Management Of Stenosis Research Articles

Surgical Management of Biliary Strictures

AbstractBiliary strictures are a complicated entity that requires careful thought and dedicated workup to define, understand, and plan the proper management pathway. From a surgical standpoint, it can be a mixed bag at the time of presentation. Even then, the information may not be fully diagnostic and often requires multiple interventions to assess the pathology and extent of the disease. In most cases, there is concern for malignancy with no effective screening tools and small surgical windows for cure. Therefore, a dedicated multidisciplinary team of surgeons, interventional radiologists, advanced endoscopists, hepatologists, and oncologists is always necessary to work together efficiently to gather information, diagnose, prevent secondary complications, and create an effective treatment plan with aligned goals of care.

Injection of platelet-rich plasma combined with dexamethasone with visual internal urethrotomy in treating short bulbar urethral stricture.

To evaluate long-term urethral patency of short bulbar urethral stricture management using visual internal urethrotomy with platelet-rich plasma (PRP) in conjunction with dexamethasone injection. This retrospective study included 78 male patients with symptomatic short bulbar urethral stricture (diagnosed by ascending urethrography) who were treated by internal urethrotomy after injection of submucosal PRP combined with dexamethasone. Every patient was monitored for urethral stricture recurrence one month after catheter removal and twenty-four months after internal urethrotomy. The etiology of urethral stricture was iatrogenic in 63 (80.8%) patients, inflammatory in 9 (11.5%) patients, and idiopathic in 6 (7.7%) patients. In terms of complications, two patients (2.7%) experienced bleeding per urethra, four patients (5.4%) had fever, three patients (4%) had hematuria, one patient (1.4%) had perineal abscess, and seven patients (9.5%) had a recurrence of stricture. The etiology of the stricture did not have any significance in patients who experienced recurrence (P = 0.77). Our findings suggest a potential protective effect of PRP and dexamethasone injection at the time of internal urethrotomy also decreased the length of stricture in case of recurrence. This protective effect lasted for at least 2years.

The use of Triamcinolone Injection in treatment of refractory benign Esophageal Stricture in children

Objectives: To evaluate the efficacy of Intra-lesional triamcinolone injection in the management of refractory benign esophageal Stricture in children. Methods: Before endoscopic dilatation, triamcinolone acetate (40 mg/ml) was be applied in the first 5 dilations with an interval of one week between the first and second dilation and then every 2 weeks. Results: A total of 67 children with refractory benign esophageal stricture out of 183 children (36.6%) who presented with esophageal stricture were enrolled in the study, Cause of esophageal stricture was post-corrosive injury (n=59, 88.1%), with a smaller proportion attributed to post-TEF repair (n=8, 11.9%), There was a significant reduction in the number of dilatations required before and after the triamcinolone injections. The mean maximum dilation improved from 10.66 mm SG(Savary-Gilliard) before injections to 13.13 mm SG after injections, periodic dilatation index (PDI) showed significant reduction post-treatment. The mean PDI decreased from 1.07 to 0.27, There was a significant improvement in the grades of dysphagia, there was no significant changes in cortisone levels, ACTH (Adrenocorticotropic hormone) levels showed no significant change, there were no major complications of the procedure. Conclusion: findings suggest that intralesional triamcinolone injection is an effective and safe treatment option for refractory benign esophageal strictures in children.

Interventional Management of Benign Biliary Strictures

Interventional Management of Benign Biliary Strictures

Diagnosis and Medical Management of Biliary Strictures

Diagnosis and Medical Management of Biliary Strictures

Long‐term outcomes of a modified nonflared fully covered self‐expandable metal stent for refractory anastomotic biliary strictures after liver transplantation (with video)

