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Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty

Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty Hindawi Advances in Urology Volume 2023, Article ID 2205306, 16 pages https://doi.org/10.1155/2023/2205306 Research Article Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty 1 1 1 2 Vladimir Beloborodov , Vladimir Vorobev , Temirlan Hovalyg , Igor Seminskiy , 1 3 4 Svetlana Sokolova , Ekaterina Lapteva , and Aleksandr Mankov Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia Department of Phatology, Irkutsk State Medical University, Irkutsk, Russia Department of Geriatrics, Propaedeutics and Management in Nursing, North-Western State Medical University Named after I.I. Mechnikov, Saint Petersburg, Russia Department of Anesthesiology-Resuscitation, Irkutsk State Medical University, Irkutsk, Russia Correspondence should be addressed to Vladimir Vorobev; vorobev_vl391@rambler.ru Received 18 August 2022; Revised 8 February 2023; Accepted 9 April 2023; Published 11 May 2023 Academic Editor: Kostis Gyftopoulos Copyright © 2023 Vladimir Beloborodov et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. Te study aims to analyze the enhanced recovery protocol efectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. Tere were two groups of patients FTS-group (group II, n � 25) and standard group (group I, n � 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. Te comparative intergroup efcacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p � 0.004). Te overall efcacy of ure- throplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p � 0.870), as well as the likelihood of relapse within two years (p � 0.512). Te predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p � 0.002). Te FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p< 0.001). Te use of the “fast track surgery” protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization. (enhanced recovery after surgery) protocols are equivalent, 1. Introduction pursuing the same goal. Fast track surgery (FTS), as well as ERAS (enhanced recovery Te main objectives of the FTS are multidisciplinary after surgery/rapid recovery programs), is the latest multi- interaction at all stages of examination and treatment [1], modal treatment strategy designed to reduce disability pe- assessment of the applied protocol for compliance with the riods and improve the quality of medical care. Tis program FTS principles [2], careful selection of patients for the includes the preoperative stage preparation, minimally in- program for various reasons, including religious reasons, vasive surgical techniques, and active management of the which may hinder participation [3]. Tere is an assessment post-operative stage to reduce the treatment period, re- of the risks of using the protocol, which may increase the habilitation time and to provide the fastest possible return of likelihood of postoperative complications or negative out- patients to normal life. In this article, the FTS and ERAS comes due to the impossibility of adhering to the protocol 2 Advances in Urology (due to lifestyle or concomitant diseases) [4]. Te program Te clinical part of the study includes an analysis of the also includes a revision of the concept of preoperative and examination and treatment results of patients who un- postoperative food and liquid intake and bowel preparation derwent surgical interventions for urethral stricture from [5–7]. As well as changing opiate and opiate-like analgesics January 2019 to August 2020. Surgeries were performed to nonsteroidal drugs and others [8]; implementation of using anastomotic and augmentation/substitution methods. multimodal anesthesia allowing minimizing operational and Te inclusion criteria were as follows: post-operative stress in combination with early mobilization (i) Te patient is planned to have surgery of the urethra [9], intraoperative normothermia maintenance [10], control for urethral stricture or distraction defect of the of fuid [11], post-operative pain [9, 12], and nausea [13]. urethra Tere are critically little works on FTS in urethroplasty. (ii) Indications for surgery meet the criteria of the Selected studies and inventions evaluated applicability in the approved protocol developed protocol. Tis made it possible to apply the concept of using fbrin glue [14] and platelet-rich plasma (iii) Te operation is planned using one of the methods (PRP) [15]. Te submucosal PRP injection for internal approved in the study optical urethrotomy signifcantly reduces the risk of re- (iv) Patients are over 18 years old currence (9.09% vs 26.82%, p 0.032) in the long-term (v) Te patient signed a voluntary informed consent to postoperative period [16]. participate in the study Currently, the number and quality of randomized re- (vi) Te patient is deliberately planned to follow the searches devoted to the fast track protocols in reconstructive treatment protocol (FTS or standard), determined urology are extremely small. At the same time, the problem of by randomization until the day of surgery preoperative preparation, optimization of surgical techniques, and acceleration of postoperative rehabilitation remain relevant, Noninclusion criteria were as follows: since there have been no signifcant changes in approaches to Lack of medical indications; perioperative management of patients over the past ten years. (i) Te patient did not sign the voluntary informed Te scientifc novelty of the study is due to several factors. consent form to participate in the study A set of fast track and ERAS measures will be evaluated for patients with planned urethroplasty, aimed at improving all (ii) Te concomitant diseases that signifcantly afect aspects of treatment (patient and medical staf satisfaction with the patient’s objective status (decompensated di- treatment, increased treatment efectiveness, improved fnan- abetes mellitus, heart failure, gross neurological cial efciency of treatment, and accelerated rehabilitation of defcits, etc.) patients after treatment). For the frst time, there will be (iii) Failure to comply with the FTS protocol a comparative analysis of the immediate and long-term results Exclusion criteria we as follows: of the application of the developed principles and the standard approach. Te study will present the evaluation of post- (i) Te patient refused to participate at any stage of operative complications associated with various methods of the study treatment; the results of the application of the developed and (ii) For any reason, there was a deviation from the traditional approaches; and predictors of complications in the research protocol long-term postoperative period. (iii) Te patient did not have surgery for any reason or Research objectives: to develop and adapt the FTS underwent another surgery that does not meet the protocol for patients with planned urethroplasty; to increase group’s criteria the overall and fnancial efciency of surgical treatment; to assess the impact of the compared approaches on the Te null hypothesis of the study was that there were no condition of patients and their satisfaction with the treat- between-group diferences on the primary point. If the null ment; to analyze the immediate and long-term results; and to hypothesis was rejected, the alternative hypothesis was that develop recommendations for the developed protocol of FTS there was an intergroup diference at the primary endpoint. urethroplasty. Taking the results of earlier studies on similar subjects, it Te study aims to analyze the efectiveness of Enhanced was calculated that 13–15 (t-test, ES � −1.136) patients in Recovery Protocol in a comparative study for elective ure- each comparison group would be sufcient to reproduce thral stricture surgery. diferences in success and postoperative status with odds of type 1 and type 2 error of 0.05 and 0.2, respectively. Study power is >0.8. To compensate for incomplete observations, 2. Materials and Methods the estimated sample size was increased by 10%. 2.1. Research Design. Te local ethics committee of the Tus, the required total sample size (two patient com- Irkutsk State Medical University (ISMU) and the Irkutsk parison groups) should be at least 33 patients. City Clinical Hospital No. 1 approved the clinical trial. Tere Te recruitment of patients who met the inclusion was a prospective, blind, randomized, and single-center criteria was carried out prospectively using the continuous study in the urological hospital of the Irkutsk City Clini- sampling method until the desired sample size was reached. During the indicated period, 123 patients had the diagnosed cal Hospital No. 1. Advances in Urology 3 stricture disease of the urethra. Only 94 patients met the Upon reaching three months after the surgery, all pa- study inclusion criteria. All included patients were ran- tients at least once every six months or once a year had to domized (simple randomization method) into two groups undergo the standard assessment of the state established by based on the approved study protocol. Te frst group fol- the study protocol as follows: consultation with a urologist, lowed the FTS treatment protocol (approved by the ethical clinical blood and urine tests, urethrography, urethroscopy, committee of the ISMU); the second group followed the urofowmetry, and ultrasound of the urinary system. Pa- standard treatment protocol (Figure 1). tients assessed the subjective status using the IPSS, QoL, Tus, the fnal clinical analysis included 54 patients (per- IIEF-5 scales, and gave complaints. protocol) who met all the study criteria. Tey formed two Tere were several criteria to assess the treatment ef- groups. Te group of patients with the standard treatment fectiveness: the maximum urine fow rate (by urofowmetry), protocol (n � 29, the group I), and the group with the FTS the diameter of the urethral lumen in the plastic zone protocol (n � 25, group II). (according to urethrography), the volume of residual urine (ultrasound assessment), and the indices of rating scales (IPSS, QoL, and IIEF-5). Successful (free from a relapse) 2.2. Checkpoints. Te study has checkpoints. were considered the results of treatment with the following Te primary “hard” checkpoints were the absence of parameters 3 months or more after surgery: Q more than max recurrence of urethral stricture in the late postoperative 12 ml/sec; absence of residual urine, signs of recurrence period (but not earlier than three months); and detected according to urethrography data (normal diameter of the relapse at any stage of postoperative follow-up. urethral lumen in the plastic zone is 5 mm or more); and Secondary “soft” checkpoints of clinical efcacy were the absence of severe LUTS, unsatisfactory quality of life. data of the subsequent postoperative examination: maxi- Te treatment results were evaluated based on a com- mum urine fow rate of more than 12 ml/sec, residual urine prehensive analysis of the parameters of all primary and volume less than 50 ml, indicators of the IIEF-5, IPSS, QoL secondary endpoints. Te absence of relapse and adequate scales, and no signs of recurrence according to urethrog- urination do not provide an accurate indication of satis- raphy data (diameter of the urethral lumen more than faction with treatment and the patient’s quality of life after 5 mm). surgery. Terefore, interpretation of the results requires consideration of all factors. Table 3 presents the treatment results divided into three groups. 2.3. Study Groups Comparison. Table 1 presents the com- parative data on the initial parameters of patients in the study groups. 