Segment Bulbar Urethral Strictures Research Articles

Role of magnetic resonance urethrography in evaluation of male urethral stricture

Background: Urethral stricture in male is a common urological disease causing lower urinary tract symptoms like thin stream of urine with straining to urinate, may be associated with dysuria or acute urinary retention. RGU is gold standard in male urethral stricture evaluation. In this study we compare magnetic resonance urethrography (MRU) with retrograde urethrography (RGU) in diagnosing male urethral stricture. Methods: The 40 male patients with the diagnosis of stricture urethra were taken for this study. Evaluation done first by RGU then after 7 days MRU. Final corroboration of above findings with the surgery (endoscopic or open). Results: Data of 40 male patients with urethral stricture are analysed with computer software SPSS v 25. mean age of stricture diagnosis is 43 years (range is 31-63 years). Mean length of stricture is 1.90 cm (with SD 0.85), 1.89 cm (with SD 0.92) and 1.91 cm (with SD 0.94) in RGU, MRU and Surgery respectively. sensitivity and specificity of RGU is 84.2% and 50% and MRU is 92.1% and 100% respectively. accuracy of RGU and MRU is 82% and 92% respectively. 3 patients out of 16 patients with long segment bulbar urethral stricture (>1.5 cm) without any spongiofibrosis managed with BMG urethroplasty. Two patients out of 24 patients with short segment bulbar urethral stricture (<1.5 cm) with dense spongiofibrosis managed with PEEAU. Conclusions: Both RGU and MRU can detect stricture lengths accurately but MRU has advantage of detection of spongifibrosis in cases of anterior urethral stricture. MRU detects orientation and alignment of both proximal and distal urethral segments in case of PFUI.

Is testosterone deficiency a predictive factor for recurrence of urethral stricture?

Testosterone plays a vital role in maintaining tissue homeostasis, and testosterone deficiency may potentially influence the likelihood of urethral stricture recurrence. To evaluate the prognostic value of testosterone levels in the recurrence after direct visual internal urethrotomy in primary short segment bulbar urethral strictures and its clinical reflections. A total of 723 patients who underwent direct vision internal urethrotomy between January 2000 and October 2022 were retrospectively analyzed. After implying exclusion criteria, 116 patients with available data were enrolled. Patients were divided into two groups as recurrence and no recurrence. Age, stricture length, etiology, time of recurrence, diagnosis of previous diabetes mellitus, hypertension, smoking, body mass index, and total testosterone levels were recorded. Free testosterone and bioavailable testosterone values were calculated using total testosterone, albumin, and sex hormone binding globulin values. Hypogonadism was considered as a total testosterone level less than 300ng/dL. Demographic characteristics and total testosterone, free testosterone, and bioavailable testosterone levels were compared between the two groups for statistical significance. The recurrence rates of patients with and without hypogonadism were compared. Recurrence was observed in 41.4% of the cases (n=48). There was no statistically significant difference between the groups in terms of age, body mass index values, diabetes mellitus, hypertension, smoking status, presence of hypogonadism, and etiology (p=0.745, 0.863, 0.621, 0.622, 0.168, 0.051, and 0.232). In terms of total testosterone levels and bioavailable testosterone levels, the recurrence group had significantly lower values (p=0.018 and 0.04). There was no significant difference between the two groups in terms of stricture length (p=0.071). Sixteen of 28 patients with hypogonadism had recurrence, whereas 32 of 88 patients without hypogonadism had recurrence (p=0.051). Testosterone levels have potential to predict recurrence in primary short-segment bulbar urethral strictures. This study represents the inaugural analysis of the impact of testosterone deficiency on recurrence within the cohort of patients with primary short-segment bulbar urethral strictures. Testosterone levels and ratios may serve as predictive factors for identifying recurrent cases in primary short-segment bulbar strictures. For patients at a higher risk of recurrence, urethroplasty may be considered as an initial treatment option, even in cases of primary and short-segment strictures.

