Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database

Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database Riccardo Autorino, Leslie Claire Licari, Eugenio Bologna, Celeste Manfredi, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3870823/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 May, 2024 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction and objectives: Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH), whose treatment options range from conservative or endoscopic approaches to more invasive ones. This study aimed to evaluate the contemporary incidence of US after different types of BPH surgery, to identify associated risk factors and to assess its management. Methods A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US. Results Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%). Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after Robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) was the primary management in most cases (76.7%). Conclusions The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (< 5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU. Health sciences/Diseases/Urogenital diseases/Prostatic diseases Health sciences/Medical research/Outcomes research Benign Prostatic Hyperplasia TURP MIST Urethra Iatrogenic Urethral Stricture Urethroplasty Urethrotomy Urethral dilatation Figures Figure 1 1. Introduction Benign Prostatic Hyperplasia (BPH) is a prevalent condition among aging males, representing the most common etiological factor for lower urinary tract symptoms (LUTS) in this population [ 1 ]. The management of symptomatic BPH is often multimodal. In selected cases, or when pharmacological treatments lose efficacy, a surgical intervention is indicated [ 2 ], [ 3 ]. For decades, transurethral resection of the prostate (TURP) represented the gold standard. The introduction of new minimally invasive surgical therapies (MIST) with the aim of reducing the incidence of treatment-related morbidity, has significantly broadened the spectrum of management options available for BPH treatment [ 4 ]–[ 8 ]. These advances have allowed for a more tailored approach to symptomatic BPH, considering both clinical features and patient preference [ 9 ]–[ 11 ]. Despite notable improvements in surgical techniques, the incidence of late complications such as urethral stricture (US) has not declined [ 12 ]. As a matter of fact, BPH surgery still represents the most common cause of iatrogenic stricture disease, accounting for up to 41% of all cases [ 13 ]. The development of urethral strictures in this setting is attributed to several etiological factors, including the use of wide caliber surgical devices, mechanical or energy induced damage, urinary tract infections, prolonged surgical time, and extended catheterization time [ 14 ], [ 15 ]. The incidence of urethral stricture disease after BPH procedures has been variably reported, ranging from 1% to 10–12% [ 16 ]–[ 19 ]. Its onset is typically 6–12 months [ 20 ]. The clinical relevance of US after new surgical approaches remains to be determined [ 21 ]. The management of urethral strictures can span from conservative options, such as observation and suprapubic tube placement, to endoscopic treatments, such as direct vision internal urethrotomy (DVIU) and urethral dilatation (UD), to more invasive options, such as urethroplasty procedures. Iatrogenic US can be particularly challenging to manage, since less invasive treatment options carry a considerable risk of recurrence [ 22 ], [ 23 ]. Urethral reconstructive surgery on the other hand, has demonstrated greater long-term success rates. Such evidence has prompted guidelines to consolidate the role of urethroplasty in managing recurrent US and to expand its indication as primary treatment [ 24 ]. In this study, our primary endpoint was to assess contemporary incidence of urethral strictures following different BPH surgical treatments. The secondary endpoint was to identify risk factors for urethral strictures development, and to assess their management. 2. Materials and Methods 2.1 Dataset We conducted a retrospective analysis using the extensive PearlDiver™ Mariner database (PearlDiver Technologies, Colorado Springs, CO). It is a commercially available, all-payer national claims database, containing over 41 billion Health Insurance Portability and Accountability Act (HIPAA)-compliant patient records collected between 2011 and 2022. The dataset uses unique patient identifier codes which allows for time-specific research while also keeping patient information de-identified. Moreover, this resource catalogs healthcare interactions across inpatient and outpatient settings, facilitating the longitudinal study of patient trajectories. Coverage is comprehensive, extending to all payer models across the entirety of United States territories. Data integrity is ensured via rigorous audits and review processes by independent third parties. Institutional Review Board provided exemption prior to data collection [ 25 ], [ 26 ]. Specific International Classification of Diseases (ICD), both 9th and 10th editions, and Current Procedural Terminology (CPT) codes were used to identify population and outcomes within the database. 2.2 Study Population and procedures We queried the database from January 1st 2011 to December 31th 2021, for all patients who underwent BHP surgery. The procedures considered for this study were: TURP, Transurethral Incision of the Prostate (TUIP), Holmium/Thulium Laser Enucleation of the Prostate (HoLEP/ThuLEP), Open Simple Prostatectomy (OSP), Laparoscopic-/Robot-Assisted Simple Prostatectomy (Lap/RobSP), Photoselective Vaporization of the Prostate (PVP), Prostatic Urethral Lift (PUL), Robotic Waterjet Treatment (Aquablation ® ), Water Vapor Thermal Therapy (Rezum ® ) and Prostatic Artery Embolization (PAE). The absence of a unique procedural CPT code was considered an exclusion criterion from the study. We then refined the cohort to include only those with active insurance claims. Within this patient population, we identified individuals who received a first diagnosis of urethral stricture within 12 months after a BPH procedure. The choice of this time frame aims to minimize the capture of other potential causes of urethral stricture [ 13 ]. Demographic variables included age, obesity, diabetes mellitus, smoking habit, and Charlson Comorbidity Index (CCI). Subsequently, using appropriate CPT codes, we assessed the utilization rates of different active management strategies for US treatment. These treatments included: Direct Visual Internal Urethrotomy (DVIU), urethroplasty, Urethral Dilation (UD) and their combination. 2.3 Statistical Analyses Categorical variables are reported as frequencies and percentages, while continuous variables are reported as mean and standard deviation (SD). To identify procedures associated with higher risk of urethral stricture, we performed a multivariable logistic regression analysis adjusting for variables such as age, obesity, smoking habits, and diabetes, and using patients who underwent TURP as reference group. Statistical analyses were performed using the R computing software incorporated into the PearlDiver™ Bellwether user interface. All p values were two-tailed with significance defined as p < 0.05. 