2.5. Statistical Analysis. Te initial data and surgical treat- Table 2 presents comparative data of the results of an ment results were analyzed using STATISTICA software for objective examination and the state of the functional status Windows version 10.0 (Statsoft, Inc, USA), SPSS Statistics of the comparison groups. version 23.0 (IBM, USA), and Stata version 16.0 (StataCorp, USA). Simple and multiple logistic regressions helped to 2.4. Diagnostic Methods. Te examination included anam- identify predictor variables for a binary response variable. To nestic (to establish the duration of the disease, concomitant determine the predictors of post-operative complications diseases, etc.), clinical, biochemical, ultrasound, tomo- development there was a univariate and multivariate logistic graphic, radiological, and endoscopic research methods. regression analysis. Te predictor variables were selected To clarify the nature and degree of pathological changes according to the initial and closest parameters (partially in the urethra there was urethrocystography (X-ray or presented in Tables 1, 2, and 4, more than 100 in total). Cox MSCT) and urethrocystoscopy. An ultrasound helped to proportional risks regression helped to assess the correlation assess the volume of residual urine and the volume of the between one or more continuous or categorical variables and prostate, urofowmetry data showed the maximum urine the time to an adverse event. Te signifcance level for all fow rate (Q ). When visiting a doctor, patients had to max methods is p≤ 0.05. assess their subjective state and functional status according to the recommended scales for assessing lower urinary tract symptoms (LUTS/IPSS), quality of life (QoL), erectile 2.6. Treatment Protocols. During the study, there were the following two diferent treatment protocols: standard (group function (IIEF-5), and other parameters. Te visual analog scale of pain (VAS) helped to assess the severity of post- I), when the patient was prohibited from drinking and eating on the day of surgery, underwent bowel cleansing the night operative pain syndrome. Tese assessments of the sub- jective state were as follows: 0-1 points-no pain; 2-3 points- before and the morning of surgery, and received a sedative slight pain; 4-5 points-moderate intermittent pain; 6- (diazepam). Intraoperatively, absorbable suture material was 7 points-moderate persistent pain; 8-9 points-severe pain; used for individual interrupted sutures, including monop- more than 10 points-unbearable pain. olar diathermocoagulation, separately interrupted skin su- Before removal of the urethral catheter, there was ture, and standard dressings. On the frst day after the a pericatheter urethrography to assess a possible defect in the surgery, only liquid intake was allowed, food intake was tightness of the urethra and to resolve the issue of prolonged allowed from the second postoperative day. In the post- urethral drainage. operative period, on the frst day after the operation, 4 Advances in Urology Patient recruitment Primary screening (n= 123) Excluded (n= 29) (i) According to criteria (n= 2) (ii) Refusal to participate (n= 17) Randomized (n=94) Standard Protocol (n= 47) FTS protocol (n= 47) (i) Received distribution (n= 47) (i) Received distribution (n= 47) (ii) Did not receive distribution (n= 0) (ii) Did not receive distribution (n= 0) Observations Lost for observation Lost for observation (i) Died (n= 1) (i) Died (n= 0) Analysis Protocol analysis (n= 25) Protocol analysis (n= 29) (i) Excluded from analysis (n= 22) (i) Excluded from analysis (n= 18) Figure XXX CONSORT (ii) Crossover (n = 0) (ii) Crossover (n = 0) Figure 1: CONSORT research diagram. anesthesia with narcotic analgesics was performed as Platelet-rich plasma (PRP method) and fbrin glue needed. Te patient was mobilized on the second day after (i-PRF and Superfbrin method) were obtained by centri- the surgery. Infusion therapy was performed within the frst fugation (“Armed” centrifuge) in special tubes from the 24–48 hours. Antibiotic therapy was carried out during the patient’s peripheral venous blood. entire hospitalization. Te minimum recommended hospital stay after surgical treatment was 7 days. Te urethral catheter 2.7. A Clinical Example of the ERAS Protocol in Urethroplasty. was removed 10–21 days after surgery. Patient K., 62 years old, presented with the following Table 5 shows the FTS protocol scheme (group II). complaints: inability to urinate adequately and presence of Te fnal choice of the method of surgical treatment was cystostomy. From the medical history it is known that made in advance and corrected intraoperatively. Te main urethral stricture was detected accidently. A cystostomy was types of operations were anastomotic urethroplasty (EPA) in inserted in 2021 due to acute urinary retention. TRUS the form of the classic Turner-Warwick/Webster operation revealed prostate volume of 20.7 cm . An urethrogram on [17, 18], vascular-sparing methods [19], intraurethral the 22.12.20 revealed a bulbo-membranous stricture of the anastomosis [20], and buccal mucosa graft urethroplasty urethra with narrowing of the lumen up to 1 mm. On using various techniques (Asopa [21], Barbagli [22] and December 29, 2020, a prostatic TUR and an internal optical others), as well as the original minimally invasive urethrotomy were performed and the cystostomy was technique [23]. preserved. In the postoperative period urination was not All patients in both groups used neuraxial analgesia, restored. On control urethrocystoscopy and MSCT- prophylaxis of thromboembolic complications (low mo- urethrocystography the diagnosis was bulbo-membranous lecular weight heparins), and protection from stress ulcers urethral stricture, recurrence, complication of underlying (proton pump blockers). Te severity of the postoperative secondary chronic cystitis, chronic urinary retention, cys- pain syndrome was possible to assess according to the visual tostoma, and hospitalized as planned for surgical treatment analog scale of pain (VAS) on the frst day after surgical of urethral stricture. treatment. Advances in Urology 5 Table 1: Comparative characteristics of patients in comparison groups before surgery. Indicator Group I (n � 29) Group II (n � 25) p General indicators: Age (years) 51.0 (±16.8) 53.6 (±13.1) 0.527 Height (cm) 173.4 (±6.8) 172.8 (±5.0) 0.719 Weight (kg) 73.8 (±12.7) 81.8 (±17.4) 0.057 Anamnesis: Duration of the established disease (months) 24 (6; 60) 24 (12; 60) 0.645 Smoking, n (%) 18 (62.0%) 15 (60%) 0.939 Contacts with harmful substances, n (%) 6 (20.6%) 6 (24%) 0.816 Allergic anamnesis, n (%) 2 (6.8%) 3 (12%) 0.557 Cystostomy, n (%) 13 (44.8%) 9 (36%) 0.668 Urological operations and manipulations: Traumatic catheterization, n (%) 9 (31.0%) 6 (24%) 0.664 Bougie of the urethra, n (%) 10 (34.4%) 10 (40%) 0.776 Optical urethrotomy, n (%) 7 (24.1%) 7 (28%) 0.804 EPA, n (%) 10 (34.4%) 4 (16%) 0.232 BMG urethroplasty, n (%) 6 (20.6%) 3 (12%) 0.468 TUR of the prostate, n (%) 5 (17.2%) 2 (8%) 0.374 TUR of the bladder, n (%) 2 (6.8%) 4 (16%) 0.343 Prostate surgery, n (%) 0 (0%) 3 (12%) 0.070 Te etiology of urethral stricture: Trauma, n (%) 12 (41.3%) 6 (24%) 0.336 Iatrogenic, n (%) 14 (48.2%) 14 (56%) 0.750 Te infammatory, n (%) 1 (3.4%) 2 (8%) 0.491 Idiopathic, n (%) 2 (6.8%) 3 (12%) 0.557 Concomitant diseases: Ischemic heart disease, n (%) 7 (24.1%) 10 (40%) 0.367 Hypertension, n (%) 10 (34.4%) 12 (48%) 0.514 Diabetes mellitus, n (%) 2 (6.8%) 4 (16%) 0.343 Chronic urinary infection, n (%) 11 (37.9%) 4 (16%) 0.173 Hyperplasia of the prostate, n (%) 9 (31.0%) 6 (24%) 0.664 Medications: Medicines afecting erection, n (%) 7 (25%) 9 (36%) 0.484 A-blockers, n (%) 5 (17.8%) 3 (12%) 0.640 Note: EPA-excision and primary anastomosis; BMG-buccal mucosa graft; TUR-transurethral resection. Table 2: Te results of an objective examination and the state of the functional status. Indicator Group I (n � 29) Group II (n � 25) p Localization of the structure: Glans urethra, n (%) 2 (6.8%) 3 (12%) 0.557 Te penile urethra, n (%) 6 (20.6%) 1 (4%) 0.107 Te bulbar urethra, n (%) 18 (62.0%) 18 (72%) 0.730 Te membranous urethra, n (%) 13 (44.8%) 12 (48%) 0.887 Length of stricture, (mm) 20 (10; 40) 15 (10; 25) 0.780 Minimum diameter of the urethra, (mm) 1 (1; 2) 1 (1; 2) 0.277 Q , (ml/s) 7.1 (±2.6) 7.2 (±2.2) 0.920 max Volume of residual urine, (ml) 150 (90; 240) 130 (45; 230) 0.564 Fistulas or diverticula of the urethra, n (%) 3 (10.3%) 1 (4%) 0.408 Prostate volume, (cm3) 23.3 (±8.8) 26.0 (±7.9) 0.262 IIEF-5, score 14 (9; 18) 12 (8; 16) 0.423 Qol, score 5 (4; 5) 5 (4; 6) 0.167 IPSS, score 26 (23; 30) 28 (26; 34) 0.095 Note: Qmax-maximum fow rate; IIEF-Iinternational Index of Erectile Function; QoL–the quality of life; IPSS-International Prostate Symptom Score. Tus, the analysis of the main characteristics of patients in the comparison groups demonstrated their comparability (p> 0.05). 6 Advances in Urology Table 3: Evaluation of treatment results using the combined (multiple) endpoint methods. Parameter Good Satisfactory Unsatisfactory Absence of relapse + + − No severe pain syndrome (>5 points on the pain scale) in the post-operative period + − − No complications + − − Satisfaction with treatment + − − Table 4: Comparative data of the nearest results in patients of the comparison groups. Indicator Group I (n � 29) Group II (n � 25) p Hematoma in the operation area, n (%) 0 0 0 Graft necrosis, n (%) 0 0 0 Urethrorrhagia, n (%) 0 0 0 Subfebrile condition in the early postoperative period, n (%) 27 (93.1%) 7 (28%) 0.014 Infectious complications, n (%) 0 (0) 0 (0) 0 Urethral suture failure, n (%) 1 (3.4%) 0 (0) 0.356 Constant pain syndrome (VAS more than 5 points) on the frst day after surgery, n 23 (79.3%) 1 (4%) 0.003 (%) Postoperative pain level on the frst day, points 8 (6; 9) 4 (4; 5) <0.001 Te need for narcotic pain relief, n (%) 13 (44.8) 1 (4%) 0.007 Average length of hospital stay, bed-day 11.5± 3.4 3.8± 1.2 <0.001 Terms of catheterization, days 15.1± 3.3 6.2± 1.8 <0.001 Total time spent on treatment, days 27.3± 5.2 13.7± 2.4 <0.001 Postoperative incontinence due to surgery, n (%) 1 (3.4%) 0 0.356 Continent after surgery, n (%) 28 (96.5%) 23 (92%) 0.902 Satisfaction with the performed treatment, n (%) 17 (58.6%) 21 (84%) 0.397 Perioperative treatment was carried out according to the Patient is scheduled for surgery date. Hospitalization on claimed method. Mini-invasive intraurethral urethroplasty the day of surgery, three hours before the planned surgical with the use of oral mucosa graft was carried out (Vorobiev intervention. Self-preparation at home. Cleansing of bowel V.A., Beloborodov V.A. method of surgical treatment of has not been carried out. Shaving of the operative feld urethral narrowing//patent No 2694477 from 15.07.19). perineum, after pretreatment with skin antiseptic. Pre- Rehabilitation according to the claimed method was vention of venous thromboembolism—compression knit- carried out. wear and subcutaneous injection of Fraxiparin 0.3 ml. On admission the patient was premedicated with cele- In the preoperative period the detailed consultation about the possible principles of urethral strictures treatment, coxib 100 mg, gabapentin 600 mg, and omeprazole 20 mg the reasons of their occurrence and consequences of refusal once oral. Carbohydrate loading of 200 ml of maltodextrose from treatment has been carried out. Possible alternative mixture orally was performed. treatments such as endoscopic dissection, dilatation, anas- Antibacterial prophylaxis was carried out once tomotic urethroplasty, and others are presented. An over- 60 minutes before surgery according to the recommenda- view of the preoperative period, intraoperative nuances and tions. Preoperative urine culture with pathogenic microfora a description of the expected state in the postoperative growth and postoperative antibiotic therapy plan were made period and possible complications, as well as rehabilitation according to culture results. measures, are presented. Intraoperative method of anesthesia was epidural an- Immediately after the initial consultation, the patient’s esthesia. Te operation time was 50 minutes. A 14Fr silicone urinary catheter was inserted. Intraoperative heating of the consent to surgical treatment according to the principles of accelerated recovery is obtained. An examination plan was patient was carried out using an electric heating mattress. prescribed as part of the accelerated pathway. All exami- Heating of infusion solutions was carried out using a fow nations were carried out on the following day within three heater. Minimally invasive was perineal linear surgical access hours. Te indications and contraindications for surgery are of 2 cm. Te operation was performed using a 4.5x mag- reassessed on the basis of the examination results. A mul- nifying lens. Monopolar coagulation was not used. After tidisciplinary team discussion was carried out as follows: the performing a bulbar urethral access, a 2 cm transbulbar urologist, anesthetist, internist, radiologist, nurse, and re- access was performed. After removal of scar tissues, habilitator. Te possibility of adhering to the protocol on a 3 ×1 cm oral graft was taken from the left cheek under local anesthesia with lidocaine 2% 20 ml solution. Te defect was religious, ethical, social, and other grounds is assessed. Evaluated the need for prehabilitation: not identifed. Rec- sutured with Vicryl 3–0. Te graft was fxed in the formed bed with 5–0 monocryl continuous suture. Te urethrotomy ommended slagfree diet 2-3 days before surgery. Advances in Urology 7 Table 5: Te FTS protocol for the supervision of patients with urethroplasty for urethral stricture. FTS protocol for the urethroplasty: Preoperative period Intraoperative period Postoperative period Informing the patient about the disease, treatment options, and possible outcomes, indicating the average efectiveness, Preferred method of anesthesia-local anesthesia/ Early fuids intake (2-3 hours after surgery) and food (6 hours risks of complications, typical post-operative condition, multimodal anesthesia after surgery) timing of catheterization, hospitalization, possible methods of prerehabilitation, and further rehabilitation methods One-day concept-the patient undergoes most of the preoperative examinations in one day, without the need for multiple repreparation. Te order of examinations and tests is optimized and sorted to achieve the desired outcome Rigorous evaluation of indications for surgical treatment: Q < 12 ml/s max Heating of the patient during the