Recurrent Stenosis Research Articles

Recurrence rates after strictureplasty for small bowel Crohn's disease remain high in the era of biologics

AbstractAimDespite advancements in therapeutic options for Crohn's disease (CD), strictureplasty is a mainstay bowel‐preserving technique for small bowel CD. We sought to audit international practice across three high‐volume centres since the widespread use of biologic medication.MethodsA retrospective audit was performed for all strictureplasties undertaken for small bowel CD, over a 15‐year period (2006–2021), in three high‐volume centres in the United Kingdom and Italy. Primary endpoints were clinical recurrence and reoperation for recurrence.ResultsIn all, 123 patients were included; 58% were men, 25% smoked and 60% had previous abdominal surgery for CD. Median age was 40 years (interquartile range 30–52 years), mean body mass index 22 (15–31) and median disease duration 138 months (81–255 months). 42% had been treated with biologics preoperatively. In total 338 strictureplasties were performed in 123 patients, with a median of two per patient (interquartile range 1–3). Complications occurred in 35%, with 8% scoring Clavien–Dindo Grade 3. There were no Grade 4/5 complications. Postoperative biologic treatment was administered to 84/123 patients (68.3%). Median follow‐up was 54 months. 41/123 patients (33.3%) developed clinical recurrence. Reoperation for recurrent stricturing was performed in 26/123 patients (21%). Clinical recurrence and reoperation rates were significantly higher in patients who continued to smoke after their index surgery.ConclusionStrictureplasty remains a safe and effective surgical treatment for small bowel CD. Recurrence and reoperation rates remain high, regardless of postoperative biologic therapy. Smoking significantly increases the risk of recurrence.

Efficacy of direct visual internal urethrotomy versus balloon dilation to treat recurrent urethral stricture following failed urethroplasty

Efficacy of direct visual internal urethrotomy versus balloon dilation to treat recurrent urethral stricture following failed urethroplasty

Multidisciplinary care in nonmalignant central airway obstruction.

The management of histologically benign central airway obstruction (CAO) is complex. Published studies have focused on the diagnostic approaches and therapeutic options provided by specific specialties, but there has been no focus on multidisciplinary management of this disease. Our objective is to review the current diagnostic and therapeutic modalities available for managing nonmalignant CAO from a multidisciplinary perspective involving otolaryngology, thoracic surgery and interventional bronchoscopists. For benign airway strictures, management is via medical and endoscopic therapy with surgical resection reserved for complex and recurrent stenoses. There is evidence and growing interest in intralesional corticosteroid injection in treating inflammation and potentially preventing recurrence. Airway specialists from distinct disciplines use different laser types, dilating balloons and anesthesia methods to manage benign CAO. Recent studies have demonstrated substantial improvements in patient breathlessness and quality of life following therapeutic airway interventions, highlighting the evolving landscape in this cross-disciplinary field. Nonmalignant CAO, arising from various mechanical, inflammatory, and infectious etiologies, poses significant morbidity and mortality risks. Current treatments include endoscopic resection, dilation, stent placement, and surgical resection which are selected based on lesion's complexity, extent, operability and patient's symptoms and goals. A multimodal and multidisciplinary approach to patient care could offer the best outcomes.

The outcome of nontransecting anastomotic urethroplasty in recurrent bulbar urethral stricture and its impact on sexual functions: A prospective observational study