3. Results We identified a total of 274,808 patients undergoing BPH-treatment between 2011 and 2021. Baseline characteristics of the study population are summarized in Supplementary Table 1 . Mean age at surgery was 70.05 (SD 7.7) years, with the oldest patients undergoing PAE (71.55 years SD 7.8) and the youngest undergoing Rezum ® (59.15 years SD 8.5). The PAE group also had the highest mean CCI compared to all the other procedures (4.26 SD 4.4). Of the total cohort, 10,918 patients were diagnosed with post-operative urethral stricture after BPH-treatment, accounting for 3.97% of the patients captured. Incidence of urethral stricture categorized by treatment group is shown in Table 1 . Higher incidence was observed following TURP, PVP, HoLEP/ThuLEP, TUIP and open SP. Lower incidence rates were observed after Laparoscopic/Robotic SP, Aquablation ® , PUL, Rezum ® and PAE. Table 1 Incidence of urethral strictures diagnosis and treatment in the total sample and stratified by procedure. Variable Overall (n = 274,808) TURP (n = 197,146) TUIP (n = 4,281) HoLEP/ ThuLEP (n = 18,169) Open SP (n = 9,949) Lap/Rob SP (n = 6,362) PVP (n = 11,813) PUL (n = 13,850) Rezum (n = 9,852) Aquablation (627) PAE (2,759) Urethral Strictures 1 , n (%) 10,918 (3.97) 8,834 (4.48) 157 (3.67) 699 (3.85) 319 (3.21) 112 (1.76) 463 (3.92) 203 (1.47) 103 (1.05) 10 (1.59) 18 (0.65) Age at diagnosis , mean (SD) 69.43 (7.4) 69.67 (7.3) 69.43 (7.4) 68.66 (7.5) 70.96 (6.8) 67.85 (7.3) 69.16 (7.23) 69.56 (8.3) 71.02 (8.8) - 71.78 (6) Patients treated for US, n (%) 2,069 (18.95) 1,737 (19.66) 31 (19.75) 112 (16.02) 55 (17.24) 15 (14.29) 74 (15.98) 20 (9.85) 21 (20.39) 1 (10) 2 (11.11) 1 Within 12 months after procedure US: Urethral stricture; TURP: Transurethral Resection of the Prostate); TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation ® : Robotic Waterjet Treatment; Rezum ® : Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization. Notably, 18.95% of patients received an active treatment - including UD, DVIU, urethroplasty or a combination of treatments - following a diagnosis of post-operative urethral stricture. Higher incidence of treatment was observed for patients undergoing Rezum ® (20.39%), TURP (19.66%) and TUIP (19.75%). Proportions of application of each treatment and their combination, stratified by BPH-surgery group, are shown in Table 2 . Around 94% of urethral strictures were managed through minimally invasive treatments, with UD and DVIU performed in 76.7% and 14.5% of cases respectively, and a combination of these approaches accounting for 2.8% of the total. Urethroplasty represented the less common primary treatment, performed in only 4.5% of instances. Considering only more representative procedures subgroups (> 10 patients), a higher incidence of DVIU was noted for TUIP (38.71%) and PVP (20.27%) procedures. A very low proportion of patients (0.1%) received a combination of all the three different analyzed treatments (UD, DVIU and urethroplasty). Table 2 Urethral stricture treatment type in the total sample and stratified by procedures. Variable Overall (n = 2069) TURP (n = 1737) TUIP (n = 31) HoLEP/ ThuLEP (n = 112) Open SP (n = 55) Lap/Rob SP (n = 16) PVP (n = 74) PUL (n = 20) Rezum (n = 21) Aquablation (n = 1) PAE (n = 2) UD , n (%) 1587 (76.70) 1345 (77.43) 17 (54.83) 87 (77.68) 40 (72.72) 11 (68.75) 53 (71.63) 17 (85) 16 (76.2) 1 (100) - DVIU , n (%) 301 (14.55) 244 (14.05) 12 (38.71) 16 (14.29) 8 (14.54) 2 (12.5) 15 (20.27) 1 (5) 2 (9.5) - 1 (50) Urethroplasty , n (%) 93 (4.50) 74 (4.26) 1 (3.23) 4 (3.57) 5 (9.1) 2 (12.5) 2 (2.70) 1 (5) 3 (14.3) - 1 (50) UD + DVIU , n (%) 58 (2.80) 51 (2.94) 1 (3.23) 3 (2.68) 1 (1.82) - 2 (2.70) - - - UD + Urethroplasty , n (%) 21 (1.02) 16 (0.92) - 2 (1.78) 1 (1.82) - 1 (1.35) 1 (5) - - - DVIU + Urethroplasty , n (%) 7 (0.33) 6 (0.35) - - - 1 (6.25) - - - - UD + DVIU + Urethroplasty , n (%) 2 (0.1) 1 (0.05) - - - - 1 (1.35) - - - UD: Urethral Dilation; DVIU: Direct Visual Internal Urethrotomy; TURP: Transurethral Resection of the Prostate; TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation ® : Robotic Waterjet Treatment; Rezum ® : Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization. Multivariable logistic regression analysis showed that patients undergoing PUL (OR 0.27, 95% CI 0.25–0.29; p < 0.001), Rezum (OR 0.28, 95% CI 0.23–0.34;p < 0.001), Aquablation (OR 0.38, 95% CI 0.19–0.67; p = 0.002), PAE (OR 0.24, 95% CI 0.16–0.34;p < 0.001) and PVP (OR 0.95, 95% CI 0.92–0.99; p = 0.01) were associated with a reduced likelihood of developing urethral stricture compared to TURP (Table 3 ). Open SP showed an increased likelihood of urethral stricture (OR 1.23, 95% CI 1.07–1.41; p = 0.002), whereas no significant difference was noted for Lap\Rob SP, HoLEP/ThuLEP, and TUIP when compared to TURP. Moreover, multivariable analysis identified tobacco use and diabetes as significant risk factors for US development (all p-values < 0.001) after BPH-surgery, while age was a protective factor (OR 0.98, 95% CI 0.98–0.99; p < 0.001). Table 3 Multivariate logistic regression analysis for predictors of US after BPH surgery. Variable Adjusted odds ratio (95% CI) p-value Age 0.98 (0.98–0.99) < 0.001 Diabetes 1.07 (1.03–1.11) < 0.001 Tobacco Use 1.08 (1.05–1.12) < 0.001 Obesity 1.02 (0.99–1.06) 0.12 TURP TUIP HoLEP/ThuLEP Open SP Lap\Rob SP PVP PUL Rezum Aquablation PAE 1 (reference) 1.09 (0.94–1.26) 0.96 (0.89–1.04) 1.23 (1.07–1.41) 1.27 (0.83–1.87) 0.95 (0.92–0.99) 0.27 (0.25–0.29) 0.28 (0.23–0.34) 0.38 (0.19–0.67) 0.24 (0.16–0.34) - 0.20 0.37 0.002 0.23 0.01 < 0.001 < 0.001 0.002 < 0.001 TURP: Transurethral Resection of the Prostate; TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation ® : Robotic Waterjet Treatment; Rezum ® : Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization. 4. Discussion Through the analysis of this extensive national database, encompassing data collected over a 10-year period, we can offer a broad picture on BPH surgery-related development of urethral strictures, including their management. We identified 274,808 patients who underwent various BPH treatment modalities, including recently introduced ones. The observed rates of postoperative incidence of urethral strictures varied from 0.65–4.48% (Table 1 ). PAE, Rezum ® , PUL and Aquablation ® showed the lowest rates (0.65–1.59%) of US development. This finding could be explained by the reduced operative time and consequent reduced urethral manipulation usually required during MIST such as PUL, Rezum ® and Aquablation ® , as well as the absence of a potentially harmful energy source [ 27 ]–[ 29 ]. Similarly, since PAE may requires only the positioning of a urethral catheter as a reference point for the interventional radiologist [ 30 ], if not already present before, is it not surprising that this procedure is the one associated with the lowest rate of US (0.65%). An interesting observation is the lower US incidence rate in patients undergoing Lap/Rob SP (1.76%), compared to the 3.21% for those undergoing the open SP procedure. This disparity may be attributed to the laparoscopic system's advantages, which include superior visualization and precision during bladder neck reconstruction [ 31 ]–[ 33 ]. Such enhancements not only help in minimizing undue stress and traction from stitches on urethral tissues, but may also contribute to better bleeding control, ultimately leading to a shorter catheterization time [ 34 ], [ 35 ]. HoLEP/ThuLEP and PVP procedures are increasingly favored by urologists [ 16 ], [ 17 ], [ 36 ], [ 37 ]. They offer functional results comparable to traditional approaches and may reduce postoperative morbidity. However, our analysis indicates that these procedures have post-operative rates of urethral strictures that are similar to those following TURP (3.85–3.92% vs 4.48%). These data are consistent with the available literature reporting a rate of urethral strictures following TURP between 2.2 and 9.8% [ 18 ], and following HoLEP/ThuLEP and PVP between 1.2–7.3% [ 16 ], [ 17 ], [ 38 ]. The overall rate of post-operative strictures observed in our study (3.97%) aligns with the lower limits of ranges reported in literature [ 13 ], [ 39 ]. This evidence may be attributable to several factors. Firstly, a retrospective analysis might underestimate the actual incidence, especially if we consider patients with mild symptomatic strictures that did not seek evaluation or treatment, ultimately leading to a potential selective reporting of outcomes. This could be further affected by the variability in complication reporting across different healthcare settings, with some institutions possibly having more comprehensive follow-up and reporting protocols that identify more cases. In fact, it is not surprising that higher incidences come from prospective single center study designs [ 21 ]. Moreover, the advancements in established surgical techniques over the years, and the growing awareness of possible complications, might have contributed to their rates reduction. Finally, it is important to acknowledge the possibility that some clinical entities reported as bladder neck contractures (BNC) may fall under the diagnosis of urethral stricture. These two conditions can cause similar urinary symptoms at presentation, and there is a possibility that the respective ICD codes could sometimes be erroneously used