operation with the Early activation (6–8 hours after surgery, after evaluation by an Urethral lumen diameter <4 mm control of normothermia anesthesiologist) Presence of residual urine Presence of urethral distraction defect Assessment of the possibility of patient compliance with the Physical therapy (breathing exercises, walking, and other Heating of infusion solutions and inhalation gases protocol and its feasibility in the medical institution exercises) Preventive administration of antihistamines and antacids Multimodal prevention of nausea and vomiting Minimally invasive surgical approaches drugs (metoclopramide + ondansetron) Te rejection of the use of monopolar coagulation and Removal of the urethral catheter after performing pericatheter Refusal of preoperative sedation resection urethrography no later than the seventh day after surgery Prerehabilitation based on indications: Age group Use of drugs that improve microcirculation, reparants, and Obesity Application of bipolar coagulation hyperbaric oxygenation (in the mode of 1.0–1.5 ATM, for Exhaustion 45 minutes, 5–10 sessions; in the absence of contraindications) Te sarcopenia Impaired carbohydrate tolerance or diabetes mellitus Preoperative antibiotic therapy according to the testimony: the presence of latent or obvious infection of the Te use of enzyme drugs (longidase, rectal suppositories) after Te rejection of coagulation on the spongy body of the genitourinary system (according to the results of 14 days after surgery in courses of 20 pieces with an interval of urethra bacteriological research, real-time PCR, and infection of 2 days every 6 months other organs Multidisciplinary examination of patients: Urologist Anesthetist Continuation of prevention of thromboembolic complications ENT doctor Sealed continuous urethral suture with 4–6/ by compression of the lower extremities and the use of Dentist 0 monoflament thread low-molecular-weight heparins General practitioner/Cardiologist Te radiologist physical therapy doctor And other specialists as needed 8 Advances in Urology Table 5: Continued. FTS protocol for the urethroplasty: Preoperative period Intraoperative period Postoperative period Performing CT/MRI of the small pelvis, CT/RI MRI of the urinary system, CT/RI MRI-urethrography with Use of platelet-rich plasma as injections into the Multimodal analgesia for pain control 3D-modeling, assessment of the state of the bone and joint submucosal layer of the urethra and surrounding tissues (Dexketoprofen + paracetomol) apparatus of the pelvis, organs A rich carbohydrate diet (if there are no contraindications) Use fbrin glue locally at the urethral seam Use of chewing gum on the frst and second day after surgery and 200 ml of liquid protein 2.5 hours before surgery Te last meal during the operation in the morning hours at Monitoring of blood and urine parameters on the frst day after 21-22 hours the day before, during the operation in the Use of silicone urethral catheters 14–16 ch surgery afternoon no later than 6 hours before the operation Antibiotic prophylaxis 60 minutes before surgery with 3rd Strict glycemic control in patients with impaired carbohydrate Te rejection of the use of drains generation cephalosporins tolerance and diabetes mellitus Shaving of the surgical feld with subsequent treatment with Sealed cosmetic skin seam with no loose ends or knots on A detailed discussion of the behavior of the patient and the solutions of skin antiseptics the skin rehabilitation plan before the discharge Oral rinsing with an aqueous solution of chlorhexidine Te adhesive bandage on the skin Detailed written instructions in the discharge documents during planned urethroplasty using buccal mucosa graft Prevention of thromboembolic complications by Strict plan of follow-up examinations in the post-operative compression of the lower extremities and administration of Intraoperative euvolemia period low-molecular-weight heparins Strict adherence to postoperative hygiene of the genitals (when Avoiding the use of cleansing enemas using an adhesive bandage, the patient is recommended to take a hygienic shower daily from the second day) Transfer of the patient to a slageless diet 2-3 days before Discharge from the hospital 1–3 days after the operation with the surgery transfer of the patient to outpatient observation Preparation of the intestines with laxatives or once Recommended return to work 2 days after removal of urethral microclysters catheter Advances in Urology 9 access is sutured with Monocryl 4–0. Sealing of the suture 2.8. Research Limitations. Limitations of the research were using Sulfacrylate adhesive was carried out. Reliable he- as follows: relatively small sample size, the average post- mostasis must be achieved. No drainage was performed. operative follow-up period of fewer than two years, single- Closure of the perineal access with Monocryl 4−0 in layers center study, mixing of various surgical techniques, and was carried out in continuous sutures. Cosmetic skin sutures diferent localizations of strictures within the protocol was carried out with Sulfacrylate adhesive dressing. Intra- (anastomotic, substitution, and others). operatively, prevention of postoperative nausea and vom- iting was performed—dexamethasone 4 mg and 3. Results ondansetron 4 mg intravenously. 3.1. Immediate Results. To compare the immediate results of After the operation, the patient was transferred to surgical treatment of urethral stricture disease after the a postoperative ward for 3 hours. Intraoperative pain standard treatment protocol (group I) and after the FTS management continued in the postoperative period protocol (group II) there was a comparative analysis of the according to the “no pain” principle, i.e. prevention rather postoperative parameters of the patients’ condition and the than elimination of pain. After the end of the epidural examination results. anesthesia the patient was prescribed oral celecoxib 100 mg In the early and late postoperative periods, there were no and acetaminophen 250 mg every 6–8 hours during the frst cases of mortality in the two groups. In the early and late postoperative day. Te use of maltodextrose mixture is postoperative periods, there were no complications of an- suggested one hour after surgery. Postoperative consump- esthetic treatment or deterioration of the general somatic tion of solid food is allowed 2 hours after surgery. Plant- status. Te need for mechanical ventilation or respiratory based chewing gum is recommended to reduce the risk of support did not arise in any case in the comparison groups. postoperative functional bowel disorders and for the pur- Tere were also no cases of heart failure that required pose of local antiseptic action. inotropic support. Te patient is activated 6 hours after the operation, Intergroup analysis of the size of the surgical approach following the cessation of epidural anesthesia. Activation showed that its average linear dimensions of group I were involves sitting and walking. Glycemic control on the frst 7.1± 2.1 cm, which is signifcantly greater than of group II and second post-operative days, no correction was neces- (3.3± 1.2 cm, p< 0.001). sary. On the second postoperative day, a control clinical Tere was a chronometric analysis of the operating blood count was performed. Postoperative antibiotic therapy period. Te average duration of surgery in groups I and II was carried out according to the culture data—levofoxacin were 1.2± 0.35 hours and 1.1± 0.31 hours, respectively 500 mg once a day, 5 days. Wound treatment was not carried (p � 0.273). out. Independent daily hygiene-showering was Table 4 shows the comparative characteristics of the recommended. postoperative state indicators of patients in the comparison Prophylaxis of venous thromboembolism was con- groups. tinued—compression knitwear was worn until 21 days after Te results analysis showed that in both comparison the operation, plenty of fuids were administered and groups and postoperative complications in the early and late Fraxiparin 0.3 ml was injected intravenously until discharge. periods developed extremely rarely. Te patient was discharged from the hospital to outpatient It should be noted that the development of incontinence care on the third postoperative day. and failure of the urethral suture occurred only in one case. Te urethral catheter was removed 7 days after surgery, Tus, univariate logistic regression analysis of these in- after a control pericatheter urethrocystography to assess dicators did not reveal a statistically signifcant correlation possible urine leakage from the access line. with the initial parameters (p> 0.05) in the comparison Daily contact with the attending physician via phone groups. calls and messenger for the frst 10 days, then once every 2- Table 6 presents the information on predictive factors for 3 days for up to a month. Monthly thereafter for one year. the occurrence of post-operative complications (univariate Check-ups and follow-ups ultrasound on the 3rd, 7th, 10th, and multivariate logistic regression analysis, the table in- 20th, and 30th day and then after 3, 6, and 12 months. cludes signs with a level of χ > 1 and p< 0.05). In 14 days after surgery, the use of the drug Longidase A simple (univariate) logistic regression analysis among was recommended under the scheme of 1 suppository 54 patients of both comparison groups revealed that some rectally once every 2 days, indicators acquired special signifcance in predicting the No intraoperative or postoperative complications≥ II development of subfebrile condition in the early post- according to Clavien-Dindo classifcation were registered in operative period – the results are presented in Table 6. the patient. Te patient was discharged in a satisfactory Te obtained results helped to build a model for pre- condition on the 3rd day after surgery. dicting subfebrile status in multivariate regression analysis According to the control urethrocystography and ure- (selection from predictor factors with a signifcance level of throscopy one year after surgery, there were no signs of p< 0.05). Low subjective assessment of the quality of life urethral stricture recurrence. Te diameter of the urethra in (more than 4 points; Coefcient 1.5; 95% CI 0.1; 2.9; the urethroplasty zone was 6.5 mm. Quality of life indicators p � 0.035), as well as the size of the surgical access (for each were in line with population averages. 10 Advances in Urology Table 6: Predictors of postoperative complications. Complications in the Univariate analysis Multivariate analysis early and late Predictor χ Coefcient (95% CI) p Coefcient (95% CI) p post-operative period Standard protocol 26.99 3.5 (1.8; 5.2) <0.001 2.3 (−1.2; 5.9) 0.208 Te quality of life 5.54 0.76 (0.06; 1.4) 0.033 1.5 (0.1; 2.9) 0.035 Subfebrile Diabetes 6.16 2.3 (0.16; 4.6) 0.035 3.4 (−3.6; 10.4) 0.340 Condition Vascular atherosclerosis 4.97 1.3 (0.14; 2.5) 0.029 1.3 (0.94; 3.6) 0.246 Multivariate logit regression: Surgical access size 28.07 0.85 (0.39; 1.3) <0.001 1.09 (0.2; 1.98) 0.016 χ � 45.75; p< 0.0001 Pain more than 5 points on the VAS scale 17.04 2.8 (1.1; 4.4) 0.001 0,77 (−10,4; 3,6) 0.874 Use of narcotic analgesics 8.63 2.4 (0.33; 4.5) 0.023 3.3 (−6.6; 13.4) 0.509 Pelvic bone injury (history) 10.88 2.8 (0.66; 4.9) 0.010 2.6 (−2.0; 7.35) 0.263 Progression of urethral stricture 8.61 1.77 (0.5; 3.02) 0.005 0.3 (−2.6; 3.2) 0.841 Persistent pain syndrome, >5 points on the VAS scale Urohematomas (history) 7.5 1.8 (0.41; 3.3) 0.011 0.99 (−1.9; 3.9) 0.514 Multivariate logit regression Penile strictures 5.89 2.2 (0.7; 4.46) 0.043 5.41 (0.55; 10.2) 0.029 χ � 7,78; p< 0.001 (0.0001) Duration of surgery 5.88 2.1 (0.27; 3.9) 0.024 2.3 (−7.4; 2.7) 0.364 Surgical access dimensions 44.14 1.2 (0.6; 1.77) <0.001 1.29 (0.45; 2.13) 0.002 Note: VAS-a visual analog scale of pain. Advances in Urology 11 1 cm; Coefcient 1, 09; 95% CI 0.2; 1.98; p � 0.016). Te rest diabetes mellitus in the long-term postoperative period of the factors were not signifcant (p > 0.05). (Coefcient 3.92; 95% CI 0.09; 7.7; p � 0.045) was a signif- Te independent predictors of persistent pain syndrome icant predictor of this complication. Consequently, after found by simple logistic regression analysis (presented in performing urethroplasty surgeries, the risk of developing Table 6) were included in further analysis. Localization of the infectious complications in the long-term period increases urethral stricture in the penile part of the urethra (Co- with decompensation of diabetes mellitus. efcient 5.41; 95% CI 0.55; 10.2; p � 0.029), as well as the size Te obtained results helped to construct a model for of the surgical access (for each 1 cm; Coefcient 1.29; 95% CI predicting penile shortening in multivariate regression 0.45; 2.13; p � 0.002), became signifcant predictors of analysis (selection from factors p< 0.05). A signifcant persistent pain syndrome. Te rest of the factors were not predictor of this complication was the length of the urethral signifcant (p > 0.05). stricture more than 3 cm (coefcient 2.87; 95% CI 0.08; 5.67; Table 7 shows postoperative indicators of urodynamics, p � 0.043). Consequently, urethroplasty for patients with objective, and functional status (IPSS, QoL, and IIEF-5) in a urethral stricture longer than 3 cm increases the risk of the comparison groups. penile shortening. Tere was a comparative intergroup analysis of these Tere was a statistical analysis of overall survival. Te indicators. Te groups were comparable according to the Kaplan–Meier estimates of the survival rate of group II results of an objective examination, the state of urody- patients during the entire observation period after ure- namics, and functional status in the early and late post- throplasty were equal to 100%. Te values of the operative periods (p> 0.05). Kaplan–Meier estimates of the survival rate of group I patients during the entire observation period (up to 2 years) were 96.3± 3.63% with a 95% CI of 76.4–99.4%. Te log- 3.2. Long-Term Results. Long-term results of surgical rank test did not reveal statistically signifcant diferences in treatment of stricture disease were possible to assess the survival rate in the long-term post-operative period in according to the control endpoints of the examination. Te the comparison groups (p � 0.335), which is graphically presented by the Kaplan–Meier method in Figure 2. average period of clinical observations was 468 days with 95% CI 423–513, and the maximum period was 721 days. Cox proportional hazards regression analysis showed no Table 8 presents general indicators of the long-term post- reliable predictor of mortality in the long-term post- operative period in the comparison groups. operative period. Probably, such a result of the statistical For group I, the average observation period was 469 days analysis is due to the small representation of the factor (a with a 95% CI of 401–537 days (maximum period of single case of mortality). 