Purpose: The management of recurrent bulbar urethral stricture had no consensus and faced many challenges such as the risk of failure, ischemia, and sexual dysfunction. Therefore, this study aimed to assess the outcome of nontransecting anastomotic urethroplasty in recurrent bulbar urethral stricture disease (USD) less than 3 cm and its impact on sexual functions. Material and methods: This is a prospective descriptive study that included patients with recurrent bulbar USD ≤ 3 cm. Full history taking and clinical examination, including International Prostate Symptoms Score (IPSS) and International Index of Erectile Function (IIEF-5), were documented. Moreover, retrograde urethrogram, uroflowmetry, and penile Doppler were undergone. The nontransecting urethroplasty techniques were performed: Heineke-Mikulicz principle stricturoplasty for stricture ≤1 cm without excision of the stricture and nontransecting excision and primary anastomosis without transecting the corpus spongiosum for stricture 1 to 3 cm. Each patient was routinely evaluated through a 12-month follow-up using IPSS and IIEF, uroflowmetry, and postvoiding residual urine. Results: Thirty-three patients were included in the study with a mean stricture length of 1.45 ± 0.7 cm. Twelve patients had failed previous urethroplasty, while 21 patients had previous visual internal urethrotomy. Nontransecting excision and primary anastomosis in 14 patients and Heineke-Mikulicz principle stricturoplasty in 19 patients were performed. There was no recurrence of stricture urethra, except for one patient, who required visual internal urethrotomy at a 3-month follow-up, with mean postoperative IPSS of 3.04 ± 2.745, Qmax 23.89 ± 2.714 mL/s, and postvoiding residual urine 26 ± 33 cc. No significant differences were reported between pre- and postoperative IIEF (18.61 ± 5.448 versus 19.33 ± 5.599, respectively, P = 0.236). Conclusion: Nontransecting urethroplasty can achieve a high success rate in short recurrent bulbar USD without the potential sexual morbidity.

A new management strategy in reopening laminectomies for cases with spinal canal stenosis

Background While a laminectomy is often mandated for spinal canal stenosis, foraminal stenosis may account for pain and functional limitations instead of central canal issues. Targeted treatment directed at this specific region may enhance patient outcomes. Methods Retrospective observational study of a total of 30 patients with previous decompression laminectomies for lumbar spinal canal stenosis were operated upon for foraminotomies from November 2012 to November 2018. The surgeries were clinically done, and EMG-confirmed nerve root compressions were treated with exact decompression techniques according to the anatomy and pathology in each case. Additionally, a systematic review followed PRISMA guidelines was conducted, utilizing Scopus and PubMed databases to identify studies on reoperation rates after decompression with or without fusion in lumbar spinal stenosis. Results The results were fearsome post-operatively, trying significant improvement in pain, functional status, and walking distance. Pain reduction was achieved in 80% of patients by an increase in the Carnovsky rating scale with evidence of improved pain reduction and walking endurance; this points to minimal resulting complications of one complete case of foot drop and three infective cases managed conservatively. It was shown in the systematic review that fusion surgeries lowered the rates of reoperations at the index level but increased those for adjacent segment reoperations, while decompression alone had higher index-level reoperation rates due to recurrent stenosis. Conclusion Most of the emphasis on foraminal stenosis, rather than traditional laminectomies, significantly reduces postoperative pain and improves functional outcomes. This strategy brings a promising alternative to the management of recurrent symptoms in patients with lumbar spinal canal stenosis.

Evaluación de los factores predictivos tras uretrotomía interna endoscópica para estenosis de uretra bulbar

Introduction: Direct vision internal urethrotomy (DVIU) is usually the first treatment offered to patients with bulbar urethral strictures (US). Advances in devices and surgical techniques have contributed to reducing associated complications. Despite the favorable success rate of DVIU, various factors predicting better outcomes have been studied, including patient characteristics, stricture features, and procedural aspects. The main aim of our study is to assess predictive factors for success.Methods: We conducted a retrospective descriptive study of patients who underwent endoscopic internal urethrotomy at our hospital over a 30 year period. Out of 788 DVIU performed, we selected 491 (62.3%) conducted for bulbar US with a minimum follow-up of 12 months. We examined clinical outcomes obtained, and assessed the relationship between different patient characteristics, stricture-related factors and procedural aspects related with clinical success -considered as the avoidance of further interventions for stricture recurrence-. Descriptive statistics were calculated and parametrical and non-parametrical comparative tests were applied. Kaplan-Meier survival analysis was used for evaluating time until recurrence.Results: Mean stricture length was 1.2 cm (SD 0.5), with only 12 patients presenting with more than 1 US in the bulbar area during DVIU. After a median follow-up of 170 months, 67.4% of patients did not experience clinical recurrence. Severe postoperative complications appear in 0.4% of cases, and need for overnight admission was 4.5%. A positive association was observed between clinical recurrence and a history of prior pelvic radiotherapy (OR 2.8, 95%IC 1.3-22.2), active smoking (OR 2.1, 95%IC 1.6-2.4), infectious etiology of stricture (OR 2.3, 95%IC 1.6-8), history of previous urethroplasty (OR 2.5, 95%IC 1.7-3.2), and higher postoperative urinary catheter sizes (OR 1.8 95%IC 1.1-2.9). Median time until recurrence after the first DVIU was 65 months, after the second was 60 months, after the third was 32 months, and after the fourth was 6 months.Conclusions: Bulbar US could be safely managed with DVIU. The best clinical success is achieved in non-irradiated, non-smoker patients, without prior urethroplasties. The repetition of the procedure is significantly associated with a shorter time to clinical recurrence.

