Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(1):13268 1 ORIGINAL PAPER management of traumatic urethral strictures, particularly in cases involving the bulbar urethra. Traumatic urethral strictures are a significant clinical challenge, often result- ing from various forms of trauma, particularly in males. The etiology of these strictures is multifaceted, with trau- ma being a predominant cause. Various mechanisms of injury contribute to the development of urethral stric- tures, including pelvic fractures, straddle injuries, and direct trauma to the urethra during accidents (1). The incidence of motorcycle road accidents leading to pelvic fractures and urethral injury in Indonesia is a sig- nificant public health issue, exacerbated by the country's high reliance on motorcycles as a primary mode of trans- portation (2). The prevalence of this condition varies, with estimates suggesting that it affects 229 to 627 individuals per 100,000, and can be particularly pronounced in cer- tain demographics (3, 4). The management of these stric- tures has evolved, with EPA urethroplasty being favored for its high success rates and low complication profiles, particularly for strictures shorter than 2 cm (5-7). The technique of EPA urethroplasty involves the excision of the diseased segment of the urethra followed by direct end-to-end anastomosis. This method is particularly effec- tive for short, isolated bulbar strictures, yielding success rates upwards of 90% (5, 6, 8). However, the risk of recur- rence remains a significant concern in the management of urethral strictures post-trauma. Factors influencing recur- rence include the length of the stricture, the presence of underlying conditions, and the surgical technique employed (8-11). Identifying factors leading to EPA ure- throplasty failure benefits both patients and surgeons. This study aims to analyze risk factors for urethral stricture recurrence after one-year follow-up of EPA urethroplasty. METHODS Pre operative patients assessment We conducted a retrospective analysis of the medical records of 95 male patients diagnosed with traumatic ure- thral stricture who were referred from nearby hospital and all across Indonesia. We reviewed demographic Introduction: Excision and Primary Anastomosis (EPA) urethroplasty is the stan- dard treatment for traumatic urethral strictures, but managing them remains challenging for urologists. Identifying factors leading to EPA urethroplasty failure benefits both patients and surgeons. This study aims to analyze risk factors for urethral stricture recurrence after one-year follow-up of EPA urethro- plasty. Materials and methods: Data on male patients undergoing EPA urethroplasty at the Urology Department of Saiful Anwar General Hospital from January 2013 until December 2023 were prospectively recorded. Successful urethroplasty, defined as the absence of additional treatment necessity, was assessed until 12 months follow-up. Demographic data, time to surgery, stricture etiology, comorbidities, prior urethral interventions, and opera- tion steps were recorded. Univariate and multivariate cox- regression analyses were performed using IBM SPSS Statistics version 21. Result: Total 95 patients were observed, and 89 patients were included, averaging 41.2 ± 15.59 years old. EPA urethroplasty succeeded in 91% of cases over a median follow-up of 16.3 months. Pelvic fracture urethral injury (PFUI) was the predomi- nant etiology in 74% of cases, with an average stricture length of 25.4 ± 16.3 mm. The average time to surgery was performed on average 6.67 ± 4.07 months after diagnosis. In univariate analysis, body mass index (BMI), time to surgery, and stricture length were associated with urethral stricture recurrence. However, only time to surgery showed a significant association in multivariate analysis. Conclusions: Obesity, the length of the stricture, and delayed surgical intervention are associated with an increased risk of urethral stricture recurrence in patients following EPA. EPA urethroplasty demonstrates a high success rate in managing traumatic urethral strictures. KEY WORDS: Urethral stricture; EPA urethroplasty; Prognosis; Risk factors. Submitted 18 October 2024; Accepted 1 November 2024 INTRODUCTION Excision and Primary Anastomosis (EPA) urethroplasty is recognized as a gold standard surgical technique for the Ten years’ single surgeon experience of excision and primary anastomosis (EPA) urethroplasty