Similar to urooncology, reconstructive urologists are increasingly confronted by an aging patient population with higher baseline risk profiles such as obesity and significant comorbidity. As for other procedures, preoperative counseling prior to urethroplasty entails risk assessment including both 1) perioperative risk and 2) potentially elevated risk of treatment failure. While for perioperative risk there are many tools at hand to facilitate risk assessment, such as the Charlson Comorbidity Index, ASA^® (American Society of Anesthesiologists^®) score or the increasingly used frailty indices, data are ambiguous for the estimation of treatment failure after urethroplasty in patients who may be at a higher risk due to their baseline characteristics.

There is no high-quality evidence to support obesity as an adverse risk factor after urethroplasty. Some series have shown controversial results,^1-5 but none of those studies was prospectively conducted or followed a standardized protocol to be able to provide statistically solid results and give clear answers. Arguably, we would need a large-scale prospective registry with hundreds of patients to address the usual confounding which is commonly introduced by many cofactors with a well-known impact on treatment outcomes, such as stricture etiology, location or length, and number and type of previous interventions. We are thus well advised to approach this issue pragmatically. Given that stricture recurrence is more or less a result of spongiofibrosis and excessive scarring, it is conceivable that the former is fostered by microvascular dysfunction, which may for example hamper the healing of a buccal graft or a reanastomosis. The major theory why obese patients may potentially have worse results compared to their normal-weight counterparts is the increased risk of wound healing, which is carried by comorbidities such as diabetes or cardiovascular disease. Generally, perineal surgery is considered more difficult in obese patients and we tend to adapt our institutional algorithms to mitigate the problems which may potentially occur in the postoperative course. To reduce early complications such as wound dehiscence or infection, we can, for example, adapt procedural algorithms and use staplers instead of running sutures or keep the Foley catheter in situ longer to guarantee a solid urethral healing. Similar considerations are appropriate for the impact of age or comorbidity on urethroplasty outcomes. There are several studies showing that comorbidity but not age had an effect on treatment success after adjusting for potential confounders,^3,6 while others found an association of older age and the incidence of early recurrence.⁷ In a cohort of more than 500 patients undergoing buccal mucosal graft urethroplasty, we have assessed the importance of cardiovascular comorbidity and smoking on recurrence. Whereas patients who presented with recurrence were indeed older, had a higher ASA score, and more often presented with coronary artery disease and hypertension, these findings did not hold true in multivariable analyses.⁸ Interestingly, we found that postoperative drop of hemoglobin was associated with improved outcomes, which may come as a surprise in the first place, but may also undergird the hypothesis of a favorable local microvasculature and circulation, leading to improved outcomes and less scarring in the long term.⁸

Similar to other urological procedures, the success of urethroplasty, including the incidence of significant postoperative complications, remains a function of stricture factors, procedural factors such as surgical volume and patient characteristics. While we are only beginning to understand what granular stricture factors contribute to recurrence (eg pathological markers such as androgen receptor status, markers for oxidative stress or inflammation, and sclerosis),⁹ we can aim at improving procedural aspects, for example by centralization of care, specialization and well-designed prospective trials to better understand what to do in which case.¹⁰ Patient characteristics, however, are preexisting and unlikely to be changed on short notice. Perioperative risk assessment should be performed as for any other oncologic or nononcologic procedure to gauge risks and benefits. Patients should be counseled that age and comorbidity might serve as a surrogate of adverse local tissue environment in the stricture in the individual, which makes them more susceptible to procedure-related morbidity and adverse outcomes. In the light of up-to-date evidence, European Association of Urology and AUA guidelines do not recommend against urethral reconstruction in the elderly, obese or comorbid patients. Thus, reconstructive urologists should continue with a pragmatic, individualized approach, but certainly not irrevocably withhold urethroplasty from patients at risk.