Outcomes of transperineal reanastomosis as a salvage treatment for recurrent vesicourethral anastomosis stenosis after radical prostatectomy

Purpose: To evaluate transperineal reanastomosis (TRPA) combined with incontinence surgery as a complex treatment for recurring vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy (RP). Methods: Retrospective analysis of 8 patients who underwent TRPA for recurring VUAS. Detailed preoperative and follow up data were assessed. Results: Mean follow up lasted 47 months (range 17-77) with mean age being 63.4 years (range 61-70). All patients achieved patency and 87.5% (7/8) maintained it to the end of follow up. However, four of them required additional procedures to retain patency. Six underwent incontinence surgery – artificial urinary sphincter (AUS) implantation – after which one cuff erosion occurred. In the end 62.5% (5/8) of patients achieved patent urethra and continence. Conclusions: TRPA combined with incontinence surgery is a reasonable treatment for patients with recurrent VUAS. Nonetheless, this is a set of difficult surgeries that may ultimately end in failure, i.e. the inability to restore urethral patency, urinary incontinence or urinary diversion, hence they should be performed by experienced surgeons.

Predictors of urethral stricture recurrence following internal urethrotomy: A systematic review.

To estimate the factors associated with urethral stricture recurrence in patients undergoing internal urethrotomy by direct vision. A systematic review was performed in MEDLINE (Ovid), EMBASE, LILACS, and central databases. Clinical, quasi-experimental, cohort, case-control, and cross-sectional trials were included. The search strategy found 402 studies, and 6 were finally included. All of them were clinical trials. A total of 1723 patients diagnosed with urethral stricture undergoing internal urethrotomy were included. The primary associated factor was the association between the length of stricture and recurrence. Other factors described were post-RTU as etiology, previous interventions for urethral stricture management, and previous Qmax on uroflowmetry less than 5 ml/s. The length of urethral stricture was identified as the leading association with stricture recurrence following internal urethrotomy. Other associated factors were post-URT as etiology, previous interventions for managing stricture, and Qmax less than 5 ml/s. However, studies with better methodology are required.

Management of Ureteral Stricture Disease After Radiation Therapy for Pelvic Malignancies: A Retrospective, Multi-Institutional Analysis

Objectives. A radiation-induced ureteral stricture (RIUS) is a challenging condition in urologic surgery, and the optimal surgical strategy is still a matter of debate. The aim of this study was to report post-operative outcomes of minimally invasive management of this condition from a multi-institutional cohort. Methods. Data of patients with diagnoses of RIUS at five referral robotic centers between January 2017 and December 2022 were retrospectively analyzed. Pre-, intra- and post-operative variables were collected. Recurrence was defined as the presence of flank pain combined with imaging findings for obstruction, and requiring further management. Univariate and multivariate logistic regression models were built to identify predictors of ureteral stricture recurrence. Results. Fifty-three patients with a diagnosis of an RIUS were included. Primary pelvic malignancy was mostly cervical (42%). In 72% of cases (mostly mid-proximal and short strictures) endourological management was attempted, which was deemed successful in 74% of patients at stent removal. The endourology success rate at a median follow-up of 12 months was 59%. Twenty-five patients (47%) were scheduled for robotic surgery. The reconstructive techniques most often performed were end-to-end anastomosis (44%) and ureteral reimplantation (52%). Three low-grade Clavien-Dindo post-operative complications (12%) occurred. Robotic surgery was successful in all cases except one. Considering the entire cohort, eight patients (15%) developed recurrence at a median follow-up of 5 months. All patients with recurrence were managed by permanent drainage. A statistically significant improvement in eGFR with respect to baseline was found at a median follow-up of 12 months (p = 0.007). The univariate logistic regression model identified ureteral stricture length >2 cm (OR 6.4, 95% C.I. 1.1–36.9, p = 0.04) and concomitant chemotherapy (OR 8.9, 95% C.I. 1.6–49.9, p = 0.01) as predictors of recurrence. At multivariate analysis concomitant chemotherapy was confirmed as an independent predictor of recurrence (OR 7.8, 95% C.I. 1.3–49.0, p = 0.03). Conclusions. Endourological management of an RIUS is reasonable for short and mid-proximal ureteral strictures, while robotics is required in almost all the remaining cases. Up to 15% of recurrence develops within 6 months. Re-do reconstructive surgery is rarely performed, even in referral centers.