ObjectivesAlthough fully covered self‐expandable metal stents (FCSEMS) are used for the management of anastomotic biliary stricture (ABS) after liver transplantation (LT), there is concern about long‐term adverse events such as recurrence of stricture. We evaluated the long‐term efficacy of a modified nonflared FCSEMS (M‐FCSEMS) compared to plastic stents (PS) for refractory ABS after LT.MethodsConsecutive patients who underwent placement of an M‐FCSEMS (M‐FCSEMS group) or multiple PS (PS group) for refractory ABS after LT were enrolled. The primary outcome was the stricture recurrence rate, and the secondary outcomes were technical success, clinical success, and the rate of de novo stricture.ResultsIn both groups, technical success was achieved in all patients. The median stent duration was 3.1 months in the M‐FCSEMS group and 7.6 months in the PS group (P < 0.001). Clinical success rates were 96.7% (29/30) for the M‐FCSEMS group and 94.4% (17/18) for the PS group (P = 0.709). Stent migration occurred in 10.0% (3/30) of the patients before removal of the stent in the M‐FCSEMS group, while 27.8% (5/18) of patients in the PS group showed stent migration (P = 0.110). Stricture recurrence occurred in 17.2% (5/29) in the M‐FCSEMS group, compared to 47.1% (8/17) in the PS group (P = 0.036). There were no de novo strictures observed in either cohort.ConclusionModified nonflared FCSEMS is effective for relieving refractory ABS after LT, with a low recurrence rate and the absence of de novo stricture after long‐term follow‐up.

A226 THE EFFICACY OF MEDICAL THERAPY TO PREVENT SURGERY AND IMPROVE OUTCOMES AMONG PATIENTS WITH STRICTURING CROHN’S DISEASE: A SYSTEMATIC REVIEW

Abstract Background Despite the advancements in inflammatory bowel disease (IBD) management, the percentage of Crohn’s Disease (CD) patients presenting with obstructive symptoms due to small and large bowel strictures is estimated to be 25% and 10%, respectively. Treatment of CD has advanced over the past 20 years to include safer, more targeted options that carry less morbidity than surgical intervention. However, the efficacy of medical therapy once fibrosis has begun is theoretically reduced and, until recently, has had limited study. Aims The aim of this systematic review is to examine the efficacy of medical therapies, such as biologics (TNF inhibitors, interleukin inhibitors, anti-integrin therapy) and immunomodulators (thiopurines and methotrexate) to avoid the need for surgical intervention in stricturing Crohn’s disease. Methods We searched Medline, Embase, the Cochrane library, and Web of Science for experimental (i.e., randomized and non-randomized controlled trials), quasi-experimental (i.e., interrupted time series) and observational studies (i.e., cross-sectional surveys) examining the effect of medical therapies among adult and pediatric CD patients admitted for the management of strictures. Records were screened, in duplicate and independently, by their title and abstract and then full-text and relevant data were extracted using a standardized data extraction sheet. Efficacy data were pooled using meta-analyses, when applicable, or synthesized narratively. Results Our preliminary search yielded a total of 1059 unique records and 22 studies (3 RCTs, 19 cohort studies) were included in our analysis. Results from 8 cohort studies show that among 546 patients receiving TNF antagonists, 80% responded to treatment and did not require surgery at an average follow-up period of 4.1 years (95% CI 71% to 88%). Furthermore, one RCT and one cohort study found that Azathioprine in combination with anti-TNF therapy improved obstructive symptoms and reduced the odds of hospitalization and surgery by half. Conclusions Our review highlights systemic medical therapy, namely TNF antagonists, as a promising solution to prevent the need for surgery among patients with stricturing Crohn’s disease. More robust research is needed to confirm these findings and compare their efficacy. Funding Agencies None

Surgical Management of Anterior Urethral Stricture: A 23-year Single-Center Study.