A Comparative Study of the Outcome of Dorsolateral and Ventral Onlay Buccal Mucosal Graft Urethroplasty for Long Segment Bulbar Urethral Stricture

Background: Urethral strictures pose a significant challenge in urological practice, and substitution urethroplasty using a buccal mucosal graft is a widely accepted surgical technique. However, the optimal placement of the graft, whether dorsal onlay, ventral onlay or dorsolateral onlay is still unresolved. This study aimed to compare the outcomes of dorsolateral and ventral onlay buccal mucosal graft urethroplasty for long-segment bulbar urethral strictures. Methods: A prospective, quasi-experimental study was conducted at the Department of Urology, Dhaka Medical College Hospital, from July 2018 to September 2019. Fifty patients with long-segment bulbar urethral strictures were equally divided into two groups: Group-A (dorsolateral onlay) and Group B (ventral onlay). Patients were followed up for six months, and the groups were compared based on the International Prostate Symptom Score (IPSS), quality of life, maximum flow rate (Qmax), findings of retrograde urethrogram and voiding cystourethrogram, urethroscopic findings, complications and success rate. Results: Preoperative stricture lengths in Group-A and Group B were 3.62 ± 0.46 cm and 3.42 ± 0.54 cm respectively. Mean IPSS improved in both groups after surgery, with no significant difference between them. Mean Qmax also improved in both groups, with no significant difference between them. Success rates were 88% and 84% in Group-A and Group B respectively. Complications included wound hematoma, wound infection, and urethral diverticulum, while urethrocutaneous fistula and erectile dysfunction were not observed. Stricture recurrence rates were 12% in Group-A and 16% in Group B. Overall, both techniques demonstrated similar effectiveness and outcomes. Conclusion: Dorsolateral and ventral onlay buccal mucosal graft urethroplasty techniques yielded favourable short-term outcomes with low complication rates for long-segment bulbar urethral strictures. Both approaches were equally effective in terms of success ...

Holmium laser versus cold knife visual internal urethrotomy for management of short segment urethral stricture: a prospective randomized clinical trial

ObjectivesTo report the safety and efficacy of holmium laser and compare its results with cold knife visual internal urethrotomy (VIU) in the management of short segment urethral stricture.MethodsThis prospective randomized study included 66 male patients aged more than 18 years, with short segment bulbar urethral strictures < 2 cm from March 2020 to March 2022. The patients were randomized into two groups each containing 33 patients. In group A (Cold knife group), Sachse cold knife was used for stricture treatment. In group B (Holmium group), internal urethrotomy was done with Ho:YAG laser. Patients were evaluated before the operation and followed up after the operation at 1, 3, 6 and 12 months by physical examination, IPSS, PVR, Qmax and retrograde urethrography.ResultsThere was significant improvement in the mean values of IPSS, PVR and Qmax in both groups. There was no significant difference between both groups in the mean values of IPSS, PVR and Qmax during follow-up visits. However, at the end of follow-up at one year there was statistically significant difference between both groups in the mean values of IPSS, PVR and Qmax due to higher recurrence rate in cold knife group than laser group. The overall complication rate is significantly lower in laser group (p = 0.014).ConclusionHolmium laser VIU is an effective and safe treatment option for short segment urethral stricture with shorter operative time, less complication rate and less recurrence than cold knife VIU.

Prevalent Practices in Male Anterior Urethral Stricture Management: A Survey

Objective: This article aimed to study the prevalent practices in the treatment and follow-up of urethral strictures. Moreover, the article aimed to investigate the present opinion among urologists as the treatment practices for urethral stricture disease are mostly dependent on the treating surgeon’s expertise and preference in the absence of widely followed standard guidelines. Methods: A questionnaire was formulated based on the responses from experts. From October to December 2020, all members of the urological society of India received a mailed questionnaire on a web-based survey platform. Practicing urologists from across the country are among its members. Results: A total of 2554 urologists were contacted by mail, and 282 (11%) urologists provided a response. The majority were doing 5 to 15 urethroplasties a year. A newly diagnosed short segment bulbar urethral stricture would be a candidate for a visualized internal urethrotomy (VIU), according to 69.5% of urologists. Recurrence after one attempt at VIU prompted 80% to switch to urethroplasty as the next choice. During preoperative evaluation, 100% of respondents wanted a retrograde urethrogram, 74% deemed micturating cystourethrogram necessary, and 60% wanted a urethroscopy. At discharge, the majority preferred silicone Foley catheters, and the preferred size was 16F (54%). The patients were discharged with both suprapubic catheter and Foley in situ by most urologists. During follow-up, 60.99% wanted uroflowmetry, and the duration of follow-up varied. Conclusion: This survey on urethral stricture management amongst urologists shows that there is wide variation in the management of stricture urethra. This survey underscores the need for large-scale, long-term studies to formulate a guideline for the management of urethral stricture disease, thereby bringing uniformity in the care provided.