interchangeably [ 40 ], [ 41 ]. Despite this potential for diagnostic overlap, the likelihood of it affecting all groups we have analyzed is uniform, and the robust sample size at our disposal ensures the reliability of the incidence ranges we have observed. Insightful observations also arise from our adjusted multivariable analysis (Table 3 ). This analysis confirms the incidence rates previously discussed, highlighting a statistically significant reduced risk of urethral stricture for some MISTs (being between 5% and 76% lower compared to TURP). The only procedure significantly associated with an increased risk of stricture, by 23%, is open SP. Moreover, we observed that diabetes (1.07 [1.03–1.11], p < 0.001) and tobacco use (1.08 [1.05–1.12], p < 0.001) were statistically significant risk factors for the development of a urethral stricture. These results are consistent with what is known about the etiology of urethral stricture, which appears connected to impaired angiogenesis, excessive formation of fibrous tissue, and inflammation [ 42 ]. Interestingly, age was found to be a protective factor (0.98 [0.98–0.99], p < 0.001). This could be attributed to a tendency for reduced postoperative follow-up and diagnosis as age advances. Additionally, healing process in older individuals may vary compared to younger patients, potentially resulting in less aggressive scar formation. We also examined the rates and treatment strategies employed among the different BPH procedures (Table 2 and Fig. 1 ). UD and DVIU were the most employed treatment in our cohort. Current literature shows wide and inconsistent ranges of patency rates after UD and DVIU, varying from 35.5–92.3% and 8–77% respectively [ 43 ]. Moreover, these procedures carry a well-known inherent risk of potentially worsening the stricture, thereby significantly increasing treatment failure and recurrence rate [ 19 ]. Only a minority of patients in our cohort (4.5%) underwent open urethral reconstruction. These data are of interest considering that urethroplasty has proven to be a durable and definitive treatment with lifetime success rates between 75–100% [ 44 ]. A possible explanation for this phenomenon is the concern about iatrogenic urinary incontinence. Because endoscopic BPH treatments disrupt the internal urethral sphincter, continence relies on the external sphincter muscle. Therefore, it is plausible that to preserve sphincter control, some urologists recommend repeated endoluminal treatments in place of open repair [ 19 ]. Moreover, such procedure is technically demanding and thus predominantly performed in specialized centers by dedicated surgeons [ 19 ], [ 45 ]. This expertise requirement is a further point that might explain why, despite its high success rates, urethroplasty was the least frequently performed intervention in our study population. Nevertheless, it is essential to acknowledge the limitations of this retrospective study, particularly those associated with the PearlDiver™ Mariner database. ICD codes do not allow for differentiation between procedure types like monopolar versus bipolar TURP or HoLEP versus ThuLEP. Moreover, since it was not made for this purpose, the database does not provide specific clinical information that could further characterize the diagnosis of interest. Our reliance on diagnosis codes, without details on the anatomical location and length of the stricture, therefore, limits our capacity to draw definitive conclusions about urethral strictures treatment strategies. The study provides valuable information on the United States population; however, these findings may not be generalizable to other countries with different medical practices and patient demographics. Finally, it is crucial to recognize that while statistics of medical needs in public health are shaped by the system's regulatory framework, there may be a difference from the scientific reality [ 46 ]. However, if we are aware of the nature and limits of this kind of database, these data still provide a valuable representation of the medical practice's reality. 5. Conclusions The present analysis from a contemporary large dataset suggests that the incidence of urethral stricture after BPH surgery is relatively low (< 5%) and varies among procedures. Around 94% of cases are managed using minimally invasive (UD and DVIU) treatment approaches. Declarations Conflicts of Interest: The authors declare no conflict of interest. References B. M. Launer, K. T. McVary, W. A. Ricke, and G. L. 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Shalkamy et al. , “Factors Predicting Urethral Stricture Recurrence after Dorsal Onlay Augmented, Buccal Mucosal Graft Urethroplasty,” Urol Int, vol. 105, no. 3–4, pp. 269–277, 2021, doi: 10.1159/000512065 . H. Wessells, A. Morey, L. Souter, L. Rahimi, and A. Vanni, “Urethral Stricture Disease Guideline Amendment (2023),” Journal of Urology , vol. 210, no. 1, pp. 64–71, Jul. 2023, doi: 10.1097/JU.0000000000003482 . G. A. Sullivan et al. , “Recurrence following laparoscopic repair of bilateral inguinal hernia in children under five,” The American Journal of Surgery , vol. 224, no. 3, pp. 1004–1008, Sep. 2022, doi: 10.1016/j.amjsurg.2022.04.014 . Ditonno F, Franco A, and Manfredi C et al., “Minimally Invasive Adrenalectomy: A Population-Based Analysis of Contemporary Trends, Outcomes, Costs, and Impact of Social Determinants of Health,” Urol Pract, 2024, doi: https://doi.org/10.1097/UPJ.0000000000000505 . D.-D. Nguyen et al. , “Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation,” Prostate Cancer Prostatic Dis , Apr. 2023, doi: 10.1038/s41391-023-00669-z . D. Rukstalis et al. , “Prostatic Urethral Lift (PUL) for obstructive median lobes: 12 month results of the MedLift Study,” Prostate Cancer Prostatic Dis , vol. 22, no. 3, pp. 411–419, Sep. 2019, doi: 10.1038/s41391-018-0118-x . C. G. Roehrborn, P. T. Chin, and H. H. Woo, “The UroLift implant: mechanism behind rapid and durable relief from prostatic obstruction,” Prostate Cancer Prostatic Dis , vol. 25, no. 1, pp. 79–85, Mar. 2022, doi: 10.1038/s41391-021-00434-0 . D. Abt et al. , “Prostatic Artery Embolisation Versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia: 2-yr Outcomes of a Randomised, Open-label, Single-centre Trial,” Eur Urol , vol. 80, no. 1, pp. 34–42, Jul. 2021, doi: 10.1016/j.eururo.2021.02.008 . R. Vince, L. J. Hampton, M. D. Vartolomei, S. F. Shariat, F. Porpiglia, and R. Autorino, “Robotic assisted simple prostatectomy,” Curr Opin Urol, vol. 28, no. 3, pp. 309–314, May 2018, doi: 10.1097/MOU.0000000000000499 . D. Meyer, S. Weprin, E. B. Zukovski, F. Porpiglia, L. J. Hampton, and R. Autorino, “Rationale for Robotic-assisted Simple Prostatectomy for Benign Prostatic Obstruction,” Eur Urol Focus , vol. 4, no. 5, pp. 643–647, Sep. 2018, doi: 10.1016/j.euf.2018.07.007 . R. Autorino, D. Amparore, D. Loizzo, S. D. Pandolfo, E. Checcucci, and F. Porpiglia, “Robot-assisted Simple Prostatectomy Is Better than Endoscopic Enucleation of the Prostate,” Eur Urol Focus , vol. 8, no. 2, pp. 368–370, Mar. 2022, doi: 10.1016/j.euf.2022.03.014 . M. S. Lee et al. , “An Outcomes Comparison Between Holmium Laser Enucleation of the Prostate, Open Simple Prostatectomy, and Robotic Simple Prostatectomy for Large Gland Benign Prostatic Hypertrophy,” Urology , vol. 173, pp. 180–186, Mar. 2023, doi: 10.1016/j.urology.2022.12.018 . Z. Xia et al. , “Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis,” Front Surg, vol. 8, Jul. 2021, doi: 10.3389/fsurg.2021.695318 . B. Geavlete, F. Stanescu, C. Moldoveanu, and P. Geavlete, “Continuous vs conventional bipolar plasma vaporisation of the prostate and standard monopolar resection: a prospective, randomised comparison of a new technological advance,” BJU Int, vol. 113, no. 2, pp. 288–295, Feb. 2014, doi: 10.1111/bju.12290 . I. Lichy et al. , “Global experience and progress in GreenLight-XPS 180-Watt photoselective vaporization of the prostate,” World J Urol , vol. 40, no. 6, pp. 1513–1522, Jun. 2022, doi: 10.1007/s00345-022-03997-2 . D. Campobasso et al. , “Predictors of re-intervention after greenlight laser photoselective vaporization of the prostate: multicenter long/mid-term follow-up experience,” Mini-invasive Surgery, 2021, doi: 10.20517/2574-1225.2021.92 . J.