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

Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy, designed to reduce the disability period and improve the medical care quality. The study aims to analyze the enhanced recovery protocol effectiveness in a comparative study of elective urethral stricture surgery. A prospective study included 54 patients with an established diagnosis of urethral stricture in 2019-2020 in the urological hospital of the Irkutsk City Clinical Hospital No. 1. All 54 patients have completed the study. There were two groups of patients FTS-group (group II, n = 25) and standard group (group I, n = 29). In terms of preoperative parameters, the comparison groups have statistical homogeneity. The comparative intergroup efficacy analysis of the treatment based on the criteria established in the study demonstrated good treatment results for 5 (17.2%) patients of group I and 20 (80%) patients of group II (p=0.004). The overall efficacy of urethroplasty surgeries, regardless of the treatment protocol, was comparable (86.2% vs 92%; p=0.870), as well as the likelihood of relapse within two years (p=0.512). The predictors of recurrence were technical complications and urethral suture failure (OR 4.36; 95% CI 1.6; 7.11; p=0.002). The FTS protocol reduced the treatment period (p < 0.001) and decreased the severity of postoperative pain (p < 0.001). The use of the “fast track surgery” protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.


Introduction
Fast track surgery (FTS), as well as ERAS (enhanced recovery after surgery/rapid recovery programs), is the latest multimodal treatment strategy designed to reduce disability periods and improve the quality of medical care. Tis program includes the preoperative stage preparation, minimally invasive surgical techniques, and active management of the post-operative stage to reduce the treatment period, rehabilitation time and to provide the fastest possible return of patients to normal life. In this article, the FTS and ERAS (enhanced recovery after surgery) protocols are equivalent, pursuing the same goal.
Te main objectives of the FTS are multidisciplinary interaction at all stages of examination and treatment [1], assessment of the applied protocol for compliance with the FTS principles [2], careful selection of patients for the program for various reasons, including religious reasons, which may hinder participation [3]. Tere is an assessment of the risks of using the protocol, which may increase the likelihood of postoperative complications or negative outcomes due to the impossibility of adhering to the protocol (due to lifestyle or concomitant diseases) [4]. Te program also includes a revision of the concept of preoperative and postoperative food and liquid intake and bowel preparation [5][6][7]. As well as changing opiate and opiate-like analgesics to nonsteroidal drugs and others [8]; implementation of multimodal anesthesia allowing minimizing operational and post-operative stress in combination with early mobilization [9], intraoperative normothermia maintenance [10], control of fuid [11], post-operative pain [9,12], and nausea [13].
Tere are critically little works on FTS in urethroplasty. Selected studies and inventions evaluated applicability in the developed protocol. Tis made it possible to apply the concept of using fbrin glue [14] and platelet-rich plasma (PRP) [15]. Te submucosal PRP injection for internal optical urethrotomy signifcantly reduces the risk of recurrence (9.09% vs 26.82%, p 0.032) in the long-term postoperative period [16].
Currently, the number and quality of randomized researches devoted to the fast track protocols in reconstructive urology are extremely small. At the same time, the problem of preoperative preparation, optimization of surgical techniques, and acceleration of postoperative rehabilitation remain relevant, since there have been no signifcant changes in approaches to perioperative management of patients over the past ten years.
Te scientifc novelty of the study is due to several factors. A set of fast track and ERAS measures will be evaluated for patients with planned urethroplasty, aimed at improving all aspects of treatment (patient and medical staf satisfaction with treatment, increased treatment efectiveness, improved fnancial efciency of treatment, and accelerated rehabilitation of patients after treatment). For the frst time, there will be a comparative analysis of the immediate and long-term results of the application of the developed principles and the standard approach. Te study will present the evaluation of postoperative complications associated with various methods of treatment; the results of the application of the developed and traditional approaches; and predictors of complications in the long-term postoperative period.
Research objectives: to develop and adapt the FTS protocol for patients with planned urethroplasty; to increase the overall and fnancial efciency of surgical treatment; to assess the impact of the compared approaches on the condition of patients and their satisfaction with the treatment; to analyze the immediate and long-term results; and to develop recommendations for the developed protocol of FTS urethroplasty.
Te study aims to analyze the efectiveness of Enhanced Recovery Protocol in a comparative study for elective urethral stricture surgery.