Anterior urethral stricture is a common clinical condition in urology with significant socioeconomic impacts and is associated with high recurrence rates of and postoperative complications. However, the long-term outcome of surgical management of urethra stricture and the associated risk factors of stricture recurrence remain limited. We conducted a 23-year single-center retrospective study to evaluate the long-term surgical outcomes of anterior urethral strictures with different clinical characteristics and to study factors that contribute to stricture recurrence. A retrospective study was conducted on 145 male patients diagnosed with anterior urethral stricture, who underwent meatotomy, anastomotic urethroplasty (AU), penile skin flap urethroplasty (PFU), single-stage buccal mucosa grafting (SSU), or multistage buccal mucosa grafting (MSU) between April 2000 and August 2023. We defined 100 months as the cut-off time point to distinguish short-term and long-term follow-up. Early surgical complications were scored using the Clavien-Dindo classification at 3 months. Patient-Reported Outcome Measure (PROM) was applied to evaluate surgical success. Risk factors for wound complications were evaluated using univariable and multivariable analysis. The overall mean stricture length was 2.3 ± 1.8 cm (a range of 0.3-7.0). Stricture locations were at the meatus, fossa navicularis, penile, bulbar, and multifocal in 15, 36, 79, 9, and 6. The short-term and long-term success rate for meatotomy, AU, PFU, SSU, and MSU were 70.0%/80%, 70.4%/62.5%, 77.8%/69.2%, 100%/75%, and 81.8%/66.7%, respectively. The early complications classified as Clavien grades I, II, III, IV, and V were 39, 5, 5, 0, and 0. The late complication rate in the short-term and long-term groups were 20.3% and 30.3% (p > 0.05). The satisfaction survey showed that 74.5% (108 of 145) patients were satisfied or very satisfied with the surgical result. There was no statistically significant difference in stricture-free survival among the five surgical groups (Log rank test: χ² = 3.83, p > 0.05). The binary univariate logistic regression analysis showed that stricture symptom duration (p < 0.05) and previous urethroplasty (p < 0.05) were independent predictors of surgery failure. This long-term retrospective study on male anterior urethral stricture disease demonstrates that surgical management is an effective and functional treatment. However, the success rate of urethroplasty shows a declining trend with longer follow-up. Stricture symptom duration and previous urethroplasty carry a high risk of surgical failure.

Efficacy of the Optilume paclitaxel drug-coated balloon after urethroplasty: short-term results from a multicenter study.

The Optilume® paclitaxel drug-coated balloon (DCB) is a relatively new-to-market alternative in the management of male anterior urethral stricture disease. The pivotal trial excluded patients with a history of urethroplasty, although these strictures may be amenable to endoscopic management. Therefore, we sought to assess the efficacy of the DCB in the management of recurrent strictures following urethroplasty. A retrospective, multi-institutional review of male patients undergoing DCB dilation from 1/1/2022 to 11/1/2023 by five surgeons at four institutions was performed. Patients were stratified by history of urethroplasty; demographics, stricture characteristics, and outcomes (surgical success, time to recurrence). Success was defined as freedom from re-intervention in patients with at least 3 months of follow-up. Among the 122 cases assessed, 33 (27.0%) had previously undergone urethroplasty. Patients in the urethroplasty group were younger than those in the control group (51.6 vs 58.8 years, p = 0.022). The two groups were otherwise similar with regard to background characteristics and comorbidities. Patients in both groups had similar stricture characteristics with short bulbar strictures being the most common. When compared to the control group, those with a history of prior urethroplasty had a greater median number of interventions prior to DCB treatment (3 vs 1, p < 0.001). Postoperative cystoscopy was performed in 37 cases, with similar patency rates between groups (p > 0.999). Early success rates were similarly high in both groups (80.0% post-urethroplasty vs 88.9% control, p = 0.338), although follow-up was limited to a median of 3.5 months in the urethroplasty group and 2.9 months in the control group (p = 0.069). Despite a greater number of prior surgical interventions, patients with a history of urethroplasty achieve similarly high success rates after treatment with DCB compared to those without a history of urethroplasty.

Endoscopic Suturing to Prevent Migration of Esophageal Fully Covered Self-Expanding Metal Stents: A Randomized Controlled Trial.