for traumatic urethral stricture: An analysis of risk factors for urethral stricture recurrence Paksi Satyagraha, Edi Wibowo, Besut Daryanto, Gede Wirya Diptanala Putra Duarsa, Adrianus Gupta Wijaya, Fauzan Kurniawan Dhani Urology Department, Faculty of Medicine, Universitas Brawijaya, Saiful Anwar General Hospital, Malang, Indonesia. DOI: 10.4081/aiua.2025.13268 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(1):13268 P. Satyagraha, E. Wibowo, B. Daryanto, et al. 2 details, educational status, underlying causes, comorbidi- ties, smoking history, previous procedures, as well as the duration of the disease, interventions, and outcomes based on both inpatient and outpatient records. Patients were classified as highly educated if they had completed an undergraduate degree. All patients underwent EPA urethroplasty performed by a single surgeon (PS) at Saiful Anwar General Hospital in Malang, Indonesia, between January 2013 and December 2023. Patients with penile strictures, a history of hypospadias, or those requiring tis- sue substitution techniques were excluded from this study. The duration of the disease was defined as the time elapsed from the initial diagnosis of the urethral stricture to the date of the EPA procedure. Each patient had a suprapubic catheter placed to allow for urethral rest. To assess the location and length of the stricture, a Bipolar Voiding Cysto-Urethrography (BVCUG) was performed. Surgical technique All patients underwent EPA urethroplasty under general anesthesia while positioned in the lithotomy position via the perineal approach. After mobilizing the bulbar ure- thra, the stricture location was identified intraoperatively using rigid cystoscopy, and the urethra was transected at the stricture site with sharp scissors. The scar tissue at both urethral ends was then completely excised until healthy urethral mucosa was reached. A wide-caliber, spatulated, tension-free anastomosis was performed using six 4-0 PGA sutures. EPA urethroplasty consists of sever- al adjunctive surgical steps to achieve a tension-free anas- tomosis, including bulbar mobilization, crural separation, inferior pubectomy, supracrural rerouting, and total pubectomy, particularly when the stricture is too long for a tension-free anastomosis. Finally, a 14Fr silicone Foley catheter was inserted, which remained in place for four weeks postoperatively. If the procedure for EPA urethro- plasty consists only in bulbar mobilization, this was clas- sified as bulbar mobilization. On the contrary, if the pro- cedure includes steps beyond bulbar mobilization, it was categorized as over bulbar mobilization. Postoperative follow-up and outcome definition Patients were followed up at 1, 3, and 12 months after surgery, and then annually, with evaluations including uroflowmetry and residual urine volume measurements. Urethrography was conducted whenever a recurrent stricture was suspected, indicated by a decrease in uri- nary flow rate and/or worsening symptoms. Successful urethroplasty was defined as the absence of the need for further treatment. Paired T-Test was used to assessed patient outcome parameters. Both univariate and multi- variate Cox regression analyses were conducted using IBM SPSS Statistics version 21. P values < 0.05 were con- sidered statistically significant. RESULTS A total of 95 patients were observed, and 89 were includ- ed in the study, with an average age of 41.2 ± 15.59 years. The patients had a mean body mass index (BMI) of 23.05 kg/m². Hypertension and diabetes mellitus (DM) were pres- ent as comorbidities in 10.1% and 16.9% of the patients, respectively. The most common aetiology of urethral stric- tures was pelvic fracture urethral injury (PFUI), followed by straddle injury, iatrogenic causes related to transurethral surgery, and direct trauma. The bulbo-membranous ure- thra had the highest incidence of strictures, followed by the bulbar urethra. More than 35% of patients had under- gone endoscopic treatment 1-2 times previously, while about 39% had never received endoscopic treatment. The average time to surgery was performed on average 6.67 ± 4.07 months after diagnosis. EPA urethroplasty was suc- cessful in 91% of cases, with a median follow-up of 16.3 months. Eight patients reported had recurrent stricture, two patients at 3 months after the surgery and six patients at 12 months after the surgery. For recurrent strictures, treatments included redo EPA