Research Design.
Te local ethics committee of the Irkutsk State Medical University (ISMU) and the Irkutsk City Clinical Hospital No. 1 approved the clinical trial. Tere was a prospective, blind, randomized, and single-center study in the urological hospital of the Irkutsk City Clinical Hospital No. 1.
Te clinical part of the study includes an analysis of the examination and treatment results of patients who underwent surgical interventions for urethral stricture from January 2019 to August 2020. Surgeries were performed using anastomotic and augmentation/substitution methods.
Te inclusion criteria were as follows: (i) Te patient is planned to have surgery of the urethra for urethral stricture or distraction defect of the urethra (ii) Indications for surgery meet the criteria of the approved protocol (iii) Te operation is planned using one of the methods approved in the study (iv) Patients are over 18 years old (v) Te patient signed a voluntary informed consent to participate in the study (vi) Te patient is deliberately planned to follow the treatment protocol (FTS or standard), determined by randomization until the day of surgery Noninclusion criteria were as follows: Lack of medical indications; (i) Te patient did not sign the voluntary informed consent form to participate in the study (ii) Te concomitant diseases that signifcantly afect the patient's objective status (decompensated diabetes mellitus, heart failure, gross neurological defcits, etc.) (iii) Failure to comply with the FTS protocol Exclusion criteria we as follows: (i) Te patient refused to participate at any stage of the study (ii) For any reason, there was a deviation from the research protocol (iii) Te patient did not have surgery for any reason or underwent another surgery that does not meet the group's criteria Te null hypothesis of the study was that there were no between-group diferences on the primary point. If the null hypothesis was rejected, the alternative hypothesis was that there was an intergroup diference at the primary endpoint.
Taking the results of earlier studies on similar subjects, it was calculated that 13-15 (t-test, ES � −1.136) patients in each comparison group would be sufcient to reproduce diferences in success and postoperative status with odds of type 1 and type 2 error of 0.05 and 0.2, respectively. Study power is >0.8. To compensate for incomplete observations, the estimated sample size was increased by 10%.
Tus, the required total sample size (two patient comparison groups) should be at least 33 patients.
Te recruitment of patients who met the inclusion criteria was carried out prospectively using the continuous sampling method until the desired sample size was reached. During the indicated period, 123 patients had the diagnosed 2 Advances in Urology stricture disease of the urethra. Only 94 patients met the study inclusion criteria. All included patients were randomized (simple randomization method) into two groups based on the approved study protocol. Te frst group followed the FTS treatment protocol (approved by the ethical committee of the ISMU); the second group followed the standard treatment protocol ( Figure 1). Tus, the fnal clinical analysis included 54 patients (perprotocol) who met all the study criteria. Tey formed two groups. Te group of patients with the standard treatment protocol (n � 29, the group I), and the group with the FTS protocol (n � 25, group II).

Checkpoints. Te study has checkpoints.
Te primary "hard" checkpoints were the absence of recurrence of urethral stricture in the late postoperative period (but not earlier than three months); and detected relapse at any stage of postoperative follow-up.
Secondary "soft" checkpoints of clinical efcacy were the data of the subsequent postoperative examination: maximum urine fow rate of more than 12 ml/sec, residual urine volume less than 50 ml, indicators of the IIEF-5, IPSS, QoL scales, and no signs of recurrence according to urethrography data (diameter of the urethral lumen more than 5 mm). Table 1 presents the comparative data on the initial parameters of patients in the study groups. Table 2 presents comparative data of the results of an objective examination and the state of the functional status of the comparison groups.

