Risk factors associated with failed EPA urethroplasty in older male patients: a single center experience

Excision with primary anastomosis (EPA) urethroplasty is the gold standard treatment for short-segment urethral strictures; however, recurrence remains a concern. This study aims to evaluate the factors associated with surgical failure in patients aged ≥ 40 years.

This retrospective study included male patients who underwent EPA urethroplasty between 2013 and 2023 by a single surgeon. Patients were stratified into < 40 years (Group A) and ≥ 40 years (Group B). Comorbidities, stricture characteristics, prior procedures, and time to surgery were analyzed. Univariate and multivariable logistic regression analyses were performed, followed by Firth's penalized logistic regression to account for the small number of outcome events.

A total of 89 patients were included (41 in Group A and 48 in Group B). The success rate was higher in Group A than in Group B (97.6% vs. 85.4%). In patients aged ≥ 40 years, hypertension, diabetes mellitus, and delayed time to surgery were associated with recurrence in univariate analysis. However, in Firth's penalized logistic regression, only delayed time to surgery (> 6 months) remained significantly associated with recurrence (OR 6.59, 95% CI 1.15-68.78, p = 0.033). Diabetes mellitus showed a trend toward increased risk but was not statistically significant.  Conclusions: EPA urethroplasty remains an effective treatment for urethral stricture. Delayed time to surgery may be associated with an increased risk of failure in patients aged ≥ 40 years, while the role of metabolic factors remains inconclusive. To establish the clinical utility of these predictors, larger prospective cohorts are essential to overcome the limitations.