Direct Visual Internal Urethrotomy in Supine Position in a Patient with Complex Deformities of Both Lower Limbs and Neurogenic Bladder: A Case Report

Direct visual internal urethrotomy (DVIU) is a minimally invasive treatment for urethral stricture and is usually done in lithotomy position. We presented a case of a 35-year-old man with complex deformities of both lower limbs from birth. The lower limbs were severely wasted with ankylosis of the hips, flexion of the knee joints and dorsiflexion at the ankle joints. He had a history of progressively worsening difficult in urination characterized by frequency, urgency, urgency incontinence, nocturia, poor urinary stream (improved by straining), intermittency and feeling of incomplete bladder emptying. He had occasional dysuria and total hematuria. He was not a known hypertensive or diabetic patient. No history of trauma, previous urethral instrumentation, and no history of purulent urethral discharge before the onset of problems. On presentation, his abdomen was full with slight suprapubic distention. The anal sphincter was spastic and the prostate was not enlarged. He had normal non-circumcised male external genitalia. There was no spinal deformity and the upper limbs were normal. White cell count was 14,000 cells/ mm3 with a differential neutrophil of 85.5% and urine culture showed moderate growth of coliforms. Abdominopelvic ultrasound showed a thickened bladder wall with mild hydronephrosis bilaterally and a retrograde urethrography and micturating cystourethrography showed 3 short segment bulbar urethral strictures. There was also a Christmas tree appearance of the bladder. A diagnosis of bladder outlet obstruction secondary to multiple short segment idiopathic bulbar urethral strictures on background neurogenic bladder was made. He had intravenous antibiotics for 48 hours and subsequently a DVIU under spinal anesthesia and in the supine position. Catheter was removed on the 7th day post procedure and he started clean intermittent catheterization (CIC) with 12 French catheters. Seven months post procedure, patient is still satisfied with the outcome of his treatment. We concluded that DVIU can be done safely in the supine position and CIC can help improve post procedure outcome and in managing comorbid neurogenic bladder.

Outcome of Anastomotic Urethroplasty for Bulbar Urethral Stricture Our Experience

Objective: For evaluation of patients who underwent bulbar end-to-end anastomosis to assess surgical outcome. Materials and Methods: We reviewed 53 patients with an average age of 44 years who underwent bulbar end-to-end anastomosis from January 2013 to July 2018. A total of 9 patients (16.98%) underwent urethrotomy, dilation, or multiple treatments before referral to our center. Stricture length d”2cm, free from infection and completed at least 6 months of follow up were included. Patients were evaluated post operatively by uroflowmetry at 3, 6, 12 months of follow up and yearly thereafter. Clinical outcome was considered a treatment failure when any postoperative instrumentation was needed. Results: Mean age 44 (SD±7.6, range 33 to 54 years). Stricture etiology was blunt perineal trauma 32 (60.37%), infection 12(22.64%), idiopathic 06(11.32%) and iatrogenic 03(05.67%). Mean operation time was 95 minutes (range, 50 to 140 minutes) and mean excised stricture length was 1.4 cm (range, 0.5 to 2 cm). 44 patients (83.02%) were symptom-free and required no further procedure. Strictures recurred in 9 patients (16.98%) within 2 to 5 months after surgery. Of 9 recurrences, 3 patient was managed successfully by urethrotomy, whereas the remaining 6 did not respond to urethrotomy or dilation and required additional urethroplasty. Conclusions: Excision and end-to-end anastomosis urethroplasty is an excellent procedure for short segment bulbar urethral stricture. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.56-61

Outcome of Optical Internal Urethrotomy and Anastomotic Uretrhoplasty for Short Segment Bulbar Urethral Stricture