Diagnostic Methods.
Te examination included anamnestic (to establish the duration of the disease, concomitant diseases, etc.), clinical, biochemical, ultrasound, tomographic, radiological, and endoscopic research methods.
To clarify the nature and degree of pathological changes in the urethra there was urethrocystography (X-ray or MSCT) and urethrocystoscopy. An ultrasound helped to assess the volume of residual urine and the volume of the prostate, urofowmetry data showed the maximum urine fow rate (Q max ). When visiting a doctor, patients had to assess their subjective state and functional status according to the recommended scales for assessing lower urinary tract symptoms (LUTS/IPSS), quality of life (QoL), erectile function (IIEF-5), and other parameters. Te visual analog scale of pain (VAS) helped to assess the severity of postoperative pain syndrome. Tese assessments of the subjective state were as follows: 0-1 points-no pain; 2-3 pointsslight pain; 4-5 points-moderate intermittent pain; 6-7 points-moderate persistent pain; 8-9 points-severe pain; more than 10 points-unbearable pain.
Before removal of the urethral catheter, there was a pericatheter urethrography to assess a possible defect in the tightness of the urethra and to resolve the issue of prolonged urethral drainage.
Upon reaching three months after the surgery, all patients at least once every six months or once a year had to undergo the standard assessment of the state established by the study protocol as follows: consultation with a urologist, clinical blood and urine tests, urethrography, urethroscopy, urofowmetry, and ultrasound of the urinary system. Patients assessed the subjective status using the IPSS, QoL, IIEF-5 scales, and gave complaints.
Tere were several criteria to assess the treatment effectiveness: the maximum urine fow rate (by urofowmetry), the diameter of the urethral lumen in the plastic zone (according to urethrography), the volume of residual urine (ultrasound assessment), and the indices of rating scales (IPSS, QoL, and IIEF-5). Successful (free from a relapse) were considered the results of treatment with the following parameters 3 months or more after surgery: Q max more than 12 ml/sec; absence of residual urine, signs of recurrence according to urethrography data (normal diameter of the urethral lumen in the plastic zone is 5 mm or more); and absence of severe LUTS, unsatisfactory quality of life.
Te treatment results were evaluated based on a comprehensive analysis of the parameters of all primary and secondary endpoints. Te absence of relapse and adequate urination do not provide an accurate indication of satisfaction with treatment and the patient's quality of life after surgery. Terefore, interpretation of the results requires consideration of all factors. Table 3 presents the treatment results divided into three groups. Simple and multiple logistic regressions helped to identify predictor variables for a binary response variable. To determine the predictors of post-operative complications development there was a univariate and multivariate logistic regression analysis. Te predictor variables were selected according to the initial and closest parameters (partially presented in Tables 1, 2, and 4, more than 100 in total). Cox proportional risks regression helped to assess the correlation between one or more continuous or categorical variables and the time to an adverse event. Te signifcance level for all methods is p ≤ 0.05.

Treatment Protocols.
During the study, there were the following two diferent treatment protocols: standard (group I), when the patient was prohibited from drinking and eating on the day of surgery, underwent bowel cleansing the night before and the morning of surgery, and received a sedative (diazepam). Intraoperatively, absorbable suture material was used for individual interrupted sutures, including monopolar diathermocoagulation, separately interrupted skin suture, and standard dressings. On the frst day after the surgery, only liquid intake was allowed, food intake was allowed from the second postoperative day. In the postoperative period, on the frst day after the operation, Advances in Urology anesthesia with narcotic analgesics was performed as needed. Te patient was mobilized on the second day after the surgery. Infusion therapy was performed within the frst 24-48 hours. Antibiotic therapy was carried out during the entire hospitalization. Te minimum recommended hospital stay after surgical treatment was 7 days. Te urethral catheter was removed 10-21 days after surgery. Table 5 shows the FTS protocol scheme (group II). Te fnal choice of the method of surgical treatment was made in advance and corrected intraoperatively. Te main types of operations were anastomotic urethroplasty (EPA) in the form of the classic Turner-Warwick/Webster operation [17,18], vascular-sparing methods [19], intraurethral anastomosis [20], and buccal mucosa graft urethroplasty using various techniques (Asopa [21], Barbagli [22] and others), as well as the original minimally invasive technique [23].
All patients in both groups used neuraxial analgesia, prophylaxis of thromboembolic complications (low molecular weight heparins), and protection from stress ulcers (proton pump blockers). Te severity of the postoperative pain syndrome was possible to assess according to the visual analog scale of pain (VAS) on the frst day after surgical treatment.
Platelet-rich plasma (PRP method) and fbrin glue (i-PRF and Superfbrin method) were obtained by centrifugation ("Armed" centrifuge) in special tubes from the patient's peripheral venous blood.