Endoscopic Suturing to Prevent Migration of Esophageal Fully Covered Self-Expanding Metal Stents: A Randomized Controlled Trial.

Evaluating the impact of a urethral reconstruction fellowship on urethral stricture disease management at a regional hospital.

Internationally, there is a trend towards early urethroplasty for treatment of urethral stricture, as opposed to endoscopic management, which is associated with short-lived patency and frequent retreatments. The objective of this study was to compare the outcomes of urethral stricture management before and after gaining urethral reconstruction expertise through a fellowship programme. This was a retrospective case-control study that compared the characteristics, management, and outcomes of urethral stricture disease managed over two consecutive periods of time-pre-fellowship period (September 2016 to September 2019) and the post-fellowship period (October 2019 to September 2022). There were 37 patients in the pre-fellowship group and 30 patients in the post-fellowship group. Regarding treatment choice, the proportion of patients undergoing index urethroplasty significantly increased from 2.7% to 36.7% [odds ratio (OR) 18.9, 95% confidence interval (CI): 2.7 to 209.8, P<0.008], due to early recognition of strictures not amenable endoscopic treatment. Retreatment became less frequent post-fellowship (37.8% vs. 16.7%, OR 2.99, 95% CI: 1.6 to 5.9, P=0.001). Average number of procedures per patient also reduced (1.65±0.98 vs. 1.23±0.63, P=0.04). Also, there was a trend towards improved overall patency rate at 6-month in the post-fellowship period compared to the pre-fellowship group. This study has demonstrated that urethral reconstruction expertise was correlated to the increased exposure of urethral stricture patients to urethroplasty as a more efficacious procedure, and was associated with reduced retreatment rates. The expertise can bring cost benefits for patients and regional institutions.

Ventral versus dorsal onlay buccal mucosal graft urethroplasty for non-traumatic proximal bulbar urethral strictures in sexually active men: erectile and urinary functions

PurposeTo compare the erectile and urinary functions of ventral and dorsal onlay buccal mucosal graft (BMG) urethroplasty in the management of proximal bulbar urethral strictures (PBUS) in sexually active men.Patients and methodsWe retrospectively included patients with primary non-traumatic PBUS who were treated with (BMG) urethroplasty at our department between March 2019 and March 2023 either ventral or dorsal approaches. Patients were assessed at 3- and 12-months postoperatively for urinary and erectile functions.Results133 patients were identified and underwent either ventral repair (n = 60, group I) or dorsal repair (n = 73, group II). There was no significant difference in baseline urinary and sexual function between both groups (p > 0.05). Overall, the success rate was 91.7% in Group I and 90.4% in Group II (p = 0.801). Transient ED (at 3 months) was detected in 5% and 25% (p = 0.002), while permeant ED (at 12 months) was 1.7% and 13.7% (p = 0.012) in group I and group II, respectively. Group I had significantly higher mean IIEF scores; 28.2 and 28.4 at 3 months (p < 0.001) and 12 months (p < 0.001); compared to Group II; 22.1 and 24.4, respectively.ConclusionThe ventral approach had better erectile functional outcomes compared to the dorsal approach in the management of non-traumatic PBUS in sexually active men. This might be related to less urethral mobilization and no dissection of the intercrural space during ventral onlay graft urethroplasty.

Central Airway Obstruction: Diagnostic Challenges and Management Strategies in Subglottic Stenosis and Poly Chondrites with Case Studies

Tumours or strictures compressing the trachea /bronchial tree cause central airway obstruction (CAO). Subglottic stenosis are a cause of respiratory symptoms and distress. Idiopathic sub glottic stenosis (ISGS) is a rare disease occurring mainly in women and has a history of recurrences. Endoscopic laser microsurgery and balloon dilatation are used in the management of strictures. Recurring strictures may require tracheoplasty. Poly chondrites is a rare disorder causing poly arthritis and inflammation of cartilaginous tissue. Inflammatory changes in the lung cause tracheobronchomalacia (TBM) and lung collapse. Relapsing polychondritis (RP) effecting the airway is life threatening as there is dynamic airway closure during expiration. The medical therapy in RP includes steroids, disease modifying agents ( methotrexate) and biologics. Surgical interventions include tracheostomies and tracheobronchial stents for severe forms of the illness.

