S202 Endoscopic Balloon Dilation vs Endoscopic Stent Placement in the Management of Dominant Strictures in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis

Abstract Background Urethral stricture is one of the oldest known urologic diseases with high recurrence rate. It is defined as narrowing of the urethral lumen caused by scarring. Injuries to the urethral epithelium or the underlying corpus spongiosum may lead to scar formation which causes narrowing of the urethral lumen leading to urethral stricture and spongiofibrosis which can lead to total replacement of the spongy tissue by scar tissue. Aim of the Work To asses the efficacy of Intralesional injection of mitomycin C following visual internal urethrotomy (VIU) in the management of recurrent urethral stricture. Patients and Methods This is prospective randomized interventional study carried on 50 male patients with recurrent bulbar urethral stricture of < 1.5 cm. They were randomised to undergo either VIU only (Group-A) or VIU with MMC injections (Group-B). The urethrotomy was performed under direct vision using a cold-knife and incisions were made at the 12-, 3-, and 9- o’clock positions followed by intralesional injection of 10 mL MMC (0.4 mg/mL) using Botox injection needle. All patients were objectively evaluated pre- and postoperatively at 3 and 6 months using uroflowmetry (maximum urinary flow rate), post-void residual urine volume, and retrograde urethrography. Results Of all 50 patients; five missed follow-up (three in Group-A, two in Group-B), therefore 45 cases were available for analysis (22 in Group-A and 23 in Group-B). The mean (SD) age of patients was 32.0 (8.1) and 34.0 (6.2) years in Group-A and Group-B, respectively (P = 0.314). The most common cause of a urethral stricture in both groups was iatrogenic injury. Regarding stricture recurrence, there was significant decrease in Group-B (four patients, 17.4%) compared with Group- A; (ten patients, 45.5%) (P = 0.042). This study demonstrated that visual internal urethrotomy for recurrent urethral stricture with intralesional injection of 10 mL mitomycin C MMC (0.4mg/mL) decreases the recurrence rate of the urethral stricture. Conclusion Intralesional injection of mitomycin C following visual internal urethrotomy for recurrent urethral stricture seems to be a safe and effective modality of treatment in reducing the incidence of recurrent stricture after VIU.

Abstract Background Esophageal strictures are seldom in children. In many countries, accidental ingestion of corrosives is a major cause of risk for stricture formation. Therefore, their management is a challenge. Safety and long-term efficacy of esophageal dilation for benign esophageal strictures has been confirmed in children. Aim and Objectives The aim of this study was to perform a systematic review and a meta-analysis about literature published in the period from 2010-2020 comparing between balloon & savary dilatation in benign esophageal strictures in pediatric age group. Subjects and Methods This systematic review and meta-analysis included 5 retrospective studies fulfilled eligibility criteria, with a total of 353 cases were included with mean age 8 years and m\f was 200\153. Results 5 studies compare success between ballon and savary dilatation showed that there were insignificant differences between two group p-value 0.052 Conclusion The efficacy and complication rates of bougie and dilation are similar. Considering this level of evidence 1A study, we can state that there is no significant difference between methods to recommend one over the other. However, all the confounding factors and limitations should be considered.

Endoscopic urethral stricture treatment has high recurrence rates. Due to research supporting amniotic membrane's (AMs) anti-inflammatory and anti-fibrotic properties reducing scar tissue formation, AM has generated interest in reconstructive urethral surgery. To the best of our knowledge, we performed the first investigation of the success rate of urethral dilation when combined with micronized AM injection for the treatment of urethral stricture. Eligible patients were adult males with anterior strictures meeting strict criteria for diameter, length, International Prostate Symptom Score (IPSS), and flow rate. Micronized AM was injected in the stricture region during urethral dilation. The primary study endpoint was an anatomical success (≥14Fr) at 6 months. Secondary endpoints were evaluated with the IPSS, urethral stricture surgery - patient-related outcome measure, International Index of Erectile Function, flow rate, and postvoid residual. Outcomes were assessed at baseline and multiple points postinjection. Injection safety was analyzed. Ten men with a mean age of 52 years were included in the study. At 6 months, 7 of 10 patients demonstrated recurrence of the urethral stricture on cystoscopy. Improvements in secondary endpoints were noted in 10 of 10 patients at 3 months and 3 of 10 patients at 6 months. No adverse events were observed. To the best of our knowledge, this is the first study evaluating micronized AM injection as an adjunct treatment at the time of urethral dilation. The urethral stricture recurrence rate did not improve with the injection of AM despite the hypothesized benefits of anti-fibrotic and anti-inflammatory properties.

