasonable treatment option for urinary incontinence after anastomotic urethroplasty as it is cost-effective and has the advantage of being adjustable by retightening of the suprapubic knot and avoids the mechanical problems of the artificial urinary sphincter. Successful repair of the urethral stricture has a positive impact on the quality of life of patients after urethroplasty.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]