A Clinical Example of the ERAS Protocol in Urethroplasty.
Patient K., 62 years old, presented with the following complaints: inability to urinate adequately and presence of cystostomy. From the medical history it is known that urethral stricture was detected accidently. A cystostomy was inserted in 2021 due to acute urinary retention. TRUS revealed prostate volume of 20.7 cm 3 . An urethrogram on the 22.12.20 revealed a bulbo-membranous stricture of the urethra with narrowing of the lumen up to 1 mm. On December 29, 2020, a prostatic TUR and an internal optical urethrotomy were performed and the cystostomy was preserved. In the postoperative period urination was not restored. On control urethrocystoscopy and MSCTurethrocystography the diagnosis was bulbo-membranous urethral stricture, recurrence, complication of underlying secondary chronic cystitis, chronic urinary retention, cystostoma, and hospitalized as planned for surgical treatment of urethral stricture.   In the preoperative period the detailed consultation about the possible principles of urethral strictures treatment, the reasons of their occurrence and consequences of refusal from treatment has been carried out. Possible alternative treatments such as endoscopic dissection, dilatation, anastomotic urethroplasty, and others are presented. An overview of the preoperative period, intraoperative nuances and a description of the expected state in the postoperative period and possible complications, as well as rehabilitation measures, are presented.
Immediately after the initial consultation, the patient's consent to surgical treatment according to the principles of accelerated recovery is obtained. An examination plan was prescribed as part of the accelerated pathway. All examinations were carried out on the following day within three hours. Te indications and contraindications for surgery are reassessed on the basis of the examination results. A multidisciplinary team discussion was carried out as follows: the urologist, anesthetist, internist, radiologist, nurse, and rehabilitator. Te possibility of adhering to the protocol on religious, ethical, social, and other grounds is assessed. Evaluated the need for prehabilitation: not identifed. Recommended slagfree diet 2-3 days before surgery.
Patient is scheduled for surgery date. Hospitalization on the day of surgery, three hours before the planned surgical intervention. Self-preparation at home. Cleansing of bowel has not been carried out. Shaving of the operative feld perineum, after pretreatment with skin antiseptic. Prevention of venous thromboembolism-compression knitwear and subcutaneous injection of Fraxiparin 0.3 ml.
On admission the patient was premedicated with celecoxib 100 mg, gabapentin 600 mg, and omeprazole 20 mg once oral. Carbohydrate loading of 200 ml of maltodextrose mixture orally was performed.
Antibacterial prophylaxis was carried out once 60 minutes before surgery according to the recommendations. Preoperative urine culture with pathogenic microfora growth and postoperative antibiotic therapy plan were made according to culture results.
Intraoperative method of anesthesia was epidural anesthesia. Te operation time was 50 minutes. A 14Fr silicone urinary catheter was inserted. Intraoperative heating of the patient was carried out using an electric heating mattress. Heating of infusion solutions was carried out using a fow heater. Minimally invasive was perineal linear surgical access of 2 cm. Te operation was performed using a 4.5x magnifying lens. Monopolar coagulation was not used. After performing a bulbar urethral access, a 2 cm transbulbar access was performed. After removal of scar tissues, a 3 × 1 cm oral graft was taken from the left cheek under local anesthesia with lidocaine 2% 20 ml solution. Te defect was sutured with Vicryl 3-0. Te graft was fxed in the formed bed with 5-0 monocryl continuous suture. Te urethrotomy Table 3: Evaluation of treatment results using the combined (multiple) endpoint methods.

Parameter
Good Satisfactory Unsatisfactory Absence of relapse + + − No severe pain syndrome (>5 points on the pain scale) in the post-operative period      After the operation, the patient was transferred to a postoperative ward for 3 hours. Intraoperative pain management continued in the postoperative period according to the "no pain" principle, i.e. prevention rather than elimination of pain. After the end of the epidural anesthesia the patient was prescribed oral celecoxib 100 mg and acetaminophen 250 mg every 6-8 hours during the frst postoperative day. Te use of maltodextrose mixture is suggested one hour after surgery. Postoperative consumption of solid food is allowed 2 hours after surgery. Plantbased chewing gum is recommended to reduce the risk of postoperative functional bowel disorders and for the purpose of local antiseptic action.
Te patient is activated 6 hours after the operation, following the cessation of epidural anesthesia. Activation involves sitting and walking. Glycemic control on the frst and second post-operative days, no correction was necessary. On the second postoperative day, a control clinical blood count was performed. Postoperative antibiotic therapy was carried out according to the culture data-levofoxacin 500 mg once a day, 5 days. Wound treatment was not carried out.
Independent daily hygiene-showering was recommended.
Prophylaxis of venous thromboembolism was continued-compression knitwear was worn until 21 days after the operation, plenty of fuids were administered and Fraxiparin 0.3 ml was injected intravenously until discharge. Te patient was discharged from the hospital to outpatient care on the third postoperative day.
Te urethral catheter was removed 7 days after surgery, after a control pericatheter urethrocystography to assess possible urine leakage from the access line.
Daily contact with the attending physician via phone calls and messenger for the frst 10 days, then once every 2-3 days for up to a month. Monthly thereafter for one year. Check-ups and follow-ups ultrasound on the 3rd, 7th, 10th, 20th, and 30th day and then after 3, 6, and 12 months.
In 14 days after surgery, the use of the drug Longidase was recommended under the scheme of 1 suppository rectally once every 2 days, # 20.
No intraoperative or postoperative complications ≥ II according to Clavien-Dindo classifcation were registered in the patient. Te patient was discharged in a satisfactory condition on the 3rd day after surgery.
According to the control urethrocystography and urethroscopy one year after surgery, there were no signs of urethral stricture recurrence. Te diameter of the urethra in the urethroplasty zone was 6.5 mm. Quality of life indicators were in line with population averages.