Decision regret and long-term success rates after ventral buccal mucosa graft urethroplasty.

To characterise the long-term success rate of ventral onlay buccal mucosa graft urethroplasty (vBMG) in the management of bulbar urethral stricture disease (USD), assess patient-reported postoperative satisfaction and decision regret, and delineate clinical factors impacting patient-reported metrics. Patients with prior vBMG for bulbar USD, performed at Cleveland Clinic between 2003 and 2022, were contacted and brief structured interviews were performed. Stricture recurrence and need for secondary procedures, baseline demographics, and patient-reported outcome surveys were collected. The surveys included the Decision Regret Scale (DRS), the Urethral Stricture Symptom Impact Measure (USSIM) and the 10-item Patient-Reported Outcomes Measurement Information System Short Form, version 1.2 (PROMIS-10). Descriptive, univariate and multivariable analyses were performed for clinical outcomes and survey responses. A total of 104 patients recorded responses. The median patient age was 49 years and the median follow-up was 7.4 years at time of survey. The median graft length was 5 cm and 38% of patients underwent partial thickness augmented anastomotic urethroplasty. At time of follow-up, 10 patients underwent a secondary procedure. Moderate to severe regret on the DRS was found in 12% of patients, and greater regret was associated with recurrence. The mean physical and mental health PROMIS-10 Global Health T-scores were 52 and 53. The mean total USSIM score was 56. A significant correlation was found between USSIM and DRS scores, with higher DRS score and recurrence negatively impacting USSIM score. USSIM scoring across all domains was significantly worse in the moderate to severe DRS group. This study showed that vBMG for bulbar USD confers both high success rates and patient-reported satisfaction at extended follow-up, based on emerging and validated patient-reported outcome measures.

Pulse Granuloma in Esophagus; A Rare finding in Achalasia Patient: Case Report and Literature Review

Abstract Introduction/Objective Pulse granuloma is a granulomatous reaction to foreign body, most commonly to food material. This is clinically silent and incidental but may be confused for a mass like lesion. This can be found any location in gastrointestinal tract but most reported in oral cavity and colon. We herein report a rare case of pulse granuloma in esophagus with literature review of the entity. Methods/Case Report A 58-year-old male with history of achalasia, surgical history of Heller myotomy, hernia reduction, hiatoplasty, gastropexy, vagotomy, presented with recurrent stricture of the esophagogastric junction. The patient received multiple esophageal balloon dilatations in the past due to high esophageal sphincter pressure and was complicated by severe reflux associated with esophagitis and large hiatal hernia. He underwent subtotal esophagectomy due to dysphagia. Gross examination of the esophagectomy specimen showed multiple previous procedure scars and was opened to reveal firm yellow food particles impacting in the mucosa. Histological examination showed gastroesophageal junctional mucosa with ulceration and fibrosis of the muscularis propria. Pink ribbon like hyalinized foci with giant cell was found which stained negative for GMS, PAS and AFB, supporting the diagnosis of pulse granuloma. Literature search for key word ‘Pulse Granuloma’ identified thirty-five case reports from year 1977 to 2024, with most reported case in the oral cavity (14 cases, 42%). Out of ten cases reported in gastrointestinal tract, 1 case was reported in small bowel and 9 cases were reported in colon and rectum and no cases were reported in esophagus. Results (if a Case Study enter NA) NA Conclusion Our patient’s history of achalasia and dysphagia along with histopathologic findings supports diagnosis of pulse granuloma in esophagus. Although clinically silent, pulse granuloma may cause mass-like lesions and result in enlargement and stenosis. In setting of esophageal achalasia recognizing this entity is important as it can mimic malignancy and other mass-forming lesions.