705 days). For group II, the average observation period was Te analysis of the dependence of mortality on general 466 days with a 95% CI of 403–529 days (maximum period surgical technical reasons was not performed due to the of 721 days). absence of such. Te survival rate for this parameter for both In the long-term postoperative period, there was a single groups was 100% over the entire observation period. episode of mortality in group I, which was not associated Table 10 presents comparative information on the success of surgical treatment in the comparison groups. with surgery. Tere were few signifcant complications in the long- In the frst group, out of 29 primary operations, 25 were term postoperative period. In 3 (10.3%) cases from group I successful (86.2%). In the second group, 23 out of 25 primary and 2 cases (8%) from group II, there was an acute in- operations were successful. Tus, the primary efciency was fammatory process of the genitourinary system in the pe- 92%. riod from 3 to 12 months, which required the antibacterial Te Kaplan–Meier estimates the absence of recurrence of drugs (p � 0.786). urethral stricture in group I as 93.1± 4.7% during the frst 7 (24.1%) patients of group I and 5 (20%) patients of three months (95% CI 75.1–98.2%), after a year–89.5± 5, 7% group II (p � 0.770) presented complaints of penile short- (95% CI 70.9–96.5%) and after two years—78.3± 11.6% ening during active questioning 3 months after surgery. (95% CI 44.8–92.8%). Tese indicators for group II during To determine the predictors of the development of the the frst three months were 100% and after one and two years above complications, there was univariate and multivariate —90.3± 6.5% (95% CI 66.3–97.5%). logistic regression analysis. Te predictor variables were Te log-rank test did not reveal statistically signifcant selected according to the initial and closest parameters diferences (p � 0.512; χ � 0.43) in the recurrence rate over (partially presented in Tables 1, 2, 5, and 7, more than 120 in the entire observation period, which is graphically expressed total). Information on predictive factors for the occurrence by the Kaplan–Meier method in Figure 3. of postoperative complications in the long-term post- Te predictor variables were selected according to the operative period (univariate and multivariate logistic re- initial parameters, as well as according to the control pa- gression analysis, the table includes signs with χ > 1 and rameters in the postoperative period. Table 11 presents a Cox p< 0.05) are presented in Table 9. proportional hazards regression model showing the efect of Te obtained results allowed constructing a model for variables on recurrence risk. the prognosis of infectious complications in the long-term Multivariate Cox proportional hazards regression postoperative period in multivariate regression analysis analysis (sample of p< 0.05) demonstrated the signifcance (selection from factors p< 0.05). Decompensation of of urethral suture failure (HR 4.36; 95% CI 1.6; 7.11; 12 Advances in Urology Table 7: Postoperative indicators of urodynamics, objective, and functional status (IPSS, QoL, and IIEF-5) in comparison groups. Parameter Group I (n � 29) Group II (n � 25) p IPSS, score 5 (2; 8) 4 (2; 7) 0.564 IIEF-5, score 15 (11; 18) 14 (9; 18) 0.794 QoL, score 1 (1; 2) 1 (1; 1) 0.187 Q , (ml/sec) 15.5± 2.7 17.0± 3.1 0.065 max Residual urine volume, ml 0 (0; 0) 0 (0; 0) 0.931 Achieved urethral lumen diameter in the operation area, mm 5.1± 1.2 5.6± 1.3 0.106 Note: IPSS-International Lower Urinary Tract Symptom Scale; IIEF-5-International Index of Erectile Function; QoL-the quality of life; Q -maximum urine max fow rate. Table 8: General indicators in the long-term period. Indicator Group I (n � 47) Group II (n � 47) Dropout patients, n (%) 18 (38.2%) 22 (46.8%) Te number of patients who completed the study, n (%) 29 (61.7%) 25 (53.1%) Nonlethal patients, n (%) 28 (96.5%) 25 (100%) Long-term general mortality, n (%) 1 (3.4%) 0 (0%) Urological mortality, n (%) 0 (0) 0 (0) Relative risk of death, (%) I/II–98.182% Reducing absolute risk I/II–1.818% Reducing relative risk I/II–54.545% A chance to die in a distant period 3.4% 0% p � 0.002) in predicting a possible recurrence after ure- rehabilitation and restoration of working capacity also re- throplasty surgery. main relevant. Analyzing the comparative intergroup efectiveness of A few interesting results were obtained in the presented the treatment based on the criteria established in the study, study. Te overall efcacy of urethroplasty operations, re- good treatment results obtained 5 (17.2%) patients of group I gardless of the treatment protocol, was comparable and 20 (80%) patients in group II (p � 0.0049). Satisfactory (p � 0.870), as well as the likelihood of recurrence within results obtained 20 (68.9%) patients of group I and 3 (12%) 2 years (p � 0.512). Te results obtained are consistent with patients of group II (p � 0.0055). Unsatisfactory results the data of other authors; the average efciency of ure- obtained 4 (13.7%) patients in group I and 2 (8%) patients in throplasty operations, regardless of the location and length group II (p � 0.544). of the stricture, when using anastomotic or replacement Terefore, the use of the FTS protocol after urethroplasty methods is 85± 10% [24–27]. allows achieving better treatment results than the classical In the development of relapse, a special role (according approach. Both methods of urethroplasty had zero operating to multivariate Cox proportional hazards regression) played and hospital mortality and a low incidence of postoperative technical complications and failure of the urethral suture general and urinary system-related complications. Both (OR 4.36; 95% CI 1.6; 7.11; p � 0.002). Te FTS protocol for methods are highly efective and safe. However, the classical urethroplasty surgery ofers several simple techniques to approach is associated with longer disability and worse minimize this risk. First, it is proposed to use only a con- tinuous and sealed urethral suture; second, the suture is subjective perception and objective assessment of the per- ioperative period for patients. additionally treated with fbrin glue; and third, the sur- rounding tissues are infltrated by platelet-rich plasma. Te 4. Discussion use of platelet-rich plasma can reduce the zones of necrosis, the severity of local infammation, and improve angiogen- Modern surgery, including urology, has many tools and esis, which has been confrmed by several works [16, 28, 29]. techniques that facilitate the perioperative period for both Fibrin glue provides better tightness, reliable fxation of the the patient and the healthcare organization. However, the graft, reduces the risk of periurethral leakage [14], and the complexity of preoperative diagnosis, its duration and cost, risk of fstula formation [30]. Tere is evidence of the and operational and postoperative surgical stress reduce the successful use of a mixture of fbrin and cyanoacrylic glue for quality of medical care. Urology is one of the leaders in the treatment of vesicourethral anastomoses leak after minimal invasiveness, making the most of endovideosurgery prostatectomy [31]. and endoscopy. Tat is why, according to the authors, of Predictors of complications were assessed separately. Tus, particular interest is the development of protocols for en- the use of anastomotic methods of urethroplasty increases the hanced recovery in urology. Tus, a typical urological risk of complaints of shortening of the penis with strictures problem postoperative pain remains relevant. Te longer than 3 cm. Decompensation of diabetes mellitus in the Advances in Urology 13 Table 9: Predictors of the complications in the long-term postoperative period. Univariate analysis Multivariate analysis Complications in the Predictor 2 2 2 long-term postoperative period χ Coefcient (95% CI) χ Coefcient (95% CI) χ Bladder cancer (history) 4.02 2.3 (0.18; 4.46) 0.033 −1.6 (−7.1; 3.7) 0.543 diabetes mellitus, and decompensation 12.59 3.8 (1.3; 6.22) 0.002 3.92 (0.09; 7.7) 0.045 Long-term infectious complications multivariate logit regression CVI 5.08 2.75 (0.47; 5.03) 0.018 2.2 (−2.4; 6.9) 0.343 χ �16.58; p � 0.0110 Vascular atherosclerosis 5.57 2.4 (0.12; 4.68) 0.039 0.07 (−3.7; 3.8) 0.969 Urethral lumen diameter (fnal) 4.12 −0.6 (−1.3; −0.08) 0.047 −0.27 (−2.6; 2.1) 0.826 Qmax (fnal) 5.55 −0.3 (−0.5; −0.04) 0.020 −0.08 (−1.0; 0.8) 0.866 Post-traumatic stricture 11.60 2.39 (0.89; 3.8) 0.002 2.03 (−1.0; 5.1) 0.202 Pelvic injury 13.57 2.87 (1.2; 4.51) 0.001 1.78 (−2.1; 5.7) 0.377 Distraction defect of the urethra 19.55 4.05 (1.75; 6.3) 0.001 0.06 (−4.4; 4.5) 0.977 Shortening of the penis Cystostomy 7.53 1.9 (0.43; 3.3) 0.011 1.4 (−1.03; 3.99) 0.249 multivariate logit regression Previous EPA 4.27 1.4 (0.07; 2.81) 0.038 −0.79 (−4.5; 2.9) 0.682 χ � 29.28; p � 0.0003 Unsuccessful treatment (history) 7.36 1.85 (0.46; 3.25) 0.009 0.11 (−2.8; 3.03) 0.939 Inadequate EPA (history) 8.86 2.12 (0.69; 3.56) 0.004 0.26 (−3.3; 3.87) 0.884 Urethral stricture> 30 mm 15.51 2.94 (1.36; 4.52) <0.001 2.87 (0.08; 5.67) 0.043 Note: CVI-chronic venous insufciency; Q -maximum fow rate; EPA-anastomotic urethroplasty. max 14 Advances in Urology Kaplan-Meier survival estimates I group II group 0.75 0.5 0.25 0 200 400 600 800 0 200 400 600 800 analysis time 95% CI Survivor function Groups I - standart protocol; II - FTS protocol Figure 2: Kaplan–Meier curve (the ratio of the number of patients without death to the duration of follow-up) of patient survival in the comparison groups. Table 10: Comparative data on the success of urethroplasty operations in the comparison groups in the long-term period. Indicator Group I (n � 29) Group II (n � 25) p Successful primary, n (%) 25 (86.2%) 23 (92%) 0.870 True relapse, n (%) 4 (13.7%) 2 (8%) 0.544 Kaplan-Meier survival estimates I Group II Group 0.75 0.5 0.25 0 200 400 600 800 0 200 400 600 800 analysis time 95% CI Survivor function Groups I - standart protocol, II - FTS protocol Figure 3: Absence of relapse in study groups according to the Kaplan–Meier method. Table 11: Cox proportional hazards regression model. Cox multivariate analysis, Univariate Cox analysis χ �13.19; p � 0.0217 Variable Wald χ HR (95% CI) p Or (95% CI) p Hemorrhoids 5.80 8.4 (1.6; 41.8) 0.009 2.35 (−0.05; 4.77) 0.055 Bladder cancer (history) 3.19 6.1 (1.02; 36.87) 0.046 1.14 (−2.1; 4.43) 0.493 Chronic venous insufciency 3.3 6.1 (1.12; 33.5) 0.036 −0.93 (−4.6; 2.8) 0.625 Inconsistency of the urethral suture 4.17 25.6 (2.32; 282.9) 0.008 4.36 (1.6; 7.11) 0.002 Infectious complications 3.07 5.64 (1.03; 30.92) 0.046 1.0 (−2.14; 4.15) 0.513 Advances in Urology 15 postoperative period increases the likelihood of an acute in- Conflicts of Interest fection of the genitals and lower urinary tract. Without con- Te authors declared no potential conficts of interest with sidering the data of univariate analysis, the results obtained are respect to the research, authorship, and/or publication of consistent with the results of similar studies [32, 33]. 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Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty

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Hindawi Publishing Corporation