Research Limitations.
Limitations of the research were as follows: relatively small sample size, the average postoperative follow-up period of fewer than two years, singlecenter study, mixing of various surgical techniques, and diferent localizations of strictures within the protocol (anastomotic, substitution, and others).

Immediate Results.
To compare the immediate results of surgical treatment of urethral stricture disease after the standard treatment protocol (group I) and after the FTS protocol (group II) there was a comparative analysis of the postoperative parameters of the patients' condition and the examination results.
In the early and late postoperative periods, there were no cases of mortality in the two groups. In the early and late postoperative periods, there were no complications of anesthetic treatment or deterioration of the general somatic status. Te need for mechanical ventilation or respiratory support did not arise in any case in the comparison groups. Tere were also no cases of heart failure that required inotropic support.
Intergroup analysis of the size of the surgical approach showed that its average linear dimensions of group I were 7.1 ± 2.1 cm, which is signifcantly greater than of group II (3.3 ± 1.2 cm, p < 0.001).
Tere was a chronometric analysis of the operating period. Te average duration of surgery in groups I and II were 1.2 ± 0.35 hours and 1.1 ± 0.31 hours, respectively (p � 0.273). Table 4 shows the comparative characteristics of the postoperative state indicators of patients in the comparison groups.
Te results analysis showed that in both comparison groups and postoperative complications in the early and late periods developed extremely rarely.
It should be noted that the development of incontinence and failure of the urethral suture occurred only in one case. Tus, univariate logistic regression analysis of these indicators did not reveal a statistically signifcant correlation with the initial parameters (p> 0.05) in the comparison groups. Table 6 presents the information on predictive factors for the occurrence of post-operative complications (univariate and multivariate logistic regression analysis, the table includes signs with a level of χ 2 > 1 and p < 0.05).
A simple (univariate) logistic regression analysis among 54 patients of both comparison groups revealed that some indicators acquired special signifcance in predicting the development of subfebrile condition in the early postoperative period -the results are presented in Table 6.
Te obtained results helped to build a model for predicting subfebrile status in multivariate regression analysis (selection from predictor factors with a signifcance level of p < 0.05). Low subjective assessment of the quality of life (more than 4 points; Coefcient 1.5; 95% CI 0.1; 2.9; p � 0.035), as well as the size of the surgical access (for each Advances in Urology Te independent predictors of persistent pain syndrome found by simple logistic regression analysis (presented in Table 6) were included in further analysis. Localization of the urethral stricture in the penile part of the urethra (Coefcient 5.41; 95% CI 0.55; 10.2; p � 0.029), as well as the size of the surgical access (for each 1 cm; Coefcient 1.29; 95% CI 0.45; 2.13; p � 0.002), became signifcant predictors of persistent pain syndrome. Te rest of the factors were not signifcant (p > 0.05). Table 7 shows postoperative indicators of urodynamics, objective, and functional status (IPSS, QoL, and IIEF-5) in the comparison groups.
Tere was a comparative intergroup analysis of these indicators. Te groups were comparable according to the results of an objective examination, the state of urodynamics, and functional status in the early and late postoperative periods (p > 0.05).