The role of ultrasound combined with water bath in the establishment of animal models of rat urethral stricture

Urinary tract injuries represent a significant clinical challenge, necessitating precise diagnosis and effective treatment strategies. Rat models are preferred for studying urinary tract injuries due to their size, visibility of external genitalia, and robust reproductive and growth capabilities. However, there is a lack of standardized methodologies for evaluating the endpoints of rat urinary tract injury models. This study aimed to investigate the methodology of model establishment, imaging evaluation techniques, and endpoint effectiveness. Twenty-four male Sprague-Dawley rats were randomly assigned to groups, including a blank control group and surgical groups. The surgical groups underwent urethral injury induced by recombinant transforming growth factor-β1 (TGF-β1) solution, followed by the random selection of one surgical group (n = 6) to receive treatment with mesenchymal stem cell (MSC) exosomes. High-frequency ultrasonography using a GE E10 device combined with a water bath method was employed to evaluate the urethral conditions of all rats. Ultrasonographic characteristics were scored for all surgical group rats, and an intergroup analysis was conducted between the surgical group and the control group rats. Statistical analysis was conducted using SPSS 22.0 software. Ultrasonographic assessment revealed significant differences in urethral echogenicity between the normal group and the surgical group, with noticeable changes in urethral morphology post-injury. Histopathological examination confirmed more severe urethral stenosis in the TGF group compared to the MSC group. High-frequency ultrasound could effectively differentiate between the two groups of rats. Additionally, there were significant differences in the scoring of ultrasonographic characteristics between the two groups. Urethral stricture presents a complex challenge in urology, often requiring invasive treatment modalities. The establishment of animal models plays a crucial role in understanding and addressing this condition. TGF-β1 induced fibrosis and MSC therapy represent promising avenues for urethral stricture management. High-frequency ultrasound combined with the immersion method offers a non-invasive and cost-effective approach for evaluating rat urethral stricture models. This study highlights the practicality of high-frequency ultrasound combined with the water bath method in evaluating rat urethral stricture models, as it can effectively differentiate between rats in the pure TGF-β1 induced group and those in the MSC treatment group based on urethral changes. The results underscore the importance of standardized methodologies for model assessment and the potential of non-invasive imaging techniques in preclinical research. Overall, this study contributes to advancing our understanding of urinary system injuries and holds implications for future therapeutic interventions in urology.

Feasibility and surgical outcomes of simultaneous urethral reconstruction for synchronous urethral strictures.

To evaluate the feasibility and surgical outcomes of simultaneous urethral reconstruction for synchronous urethral strictures (SUS) and analyze the surgical techniques employed for different stricture combinations. Twenty-two male patients with SUS who underwent urethral reconstruction between February 2018 and July 2023 were retrospectively reviewed. Stricture locations and lengths were evaluated using cystoscopy and urethrography after urethral rest for at least 3 months. Multiple reconstruction techniques were employed based on stricture characteristics, including anastomotic urethroplasty, substitution urethroplasty, staged urethroplasty, perineal urethrostomy, and deep lateral incision of the bladder neck. Anatomical success was defined as the ability to pass a cystoscope without resistance and void without additional interventions. The median age was 72, with iatrogenic causes accounting for 77.2%. The most common stricture combination was strictures at the penoscrotal junction and proximal bulbar urethra (59.1%). Two (9.1%) had strictures in three locations, and one (4.5%) had strictures in four locations. A total of 15 different combinations of reconstruction techniques were utilized to address various stricture patterns. Overall, 86.4% were treated in one stage. The median operation time was 177 min, and the median blood loss was 72 mL. At a median follow-up of 31 months, anatomical success was achieved at 77.3%. No perioperative complications were observed. Simultaneous repair of SUS is feasible using various reconstructive techniques tailored to each stricture site. The high prevalence of iatrogenic etiology and previous transurethral treatments emphasize the importance of appropriate initial management of urethral strictures.