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1687-6369
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DOI
10.1155/2023/2205306
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Abstract

Hindawi Advances in Urology Volume 2023, Article ID 2205306, 16 pages https://doi.org/10.1155/2023/2205306 Research Article Fast Track Surgery as the Latest Multimodal Strategy of Enhanced Recovery after Urethroplasty 1 1 1 2 Vladimir Beloborodov , Vladimir Vorobev , Temirlan Hovalyg , Igor Seminskiy , 1 3 4 Svetlana Sokolova , Ekaterina Lapteva , and Aleksandr Mankov Department of General Surgery, Irkutsk State Medical University, Irkutsk, Russia Department of Phatology, Irkutsk State Medical University, Irkutsk, Russia Department of Geriatrics, Propaedeutics and Management in Nursing, North-Western State Medical University Named after I.I. Mechnikov, Saint Petersburg, Russia Department of Anesthesiology-Resuscitation, Irkutsk State Medical University, Irkutsk, Russia Correspondence should be addressed to Vladimir Vorobev; vorobev_vl391@rambler.ru Received 18 August 2022; Revised 8 February 2023; Accepted 9 April 2023; Published 11 May 2023 Academic Editor: Kostis Gyftopoulos Copyright © 2023 Vladimir Beloborodov et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. Te study aims to analyze the enhanced recovery protocol efectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. Tere were two groups of patients FTS-group (group II, n � 25) and standard group (group I, n � 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. Te comparative intergroup efcacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p � 0.004). Te overall efcacy of ure- throplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p � 0.870), as well as the likelihood of relapse within two years (p � 0.512). Te predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p � 0.002). Te FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p< 0.001). Te use of the “fast track surgery” protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization. (enhanced recovery after surgery) protocols are equivalent, 1. Introduction pursuing the same goal. Fast track surgery (FTS), as well as ERAS (enhanced recovery Te main objectives of the FTS are multidisciplinary after surgery/rapid recovery programs), is the latest multi- interaction at all stages of examination and treatment [1], modal treatment strategy designed to reduce disability pe- assessment of the applied protocol for compliance with the riods and improve the quality of medical care. Tis program FTS principles [2], careful selection of patients for the includes the preoperative stage preparation, minimally in- program for various reasons, including religious reasons, vasive surgical techniques, and active management of the which may hinder participation [3]. Tere is an assessment post-operative stage to reduce the treatment period, re- of the risks of using the protocol, which may increase the habilitation time and to provide the fastest possible return of likelihood of postoperative complications or negative out- patients to normal life. In this article, the FTS and ERAS comes due to the impossibility of adhering to the protocol 2 Advances in Urology (due to lifestyle or concomitant diseases) [4]. Te program Te clinical part of the study includes an analysis of the also includes a revision of the concept of preoperative and examination and treatment results of patients who un- postoperative food and liquid intake and bowel preparation derwent surgical interventions for urethral stricture from [5–7]. As well as changing opiate and opiate-like analgesics January 2019 to August 2020. Surgeries were performed to nonsteroidal drugs and others [8]; implementation of using anastomotic and augmentation/substitution methods. multimodal anesthesia allowing minimizing operational and Te inclusion criteria were as follows: post-operative stress in combination with early mobilization (i) Te patient is planned to have surgery of the urethra [9], intraoperative normothermia maintenance [10], control for urethral stricture or distraction defect of the of fuid [11], post-operative pain [9, 12], and nausea [13]. urethra Tere are critically little works on FTS in urethroplasty. (ii) Indications for surgery meet the criteria of the Selected studies and inventions evaluated applicability in the approved protocol developed protocol. Tis made it possible to apply the concept of using fbrin glue [14] and platelet-rich plasma (iii) Te operation is planned using one of the methods (PRP) [15]. Te submucosal PRP injection for internal approved in the study optical urethrotomy signifcantly reduces the risk of re- (iv) Patients are over 18 years old currence (9.09% vs 26.82%, p 0.032) in the long-term (v) Te patient signed a voluntary informed consent to postoperative period [16]. participate in the study Currently, the number and quality of randomized re- (vi) Te patient is deliberately planned to follow the searches devoted to the fast track protocols in reconstructive treatment protocol (FTS or standard), determined urology are extremely small. At the same time, the problem of by randomization until the day of surgery preoperative preparation, optimization of surgical techniques, and acceleration of postoperative rehabilitation remain relevant, Noninclusion criteria were as follows: since there have been no signifcant changes in approaches to Lack of medical indications; perioperative management of patients over the past ten years. (i) Te patient did not sign the voluntary informed Te scientifc novelty of the study is due to several factors. consent form to participate in the study A set of fast track and ERAS measures will be evaluated for patients with planned urethroplasty, aimed at improving all (ii) Te concomitant diseases that signifcantly afect aspects of treatment (patient and medical staf satisfaction with the patient’s objective status (decompensated di- treatment, increased treatment efectiveness, improved fnan- abetes mellitus, heart failure, gross neurological cial efciency of treatment, and accelerated rehabilitation of defcits, etc.) patients after treatment). For the frst time, there will be (iii) Failure to comply with the FTS protocol a comparative analysis of the immediate and long-term results Exclusion criteria we as follows: of the application of the developed principles and the standard approach. Te study will present the evaluation of post- (i) Te patient refused to participate at any stage of operative complications associated with various methods of the study treatment; the results of the application of the developed and (ii) For any reason, there was a deviation from the traditional approaches; and predictors of complications in the research protocol long-term postoperative period. (iii) Te patient did not have surgery for any reason or Research objectives: to develop and adapt the FTS underwent another surgery that does not meet the protocol for patients with planned urethroplasty; to increase group’s criteria the overall and fnancial efciency of surgical treatment; to assess the impact of the compared approaches on the Te null hypothesis of the study was that there were no condition of patients and their satisfaction with the treat- between-group diferences on the primary point. If the null ment; to analyze the immediate and long-term results; and to hypothesis was rejected, the alternative hypothesis was that develop recommendations for the developed protocol of FTS there was an intergroup diference at the primary endpoint. urethroplasty. Taking the results of earlier studies on similar subjects, it Te study aims to analyze the efectiveness of Enhanced was calculated that 13–15 (t-test, ES � −1.136) patients in Recovery Protocol in a comparative study for elective ure- each comparison group would be sufcient to reproduce thral stricture surgery. diferences in success and postoperative status with odds of type 1 and type 2 error of 0.05 and 0.2, respectively. Study power is >0.8. To compensate for incomplete observations, 2. Materials and Methods the estimated sample size was increased by 10%. 2.1. Research Design. Te local ethics committee of the Tus, the required total sample size (two patient com- Irkutsk State Medical University (ISMU) and the Irkutsk parison groups) should be at least 33 patients. City Clinical Hospital No. 1 approved the clinical trial. Tere Te recruitment of patients who met the inclusion was a prospective, blind, randomized, and single-center criteria was carried out prospectively using the continuous study in the urological hospital of the Irkutsk City Clini- sampling method until the desired sample size was reached. During the indicated period, 123 patients had the diagnosed cal Hospital No. 1. Advances in Urology 3 stricture disease of the urethra. Only 94 patients met the Upon reaching three months after the surgery, all pa- study inclusion criteria. All included patients were ran- tients at least once every six months or once a year had to domized (simple randomization method) into two groups undergo the standard assessment of the state established by based on the approved study protocol. Te frst group fol- the study protocol as follows: consultation with a urologist, lowed the FTS treatment protocol (approved by the ethical clinical blood and urine tests, urethrography, urethroscopy, committee of the ISMU); the second group followed the urofowmetry, and ultrasound of the urinary system. Pa- standard treatment protocol (Figure 1). tients assessed the subjective status using the IPSS, QoL, Tus, the fnal clinical analysis included 54 patients (per- IIEF-5 scales, and gave complaints. protocol) who met all the study criteria. Tey formed two Tere were several criteria to assess the treatment ef- groups. Te group of patients with the standard treatment fectiveness: the maximum urine fow rate (by urofowmetry), protocol (n � 29, the group I), and the group with the FTS the diameter of the urethral lumen in the plastic zone protocol (n � 25, group II). (according to urethrography), the volume of residual urine (ultrasound assessment), and the indices of rating scales (IPSS, QoL, and IIEF-5). Successful (free from a relapse) 2.2. Checkpoints. Te study has checkpoints. were considered the results of treatment with the following Te primary “hard” checkpoints were the absence of parameters 3 months or more after surgery: Q more than max recurrence of urethral stricture in the late postoperative 12 ml/sec; absence of residual urine, signs of recurrence period (but not earlier than three months); and detected according to urethrography data (normal diameter of the relapse at any stage of postoperative follow-up. urethral lumen in the plastic zone is 5 mm or more); and Secondary “soft” checkpoints of clinical efcacy were the absence of severe LUTS, unsatisfactory quality of life. data of the subsequent postoperative examination: maxi- Te treatment results were evaluated based on a com- mum urine fow rate of more than 12 ml/sec, residual urine prehensive analysis of the parameters of all primary and volume less than 50 ml, indicators of the IIEF-5, IPSS, QoL secondary endpoints. Te absence of relapse and adequate scales, and no signs of recurrence according to urethrog- urination do not provide an accurate indication of satis- raphy data (diameter of the urethral lumen more than faction with treatment and the patient’s quality of life after 5 mm). surgery. Terefore, interpretation of the results requires consideration of all factors. Table 3 presents the treatment results divided into three groups. 2.3. Study Groups Comparison. Table 1 presents the com- parative data on the initial parameters of patients in the study groups. 