Long-Term
Results. Long-term results of surgical treatment of stricture disease were possible to assess according to the control endpoints of the examination. Te average period of clinical observations was 468 days with 95% CI 423-513, and the maximum period was 721 days. Table 8 presents general indicators of the long-term postoperative period in the comparison groups.
For group I, the average observation period was 469 days with a 95% CI of 401-537 days (maximum period of 705 days). For group II, the average observation period was 466 days with a 95% CI of 403-529 days (maximum period of 721 days).
In the long-term postoperative period, there was a single episode of mortality in group I, which was not associated with surgery.
Tere were few signifcant complications in the longterm postoperative period. In 3 (10.3%) cases from group I and 2 cases (8%) from group II, there was an acute infammatory process of the genitourinary system in the period from 3 to 12 months, which required the antibacterial drugs (p � 0.786). 7 (24.1%) patients of group I and 5 (20%) patients of group II (p � 0.770) presented complaints of penile shortening during active questioning 3 months after surgery.
To determine the predictors of the development of the above complications, there was univariate and multivariate logistic regression analysis. Te predictor variables were selected according to the initial and closest parameters (partially presented in Tables 1, 2, 5, and 7, more than 120 in total). Information on predictive factors for the occurrence of postoperative complications in the long-term postoperative period (univariate and multivariate logistic regression analysis, the table includes signs with χ 2 > 1 and p < 0.05) are presented in Table 9.
Te obtained results allowed constructing a model for the prognosis of infectious complications in the long-term postoperative period in multivariate regression analysis (selection from factors p < 0.05). Decompensation of diabetes mellitus in the long-term postoperative period (Coefcient 3.92; 95% CI 0.09; 7.7; p � 0.045) was a significant predictor of this complication. Consequently, after performing urethroplasty surgeries, the risk of developing infectious complications in the long-term period increases with decompensation of diabetes mellitus.
Te obtained results helped to construct a model for predicting penile shortening in multivariate regression analysis (selection from factors p < 0.05). A signifcant predictor of this complication was the length of the urethral stricture more than 3 cm (coefcient 2.87; 95% CI 0.08; 5.67; p � 0.043). Consequently, urethroplasty for patients with a urethral stricture longer than 3 cm increases the risk of penile shortening.
Tere was a statistical analysis of overall survival. Te Kaplan-Meier estimates of the survival rate of group II patients during the entire observation period after urethroplasty were equal to 100%. Te values of the Kaplan-Meier estimates of the survival rate of group I patients during the entire observation period (up to 2 years) were 96.3 ± 3.63% with a 95% CI of 76.4-99.4%. Te logrank test did not reveal statistically signifcant diferences in the survival rate in the long-term post-operative period in the comparison groups (p � 0.335), which is graphically presented by the Kaplan-Meier method in Figure 2.
Cox proportional hazards regression analysis showed no reliable predictor of mortality in the long-term postoperative period. Probably, such a result of the statistical analysis is due to the small representation of the factor (a single case of mortality).
Te analysis of the dependence of mortality on general surgical technical reasons was not performed due to the absence of such. Te survival rate for this parameter for both groups was 100% over the entire observation period. Table 10 presents comparative information on the success of surgical treatment in the comparison groups.
In the frst group, out of 29 primary operations, 25 were successful (86.2%). In the second group, 23 out of 25 primary operations were successful. Tus, the primary efciency was 92%.
Te log-rank test did not reveal statistically signifcant diferences (p � 0.512; χ 2 � 0.43) in the recurrence rate over the entire observation period, which is graphically expressed by the Kaplan-Meier method in Figure 3.
Te predictor variables were selected according to the initial parameters, as well as according to the control parameters in the postoperative period. p � 0.002) in predicting a possible recurrence after urethroplasty surgery.
Analyzing the comparative intergroup efectiveness of the treatment based on the criteria established in the study, good treatment results obtained 5 (17.2%) patients of group I and 20 (80%) patients in group II (p � 0.0049). Satisfactory results obtained 20 (68.9%) patients of group I and 3 (12%) patients of group II (p � 0.0055). Unsatisfactory results obtained 4 (13.7%) patients in group I and 2 (8%) patients in group II (p � 0.544).
Terefore, the use of the FTS protocol after urethroplasty allows achieving better treatment results than the classical approach. Both methods of urethroplasty had zero operating and hospital mortality and a low incidence of postoperative general and urinary system-related complications. Both methods are highly efective and safe. However, the classical approach is associated with longer disability and worse subjective perception and objective assessment of the perioperative period for patients.