Optimal diameter of endoscopic dilatation in anastomotic stricture after esophagectomy.

The optimal diameter for endoscopic dilatation of anastomotic strictures after esophagectomy has not been elucidated. This study aimed to determine the optimal target diameter for endoscopic dilatation for anastomotic stricture after esophagectomy. The medical records of patients who underwent endoscopic dilatation for anastomotic stricture after esophagectomy between January 2009 and June 2024 at Pusan National University Yangsan Hospital were reviewed. The stricture recurrence rate, dilatation-free period, and complications according to the dilatation diameter were collected and included in the analysis. We analyzed 149 endoscopic dilatations (diameters from 10 to 18mm) in 43 patients. The median follow-up period was 47months (range, 5-157). The stricture recurrence rate was 72.5%, and the median dilatation-free period was 60days. The stricture recurrence rate was the lowest (41.7%, p = 0.022), and the overall dilatation-free period was the longest (median 490days, p = 0.171) in dilations up to 16.5mm. The stricture recurrence rate was higher in dilations up to 18mm than in those up to 16.5mm (54.5% vs. 41.7%, p = 0.331). Moreover, the bleeding rate was higher in patients with dilations up to 18mm (18.2% vs. 4.2%, p = 0.205). In patients with anastomotic strictures after esophagectomy, dilation up to 16.5mm showed a lower stricture recurrence rate, longer dilation-free period, and less postprocedural bleeding than those of dilation up to 18mm.

Intralesional injection of mitomycin C following visual internal urethrotomy for recurrent urethral stricture: a randomized controlled study.

To assess the efficacy of Intralesional injection of mitomycin C (MMC) following visual internal urethrotomy (VIU) in the management of recurrent urethral stricture. Fifty male patients diagnosed with recurrent single bulbar urethral stricture measuring less than 1.5 cm previously treated with VIU were randomly allocated into two equal groups, (Group A) planned for VIU only and (Group B) planned for VIU with intralesional MMC injection using Botox injection needle. All patients were objectively evaluated pre- and post-operatively at 3, 6, and 12 months using uroflowmetry, post-void residual urine volume, and retrograde urethrography. Forty-five patients completed their follow-up in our study. Patients who underwent intralesional MMC injection showed significant improvement in uroflowmetry, post-voiding residual, and with a success rate (82.6% in Group B, compared to 50% in Group A with a highly statistically significant difference, p-value: <0.001). VIU with MMC was the only factor associated with a marked decrease in stricture recurrence (p = 0.02) as shown in the Multivariate Cox regression analysis. Intralesional injection of mitomycin C seems to be a safe and effective modality in reducing the recurrent stricture rate after VIU.

Outcomes of Percutaneous Endobiliary Radiofrequency Ablation in Managing Resistant Benign Biliary Strictures: A Retrospective Analysis.

To assess the safety and effectiveness of percutaneous endobiliary radiofrequency ablation (EB-RFA) in the management of refractory benign biliary strictures. Percutaneous EB-RFA was performed in 15 individuals (M/F = 8/7; median age: 57 [33-84]) for benign biliary strictures resistant to traditional methods (transhepatic cholangioplasty and biliary drains). All patients underwent ≥1 unsuccessful cholangioplasty session and upsizing of their transhepatic biliary drains pre-procedure. Technical and clinical success were defined as luminal gain with enhanced flow and a lack of clinically evident recurrent stricture on follow-up after drain/stent removal, respectively. A total of 16 EB-RFA procedures were performed. Technical success rate was 100% (16/16). Procedure-related complications occurred in 1/16 cases (drain leakage with subsequent cellulitis). Clinical success rate was 87% (13/15) with a median follow-up of 17 (2-24) months. Drain/stent was not removed in one case (1/16) as the patient was lost to follow-up immediately post-procedure. The 1-year patency rate was 100%. A significant reduction was observed in the median number of IR visits (8 [1-51] to 1 [0-9]; p = 0.003) and drain insertion/exchange procedures (5 [1-45] to 0 [0-6]; p = 0.003) pre- and post-EB-RFA with a median follow-up of 18 (0-26) months. Percutaneous EB-RFA can safely and effectively treat refractory benign biliary strictures. However, larger prospective studies with extended follow-ups are needed to gather more robust data. This study contributes to the limited evidence on the role of EB-RFA in addressing refractory benign biliary strictures, enhancing the understanding of its clinical utility.