2.5. Statistical Analysis. Te initial data and surgical treat- Table 2 presents comparative data of the results of an ment results were analyzed using STATISTICA software for objective examination and the state of the functional status Windows version 10.0 (Statsoft, Inc, USA), SPSS Statistics of the comparison groups. version 23.0 (IBM, USA), and Stata version 16.0 (StataCorp, USA). Simple and multiple logistic regressions helped to 2.4. Diagnostic Methods. Te examination included anam- identify predictor variables for a binary response variable. To nestic (to establish the duration of the disease, concomitant determine the predictors of post-operative complications diseases, etc.), clinical, biochemical, ultrasound, tomo- development there was a univariate and multivariate logistic graphic, radiological, and endoscopic research methods. regression analysis. Te predictor variables were selected To clarify the nature and degree of pathological changes according to the initial and closest parameters (partially in the urethra there was urethrocystography (X-ray or presented in Tables 1, 2, and 4, more than 100 in total). Cox MSCT) and urethrocystoscopy. An ultrasound helped to proportional risks regression helped to assess the correlation assess the volume of residual urine and the volume of the between one or more continuous or categorical variables and prostate, urofowmetry data showed the maximum urine the time to an adverse event. Te signifcance level for all fow rate (Q ). When visiting a doctor, patients had to max methods is p≤ 0.05. assess their subjective state and functional status according to the recommended scales for assessing lower urinary tract symptoms (LUTS/IPSS), quality of life (QoL), erectile 2.6. Treatment Protocols. During the study, there were the following two diferent treatment protocols: standard (group function (IIEF-5), and other parameters. Te visual analog scale of pain (VAS) helped to assess the severity of post- I), when the patient was prohibited from drinking and eating on the day of surgery, underwent bowel cleansing the night operative pain syndrome. Tese assessments of the sub- jective state were as follows: 0-1 points-no pain; 2-3 points- before and the morning of surgery, and received a sedative slight pain; 4-5 points-moderate intermittent pain; 6- (diazepam). Intraoperatively, absorbable suture material was 7 points-moderate persistent pain; 8-9 points-severe pain; used for individual interrupted sutures, including monop- more than 10 points-unbearable pain. olar diathermocoagulation, separately interrupted skin su- Before removal of the urethral catheter, there was ture, and standard dressings. On the frst day after the a pericatheter urethrography to assess a possible defect in the surgery, only liquid intake was allowed, food intake was tightness of the urethra and to resolve the issue of prolonged allowed from the second postoperative day. In the post- urethral drainage. operative period, on the frst day after the operation, 4 Advances in Urology Patient recruitment Primary screening (n= 123) Excluded (n= 29) (i) According to criteria (n= 2) (ii) Refusal to participate (n= 17) Randomized (n=94) Standard Protocol (n= 47) FTS protocol (n= 47) (i) Received distribution (n= 47) (i) Received distribution (n= 47) (ii) Did not receive distribution (n= 0) (ii) Did not receive distribution (n= 0) Observations Lost for observation Lost for observation (i) Died (n= 1) (i) Died (n= 0) Analysis Protocol analysis (n= 25) Protocol analysis (n= 29) (i) Excluded from analysis (n= 22) (i) Excluded from analysis (n= 18) Figure XXX CONSORT (ii) Crossover (n = 0) (ii) Crossover (n = 0) Figure 1: CONSORT research diagram. anesthesia with narcotic analgesics was performed as Platelet-rich plasma (PRP method) and fbrin glue needed. Te patient was mobilized on the second day after (i-PRF and Superfbrin method) were obtained by centri- the surgery. Infusion therapy was performed within the frst fugation (“Armed” centrifuge) in special tubes from the 24–48 hours. Antibiotic therapy was carried out during the patient’s peripheral venous blood. entire hospitalization. Te minimum recommended hospital stay after surgical treatment was 7 days. Te urethral catheter 2.7. A Clinical Example of the ERAS Protocol in Urethroplasty. was removed 10–21 days after surgery. Patient K., 62 years old, presented with the following Table 5 shows the FTS protocol scheme (group II). complaints: inability to urinate adequately and presence of Te fnal choice of the method of surgical treatment was cystostomy. From the medical history it is known that made in advance and corrected intraoperatively. Te main urethral stricture was detected accidently. A cystostomy was types of operations were anastomotic urethroplasty (EPA) in inserted in 2021 due to acute urinary retention. TRUS the form of the classic Turner-Warwick/Webster operation revealed prostate volume of 20.7 cm . An urethrogram on [17, 18], vascular-sparing methods [19], intraurethral the 22.12.20 revealed a bulbo-membranous stricture of the anastomosis [20], and buccal mucosa graft urethroplasty urethra with narrowing of the lumen up to 1 mm. On using various techniques (Asopa [21], Barbagli [22] and December 29, 2020, a prostatic TUR and an internal optical others), as well as the original minimally invasive urethrotomy were performed and the cystostomy was technique [23]. preserved. In the postoperative period urination was not All patients in both groups used neuraxial analgesia, restored. On control urethrocystoscopy and MSCT- prophylaxis of thromboembolic complications (low mo- urethrocystography the diagnosis was bulbo-membranous lecular weight heparins), and protection from stress ulcers urethral stricture, recurrence, complication of underlying (proton pump blockers). Te severity of the postoperative secondary chronic cystitis, chronic urinary retention, cys- pain syndrome was possible to assess according to the visual tostoma, and hospitalized as planned for surgical treatment analog scale of pain (VAS) on the frst day after surgical of urethral stricture. treatment. Advances in Urology 5 Table 1: Comparative characteristics of patients in comparison groups before surgery. Indicator Group I (n � 29) Group II (n � 25) p General indicators: Age (years) 51.0 (±16.8) 53.6 (±13.1) 0.527 Height (cm) 173.4 (±6.8) 172.8 (±5.0) 0.719 Weight (kg) 73.8 (±12.7) 81.8 (±17.4) 0.057 Anamnesis: Duration of the established disease (months) 24 (6; 60) 24 (12; 60) 0.645 Smoking, n (%) 18 (62.0%) 15 (60%) 0.939 Contacts with harmful substances, n (%) 6 (20.6%) 6 (24%) 0.816 Allergic anamnesis, n (%) 2 (6.8%) 3 (12%) 0.557 Cystostomy, n (%) 13 (44.8%) 9 (36%) 0.668 Urological operations and manipulations: Traumatic catheterization, n (%) 9 (31.0%) 6 (24%) 0.664 Bougie of the urethra, n (%) 10 (34.4%) 10 (40%) 0.776 Optical urethrotomy, n (%) 7 (24.1%) 7 (28%) 0.804 EPA, n (%) 10 (34.4%) 4 (16%) 0.232 BMG urethroplasty, n (%) 6 (20.6%) 3 (12%) 0.468 TUR of the prostate, n (%) 5 (17.2%) 2 (8%) 0.374 TUR of the bladder, n (%) 2 (6.8%) 4 (16%) 0.343 Prostate surgery, n (%) 0 (0%) 3 (12%) 0.070 Te etiology of urethral stricture: Trauma, n (%) 12 (41.3%) 6 (24%) 0.336 Iatrogenic, n (%) 14 (48.2%) 14 (56%) 0.750 Te infammatory, n (%) 1 (3.4%) 2 (8%) 0.491 Idiopathic, n (%) 2 (6.8%) 3 (12%) 0.557 Concomitant diseases: Ischemic heart disease, n (%) 7 (24.1%) 10 (40%) 0.367 Hypertension, n (%) 10 (34.4%) 12 (48%) 0.514 Diabetes mellitus, n (%) 2 (6.8%) 4 (16%) 0.343 Chronic urinary infection, n (%) 11 (37.9%) 4 (16%) 0.173 Hyperplasia of the prostate, n (%) 9 (31.0%) 6 (24%) 0.664 Medications: Medicines afecting erection, n (%) 7 (25%) 9 (36%) 0.484 A-blockers, n (%) 5 (17.8%) 3 (12%) 0.640 Note: EPA-excision and primary anastomosis; BMG-buccal mucosa graft; TUR-transurethral resection. Table 2: Te results of an objective examination and the state of the functional status. Indicator Group I (n � 29) Group II (n � 25) p Localization of the structure: Glans urethra, n (%) 2 (6.8%) 3 (12%) 0.557 Te penile urethra, n (%) 6 (20.6%) 1 (4%) 0.107 Te bulbar urethra, n (%) 18 (62.0%) 18 (72%) 0.730 Te membranous urethra, n (%) 13 (44.8%) 12 (48%) 0.887 Length of stricture, (mm) 20 (10; 40) 15 (10; 25) 0.780 Minimum diameter of the urethra, (mm) 1 (1; 2) 1 (1; 2) 0.277 Q , (ml/s) 7.1 (±2.6) 7.2 (±2.2) 0.920 max Volume of residual urine, (ml) 150 (90; 240) 130 (45; 230) 0.564 Fistulas or diverticula of the urethra, n (%) 3 (10.3%) 1 (4%) 0.408 Prostate volume, (cm3) 23.3 (±8.8) 26.0 (±7.9) 0.262 IIEF-5, score 14 (9; 18) 12 (8; 16) 0.423 Qol, score 5 (4; 5) 5 (4; 6) 0.167 IPSS, score 26 (23; 30) 28 (26; 34) 0.095 Note: Qmax-maximum fow rate; IIEF-Iinternational Index of Erectile Function; QoL–the quality of life; IPSS-International Prostate Symptom Score. Tus, the analysis of the main characteristics of patients in the comparison groups demonstrated their comparability (p> 0.05). 6 Advances in Urology Table 3: Evaluation of treatment results using the combined (multiple) endpoint methods. Parameter Good Satisfactory Unsatisfactory Absence of relapse + + − No severe pain syndrome (>5 points on the pain scale) in the post-operative period + − − No complications + − − Satisfaction with treatment + − − Table 4: Comparative data of the nearest results in patients of the comparison groups. Indicator Group I (n � 29) Group II (n � 25) p Hematoma in the operation area, n (%) 0 0 0 Graft necrosis, n (%) 0 0 0 Urethrorrhagia, n (%) 0 0 0 Subfebrile condition in the early postoperative period, n (%) 27 (93.1%) 7 (28%) 0.014 Infectious complications, n (%) 0 (0) 0 (0) 0 Urethral suture failure, n (%) 1 (3.4%) 0 (0) 0.356 Constant pain syndrome (VAS more than 5 points) on the frst day after surgery, n 23 (79.3%) 1 (4%) 0.003 (%) Postoperative pain level on the frst day, points 8 (6; 9) 4 (4; 5) <0.001 Te need for narcotic pain relief, n (%) 13 (44.8) 1 (4%) 0.007 Average length of hospital stay, bed-day 11.5± 3.4 3.8± 1.2 <0.001 Terms of catheterization, days 15.1± 3.3 6.2± 1.8 <0.001 Total time spent on treatment, days 27.3± 5.2 13.7± 2.4 <0.001 Postoperative incontinence due to surgery, n (%) 1 (3.4%) 0 0.356 Continent after surgery, n (%) 28 (96.5%) 23 (92%) 0.902 Satisfaction with the performed treatment, n (%) 17 (58.6%) 21 (84%) 0.397 Perioperative treatment was carried out according to the Patient is scheduled for surgery date. Hospitalization on claimed method. Mini-invasive intraurethral urethroplasty the day of surgery, three hours before the planned surgical with the use of oral mucosa graft was carried out (Vorobiev intervention. Self-preparation at home. Cleansing of bowel V.A., Beloborodov V.A. method of surgical treatment of has not been carried out. Shaving of the operative feld urethral narrowing//patent No 2694477 from 15.07.19). perineum, after pretreatment with skin antiseptic. Pre- Rehabilitation according to the claimed method was vention of venous thromboembolism—compression knit- carried out. wear and subcutaneous injection of Fraxiparin 0.3 ml. On admission the patient was premedicated with cele- In the preoperative period the detailed consultation about the possible principles of urethral strictures treatment, coxib 100 mg, gabapentin 600 mg, and omeprazole 20 mg the reasons of their occurrence and consequences of refusal once oral. Carbohydrate loading of 200 ml of maltodextrose from treatment has been carried out. Possible alternative mixture orally was performed. treatments such as endoscopic dissection, dilatation, anas- Antibacterial prophylaxis was carried out once tomotic urethroplasty, and others are presented. An over- 60 minutes before surgery according to the recommenda- view of the preoperative period, intraoperative nuances and tions. Preoperative urine culture with pathogenic microfora a description of the expected state in the postoperative growth and postoperative antibiotic therapy plan were made period and possible complications, as well as rehabilitation according to culture results. measures, are presented. Intraoperative method of anesthesia was epidural an- Immediately after the initial consultation, the patient’s esthesia. Te operation time was 50 minutes. A 14Fr silicone urinary catheter was inserted. Intraoperative heating of the consent to surgical treatment according to the principles of accelerated recovery is obtained. An examination plan was patient was carried out using an electric heating mattress. prescribed as part of the accelerated pathway. All exami- Heating of infusion solutions was carried out using a fow nations were carried out on the following day within three heater. Minimally invasive was perineal linear surgical access hours. Te indications and contraindications for surgery are of 2 cm. Te operation was performed using a 4.5x mag- reassessed on the basis of the examination results. A mul- nifying lens. Monopolar coagulation was not used. After tidisciplinary team discussion was carried out as follows: the performing a bulbar urethral access, a 2 cm transbulbar urologist, anesthetist, internist, radiologist, nurse, and re- access was performed. After removal of scar tissues, habilitator. Te possibility of adhering to the protocol on a 3 ×1 cm oral graft was taken from the left cheek under local anesthesia with lidocaine 2% 20 ml solution. Te defect was religious, ethical, social, and other grounds is assessed. Evaluated the need for prehabilitation: not identifed. Rec- sutured with Vicryl 3–0. Te graft was fxed in the formed bed with 5–0 monocryl continuous suture. Te urethrotomy ommended slagfree diet 2-3 days before surgery. Advances in Urology 7 Table 5: Te FTS protocol for the supervision of patients with urethroplasty for urethral stricture. FTS protocol for the urethroplasty: Preoperative period Intraoperative period Postoperative period Informing the patient about the disease, treatment options, and possible outcomes, indicating the average efectiveness, Preferred method of anesthesia-local anesthesia/ Early fuids intake (2-3 hours after surgery) and food (6 hours risks of complications, typical post-operative condition, multimodal anesthesia after surgery) timing of catheterization, hospitalization, possible methods of prerehabilitation, and further rehabilitation methods One-day concept-the patient undergoes most of the preoperative examinations in one day, without the need for multiple repreparation. Te order of examinations and tests is optimized and sorted to achieve the desired