Anastomotic strictures following colectomy and proctectomy are a significant cause of benign lower gastrointestinal tract (LGIT) obstruction, with a reported incidence of up to 30%. Endoscopic interventions such as balloon dilation, stricturotomy, mechanical dilation, electrocautery incision, and stent placement are utilized for management. This meta-analysis aimed to evaluate the efficacy and safety of endoscopic interventions for the management of benign LGIT anastomotic strictures. Literature search was performed for published full-text articles using the Embase, Pubmed, Web of Sciences, and Cochrane databases for endoscopic management of anastomosis strictures and related terms including endoscopic balloon dilation (EBD), stricturotomy (EST), mechanical dilation, electrocautery incision (ECI), and stent placement. A total of 1363 patients from 33 studies were included. The most common indication for anastomosis was colorectal cancer (92%). Overall technical success (ability to pass the endoscope) was achieved in 93% of cases, with immediate clinical success in 85% and sustained success in 81% at follow-up. ECI demonstrated the highest clinical success rates (98% immediate, 91% at the end of follow-up). Adverse events occurred in 6% of patients, most commonly perforation, which was most frequent with EBD. Stent placement showed high initial success but had issues with stent migration and adverse events. Overall, EBD and ECI were the most effective, with ECI showing the highest success rates. Despite its technical challenges, EST was both effective and safe. This study underscores the need for further prospective research comparing various endoscopic interventions to improve management strategies for LGIT anastomotic strictures.

Introduction John Blair Deaver was an iconic American surgeon who rose in prominence at the outset of the 20th century when the specialty of urology was in its infancy. By some accounts he was a difficult personality and made an enemy of J. William White, the then Chair of surgery at the University of Pennsylvania. Deaver was also known as a brilliant operative surgeon and educator, performed over 15,000 appendectomies, and invented his eponymous retractor very much in use today. Known more as an abdominal surgeon than a urologist, he still made contributions to the urologic literature and he himself became a revered expert in prostatectomy. We aimed to clarify the contemporary biography of Deaver and his influence in the creation of the modern urologic armamentarium. Sources and Methods We used primary source materials from the archives of the University of Pennsylvania, the National Library of Medicine, the Wellcome Fund, the Lancaster County Medical Society, the Medical History Library of the University of Pennsylvania, the Medical Society of the State of New Jersey, the American College of Surgeons, and published literature. Results Deaver was a general surgeon and proponent of early appendectomy and “preventative surgery”. He devised the retractor that bears his name to allow surgical exposure through small incisions. He was particularly skilled at suprapubic prostatectomy for benign diseases, for the endoscopic management of urethral stricture, and of ureteral stone disease. His Saturday teaching clinics for practicing surgeons became a world-wide phenomenon in his lengthy career. He foresaw the rise of surgical specialists and recognized the need for surgeons of the future to embrace expertise in a precise field. At the same time, he called for increasing communication among medical and surgical fields and a dedication to lifelong excellence. Two quotations credited to Deaver, which encompassed his simple philosophy regarding surgical interventions were “Cut well, get well, stay well” and “Let the patient heal”. Conclusions Deaver’s death in 1931 ended the life of one of surgery’s titans, an innovative force in surgical skill and education. His death while undergoing therapeutic radiation serves as an ironic metaphor that those who serve may not reap similar benefits.

Comparative Analysis of Dorsal Onlay Buccal Mucosal Graft and Vaginal Wall Graft Urethroplasty for Female Urethral Stricture at a Tertiary Care Centre

This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures. A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation. Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N=27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n=15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse eventsoccurred in 28% (n=12) overall, with a 24% migration rate (n=10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n=27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively. LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