Background: Urethral stricture diseases are common urological problems in our country. The etiologies include iatrogenic, trauma, infection, congenital and very few are idiopathic. Urethral strictures have the potential for great negative impact on patients. These have several treatment modalities, ranging from simple dilations to complex multistaged urethroplasties. Optical internal urethrotomy and anastomotic urethroplasty are the common procedures among them which are particular topics in this study. Objectives: To evaluate the outcome of two surgical techniques- Optical Internal Urethrotomy (OIU) and Anastomotic Urethroplasty. Methodology: A total of 50 patients with short segment bulbar urethral strictures were consecutively included in the study. Purposive sampling method was applied. The present outcome clinical study was conducted in the department of Urology, National Institute of Kidney Diseases and Urology, Sher-E-Bangla Nagar, Dhaka, Bangladesh over a period of 1 year from February 2016 to January 2017. Student’s t-test and chi-square test were applied for hypothesis testing. ‘P’ value &lt;0.05 was considered as significant. Result: There is no significant difference between two groups regarding age, history of previous operation for stricture urethra, mode of clinical presentations before intervention, immediate post-operative complication and uroflowmetry during follow-up. But length of stricture of two groups, urinary stream at 3 and 6 months after operation, urinary tract infection at 6 month after operation, recurrence of stricture in two groups were statistically significant (p&lt;0.05). Conclusion: The study concluded that anastomotic urethroplasty was an effective and satisfactory technique for the treatment of short segment bulbar urethral stricture. The morbidity and complications were low and outcomes were excellent. Bangladesh Journal of Urology, Vol. 22, No. 1, January 2019 p.30-35

Buccal Mucosal Graft Urethroplasty as Primary Repair Has Significantly Better Outcome Than After Failed Dviu Cases- a Clinical Trial

Introduction: Direct Visual Internal Urethrotomy (DVIU) is the most commonly used technique for short segment bulbar urethral stricture till date. But it has a high failure and recurrence rate. On the other hand, urethroplasty is regarded as the gold standard treatment for urethral stricture. Moreover, for bulbar urethral stricture, usually more than 3cm stricture are treated with substitution urethroplasty. Current practice for short segment bulbar urethral stricture is multiple sessions of DVIU and then buccal mucosal graft (BMG) urethroplasty if they fail. But repeated DVIU make the stricture segment longer and more fibrotic. Considering the morbidities following repeated DVIU, this prospective clinical trial has been designed to compare the outcome of BMG urethroplasty after failed urethrotomy versus primary repair. Objective: To determine stricture recurrence, PVR and flow of urine in between primary BMG urethroplasty group and after failed DVIU group. Patients and Methods: The present study was conducted in the department of Urology, BSMMU between July’15 - February’17. Patients of short segment bulbar urethral stricture between 1.5- 3 cm without any previous DVIU were enrolled as study group(n=22) and patients with history of failed DVIU were included as control group(n=22). All the patients were followed upto 12 months after BMG urethroplasty and recurrence of stricture (by RGU and MCU), PVR and maximum urine flow rate (Qmax) in between two groups were compared. Results: The stricture recurrence rate was found significantly higher in control group than in the study group (p=0.042). The study group showed highly significant (0.000) decrease in post-operative PVR and significant (0.009) increase in post operative maximum urine flow rate than the control group as was assumed in the hypothesis. Conclusion: The present study propose that BMG urethroplasty as primary repair for bulbar urethral stricture within a length of 1.5-3 cm in younger age group (upto 45 years ) is very effective than BMG urethroplasty after failed DVIU cases. But long term multicentric trial is needed to further comment. Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p.3-7

Augmented Anastomotic Urethroplasty for Long Segment Bulbous Urethral Strictures

Background: During urethroplasty, if the stricture contains a 2 to 4 cm region that is particularly narrow and/or fibrotic, anastomotic repair is not ideal, so that portion may be excised with subsequent anastomosis of the ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty Objectives: Evaluation of the outcome of augmented anastomotic urethroplasty with dorsal onlay for long segment bulbar urethral stricture. Patients and Methods: A prospective clinical trial was carried out during the period from March 2017 to September 2019 of 55 patients underwent dorsal onlay augmented anastomosis using buccal mucosa graft for long segment bulbar urethral strictures. All patients underwent pre-operative medical history taking and physical examination, sono-urethrography and voiding cystourethrogram. Patients were followed-up and re-assessed at 3 and 6 months post-operatively. Follow-up urethrography was performed at 6 months. The primary outcome was the procedure success rate defined by the successful voiding function. Stricture recurrence was defined the presence of intractable voiding symptoms or the need for any urethral interventions. The data were analyzed using the appropriate statistical tests. Results: During the study period, 55 patients completed the follow-up protocol and included in the study. The mean age was 41.93±10.70 years. The mean intra-operative stricture length was 3.39±0.59 cm. Buccal mucosal graft was used in all cases. Mean graft length was 4.15±0.62 cm. At 6 months follow up, 51 patients had no evidence of stricture recurrence and required no further intervention with an overall success rate of 92.7%. Stricture recurrence occurred in 4 patients (7.3%). No donor site major complications were detected. The urethroplasty complication rate was 20.0%, and all were minor. No effect of urethroplasty on erectile function in adult sexually active patients. No penile shortening or chordee. Conclusions: Dorsal onlay augmented anastomosis was a useful technique for long bulbar strictures. High stricture-free rates and complications are few and minor. Although longer follow up was needed.