outcome Rigorous evaluation of indications for surgical treatment: Q < 12 ml/s max Heating of the patient during the operation with the Early activation (6–8 hours after surgery, after evaluation by an Urethral lumen diameter <4 mm control of normothermia anesthesiologist) Presence of residual urine Presence of urethral distraction defect Assessment of the possibility of patient compliance with the Physical therapy (breathing exercises, walking, and other Heating of infusion solutions and inhalation gases protocol and its feasibility in the medical institution exercises) Preventive administration of antihistamines and antacids Multimodal prevention of nausea and vomiting Minimally invasive surgical approaches drugs (metoclopramide + ondansetron) Te rejection of the use of monopolar coagulation and Removal of the urethral catheter after performing pericatheter Refusal of preoperative sedation resection urethrography no later than the seventh day after surgery Prerehabilitation based on indications: Age group Use of drugs that improve microcirculation, reparants, and Obesity Application of bipolar coagulation hyperbaric oxygenation (in the mode of 1.0–1.5 ATM, for Exhaustion 45 minutes, 5–10 sessions; in the absence of contraindications) Te sarcopenia Impaired carbohydrate tolerance or diabetes mellitus Preoperative antibiotic therapy according to the testimony: the presence of latent or obvious infection of the Te use of enzyme drugs (longidase, rectal suppositories) after Te rejection of coagulation on the spongy body of the genitourinary system (according to the results of 14 days after surgery in courses of 20 pieces with an interval of urethra bacteriological research, real-time PCR, and infection of 2 days every 6 months other organs Multidisciplinary examination of patients: Urologist Anesthetist Continuation of prevention of thromboembolic complications ENT doctor Sealed continuous urethral suture with 4–6/ by compression of the lower extremities and the use of Dentist 0 monoflament thread low-molecular-weight heparins General practitioner/Cardiologist Te radiologist physical therapy doctor And other specialists as needed 8 Advances in Urology Table 5: Continued. FTS protocol for the urethroplasty: Preoperative period Intraoperative period Postoperative period Performing CT/MRI of the small pelvis, CT/RI MRI of the urinary system, CT/RI MRI-urethrography with Use of platelet-rich plasma as injections into the Multimodal analgesia for pain control 3D-modeling, assessment of the state of the bone and joint submucosal layer of the urethra and surrounding tissues (Dexketoprofen + paracetomol) apparatus of the pelvis, organs A rich carbohydrate diet (if there are no contraindications) Use fbrin glue locally at the urethral seam Use of chewing gum on the frst and second day after surgery and 200 ml of liquid protein 2.5 hours before surgery Te last meal during the operation in the morning hours at Monitoring of blood and urine parameters on the frst day after 21-22 hours the day before, during the operation in the Use of silicone urethral catheters 14–16 ch surgery afternoon no later than 6 hours before the operation Antibiotic prophylaxis 60 minutes before surgery with 3rd Strict glycemic control in patients with impaired carbohydrate Te rejection of the use of drains generation cephalosporins tolerance and diabetes mellitus Shaving of the surgical feld with subsequent treatment with Sealed cosmetic skin seam with no loose ends or knots on A detailed discussion of the behavior of the patient and the solutions of skin antiseptics the skin rehabilitation plan before the discharge Oral rinsing with an aqueous solution of chlorhexidine Te adhesive bandage on the skin Detailed written instructions in the discharge documents during planned urethroplasty using buccal mucosa graft Prevention of thromboembolic complications by Strict plan of follow-up examinations in the post-operative compression of the lower extremities and administration of Intraoperative euvolemia period low-molecular-weight heparins Strict adherence to postoperative hygiene of the genitals (when Avoiding the use of cleansing enemas using an adhesive bandage, the patient is recommended to take a hygienic shower daily from the second day) Transfer of the patient to a slageless diet 2-3 days before Discharge from the hospital 1–3 days after the operation with the surgery transfer of the patient to outpatient observation Preparation of the intestines with laxatives or once Recommended return to work 2 days after removal of urethral microclysters catheter Advances in Urology 9 access is sutured with Monocryl 4–0. Sealing of the suture 2.8. Research Limitations. Limitations of the research were using Sulfacrylate adhesive was carried out. Reliable he- as follows: relatively small sample size, the average post- mostasis must be achieved. No drainage was performed. operative follow-up period of fewer than two years, single- Closure of the perineal access with Monocryl 4−0 in layers center study, mixing of various surgical techniques, and was carried out in continuous sutures. Cosmetic skin sutures diferent localizations of strictures within the protocol was carried out with Sulfacrylate adhesive dressing. Intra- (anastomotic, substitution, and others). operatively, prevention of postoperative nausea and vom- iting was performed—dexamethasone 4 mg and 3. Results ondansetron 4 mg intravenously. 3.1. Immediate Results. To compare the immediate results of After the operation, the patient was transferred to surgical treatment of urethral stricture disease after the a postoperative ward for 3 hours. Intraoperative pain standard treatment protocol (group I) and after the FTS management continued in the postoperative period protocol (group II) there was a comparative analysis of the according to the “no pain” principle, i.e. prevention rather postoperative parameters of the patients’ condition and the than elimination of pain. After the end of the epidural examination results. anesthesia the patient was prescribed oral celecoxib 100 mg In the early and late postoperative periods, there were no and acetaminophen 250 mg every 6–8 hours during the frst cases of mortality in the two groups. In the early and late postoperative day. Te use of maltodextrose mixture is postoperative periods, there were no complications of an- suggested one hour after surgery. Postoperative consump- esthetic treatment or deterioration of the general somatic tion of solid food is allowed 2 hours after surgery. Plant- status. Te need for mechanical ventilation or respiratory based chewing gum is recommended to reduce the risk of support did not arise in any case in the comparison groups. postoperative functional bowel disorders and for the pur- Tere were also no cases of heart failure that required pose of local antiseptic action. inotropic support. Te patient is activated 6 hours after the operation, Intergroup analysis of the size of the surgical approach following the cessation of epidural anesthesia. Activation showed that its average linear dimensions of group I were involves sitting and walking. Glycemic control on the frst 7.1± 2.1 cm, which is signifcantly greater than of group II and second post-operative days, no correction was neces- (3.3± 1.2 cm, p< 0.001). sary. On the second postoperative day, a control clinical Tere was a chronometric analysis of the operating blood count was performed. Postoperative antibiotic therapy period. Te average duration of surgery in groups I and II was carried out according to the culture data—levofoxacin were 1.2± 0.35 hours and 1.1± 0.31 hours, respectively 500 mg once a day, 5 days. Wound treatment was not carried (p � 0.273). out. Independent daily hygiene-showering was Table 4 shows the comparative characteristics of the recommended. postoperative state indicators of patients in the comparison Prophylaxis of venous thromboembolism was con- groups. tinued—compression knitwear was worn until 21 days after Te results analysis showed that in both comparison the operation, plenty of fuids were administered and groups and postoperative complications in the early and late Fraxiparin 0.3 ml was injected intravenously until discharge. periods developed extremely rarely. Te patient was discharged from the hospital to outpatient It should be noted that the development of incontinence care on the third postoperative day. and failure of the urethral suture occurred only in one case. Te urethral catheter was removed 7 days after surgery, Tus, univariate logistic regression analysis of these in- after a control pericatheter urethrocystography to assess dicators did not reveal a statistically signifcant correlation possible urine leakage from the access line. with the initial parameters (p> 0.05) in the comparison Daily contact with the attending physician via phone groups. calls and messenger for the frst 10 days, then once every 2- Table 6 presents the information on predictive factors for 3 days for up to a month. Monthly thereafter for one year. the occurrence of post-operative complications (univariate Check-ups and follow-ups ultrasound on the 3rd, 7th, 10th, and multivariate logistic regression analysis, the table in- 20th, and 30th day and then after 3, 6, and 12 months. cludes signs with a level of χ > 1 and p< 0.05). In 14 days after surgery, the use of the drug Longidase A simple (univariate) logistic regression analysis among was recommended under the scheme of 1 suppository 54 patients of both comparison groups revealed that some rectally once every 2 days, indicators acquired special signifcance in predicting the No intraoperative or postoperative complications≥ II development of subfebrile condition in the early post- according to Clavien-Dindo classifcation were registered in operative period – the results are presented in Table 6. the patient. Te patient was discharged in a satisfactory Te obtained results helped to build a model for pre- condition on the 3rd day after surgery. dicting subfebrile status in multivariate regression analysis According to the control urethrocystography and ure- (selection from predictor factors with a signifcance level of throscopy one year after surgery, there were no signs of p< 0.05). Low subjective assessment of the quality of life urethral stricture recurrence. Te diameter of the urethra in (more than 4 points; Coefcient 1.5; 95% CI 0.1; 2.9; the urethroplasty zone was 6.5 mm. Quality of life indicators p � 0.035), as well as the size of the surgical access (for each were in line with population averages. 10 Advances in Urology Table 6: Predictors of postoperative complications. Complications in the Univariate analysis Multivariate analysis early and late Predictor χ Coefcient (95% CI) p Coefcient (95% CI) p post-operative period Standard protocol 26.99 3.5 (1.8; 5.2) <0.001 2.3 (−1.2; 5.9) 0.208 Te quality of life 5.54 0.76 (0.06; 1.4) 0.033 1.5 (0.1; 2.9) 0.035 Subfebrile Diabetes 6.16 2.3 (0.16; 4.6) 0.035 3.4 (−3.6; 10.4) 0.340 Condition Vascular atherosclerosis 4.97 1.3 (0.14; 2.5) 0.029 1.3 (0.94; 3.6) 0.246 Multivariate logit regression: Surgical access size 28.07 0.85 (0.39; 1.3) <0.001 1.09 (0.2; 1.98) 0.016 χ � 45.75; p< 0.0001 Pain more than 5 points on the VAS scale 17.04 2.8 (1.1; 4.4) 0.001 0,77 (−10,4; 3,6) 0.874 Use of narcotic analgesics 8.63 2.4 (0.33; 4.5) 0.023 3.3 (−6.6; 13.4) 0.509 Pelvic bone injury (history) 10.88 2.8 (0.66; 4.9) 0.010 2.6 (−2.0; 7.35) 0.263 Progression of urethral stricture 8.61 1.77 (0.5; 3.02) 0.005 0.3 (−2.6; 3.2) 0.841 Persistent pain syndrome, >5 points on the VAS scale Urohematomas (history) 7.5 1.8 (0.41; 3.3) 0.011 0.99 (−1.9; 3.9) 0.514 Multivariate logit regression Penile strictures 5.89 2.2 (0.7; 4.46) 0.043 5.41 (0.55; 10.2) 0.029 χ � 7,78; p< 0.001 (0.0001) Duration of surgery 5.88 2.1 (0.27; 3.9) 0.024 2.3 (−7.4; 2.7) 0.364 Surgical access dimensions 44.14 1.2 (0.6; 1.77) <0.001 1.29 (0.45; 2.13) 0.002 Note: VAS-a visual analog scale of pain. Advances in Urology 11 1 cm; Coefcient 1, 09; 95% CI 0.2; 1.98; p � 0.016). Te rest diabetes mellitus in the long-term postoperative period of the factors were not signifcant (p > 0.05). (Coefcient 3.92; 95% CI 0.09; 7.7; p � 0.045) was a signif- Te independent predictors of persistent pain syndrome icant predictor of this complication. Consequently, after found by simple logistic regression analysis (presented in performing urethroplasty surgeries, the risk of developing Table 6) were included in further analysis. Localization of the infectious complications in the long-term period increases urethral stricture in the penile part of the urethra (Co- with decompensation of diabetes mellitus. efcient 5.41; 95% CI 0.55; 10.2; p � 0.029), as well as the size Te obtained results helped to construct a model for of the surgical access (for each 1 cm; Coefcient 1.29; 95% CI predicting penile shortening in multivariate regression 0.45; 2.13; p � 0.002), became signifcant predictors of analysis (selection from factors p< 0.05). A signifcant persistent pain syndrome. Te rest of the factors were not predictor of this complication was the