urethroplasty in 3 cases, urethral dilatation in 4 cases, and redo non-transecting urethroplasty in 1 case (Table 1). The uroflowmetry outcomes from 1 month, 3 months and 12 months after the surgery of the patient did not show any different such as Qmax, Voided Volume and post void residual volume (PVR) (Table 2, Figure 1). In univari- ate analysis, body mass index (BMI) (OR 4.45, 95%CI Table 1. Patient characteristics. Number of patient 89 Age (year) (SD) 41.24 (± 15.59) Median follow-up (months) (SD) 16.3 (± 3.15) BMI (kg/m2), mean (SD) 23.05 (± 2.57) Highly educated, n (%) 23 (25.8) Current smoker, n (%) 26 (29.2) DM Type 2, n (%) 9 (10.1) Hypertension, n (%) 15 (16.9) Stricture length (mm), mean (SD) 25.4 (± 16.3) Time to surgery (month), mean (SD) 6.67 (± 4.07) Stricture aetiology, n (%) Straddle injury 11 (12.35) Iatrogenic 10 (11.23) Direct 2 (2.24) PFUI 66 (74.15) Stricture site, n (%) Bulbar 27 (30.34) Bulbo-membranous 62 (69.66) Previous endoscopic treatment, n (%) 0 28 (31.46) 1-2 32 (35.95) > 2 29 (32.58) Surgical steps, n(%) Bulbar mobilization 35 (39.33) Crural separation 29 (32.58) Inferior pubectomy 24 (26.96) Supracrural rerouting 1 (1.12) EPA Outcome, n (%) Success 81 (91) Recurrance 8 (9.00) Recurrence operative treatement Redo EPA urethroplasty 3 (37.5) Redo non-transecting urethroplasty 1 (12.5) Urethral dilatation 4 (50) BMI: Body Mass Index; DM: Diabetes Mellitus; SD: Standard Deviation; EPA: Excision Primary Anastomosis; PFUI: Pelvic Fracture Urethral Injury. Archivio Italiano di Urologia e Andrologia 2025; 97(1):13268 3 Urethroplasty for traumatic urethral stricture thral stricture recurrence. However, only time to surgery (OR 2.44, 95%CI 1.06-12,93, p = 0.04) showed a sig- nificant association in multivariate analysis (Table 3). Figure 1. Changes in Qmax (A), Voided volume (B), Post void residual (C) from 1, 3, and 12 months. Table 2. Uroflowmetry outcomes. 1 Month (n: 89) 3 Months (n: 87) 12 Months (n: 81) Mean ± SD Mean ± SD p value* Mean ± SD p value * p value * (vs 1 month) (vs 1 month) (vs 3 Months) Qmax (mL/s) 20.63 ± 3.47 20.18 ± 3.69 0.14 20.95 ± 3.39 0.17 0.4 Voided volume (mL/s) 139.8 ± 15.47 137.75 ± 18.28 0.12 140.58 ± 17.12 0.73 0.52 PVR (mL/s) 29.47 ± 5.09 31.78 ± 8.87 0.73 30.31 ± 8.25 0.87 0.67 * Includes only patients who were able to void (n: 81). Qmax: maximum flow rate; PVR: postvoid residual; SD: Standard Deviation. Table 3. Uni- and multivariate Cox regression analysis for risk factor recurrence rate EPA urethroplasty. Univariate analysis Multivariate analysis OR 95% CI p value OR 95% CI p value Age 1.25 0.16-6.78 0.55 ≤ 60 vs > 60 Education 3.56 1.26-4.56 0.15 Low vs High BMI 4.45 1.36-28.1 0.007 * 2.40 0.96-22.7 0.49 ≤ 25 vs > 25 Current smoker 1.89 0.30-8.14 0.12 DM type 2 6.34 0.41-20.85 0.07 Hypertension 3.52 1.38-29.23 0.09 Time to surgery 3.89 1.63-13.24 0.003 * 2.44 1.06-12,93 0.04 * ≤ 6 months vs > 6 months Stricture Length 2.14 1.05–1.62 0.01 * 0.08 0.98–2.17 0.35 ≤ 20 mm vs > 20 mm Stricture Side 1.26 0.30-5.14 0.12 Bulbo-membranous vs bulbar Previous endoscopic treatment 1.63 0.37-6.06 0.48 Yes vs no Type of Injury 1.83 0.27-8.349 0.29 Non PFUI vs PFUI Surgical steps 1.5 0.19-7.93 0.43 Bulbar mobilization vs over bulbar mobilization * Significant result. BMI: Body Mass Index; CI: Confidence Interval; DM: Diabetes Mellitus; OR: Odd Ratio; PFUI: Pelvic Fracture Urethral Injury. 1.36-28.1, p = 0.007), time to surgery (OR 3.89, 95%CI 1.63-13.24, p = 0.003), and stricture length (OR 2.14, 95%CI 1.05-1.62, p = 0.01) were associated with ure- Archivio Italiano di Urologia e Andrologia 2025; 97(1):13268 P. Satyagraha, E. Wibowo, B. Daryanto, et al. 4 DISCUSSION EPA urethroplasty is widely regarded as the gold standard for treating traumatic urethral strictures, particularly those caused by pelvic fractures or direct trauma. In Indonesia, motorcycle accidents often result in pelvic fractures and associated urethral injuries (2). This finding is consistent with our cohort, where PFUI accounted for 74% of the causes of traumatic urethral strictures. Our cohort achieved a high success rate of 91% in EPA urethroplasty, compris- ing 89 patients, making it one of the largest series of patients undergoing this procedure in Southeast Asia, despite the relatively short follow-up period (median of 16.3 months). This outcome is consistent with previous studies that report success rates ranging from 85% to 95% (12). However, the definition of a