-N. Cornu et al. , “A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update,” Eur Urol , vol. 67, no. 6, pp. 1066–1096, Jun. 2015, doi: 10.1016/j.eururo.2014.06.017 . H. L. Nicholson, Y. Al-Hakeem, J. J. Maldonado, and V. Tse, “Management of bladder neck stenosis and urethral stricture and stenosis following treatment for prostate cancer,” Transl Androl Urol, vol. 6, no. S2, pp. S92–S102, Jul. 2017, doi: 10.21037/tau.2017.04.33 . L. Cindolo et al. , “Bladder neck contracture after surgery for benign prostatic obstruction,” Minerva Urology and Nephrology, vol. 69, no. 2, Feb. 2017, doi: 10.23736/S0393-2249.16.02777-6 . I. Isali et al. , “Genomic Risk Factors for Urethral Stricture: A Systematic Review and Gene Network Analysis,” Urology, Dec. 2023, doi: 10.1016/j.urology.2023.12.014 . Y. Güler, “Urethral Injury Treatment Challenge. Comparison of Surgical Treatments for Acquired or Iatrogenic Urethral Stenosis and Predictive Values for Failure of Each Surgical Method,” Folia Med (Plovdiv), vol. 63, no. 1, pp. 42–50, Feb. 2021, doi: 10.3897/folmed.63.e53739 . J. J. Meeks, B. A. Erickson, M. A. Granieri, and C. M. Gonzalez, “Stricture Recurrence After Urethroplasty: A Systematic Review,” Journal of Urology, vol. 182, no. 4, pp. 1266–1270, Oct. 2009, doi: 10.1016/j.juro.2009.06.027 . T. E. Helmy, O. Sarhan, A. T. Hafez, M. Dawaba, and M. A. Ghoneim, “Perineal Anastomotic Urethroplasty in a Pediatric Cohort With Posterior Urethral Strictures: Critical Analysis of Outcomes in a Contemporary Series,” Urology, vol. 83, no. 5, pp. 1145–1148, May 2014, doi: 10.1016/j.urology.2013.11.028 . S. Yokoyama, “What does Commercial Database Tell us About Medical Sciences?,” J Atheroscler Thromb , vol. 25, no. 7, pp. 568–569, Jul. 2018, doi: 10.5551/jat.ED090 . Additional Declarations There is NO conflict of interest to disclose. Supplementary Files SupplementaryStricturesLCL.docx Cite Share Download PDF Status: Published Journal Publication published 07 May, 2024 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted Editorial decision: revise 28 Mar, 2024 Review # 2 received at journal 17 Mar, 2024 Reviewer # 2 agreed at journal 17 Mar, 2024 Review # 1 received at journal 03 Feb, 2024 Reviewer # 1 agreed at journal 20 Jan, 2024 Reviewers invited by journal 18 Jan, 2024 Submission checks completed at journal 18 Jan, 2024 Editor assigned by journal 18 Jan, 2024 First submitted to journal 16 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3870823","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":267804637,"identity":"8b7a7f77-497c-4066-baf9-7dbeedd31b44","order_by":0,"name":"Riccardo Autorino","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDACZijNDyISCojWksDAINkAog2ItgqoxeAAiEGMFvN25oefeX/Y5BufX5344YEBgzy/2AH8WmQOsxlL8ySkWW678XazBNBhhjNnJ+DXIsHMwwDUctjA7MbZDSAtCQa3CWth/g3SYjzj7OYfxGphA9tiwN+7jVhb2Mws56SlGUjc4N1mkWAgQYRf+A8/vvHGxsaAv//s5ps/Kmzk+aUJaEHSDFYpQaxyEOA/QIrqUTAKRsEoGEkAAOz2OuDdmWEoAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0001-7045-7725","institution":"Rush University","correspondingAuthor":true,"prefix":"","firstName":"Riccardo","middleName":"","lastName":"Autorino","suffix":""},{"id":267804638,"identity":"a252753e-48ac-4e9c-a97d-b973c4d33561","order_by":1,"name":"Leslie Claire Licari","email":"","orcid":"","institution":"Sapienza University Rome, Policlinico Umberto I Hospital","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"Claire","lastName":"Licari","suffix":""},{"id":267804639,"identity":"e324bf59-8e0a-4f04-add3-b6dccb6fc64d","order_by":2,"name":"Eugenio Bologna","email":"","orcid":"https://orcid.org/0000-0002-1140-0590","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Eugenio","middleName":"","lastName":"Bologna","suffix":""},{"id":267804640,"identity":"725e864e-8b19-4d2b-903e-a745de80c114","order_by":3,"name":"Celeste Manfredi","email":"","orcid":"https://orcid.org/0000-0002-9706-8516","institution":"University of Campania","correspondingAuthor":false,"prefix":"","firstName":"Celeste","middleName":"","lastName":"Manfredi","suffix":""},{"id":267804641,"identity":"ca8d7d0c-e231-4390-886f-b993f4694459","order_by":4,"name":"Antonio Franco","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Franco","suffix":""},{"id":267804642,"identity":"5b070b13-98cf-4781-9f07-101554016d5e","order_by":5,"name":"Francesco Ditonno","email":"","orcid":"https://orcid.org/0009-0005-0126-4731","institution":"Azienda Ospedaliera Universitaria Integrata Verona","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Ditonno","suffix":""},{"id":267804643,"identity":"f094a992-ecb0-4204-bc71-3d74c56543e9","order_by":6,"name":"COSIMO DE NUNZIO","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"COSIMO","middleName":"","lastName":"DE NUNZIO","suffix":""},{"id":267804644,"identity":"fa29537e-a3be-483c-9774-59a304e2a838","order_by":7,"name":"Alessandro Antonelli","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Alessandro","middleName":"","lastName":"Antonelli","suffix":""},{"id":267804645,"identity":"b14b9d89-48ee-4ef3-9a09-4f402063df2b","order_by":8,"name":"Giuseppe Simone","email":"","orcid":"https://orcid.org/0000-0002-4868-9025","institution":"IRCCS \"Regina Elena\" National Cancer Institute","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Simone","suffix":""},{"id":267804646,"identity":"37fc5580-2696-4866-a5ef-88cfdbfe3d85","order_by":9,"name":"Marco De Sio","email":"","orcid":"https://orcid.org/0000-0003-0820-6030","institution":"Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"De Sio","suffix":""},{"id":267804647,"identity":"9e13859e-4706-4258-a94d-284e05c4c10b","order_by":10,"name":"Luca Cindolo","email":"","orcid":"https://orcid.org/0000-0002-0712-2719","institution":"Villa Stuart Private Hospital","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Cindolo","suffix":""},{"id":267804648,"identity":"498736e1-ae72-408b-ab97-307f8f34bef4","order_by":11,"name":"Ephrem Olweny","email":"","orcid":"","institution":"Rush University","correspondingAuthor":false,"prefix":"","firstName":"Ephrem","middleName":"","lastName":"Olweny","suffix":""},{"id":267804649,"identity":"c25e6195-3bdb-4575-b7b1-dfc35f0db6c3","order_by":12,"name":"Edward E. Cherullo","email":"","orcid":"","institution":"Department of Urology, Rush University Medical Center, Chicago, IL, USA","correspondingAuthor":false,"prefix":"","firstName":"Edward","middleName":"E.","lastName":"Cherullo","suffix":""},{"id":267804650,"identity":"c648db13-b975-4ded-af0a-4bbce50a3b22","order_by":13,"name":"Costantino Leonardo","email":"","orcid":"","institution":"\"Sapienza\" University, Policlinico Umberto I","correspondingAuthor":false,"prefix":"","firstName":"Costantino","middleName":"","lastName":"Leonardo","suffix":""}],"badges":[],"createdAt":"2024-01-16 19:50:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3870823/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3870823/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41391-024-00841-z","type":"published","date":"2024-05-07T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50057708,"identity":"7a84edf2-673e-4490-9393-3d3c9440a446","added_by":"auto","created_at":"2024-01-23 18:35:30","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":464239,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA) Rate of urethral stricture (US) diagnosis and treatment stratified by procedures. B) Graphic representation of the different US treatment strategies in our cohort.