The Management of Panurethral Strictures – The Kulkarni Technique

Introduction: This study aims to evaluate the effectiveness of a novel technique using an internal-external biliary drainage catheter and a homemade internal plastic stent, both inserted simultaneously via percutaneous access, for treating biliary strictures in liver transplant patients with hepaticojejunostomy. Materials and Methods: Seventeen patients included in the study underwent balloon dilatation, and an internal-external biliary drainage catheter was placed for biliary anastomotic stenosis at first. In a follow-up procedure, an internal plastic stent was placed dually along with a drainage catheter from the same access. The plastic stent is derived from the biliary drainage catheter by modifying the distal end of the catheter to fit the required size and removing the proximal part. Two stiff wires are placed from the transhepatic access to intestinal segment. Firstly, stent is placed over one of the wires across the anastomosis then internal-external biliary drainage catheter is placed side by side with the internal stent. This method effectively doubles the diameter at the site of anastomosis or stenosis using an access point only one catheter wide. The patient is followed at least six weeks with this dual system. The drainage catheter and internal plastic stent were removed when follow-up cholangiography showed improved passage with no recurrence of symptoms or elevation of biochemical markers. Results: Technical success was achieved in all 17 (100%) patients after percutaneous transhepatic treatment. Clinical success was achieved in 13 (77%) patients, and drainage catheters with internal plastic stents were removed after a mean period of 3.1 months (range, 1.5–10.8 months). During the follow-up, the primary patency rates were 76%, 94% at 6 and 12 months, respectively. Four (%23) of the 17 patients developed recurrent symptoms after the removal of both internal plastic stent and drainage catheter. Conclusion: Dual placement of an internal plastic stent and an internal-external biliary drainage catheter is a safe and effective method of overcoming persistent anastomotic stenosis in liver transplant patients with hepaticojejunostomy.

Abstract ID: 100Self-Dilatation for the Management of Refractory Benign Oesophageal Strictures: Outcomes from the Largest European Tertiary Centre Experience to Date

Recurrent ureteric strictures pose significant challenges in urological practice, necessitating innovative surgical strategies for successful resolution. This case report details the use of on-table flexible ureteroscopy during laparoscopic management of a left mid-ureteric recurrent stricture. A 41-year-old male patient was successfully managed using a combined laparoscopic and flexible ureteroscopic approach, presenting a novel technique that enhances surgical precision and patient outcomes.

Crohn's disease (CD) is a chronic inflammatory disease associated with a significant burden in terms of quality of life and health care costs. It is frequently associated with several complications, including the development of intestinal strictures. Stricturing CD requires a careful multidisciplinary approach involving medical therapy and surgery, still posing a continuous management challenge; in this context, endoscopic treatment represents a valuable, in-between opportunity as a minimally invasive strategy endorsed by extensive yet heterogeneous evidence and evolving research and techniques. This review summarizes current knowledge on the role of therapeutic endoscopy in stricturing CD, focusing on evidence gaps, recent updates, and novel techniques intended for optimizing efficacy, safety, and tailoring of this approach in the view of precision endoscopy.

Sono-urethrogram versus conventional urethrogram in the assessment of urethral stricture disease: A prospective comparative study

Abstract The obesity epidemic continues to be a global health concern impacting over 890 million adults worldwide. These numbers have quadrupled since 1990, and global health surveys estimate another 2.5 billion adults are overweight. The disease of obesity is chronic in nature and difficult to treat. The number of metabolic and bariatric surgeries performed today continues to increase and with it the number of revisional surgeries and management of complications. Upper gastrointestinal endoscopy has played an important role in diagnosing and managing patients with obesity. Endoscopy is a safe and minimally invasive technique to address surgical complications and explore new techniques for the management of obesity. In this article, we aim to review the evolving role of endoscopy in revisional bariatric surgery: management of immediate complications, including bleeding, strictures, leaks, and erosion of bands; techniques to access the gastric remnant after a gastric bypass; and management of weight regain.

The purpose of this review article is to provide a contemporary overview of benign uretero-enteric anastomotic stricture (UAS) management and outcomes. In this article, we will review the most recent studies investigating UAS and evaluate etiology, potential risk factors, presentation, diagnosis, and management options, along with personal insight gained from our experience with managing this challenging reconstructive complication. Benign UAS is a relatively common long-term complication of intestinal urinary diversion, affecting approximately 1 in 10 patients. It is thought to be caused by ureteral tissue ischemia and fibrosis at the anastomotic site. Risk factors appear to include any that increase the likelihood of leak or ischemia; it is not clear if anastomotic approach impacts risk for stricture as well. Management options are varied and include endourologic, open, and robotic approaches. Endoscopic approaches may be less morbid but are considerably less effective than reconstruction performed after a period of ureteral rest.