successful urethroplasty remains a topic of debate, with no clear agreement on the best postoperative follow-up approach. In our study, suc- cessful urethroplasty was defined as the absence of the need for further treatment, which has been widely used in most previous research (13). At our center, postoperative follow- up typically involves catheter removal four weeks after sur- gery, followed by uroflowmetry. We do not routinely per- form postoperative cystoscopy due to the unavailability of flexible cystoscopy, as well as concerns about cost-effec- tiveness and the geographical burden, which requires patients to travel to our center. Despite this positive result, the potential for stricture recurrence remains a concern, with various factors influencing the risk of recurrence. One of the primary risk factors identified in the literature is the length of the stricture. Studies have shown that longer strictures, particularly those exceeding 2 cm, are associated with higher recurrence rates following ure- throplasty (14, 15). This is likely due to the increased complexity of surgical repair and the potential for inade- quate vascularization of the anastomosed segment. Furthermore, the presence of dense periurethral fibrosis, often seen in long strictures, can complicate the surgical approach and contribute to poorer outcomes (16). In our cohort, strictures longer than 2 cm were associated with a greater risk of recurrence. Two patients experienced recurrence within the first 3 months, and six within 12 months after surgery. This is in line with the findings of Kinnaird et al., who reported an average recurrence time of 11.7 months, with occurrences ranging from 2 weeks to 77 months (17). Similarly, Barbagli et al., observed that recurrences in their cohort of both anastomotic and sub- stitution urethroplasty patients were evenly distributed over time, with a plateau reached only after 5 years (18). BMI has been identified as a potential risk factor influenc- ing the recurrence of urethral strictures following EPA urethroplasty. The relationship between BMI and surgical outcomes is multifaceted, as obesity can impact both the surgical procedure and the healing process (19). In our cohort, patients with BMI over 25 significantly had higher risk of recurrence. the technical challenges posed by a higher BMI can complicate the surgical approach. Increased adipose tissue in the perineal region may hinder access to the urethra, making it more difficult to achieve a tension-free anastomosis, which is crucial for successful outcomes (20). Additionally, the presence of excess tissue may lead to increased tension at the anastomosis site, fur- ther contributing to the risk of recurrence (21). One notable finding from this cohort is that delayed sur- gical intervention exceeding 6 months is a significant pre- dictor of recurrence in patients undergoing EPA urethro- plasty. As we know, Indonesia is one of the largest archi- pelagic countries in the world, comprising numerous islands, which makes accessing adequate healthcare facil- ities time-consuming and costly (22). Furthermore, the limited distribution of reconstructive urologists is a major factor contributing to the prolonged time before patients receive treatment. This correlation underscores the importance of prompt evaluation and management of urethral strictures, as timely surgical intervention is linked to better healing conditions and outcomes (23). Comorbidities such as DM and hypertension have been shown to influence stricture recurrence in some studies. These conditions may predispose patients to recurrence due to poor microvascular circulation and impaired wound healing associated with DM and hypertension (24). However, this finding contrasts with the results of our cohort study, where DM and hypertension were not statistically significant risk factors for recurrence. We believe this discrepancy may be attributed to the relative- ly young average age of patients undergoing EPA urethro- plasty in our study, which was 41.2 years, at an age when few individuals have developed degenerative diseases. The location of the stricture is another critical factor. A study by Bagchi et al. identified the bulbar urethra as the most common site of stricture, which is generally associ- ated with better outcomes compared to membranous ure- thral strictures, where recurrence rates tend to be higher due to the complexity of the anatomical region and