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUD: Urethral Dilation; DVIU: Direct Visual Internal Urethrotomy; TURP: Transurethral Resection of the Prostate); TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation\u003csup\u003eÒ\u003c/sup\u003e: Robotic Waterjet Treatment\u003cstrong\u003e; \u003c/strong\u003eRezum\u003csup\u003eÒ\u003c/sup\u003e: Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3870823/v1/72a872ddc1c02178a7bda64d.jpeg"},{"id":56070730,"identity":"4315241e-d70d-4332-80d6-772f3a7a928d","added_by":"auto","created_at":"2024-05-08 07:16:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":782671,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3870823/v1/e78b8a2a-cf59-450e-993c-c21114fc6504.pdf"},{"id":50057707,"identity":"5e6e3f49-bfcc-467e-9100-38d00d538c61","added_by":"auto","created_at":"2024-01-23 18:35:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":88222,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"SupplementaryStricturesLCL.docx","url":"https://assets-eu.researchsquare.com/files/rs-3870823/v1/665460814027c9d6f75276da.docx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBenign Prostatic Hyperplasia (BPH) is a prevalent condition among aging males, representing the most common etiological factor for lower urinary tract symptoms (LUTS) in this population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The management of symptomatic BPH is often multimodal. In selected cases, or when pharmacological treatments lose efficacy, a surgical intervention is indicated [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For decades, transurethral resection of the prostate (TURP) represented the gold standard. The introduction of new minimally invasive surgical therapies (MIST) with the aim of reducing the incidence of treatment-related morbidity, has significantly broadened the spectrum of management options available for BPH treatment [\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These advances have allowed for a more tailored approach to symptomatic BPH, considering both clinical features and patient preference [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite notable improvements in surgical techniques, the incidence of late complications such as urethral stricture (US) has not declined [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As a matter of fact, BPH surgery still represents the most common cause of iatrogenic stricture disease, accounting for up to 41% of all cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The development of urethral strictures in this setting is attributed to several etiological factors, including the use of wide caliber surgical devices, mechanical or energy induced damage, urinary tract infections, prolonged surgical time, and extended catheterization time [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe incidence of urethral stricture disease after BPH procedures has been variably reported, ranging from 1% to 10\u0026ndash;12% [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Its onset is typically 6\u0026ndash;12 months [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The clinical relevance of US after new surgical approaches remains to be determined [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe management of urethral strictures can span from conservative options, such as observation and suprapubic tube placement, to endoscopic treatments, such as direct vision internal urethrotomy (DVIU) and urethral dilatation (UD), to more invasive options, such as urethroplasty procedures. Iatrogenic US can be particularly challenging to manage, since less invasive treatment options carry a considerable risk of recurrence [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Urethral reconstructive surgery on the other hand, has demonstrated greater long-term success rates. Such evidence has prompted guidelines to consolidate the role of urethroplasty in managing recurrent US and to expand its indication as primary treatment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, our primary endpoint was to assess contemporary incidence of urethral strictures following different BPH surgical treatments. The secondary endpoint was to identify risk factors for urethral strictures development, and to assess their management.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Dataset\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis using the extensive PearlDiver\u0026trade; Mariner database (PearlDiver Technologies, Colorado Springs, CO). It is a commercially available, all-payer national claims database, containing over 41\u0026nbsp;billion Health Insurance Portability and Accountability Act (HIPAA)-compliant patient records collected between 2011 and 2022. The dataset uses unique patient identifier codes which allows for time-specific research while also keeping patient information de-identified. Moreover, this resource catalogs healthcare interactions across inpatient and outpatient settings, facilitating the longitudinal study of patient trajectories. Coverage is comprehensive, extending to all payer models across the entirety of United States territories. Data integrity is ensured via rigorous audits and review processes by independent third parties.\u003c/p\u003e \u003cp\u003eInstitutional Review Board provided exemption prior to data collection [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSpecific International Classification of Diseases (ICD), both 9th and 10th editions, and Current Procedural Terminology (CPT) codes were used to identify population and outcomes within the database.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Population and procedures\u003c/h2\u003e \u003cp\u003eWe queried the database from January 1st 2011 to December 31th 2021, for all patients who underwent BHP surgery. The procedures considered for this study were: TURP, Transurethral Incision of the Prostate (TUIP), Holmium/Thulium Laser Enucleation of the Prostate (HoLEP/ThuLEP), Open Simple Prostatectomy (OSP), Laparoscopic-/Robot-Assisted Simple Prostatectomy (Lap/RobSP), Photoselective Vaporization of the Prostate (PVP), Prostatic Urethral Lift (PUL), Robotic Waterjet Treatment (Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e), Water Vapor Thermal Therapy (Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e) and Prostatic Artery Embolization (PAE). The absence of a unique procedural CPT code was considered an exclusion criterion from the study.\u003c/p\u003e \u003cp\u003eWe then refined the cohort to include only those with active insurance claims. Within this patient population, we identified individuals who received a first diagnosis of urethral stricture within 12 months after a BPH procedure. The choice of this time frame aims to minimize the capture of other potential causes of urethral stricture [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Demographic variables included age, obesity, diabetes mellitus, smoking habit, and Charlson Comorbidity Index (CCI).\u003c/p\u003e \u003cp\u003eSubsequently, using appropriate CPT codes, we assessed the utilization rates of different active management strategies for US treatment. These treatments included: Direct Visual Internal Urethrotomy (DVIU), urethroplasty, Urethral Dilation (UD) and their combination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Analyses\u003c/h2\u003e \u003cp\u003eCategorical variables are reported as frequencies and percentages, while continuous variables are reported as mean and standard deviation (SD).\u003c/p\u003e \u003cp\u003eTo identify procedures associated with higher risk of urethral stricture, we performed a multivariable logistic regression analysis adjusting for variables such as age, obesity, smoking habits, and diabetes, and using patients who underwent TURP as reference group. Statistical analyses were performed using the R computing software incorporated into the PearlDiver\u0026trade; Bellwether user interface. All p values were two-tailed with significance defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eWe identified a total of 274,808 patients undergoing BPH-treatment between 2011 and 2021. Baseline characteristics of the study population are summarized in \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eMean age at surgery was 70.05 (SD 7.7) years, with the oldest patients undergoing PAE (71.55 years SD 7.8) and the youngest undergoing Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e (59.15 years SD 8.5). The PAE group also had the highest mean CCI compared to all the other procedures (4.26 SD 4.4). Of the total cohort, 10,918 patients were diagnosed with post-operative urethral stricture after BPH-treatment, accounting for 3.97% of the patients captured.\u003c/p\u003e \u003cp\u003eIncidence of urethral stricture categorized by treatment group is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Higher incidence was observed following TURP, PVP, HoLEP/ThuLEP, TUIP and open SP. Lower incidence rates were observed after Laparoscopic/Robotic SP, Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e, PUL, Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e and PAE.