Percutaneous Biodegradable Stent Placement for Treatment of Benign Biliary Strictures: A Systematic Review.

To assess whether safety profile and treatment success of percutaneous biodegradable biliary stent placement are competitive with traditional treatment options for treatment of benign biliary strictures. PubMed and Embase were systematically reviewed for articles reporting percutaneous biodegradable stent placement for treating benign biliary strictures. Databases were searched for articles until December 2023, with the earliest included article dating April 2016. Treatment outcome was assessed by evaluating outcomes described in the included articles, including technical success of stent placement, migration rates, restenosis rates, time to restenosis, and biochemical liver panel measures. Stent safety was assessed by examining stent placement-related adverse events and occurrence of cholangitis after placement. Seven of 39 studies in the primary search met the inclusion criteria and were further analyzed. All included studies were cases series, totaling 323 stent placements. High rates of technical success were observed (98%-100%). Bile duct patency rates following biodegradable stent placement ranged from 94% (3-month follow-up) to 72% (60-month follow-up). The most frequently reported adverse event was hemobilia, followed by fever and pain. Available literature reports high technical success in initial placement of biodegradable stents for benign biliary strictures, and the technique seems safe. Further investigation with comparison arms is warranted to establish this technique as the preferred management for benign biliary strictures.

The use of robotic surgery for the management of urethral strictures and bladder neck contractures: A systematic review

The use of robotic surgery for the management of urethral strictures and bladder neck contractures: A systematic review

A case study on ayurvedic management of urethral stricture in an elderly male through Uttar Basti with Til Tail

A case study on ayurvedic management of urethral stricture in an elderly male through Uttar Basti with Til Tail

History of urethral surgery: Lessons learnt from the past.

History of urethral surgery: Lessons learnt from the past.

Partially Obstructed Urethral Strictures Due to Balanitis Xerotica Obliterans Improved by the Use of Topical Tacrolimus: Experience at a Tertiary Care Centre.

Introduction Balanitis xerotica obliterans (BXO) can cause phimosis, meatal stenosis, and urethral strictures. However, management of these conditions in BXO patients is difficult. Surgical interventions, with their own risks and complications, demonstrate higher rates of disease recurrence. Recently, topical applications of steroids and immunomodulators have been evaluated for their role in the management of urethral strictures associated with BXO. In this study, we evaluated the role of topical application of tacrolimus in urethral strictures associated with BXO. Materials and methods This was a prospective study on male patients having urethral strictures associated with BXO. Patients were thoroughly evaluated and advised topical application of 0.1% tacrolimus. They were then reevaluated at six weeks. If the effects of tacrolimus were found to be satisfactory, then patients were advised to continue this treatment for three months. After three months, the patients were again evaluated. At the time of each reevaluation, changes in uroflowmetry and International Prostate Symptom Score (IPSS) were noted. Results A total of 53 patients were included in this study. The mean values of pre- and post-tacrolimus maximum urinary flow rate on uroflowmetry(Qmax) were 12.00±1.43 m/s and 15.26±3.14 m/s, respectively (p<0.001). The mean values ofpre- and post-tacrolimus IPSS scores were 18.55±2.28 and 13.04±4.72, respectively (p<0.001). Based on the results, the application oftacrolimus was found to be ineffective in those with strictures >2 cm in length. Of the 53 patients included in the study, 21 required surgical intervention, as their response to tacrolimus was unsatisfactory. Conclusion Topical application of tacrolimus is a safe and feasible treatment option for short-segment (≤2cm) urethralstrictures associated with BXO.