the proximity to the external urinary sphincter (7). In our cohort, the bulbomembranous urethra exhibited the highest incidence of strictures; however, there was no sig- nificant difference in recurrence risk based on the loca- tion of the stricture. Several studies indicate that prior urethral procedures can impact outcomes. These patients tend to have a slightly higher incidence of recurrence, likely due to the cumulative trauma resulting from previ- ous dilatations or urethrotomies (12, 18). In our cohort, over 35% of patients had undergone one or more endo- scopic treatments before opting for EPA urethroplasty; however, interestingly, this finding does not align with the results of our study. Limitations of the present study include its retrospective nature, limited follow-up duration, single institution and surgeon, relatively small sample size, and subjectivity in outcome assessment. While our criteria for defining recurrence were somewhat subjective and relied on patient-reported symptoms that prompted urethrogra- phy, we believe this approach is clinically valid due to the lack of consensus on how to define stricture recurrence following urethroplasty. Addressing these limitations through larger, multicenter, and prospective studies will be essential for optimizing surgical techniques and improving patient outcomes. CONCLUSIONS Obesity, the length of the stricture, and delayed surgical intervention are associated with an increased risk of ure- thral stricture recurrence in patients following EPA. EPA Archivio Italiano di Urologia e Andrologia 2025; 97(1):13268 5 Urethroplasty for traumatic urethral stricture urethroplasty demonstrates a high success rate in manag- ing traumatic urethral strictures. Careful patient selec- tion, along with prompt and appropriate surgical inter- vention, is crucial to improving long-term outcomes and reducing the risk of re-stricture. REFERENCES 1. Yücetürk CN, Keseroglu BB. Etiology of Posterior Urethral Strictures: Analysis of 116 Cases. Ankara Education and Research Hospital Medical Journal. 2020; 53:76-80. 2. Djoeworo WR, Tasono Hadi DP, Darjoko ST. 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Barbagli G, Kulkarni SB, Fossati N, et al. Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol. 2014; 192:808-813. 19. Wiegand LR, Brandes SB. The UREThRAL stricture score: A novel method for describing anterior urethral strictures. Can Urol Assoc J. 2012; 6:260-4. 20. Akyüz M, Sertkaya Z, Koca O, et al. Adult urethral stricture: practice of Turkish urologists. Int Braz J Urol. 2016; 42:339-345. 21. Ansari IS, Islam SU, Ali W, Haq IU. Urethrotomy and end-to- end urethroplasty in anterior urethral strictures up to 1.5 cm Dept of Urology Mayo Hospital, Lahore. Pak J Med Health Sci. 2022; 16:174-175. 22. Leosari Y, Uelmen JA, Carney RM. Spatial evaluation of health- care accessibility across archipelagic communities of Maluku Province, Indonesia. PLOS Glob Public Health. 2023; 3:e0001600 23. Desai D, Harrison W, Raveenthiran S, et al. Urethronav: the aetiology and extent of idiopathic urethral stricture in an Australian population. Transl Androl Urol. 2024; 13:423-432. 24. Blaschko SD, McAninch JW, Myers JB, et al. Repeat urethro- plasty after failed urethral reconstruction: outcome analysis of 130 patients. J Urol. 2012; 188:2260-2264. Correspondence Paksi Satyagraha (Corresponding Author) uropas.fk@ub.ac.id Edi Wibowo eddiewibowo283@gmail.com Besut Daryanto urobes.fk@ub.ac.id Gede Wirya Diptanala Putra Duarsa diptaduarsa@gmail.com Adrianus Gupta Wijaya guptawijaya@gmail.com Fauzan Kurniawan Dhani fauzankurniawandhani@gmail.com Urology Department, Saiful Anwar General Hospital Malang, Jalan Jaksa Agung Suprapto 2, Klojen, Malang, East Java 65112, Indonesia DECLARATIONS Ethical approval: This study was approved by the Health Research Ethics Commission of Saiful Anwar General Hospital Number: 400/214/K.3/102.7/2024. Availability of data and material: The datasets used and/or analyzed during the current study are available upon reason- able request. Competing interests: The authors declare no conflict of inter- est. Funding: The authors report no funding. Authors' contributions: PS, EW, BD: conceptualization, methodology, writing-original draft, visualization, project administration, validation, GWDPD, AGW, FKD: conceptual- ization, methodology, writing-original draft, investigation, val- idation, data analysis. Acknowledgments: not applicable.