First diagnosis of severe coarctation of the aorta necessitation percutaneous intervention during pregnancy, a case report

Abstract Background Coarctation of the aorta (CoA) is a common congenital heart defect that affects about 3-4 in every 10,000 live births. Despite clear signs on clinical examination, the diagnosis is sometimes not made until adulthood. An increasing number of patients with CoA are reaching child-bearing age. Unrepaired CoA or severe recurrent stenosis during pregnancy is a significant concern, as it poses a high risk of maternal and foetal complications and even death. Case summary A 21-year-old women was referred to the cardiology department at 17 weeks’ gestation for management of arterial hypertension and unexplained systolic murmur. She had been diagnosed with hypertension elsewhere the year before presentation, but unfortunately this remained unexplored. She had been started on labetalol early in the pregnancy. Clinical examination showed a loud systolic heart murmur extending from parasternal to subclavicular and scapular areas. Pulses in the lower extremities were very weak and blood pressure was slightly elevated with a significant gradient between the upper and lower extremities. Echocardiography showed remarkable absence of pulsatile flow in the abdominal aorta and narrowing just distal to the subclavian artery with typical diastolic tail pattern on suprasternal imaging. Cardiac magnetic resonance confirmed the presence of a severe coarctation distal to the subclavian artery and presence of multiple collaterals allocating this patient in the extremely high-risk category with a risk of up to up 40-100% of maternal cardiac event during pregnancy. An extensive multidisciplinary team meeting was convened. After initial medical optimisation, increased claudication and signs of placental hypoperfusion necessitated an endovascular procedure under general anaesthesia at 23 weeks’ gestation. A Bentley BeGraft Plus stent (16x38 mm) was successfully placed. Postoperative ultrasound showed biphasic placental perfusion and normalisation of blood pressure and ankle-brachial indices. At 36 weeks’ gestation, the patient gave birth to a healthy child. Conclusion CoA should be considered in any young patient with arterial hypertension. Altered maternal haemodynamics during pregnancy resulted in severe symptomatic CoA and reduced placental flow necessitating percutaneous intervention during pregnancy. A multidisciplinary pregnancy heart team is essential for optimal treatment management in these high-risk patients.

Open laryngotracheal reconstruction for iatrogenic posterior glottic stenosis in adults: international multicenter experience.

Posterior glottic stenosis (PGS) has a significant impact on breathing and quality of life, and remains a challenging condition to manage. Literature does not provide a single optimal approach. In this study we aim to assess post-operative outcomes of adult patients with acquired PGS treated with open laryngotracheal reconstruction (LTR) with autologous or cadaveric rib grafting. This multicenter retrospective cohort study included adults who underwent open LTR for iatrogenic PGS (2015-2023) and were followed for 26 months on average. Data on comorbidities, surgical complications, and interventions following surgery were collected. Forty-three adult patients were included. Decannulation was successful in 76.7%, and 53.5% of patients required an endoscopic or open revision procedure for recurrent stenosis during the mean post-operative follow-up of 26 months. Patients with severe obesity (BMI ≥ 35), moderate to severe co-morbidity (ASA ≥ 3) or Chronic Kidney Disease were significantly more likely to fail decannulation after LTR. Diabetes Mellitus and ASA ≥ 3 were significant negative predictors for intervention-free survival. There were no significant differences in decannulation rate or intervention free survival between patients that had LTR with autologous (n = 26) versus cadaveric (n = 17) cartilaginous grafting. This study describes the largest consecutive multicenter cohort of adult PGS patients treated with open LTR. This technique significantly improves breathing outcomes in PGS, with minimal complications in selected patients with a healthy weight and few comorbidities. Patients with a BMI ≥ 35, ASA ≥ 3, Diabetes Mellitus or renal failure have less favorable outcomes, with respect to decannulation rates and intervention-free survival.