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence of urethral strictures diagnosis and treatment in the total sample and stratified by procedure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;274,808)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTURP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;197,146)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTUIP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;4,281)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHoLEP/\u003c/p\u003e \u003cp\u003eThuLEP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;18,169)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOpen SP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9,949)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLap/Rob SP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6,362)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePVP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11,813)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePUL\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;13,850)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRezum\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9,852)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAquablation\u003c/p\u003e \u003cp\u003e(627)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePAE\u003c/p\u003e \u003cp\u003e(2,759)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrethral Strictures\u003c/b\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10,918 (3.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,834\u003c/p\u003e \u003cp\u003e(4.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e157\u003c/p\u003e \u003cp\u003e(3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e699\u003c/p\u003e \u003cp\u003e(3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e319\u003c/p\u003e \u003cp\u003e(3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e112\u003c/p\u003e \u003cp\u003e(1.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e463\u003c/p\u003e \u003cp\u003e(3.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e203\u003c/p\u003e \u003cp\u003e(1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e103\u003c/p\u003e \u003cp\u003e(1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e(1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e18 (0.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at diagnosis\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003emean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.43\u003c/p\u003e \u003cp\u003e(7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.67\u003c/p\u003e \u003cp\u003e(7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.43 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.66\u003c/p\u003e \u003cp\u003e(7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.96 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e67.85\u003c/p\u003e \u003cp\u003e(7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e69.16 (7.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e69.56\u003c/p\u003e \u003cp\u003e(8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e71.02 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e71.78 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatients treated for US, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,069 (18.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,737 (19.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003cp\u003e(19.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112 (16.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e(17.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e74\u003c/p\u003e \u003cp\u003e(15.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e(9.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(20.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2 (11.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003csup\u003e1\u003c/sup\u003eWithin 12 months after procedure\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eUS: Urethral stricture; TURP: Transurethral Resection of the Prostate); TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e: Robotic Waterjet Treatment; Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e: Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNotably, 18.95% of patients received an active treatment - including UD, DVIU, urethroplasty or a combination of treatments - following a diagnosis of post-operative urethral stricture. Higher incidence of treatment was observed for patients undergoing Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e (20.39%), TURP (19.66%) and TUIP (19.75%).\u003c/p\u003e \u003cp\u003eProportions of application of each treatment and their combination, stratified by BPH-surgery group, are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Around 94% of urethral strictures were managed through minimally invasive treatments, with UD and DVIU performed in 76.7% and 14.5% of cases respectively, and a combination of these approaches accounting for 2.8% of the total. Urethroplasty represented the less common primary treatment, performed in only 4.5% of instances. Considering only more representative procedures subgroups (\u0026gt;\u0026thinsp;10 patients), a higher incidence of DVIU was noted for TUIP (38.71%) and PVP (20.27%) procedures. A very low proportion of patients (0.1%) received a combination of all the three different analyzed treatments (UD, DVIU and urethroplasty).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUrethral stricture treatment type in the total sample and stratified by procedures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;2069)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTURP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1737)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTUIP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHoLEP/\u003c/p\u003e \u003cp\u003eThuLEP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;112)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOpen SP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLap/Rob SP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePVP\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePUL\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRezum\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAquablation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePAE\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUD\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1587 (76.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1345 (77.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (54.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87 (77.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003e(72.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e(68.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e53\u003c/p\u003e \u003cp\u003e(71.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e(85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDVIU\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301\u003c/p\u003e \u003cp\u003e(14.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e244 (14.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (38.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e(14.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(20.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrethroplasty\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003cp\u003e(4.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003cp\u003e(4.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(3.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUD\u0026thinsp;+\u0026thinsp;DVIU\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003cp\u003e(2.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003cp\u003e(2.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(2.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUD\u0026thinsp;+\u0026thinsp;Urethroplasty\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDVIU\u0026thinsp;+\u0026thinsp;Urethroplasty\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(0.