length of the urethral signifcant (p > 0.05). stricture more than 3 cm (coefcient 2.87; 95% CI 0.08; 5.67; Table 7 shows postoperative indicators of urodynamics, p � 0.043). Consequently, urethroplasty for patients with objective, and functional status (IPSS, QoL, and IIEF-5) in a urethral stricture longer than 3 cm increases the risk of the comparison groups. penile shortening. Tere was a comparative intergroup analysis of these Tere was a statistical analysis of overall survival. Te indicators. Te groups were comparable according to the Kaplan–Meier estimates of the survival rate of group II results of an objective examination, the state of urody- patients during the entire observation period after ure- namics, and functional status in the early and late post- throplasty were equal to 100%. Te values of the operative periods (p> 0.05). Kaplan–Meier estimates of the survival rate of group I patients during the entire observation period (up to 2 years) were 96.3± 3.63% with a 95% CI of 76.4–99.4%. Te log- 3.2. Long-Term Results. Long-term results of surgical rank test did not reveal statistically signifcant diferences in treatment of stricture disease were possible to assess the survival rate in the long-term post-operative period in according to the control endpoints of the examination. Te the comparison groups (p � 0.335), which is graphically presented by the Kaplan–Meier method in Figure 2. average period of clinical observations was 468 days with 95% CI 423–513, and the maximum period was 721 days. Cox proportional hazards regression analysis showed no Table 8 presents general indicators of the long-term post- reliable predictor of mortality in the long-term post- operative period in the comparison groups. operative period. Probably, such a result of the statistical For group I, the average observation period was 469 days analysis is due to the small representation of the factor (a with a 95% CI of 401–537 days (maximum period of single case of mortality). 705 days). For group II, the average observation period was Te analysis of the dependence of mortality on general 466 days with a 95% CI of 403–529 days (maximum period surgical technical reasons was not performed due to the of 721 days). absence of such. Te survival rate for this parameter for both In the long-term postoperative period, there was a single groups was 100% over the entire observation period. episode of mortality in group I, which was not associated Table 10 presents comparative information on the success of surgical treatment in the comparison groups. with surgery. Tere were few signifcant complications in the long- In the frst group, out of 29 primary operations, 25 were term postoperative period. In 3 (10.3%) cases from group I successful (86.2%). In the second group, 23 out of 25 primary and 2 cases (8%) from group II, there was an acute in- operations were successful. Tus, the primary efciency was fammatory process of the genitourinary system in the pe- 92%. riod from 3 to 12 months, which required the antibacterial Te Kaplan–Meier estimates the absence of recurrence of drugs (p � 0.786). urethral stricture in group I as 93.1± 4.7% during the frst 7 (24.1%) patients of group I and 5 (20%) patients of three months (95% CI 75.1–98.2%), after a year–89.5± 5, 7% group II (p � 0.770) presented complaints of penile short- (95% CI 70.9–96.5%) and after two years—78.3± 11.6% ening during active questioning 3 months after surgery. (95% CI 44.8–92.8%). Tese indicators for group II during To determine the predictors of the development of the the frst three months were 100% and after one and two years above complications, there was univariate and multivariate —90.3± 6.5% (95% CI 66.3–97.5%). logistic regression analysis. Te predictor variables were Te log-rank test did not reveal statistically signifcant selected according to the initial and closest parameters diferences (p � 0.512; χ � 0.43) in the recurrence rate over (partially presented in Tables 1, 2, 5, and 7, more than 120 in the entire observation period, which is graphically expressed total). Information on predictive factors for the occurrence by the Kaplan–Meier method in Figure 3. of postoperative complications in the long-term post- Te predictor variables were selected according to the operative period (univariate and multivariate logistic re- initial parameters, as well as according to the control pa- gression analysis, the table includes signs with χ > 1 and rameters in the postoperative period. Table 11 presents a Cox p< 0.05) are presented in Table 9. proportional hazards regression model showing the efect of Te obtained results allowed constructing a model for variables on recurrence risk. the prognosis of infectious complications in the long-term Multivariate Cox proportional hazards regression postoperative period in multivariate regression analysis analysis (sample of p< 0.05) demonstrated the signifcance (selection from factors p< 0.05). Decompensation of of urethral suture failure (HR 4.36; 95% CI 1.6; 7.11; 12 Advances in Urology Table 7: Postoperative indicators of urodynamics, objective, and functional status (IPSS, QoL, and IIEF-5) in comparison groups. Parameter Group I (n � 29) Group II (n � 25) p IPSS, score 5 (2; 8) 4 (2; 7) 0.564 IIEF-5, score 15 (11; 18) 14 (9; 18) 0.794 QoL, score 1 (1; 2) 1 (1; 1) 0.187 Q , (ml/sec) 15.5± 2.7 17.0± 3.1 0.065 max Residual urine volume, ml 0 (0; 0) 0 (0; 0) 0.931 Achieved urethral lumen diameter in the operation area, mm 5.1± 1.2 5.6± 1.3 0.106 Note: IPSS-International Lower Urinary Tract Symptom Scale; IIEF-5-International Index of Erectile Function; QoL-the quality of life; Q -maximum urine max fow rate. Table 8: General indicators in the long-term period. Indicator Group I (n � 47) Group II (n � 47) Dropout patients, n (%) 18 (38.2%) 22 (46.8%) Te number of patients who completed the study, n (%) 29 (61.7%) 25 (53.1%) Nonlethal patients, n (%) 28 (96.5%) 25 (100%) Long-term general mortality, n (%) 1 (3.4%) 0 (0%) Urological mortality, n (%) 0 (0) 0 (0) Relative risk of death, (%) I/II–98.182% Reducing absolute risk I/II–1.818% Reducing relative risk I/II–54.545% A chance to die in a distant period 3.4% 0% p � 0.002) in predicting a possible recurrence after ure- rehabilitation and restoration of working capacity also re- throplasty surgery. main relevant. Analyzing the comparative intergroup efectiveness of A few interesting results were obtained in the presented the treatment based on the criteria established in the study, study. Te overall efcacy of urethroplasty operations, re- good treatment results obtained 5 (17.2%) patients of group I gardless of the treatment protocol, was comparable and 20 (80%) patients in group II (p � 0.0049). Satisfactory (p � 0.870), as well as the likelihood of recurrence within results obtained 20 (68.9%) patients of group I and 3 (12%) 2 years (p � 0.512). Te results obtained are consistent with patients of group II (p � 0.0055). Unsatisfactory results the data of other authors; the average efciency of ure- obtained 4 (13.7%) patients in group I and 2 (8%) patients in throplasty operations, regardless of the location and length group II (p � 0.544). of the stricture, when using anastomotic or replacement Terefore, the use of the FTS protocol after urethroplasty methods is 85± 10% [24–27]. allows achieving better treatment results than the classical In the development of relapse, a special role (according approach. Both methods of urethroplasty had zero operating to multivariate Cox proportional hazards regression) played and hospital mortality and a low incidence of postoperative technical complications and failure of the urethral suture general and urinary system-related complications. Both (OR 4.36; 95% CI 1.6; 7.11; p � 0.002). Te FTS protocol for methods are highly efective and safe. However, the classical urethroplasty surgery ofers several simple techniques to approach is associated with longer disability and worse minimize this risk. First, it is proposed to use only a con- tinuous and sealed urethral suture; second, the suture is subjective perception and objective assessment of the per- ioperative period for patients. additionally treated with fbrin glue; and third, the sur- rounding tissues are infltrated by platelet-rich plasma. Te 4. Discussion use of platelet-rich plasma can reduce the zones of necrosis, the severity of local infammation, and improve angiogen- Modern surgery, including urology, has many tools and esis, which has been confrmed by several works [16, 28, 29]. techniques that facilitate the perioperative period for both Fibrin glue provides better tightness, reliable fxation of the the patient and the healthcare organization. However, the graft, reduces the risk of periurethral leakage [14], and the complexity of preoperative diagnosis, its duration and cost, risk of fstula formation [30]. Tere is evidence of the and operational and postoperative surgical stress reduce the successful use of a mixture of fbrin and cyanoacrylic glue for quality of medical care. Urology is one of the leaders in the treatment of vesicourethral anastomoses leak after minimal invasiveness, making the most of endovideosurgery prostatectomy [31]. and endoscopy. Tat is why, according to the authors, of Predictors of complications were assessed separately. Tus, particular interest is the development of protocols for en- the use of anastomotic methods of urethroplasty increases the hanced recovery in urology. Tus, a typical urological risk of complaints of shortening of the penis with strictures problem postoperative pain remains relevant. Te longer than 3 cm. Decompensation of diabetes mellitus in the Advances in Urology 13 Table 9: Predictors of the complications in the long-term postoperative period. Univariate analysis Multivariate analysis Complications in the Predictor 2 2 2 long-term postoperative period χ Coefcient (95% CI) χ Coefcient (95% CI) χ Bladder cancer (history) 4.02 2.3 (0.18; 4.46) 0.033 −1.6 (−7.1; 3.7) 0.543 diabetes mellitus, and decompensation 12.59 3.8 (1.3; 6.22) 0.002 3.92 (0.09; 7.7) 0.045 Long-term infectious complications multivariate logit regression CVI 5.08 2.75 (0.47; 5.03) 0.018 2.2 (−2.4; 6.9) 0.343 χ �16.58; p � 0.0110 Vascular atherosclerosis 5.57 2.4 (0.12; 4.68) 0.039 0.07 (−3.7; 3.8) 0.969 Urethral lumen diameter (fnal) 4.12 −0.6 (−1.3; −0.08) 0.047 −0.27 (−2.6; 2.1) 0.826 Qmax (fnal) 5.55 −0.3 (−0.5; −0.04) 0.020 −0.08 (−1.0; 0.8) 0.866 Post-traumatic stricture 11.60 2.39 (0.89; 3.8) 0.002 2.03 (−1.0; 5.1) 0.202 Pelvic injury 13.57 2.87 (1.2; 4.51) 0.001 1.78 (−2.1; 5.7) 0.377 Distraction defect of the urethra 19.55 4.05 (1.75; 6.3) 0.001 0.06 (−4.4; 4.5) 0.977 Shortening of the penis Cystostomy 7.53 1.9 (0.43; 3.3) 0.011 1.4 (−1.03; 3.99) 0.249 multivariate logit regression Previous EPA 4.27 1.4 (0.07; 2.81) 0.038 −0.79 (−4.5; 2.9) 0.682 χ � 29.28; p � 0.0003 Unsuccessful treatment (history) 7.36 1.85 (0.46; 3.25) 0.009 0.11 (−2.8; 3.03) 0.939 Inadequate EPA (history) 8.86 2.12 (0.69; 3.56) 0.004 0.26 (−3.3; 3.87) 0.884 Urethral stricture> 30 mm 15.51 2.94 (1.36; 4.52) <0.001 2.87 (0.08; 5.67) 0.043 Note: CVI-chronic venous insufciency; Q -maximum fow rate; EPA-anastomotic urethroplasty. max 14 Advances in Urology Kaplan-Meier survival estimates I group II group 0.75 0.5 0.25 0 200 400 600 800 0 200 400 600 800 analysis time 95% CI Survivor function Groups I - standart protocol; II - FTS protocol Figure 2: Kaplan–Meier curve (the ratio of the number of patients without death to the duration of follow-up) of patient survival in the comparison groups. Table 10: Comparative data on the success of urethroplasty operations in the comparison groups in the long-term period. Indicator Group I (n � 29) Group II (n � 25) p Successful primary, n (%) 25 (86.2%) 23 (92%) 0.870 True relapse, n (%) 4 (13.7%) 2 (8%) 0.544 Kaplan-Meier survival estimates I Group II Group 0.75 0.5 0.25 0 200 400 600 800 0 200 400 600 800 analysis time 95% CI Survivor function Groups I - standart protocol, II - FTS protocol Figure 3: Absence of relapse in study groups according to the Kaplan–Meier method. Table 11: Cox proportional hazards regression model. Cox multivariate analysis, Univariate Cox analysis χ �13.19; p � 0.0217 Variable Wald χ HR (95% CI) p Or (95% CI) p Hemorrhoids 5.80 8.4 (1.6; 41.8) 0.009 2.35 (−0.05; 4.77) 0.055 Bladder cancer (history) 3.19 6.1 (1.02; 36.87) 0.046 1.14 (−2.1; 4.43) 0.493 Chronic venous insufciency 3.3 6.1 (1.12; 33.5) 0.036 −0.93 (−4.6; 2.8) 0.625 Inconsistency of the urethral suture 4.17 25.6 (2.32; 282.9) 0.008 4.36 (1.6; 7.11) 0.002 Infectious complications 3.07 5.64 (1.03; 30.92) 0.046 1.0 (−2.14; 4.15) 0.513 Advances in Urology 15 postoperative period increases the likelihood of an acute in- Conflicts of Interest fection of the genitals and lower urinary tract. Without con- Te authors declared no potential conficts of interest with sidering the data of univariate analysis, the results obtained are respect to the research, authorship, and/or publication of consistent with the results of similar studies [32, 33]. 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