Clinical case: intraluminal incision and tandem ureteral stenting in obstructive upper urinary tract uropathy

One of the common causes of urinary retention and pain symptom in urological practice is ureteric stricture. Surgery remains the only effective method of treatment. Currently, the modern minimally invasive operations are the most relevant. Minimally invasive high-tech surgery: percutaneous endoureterotomy followed by the installation of tandem stents demonstrates effectiveness in treatment of recurrent strictures of the upper urinary tract.

The use of amniotic membrane injection as an adjunct in endoscopic urethral stricture management

ABSTRACT Introduction: 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. Methods: 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. Results: 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. Conclusions: 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.

Clinical outcomes of endoscopic balloon dilation for refractory esophageal strictures after esophageal atresia repair

BackgroundManaging refractory esophageal strictures (RES) presents formidable challenges. Although endoscopic balloon dilation (EBD) is the first step for esophageal stricture, the clinical outcomes of EBD for RES after esophageal atresia (EA) repair are not established. MethodsAll EA patients with esophageal balloon strictures (EBS) from October 2016 to October 2022 treated by EBD in our institution were retrospectively reviewed. The primary endpoint was to evaluate the clinical outcomes and the risk factors for poor outcomes of EBD for RES. The secondary endpoint was to evaluate the risk factors for pathological weight in RES patients. Results87 patients with RES were included in our study. After the first session of EBDs, 40.2 % experienced a recurrence of esophageal strictures. The median number (IQR) of the first session of EBD was 13.0 (8.0, 16.0), and the median number (IQR) of total dilations of achieving long-term clinical success was 14.0 (10.0, 19.0) with 81.6 % achieving long-term clinical success with less than 20 EBDs. In follow-up, all patients achieved a total oral diet. On multivariable analysis, the presence of GERD (OR 4.17, 95%Cl 1.29–13.51, p = 0.017), LGEA (long-gap esophageal atresia) (OR 5.19, 95 % Cl 1.15–23.52, p = 0.033), eccentric stricture shape (OR 3.34, 95%Cl 1.06–10.53, p = 0.040), and longer stricture length (OR 10.22, 95%Cl 1.14–92.01, p = 0.038) were statistically significant associated with increased endoscopic dilations. The presence of LGEA (OR 3.25, 95%Cl 1.03–10.20, p = 0.044) was significantly associated with recurrence after short-term clinical success. Additionally, Older age at first dilation after LEAP, stricture level at 1/3 upper (ref = 1/3 middle), and LGEA were identified as risk factors for developing pathological weight. ConclusionEndoscopic balloon dilation is an effective method for treating RES after EA repair. GERD, LGEA, eccentric stricture shape, and longer stricture length are the risk factors for increased dilation times. Older age at first dilation after LEAP, stricture level at 1/3 upper, and LGEA were identified as risk factors for developing pathological weight.

Feasibility, efficacy, and safety of retrograde intrarenal surgery in &lt;1-year age group: A single-center experience

Purpose: Urolithiasis in infants is uncommon. Percutaneous nephrolithotomy, extracorporeal shockwave lithotripsy, and retrograde intrarenal surgery (RIRS) are the management options. RIRS is the least studied of these options in infants. In our series of 23 cases, we aim to assess the feasibility, efficacy, and safety of RIRS in &lt;1-year age group. Materials and Methods: This was a retrospective analysis of a series of 23 infants who underwent RIRS in our hospital from January 2018 to March 2021. Children who were &lt;12 months of age and had the largest stone size of &lt;20 mm were included in the study. Results: Twenty-three patients (male – 15; female – 8) were included in the study. The mean age was 10 ± 2.31 months (range, 4–12 months). The mean stone size was 11.6 ± 2.96 mm (range, 7.5–19 mm). The mean operative time was 29.44 ± 7.45 min (range, 17–42 min). Six patients (22.2%) had mild hematuria (Clavien I), and seven patients (25.9%) had postoperative fever. Stone size had a significant positive correlation with laser time, operative time, and intraoperative intravasation, but no significant association with stone-free rate. At 2-month follow-up, 4 (three patients) out of 27 renal units had residual stones (stone-free rate [SFR] – 85.1%). No patient had long-term complications like urethral or ureteric stricture or stone recurrence during the given follow-up period. Conclusion: RIRS is a feasible and minimally invasive treatment for renal stones in infants with acceptable SFRs.