Discussion
Modern surgery, including urology, has many tools and techniques that facilitate the perioperative period for both the patient and the healthcare organization. However, the complexity of preoperative diagnosis, its duration and cost, and operational and postoperative surgical stress reduce the quality of medical care. Urology is one of the leaders in minimal invasiveness, making the most of endovideosurgery and endoscopy. Tat is why, according to the authors, of particular interest is the development of protocols for enhanced recovery in urology. Tus, a typical urological problem postoperative pain remains relevant. Te rehabilitation and restoration of working capacity also remain relevant.
A few interesting results were obtained in the presented study. Te overall efcacy of urethroplasty operations, regardless of the treatment protocol, was comparable (p � 0.870), as well as the likelihood of recurrence within 2 years (p � 0.512). Te results obtained are consistent with the data of other authors; the average efciency of urethroplasty operations, regardless of the location and length of the stricture, when using anastomotic or replacement methods is 85 ± 10% [24][25][26][27].
In the development of relapse, a special role (according to multivariate Cox proportional hazards regression) played technical complications and failure of the urethral suture (OR 4.36; 95% CI 1.6; 7.11; p � 0.002). Te FTS protocol for urethroplasty surgery ofers several simple techniques to minimize this risk. First, it is proposed to use only a continuous and sealed urethral suture; second, the suture is additionally treated with fbrin glue; and third, the surrounding tissues are infltrated by platelet-rich plasma. Te use of platelet-rich plasma can reduce the zones of necrosis, the severity of local infammation, and improve angiogenesis, which has been confrmed by several works [16,28,29]. Fibrin glue provides better tightness, reliable fxation of the graft, reduces the risk of periurethral leakage [14], and the risk of fstula formation [30]. Tere is evidence of the successful use of a mixture of fbrin and cyanoacrylic glue for the treatment of vesicourethral anastomoses leak after prostatectomy [31].
Predictors of complications were assessed separately. Tus, the use of anastomotic methods of urethroplasty increases the risk of complaints of shortening of the penis with strictures longer than 3 cm. Decompensation of diabetes mellitus in the        14 Advances in Urology postoperative period increases the likelihood of an acute infection of the genitals and lower urinary tract. Without considering the data of univariate analysis, the results obtained are consistent with the results of similar studies [32,33]. Separately, it should be noted the efect of the size of the surgical approach on the severity of postoperative pain. Such conclusions have been repeatedly confrmed by early works [34]. Logistic analysis of predictors was performed in order to establish a possible relationship between elements of the FTS protocol and treatment outcomes. Te negative impact of pathological hyperglycemia and the use of narcotic analgesics on the likelihood of developing subfebrility confrm the expediency of including in the protocol such elements as minimizing the use of opiate analgesics and performing strict control of glycemia and its mandatory correction. In turn, minimizing surgical trauma directly afects the need for analgesics and the risks of other complications.
An excellent result is considered a signifcant decrease in the severity of post-operative pain (p < 0.001), and, consequently, a decrease in surgical stress, as well as a reduction in the treatment period, from the moment of diagnosis to full recovery (p < 0.001) when using the developed FTS protocol. Te authors did not fnd similar studies of the efectiveness of FTS in urethroplasty; however, the general concept of the system and many works [35][36][37][38][39][40][41] demonstrate similar results.
Te evaluation of treatment outcomes according to the most rigorous analysis of subjective perception and objective status (such as general perception of treatment, the severity of pain, and general indicators of success and risks of complications) shows that the FTS protocol provides superior results. Good results obtained 80% of Group II patients compared with 17.2% of Group I patients, p � 0.0049. Tus, we consider it expedient to introduce the developed FTS protocol in specialized urethroplasty centers with the aim of a further in-depth multicenter study of its efectiveness.
Distinctive features of our study are prospective recruitment of patients, distribution into groups by randomization; homogeneity of groups in terms of initial characteristics, similar morphological characteristics of patients; mandatory diagnostic algorithm before surgery and post-operative control for all patients; description of the patient management algorithm with a detailed presentation of materials and research results.

Conclusion
Both treatment protocols are safe, efective, and bring minimal risks of complications. Both protocols lead to the restoration of independent adequate urination equally (86.2% vs 92%; p � 0.870). Te use of the "fast track surgery" protocol in urethroplasty with generally similar treatment results makes it possible to achieve a better functional and objective condition of patients in the postoperative period due to less pain, shorter catheterization, and hospitalization.

Data Availability
Te data used for supporting this study will be available from the corresponding authors upon request.