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUD\u0026thinsp;+\u0026thinsp;DVIU\u0026thinsp;+\u0026thinsp;Urethroplasty\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eUD: Urethral Dilation; DVIU: Direct Visual Internal Urethrotomy; TURP: Transurethral Resection of the Prostate; TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e: Robotic Waterjet Treatment; Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e: Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariable logistic regression analysis showed that patients undergoing PUL (OR 0.27, 95% CI 0.25\u0026ndash;0.29; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Rezum (OR 0.28, 95% CI 0.23\u0026ndash;0.34;p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Aquablation (OR 0.38, 95% CI 0.19\u0026ndash;0.67; p\u0026thinsp;=\u0026thinsp;0.002), PAE (OR 0.24, 95% CI 0.16\u0026ndash;0.34;p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PVP (OR 0.95, 95% CI 0.92\u0026ndash;0.99; p\u0026thinsp;=\u0026thinsp;0.01) were associated with a reduced likelihood of developing urethral stricture compared to TURP (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Open SP showed an increased likelihood of urethral stricture (OR 1.23, 95% CI 1.07\u0026ndash;1.41; p\u0026thinsp;=\u0026thinsp;0.002), whereas no significant difference was noted for Lap\\Rob SP, HoLEP/ThuLEP, and TUIP when compared to TURP. Moreover, multivariable analysis identified tobacco use and diabetes as significant risk factors for US development (all p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.001) after BPH-surgery, while age was a protective factor (OR 0.98, 95% CI 0.98\u0026ndash;0.99; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis for predictors of US after BPH surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted odds ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.98\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07 (1.03\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTobacco Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.08 (1.05\u0026ndash;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObesity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02 (0.99\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTURP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eTUIP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eHoLEP/ThuLEP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOpen SP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eLap\\Rob SP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePVP\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePUL\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eRezum\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eAquablation\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePAE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 \u003cem\u003e(reference)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e1.09 (0.94\u0026ndash;1.26)\u003c/p\u003e \u003cp\u003e0.96 (0.89\u0026ndash;1.04)\u003c/p\u003e \u003cp\u003e1.23 (1.07\u0026ndash;1.41)\u003c/p\u003e \u003cp\u003e1.27 (0.83\u0026ndash;1.87)\u003c/p\u003e \u003cp\u003e0.95 (0.92\u0026ndash;0.99)\u003c/p\u003e \u003cp\u003e0.27 (0.25\u0026ndash;0.29)\u003c/p\u003e \u003cp\u003e0.28 (0.23\u0026ndash;0.34)\u003c/p\u003e \u003cp\u003e0.38 (0.19\u0026ndash;0.67)\u003c/p\u003e \u003cp\u003e0.24 (0.16\u0026ndash;0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e0.20\u003c/p\u003e \u003cp\u003e0.37\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0.23\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eTURP: Transurethral Resection of the Prostate; TUIP: Transurethral Incision of the Prostate; SP: Simple Prostatectomy; HoLEP/ThuLEP: Holmium/Thulium Laser Enucleation of the Prostate; PVP: Photoselective Vaporization of the Prostate; PUL: Prostatic Urethral Lift; Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e: Robotic Waterjet Treatment; Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e: Water Vapor Thermal Therapy; PAE: Prostatic Artery Embolization.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThrough the analysis of this extensive national database, encompassing data collected over a 10-year period, we can offer a broad picture on BPH surgery-related development of urethral strictures, including their management.\u003c/p\u003e \u003cp\u003eWe identified 274,808 patients who underwent various BPH treatment modalities, including recently introduced ones. The observed rates of postoperative incidence of urethral strictures varied from 0.65\u0026ndash;4.48% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). PAE, Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e, PUL and Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e showed the lowest rates (0.65\u0026ndash;1.59%) of US development. This finding could be explained by the reduced operative time and consequent reduced urethral manipulation usually required during MIST such as PUL, Rezum\u003csup\u003e\u0026reg;\u003c/sup\u003e and Aquablation\u003csup\u003e\u0026reg;\u003c/sup\u003e, as well as the absence of a potentially harmful energy source [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, since PAE may requires only the positioning of a urethral catheter as a reference point for the interventional radiologist [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], if not already present before, is it not surprising that this procedure is the one associated with the lowest rate of US (0.65%). An interesting observation is the lower US incidence rate in patients undergoing Lap/Rob SP (1.76%), compared to the 3.21% for those undergoing the open SP procedure. This disparity may be attributed to the laparoscopic system's advantages, which include superior visualization and precision during bladder neck reconstruction [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Such enhancements not only help in minimizing undue stress and traction from stitches on urethral tissues, but may also contribute to better bleeding control, ultimately leading to a shorter catheterization time [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHoLEP/ThuLEP and PVP procedures are increasingly favored by urologists [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. They offer functional results comparable to traditional approaches and may reduce postoperative morbidity. However, our analysis indicates that these procedures have post-operative rates of urethral strictures that are similar to those following TURP (3.85\u0026ndash;3.92% vs 4.48%). These data are consistent with the available literature reporting a rate of urethral strictures following TURP between 2.2 and 9.8% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and following HoLEP/ThuLEP and PVP between 1.2\u0026ndash;7.3% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe overall rate of post-operative strictures observed in our study (3.97%) aligns with the lower limits of ranges reported in literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This evidence may be attributable to several factors. Firstly, a retrospective analysis might underestimate the actual incidence, especially if we consider patients with mild symptomatic strictures that did not seek evaluation or treatment, ultimately leading to a potential selective reporting of outcomes. This could be further affected by the variability in complication reporting across different healthcare settings, with some institutions possibly having more comprehensive follow-up and reporting protocols that identify more cases. In fact, it is not surprising that higher incidences come from prospective single center study designs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Moreover, the advancements in established surgical techniques over the years, and the growing awareness of possible complications, might have contributed to their rates reduction.\u003c/p\u003e \u003cp\u003eFinally, it is important to acknowledge the possibility that some clinical entities reported as bladder neck contractures (BNC) may fall under the diagnosis of urethral stricture. These two conditions can cause similar urinary symptoms at presentation, and there is a possibility that the respective ICD codes could sometimes be erroneously used interchangeably [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Despite this potential for diagnostic overlap, the likelihood of it affecting all groups we have analyzed is uniform, and the robust sample size at our disposal ensures the reliability of the incidence ranges we have observed.