Introduction: Malignant biliary strictures have been increasingly prevalent in recent years. These tumors are often managed palliatively, with biliary drainage being the primary therapeutic approach. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting remains the gold standard technique for biliary drainage. The aim of this study is to evaluate the success and failure rates of different biliary drainage techniques and assess the success rate of biliary stent placement. Materials and Methods: This is a descriptive study conducted from March 2015 to January 2023, including all patients with tumor-related biliary strictures who underwent palliative biliary drainage. Results: 388 patients were included. The average age was 61.2 years, with a male predominance of 61.8%. 98.9% of patients presented with cholestatic jaundice. The average levels of Total Bilirubin and C-reactive protein (CRP) were 220.11 mg/l and 62.59 mg/l, respectively. The location of the obstruction was: distal common bile duct in 54.8%, proximal common bile duct in 24.1%, confluence in 18%, intrahepatic bile ducts in 2%, and middle common bile duct in 1.3% of cases. Sphincterotomy was performed in 40.3% of cases, and precut in 33.7% of cases. The overall success rate was 90.9%. 24.1% of cases underwent a repermeabilization technique: balloon dilation in 6.9% of cases, intratumoral drilling in 5.4%, with success rates of 66% and 95%, respectively. A biliary stent was placed in 86.8% of patients. In case of ERCP failure, biliary-enteric anastomosis under endoscopic ultrasound guidance was performed in 6.6% of patients, and transhepatic drainage in 1.6% of patients. Short-term complications were noted in 10.4% of cases. Clinical and biochemical evolution at 1 month after ERCP was favorable in 86% of cases. Conclusion: Palliative drainage of malignant biliary strictures primarily relies on ERCP as the first-line approach, demonstrating satisfactory success and complication rates.

Endoscopic biliary stent placement is a mainstay in the management of biliary strictures both malignant and benign. Distal stent migration is a known complication of metal biliary stents, however small bowel obstruction or perforation are rare. In this report from a tertiary referral centre, we detail a mid-small bowel obstruction caused by covered metal stent migration requiring a laparotomy and enterotomy for definitive management. A 69-year-old male was admitted to the Sunshine Coast University Hospital with obstructive jaundice on a background of previous metal biliary stent placement. On day 3 of his admission, he developed worsening abdominal pain. Cross-sectional imaging demonstrated distal migration of his stent to his mid-jejunum, causing a high-grade small bowel obstruction. He underwent laparotomy to retrieve the stent. He recovered well and underwent a percutaneous transhepatic cholangiogram with stent replacement. In this case, distal biliary stent migration causes a small bowel obstruction. Whilst uncommon, risk factors including previous intra-abdominal operation can be used to identify patients unlikely to achieve successful expectant management of distal migration.

Introduction. Female urethral stricture is rare. Treatment option includes urethroplasty with various techniques, but no single approach has been demonstrated to be the best. One major issue has been the risk of post operative incontinence.Case. We present our experience of the management of female urethral stricture with transurethral inlay vaginal graft urethroplasty. A 51 year old female patient presented with urinary retention and foley insertion failed. Urethroscopy showed panstricture of the urethra and transurethral inlay urethroplasty was performed using vaginal graft. The patient showed improvement of the symptoms postoperatively.Conclusion. Transurethral inlay urethroplasty is a feasible option for the management of female urethral stricture to reduce the risk of post op incontinence because it doesn’t require high urethral mobilization.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for medically refractory inflammatory bowel disease (IBD). In this systematic review and meta-analysis, we assess outcomes and safety of endoscopic balloon dilatation (EBD) for IPAA strictures. A systematic search of numerous databases was performed through June 2023 to identify studies reporting on the outcomes of EBD in pouch-related strictures. Outcomes included technical success, clinical success at index dilation and in pouch retention, recurrence of symptoms post-EBD, and adverse events of EBD. Meta-analysis was performed using a random-effects model, and results were expressed in terms of pooled rates along with relevant 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran Q statistical test with I2 statistics. Seven studies with 504 patients were included. The pooled rate of technical success and clinical success of index dilatation was 98.9% (95% CI, 94.8-99.8%; I20%) and 30.2% (95% CI, 7.1-71%; I20%), respectively. The pooled rate of clinical success in pouch retention without the need for additional surgery was 81.4% (95% CI, 69.6-89.3%; I272%). The pooled failure rate of EBD was 18.6% (95% CI, 10.7-30.4%, I272%). The pooled rate of recurrence of symptoms after index dilatation was 58.9% (95% CI, 33.3-80.5%; I213%). The pooled rate of serious adverse events was 1.8% (95% CI, 1-3.5%, I20%). No deaths related to EBD were reported. Endoscopic balloon dilatation is safe and highly effective for management of IPAA strictures. Additional studies are needed to compare its efficacy with surgical interventions.