\u003c/p\u003e \u003cp\u003eInsightful observations also arise from our adjusted multivariable analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This analysis confirms the incidence rates previously discussed, highlighting a statistically significant reduced risk of urethral stricture for some MISTs (being between 5% and 76% lower compared to TURP). The only procedure significantly associated with an increased risk of stricture, by 23%, is open SP.\u003c/p\u003e \u003cp\u003eMoreover, we observed that diabetes (1.07 [1.03\u0026ndash;1.11], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and tobacco use (1.08 [1.05\u0026ndash;1.12], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were statistically significant risk factors for the development of a urethral stricture. These results are consistent with what is known about the etiology of urethral stricture, which appears connected to impaired angiogenesis, excessive formation of fibrous tissue, and inflammation [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Interestingly, age was found to be a protective factor (0.98 [0.98\u0026ndash;0.99], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This could be attributed to a tendency for reduced postoperative follow-up and diagnosis as age advances. Additionally, healing process in older individuals may vary compared to younger patients, potentially resulting in less aggressive scar formation.\u003c/p\u003e \u003cp\u003eWe also examined the rates and treatment strategies employed among the different BPH procedures (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). UD and DVIU were the most employed treatment in our cohort. Current literature shows wide and inconsistent ranges of patency rates after UD and DVIU, varying from 35.5\u0026ndash;92.3% and 8\u0026ndash;77% respectively [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Moreover, these procedures carry a well-known inherent risk of potentially worsening the stricture, thereby significantly increasing treatment failure and recurrence rate [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Only a minority of patients in our cohort (4.5%) underwent open urethral reconstruction. These data are of interest considering that urethroplasty has proven to be a durable and definitive treatment with lifetime success rates between 75\u0026ndash;100% [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. A possible explanation for this phenomenon is the concern about iatrogenic urinary incontinence. Because endoscopic BPH treatments disrupt the internal urethral sphincter, continence relies on the external sphincter muscle. Therefore, it is plausible that to preserve sphincter control, some urologists recommend repeated endoluminal treatments in place of open repair [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, such procedure is technically demanding and thus predominantly performed in specialized centers by dedicated surgeons [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This expertise requirement is a further point that might explain why, despite its high success rates, urethroplasty was the least frequently performed intervention in our study population.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNevertheless, it is essential to acknowledge the limitations of this retrospective study, particularly those associated with the PearlDiver\u0026trade; Mariner database. ICD codes do not allow for differentiation between procedure types like monopolar versus bipolar TURP or HoLEP versus ThuLEP. Moreover, since it was not made for this purpose, the database does not provide specific clinical information that could further characterize the diagnosis of interest. Our reliance on diagnosis codes, without details on the anatomical location and length of the stricture, therefore, limits our capacity to draw definitive conclusions about urethral strictures treatment strategies.\u003c/p\u003e \u003cp\u003eThe study provides valuable information on the United States population; however, these findings may not be generalizable to other countries with different medical practices and patient demographics.\u003c/p\u003e \u003cp\u003eFinally, it is crucial to recognize that while statistics of medical needs in public health are shaped by the system's regulatory framework, there may be a difference from the scientific reality [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, if we are aware of the nature and limits of this kind of database, these data still provide a valuable representation of the medical practice's reality.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe present analysis from a contemporary large dataset suggests that the incidence of urethral stricture after BPH surgery is relatively low (\u0026lt;\u0026thinsp;5%) and varies among procedures. Around 94% of cases are managed using minimally invasive (UD and DVIU) treatment approaches.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflicts of Interest: The authors declare no conflict of interest. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eB. M. Launer, K. T. McVary, W. A. Ricke, and G. L. 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Yokoyama, \u0026ldquo;What does Commercial Database Tell us About Medical Sciences?,\u0026rdquo; \u003cem\u003eJ Atheroscler Thromb\u003c/em\u003e, vol. 25, no. 7, pp. 568\u0026ndash;569, Jul. 2018, doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5551/jat.ED090\u003c/span\u003e\u003cspan address=\"10.5551/jat.ED090\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Benign Prostatic Hyperplasia, TURP, MIST, Urethra, Iatrogenic Urethral Stricture, Urethroplasty, Urethrotomy, Urethral dilatation","lastPublishedDoi":"10.21203/rs.3.rs-3870823/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3870823/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction and objectives:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUrethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH), whose treatment options range from conservative or endoscopic approaches to more invasive ones. This study aimed to evaluate the contemporary incidence of US after different types of BPH surgery, to identify associated risk factors and to assess its management.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA retrospective analysis was conducted using the PearlDiver\u0026trade; Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%). Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after Robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) was the primary management in most cases (76.7%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (\u0026lt;\u0026thinsp;5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.\u003c/p\u003e","manuscriptTitle":"Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-23 18:35:25","doi":"10.21203/rs.3.rs-3870823/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-03-28T16:07:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-03-17T10:35:01+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-03-17T10:12:40+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-02-03T17:07:24+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-01-20T22:56:29+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2024-01-19T02:01:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-18T09:58:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-18T09:58:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Prostate Cancer and Prostatic Diseases","date":"2024-01-16T19:45:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"06604cb1-598e-4e5d-a0dc-688cb60e8d83","owner":[],"postedDate":"January 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":28217830,"name":"Health sciences/Diseases/Urogenital diseases/Prostatic diseases"},{"id":28217831,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2024-05-08T07:15:07+00:00","versionOfRecord":{"articleIdentity":"rs-3870823","link":"https://doi.org/10.1038/s41391-024-00841-z","journal":{"identity":"prostate-cancer-and-prostatic-diseases","isVorOnly":false,"title":"Prostate Cancer and Prostatic Diseases"},"publishedOn":"2024-05-07 04:00:00","publishedOnDateReadable":"May 7th, 2024"},"versionCreatedAt":"2024-01-23 18:35:25","video":"","vorDoi":"10.1038/s41391-024-00841-z","vorDoiUrl":"https://doi.org/10.1038/s41391-024-00841-z","workflowStages":[]},"version":"v1","identity":"rs-3870823","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3870823","identity":"rs-3870823","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}