An audit of management of male urethral stricture and it’s outcome: a single centre retrospective review

Background: Anterior urethral stricture involves penile, bulbar or panurethra with varied aetiology. Direct vision internal urethrotomy (DVIU), stricture excision with primary end to end anastomosis, single stage or staged reconstruction with local flap or buccal mucosal graft (BMG) are surgical options.Methods: This single centre retrospective study was conducted from April 2017 to March 2019. Patient underwent DVIU, stricture excision with primary end to end anastomotic, staged urethroplasty, BMG urethroplasty (BMGU) dorsal inlay Asopa technique, dorsal onlay Kulkarni technique and ventral onlay technique depending on site and extent of strictures. Preoperative, intraoperative, post-operative data were reviewed.Results: Here, 51 patients underwent DVIU for single soft short segment bulbar urethral stricture with success rate 58.82%. 26 patients with post traumatic short segment bulbar urethral stricture underwent excision and primary end to end anastomosis with success rate 92.31%. Patients with long segment bulbar urethral stricture underwent either dorsal onlay (n=19) or ventral onlay (n=14) BMGU with success rate 89.47% and 85.71% respectively. Total 59 patients with long segment penile or pan urethral stricture underwent either single stage (n=27) or staged reconstruction (n=32) with success rate of 85.18% and 90.63% respectively. Patients with staged reconstruction had significantly longer hospital stay (p&lt;0.0001) and poor quality of life due to laid opened urethra. Asopa’s dorsal inlay (n=15) and Kulkarni’s dorsal onlay (n=12) BMGU had equivalent success rate of 86.67% and 83.33% and comparable complications.Conclusions: Surgery for urethral stricture differs according to site and extent of stricture. Single stage BMG urethroplasty is preferred modality for long segment bulbar, penile and panurethral stricture.

Dorsal onlay buccal mucosa graft urethroplasty for bulbar urethral stricture: a single centre experience.

Introductionthe successful treatment for urethral strictures demands not just attention to surgical details but careful selection of the reconstructive technique. For long segment urethral strictures substitution urethroplasty is required. This study sought to determine the success rate and complications of dorsal onlay buccal mucosal graft (BMG) urethroplasty for long segment urethral strictures in our hospital.Methodsthis was a retrospective study carried out at Jos University Teaching Hospital from March 2015 to March 2018. The case notes of male patients who had dorsal onlay buccal mucosal graft urethroplasty for long segment bulbar urethral stricture within the study period were retrieved. Patients´ demographics, cause and nature of urethral strictures, duration of follow up, the success rate and complications were collected and subjected to statistical analysis using SPSS® version 22.Resultstwenty-four men with mean age of 45 years (range 14-67 years) had dorsal onlay buccal mucosal graft urethroplasty during the study period. The mean stricture length was 4.5cm (range, 2-7cm). After a mean follow up duration of 2 years (range, 1 4 years), 21(87.5%) patients had a successful urethroplasty as they were able to pass urine at one year post urethroplasty without lower urinary tract symptoms, while 3(12.5%) had recurrence of the urethral stricture. At the recipient site, 2(8.3%) patients had primary bleeding that did not require blood transfusion. Also, 2(8.3%) patients had superficial wound infection which was treated with antibiotics. At the donor site, 4(16.7%), 2(8.3%), 4(16.7%) had donor site swelling, transient bleeding and soreness respectively.Conclusiondorsal onlay BMG urethroplasty has a good success rate and minor complications and therefore suitable for long segment bulbar urethral strictures.

Vicryl Tack for graft fixation during bulbar urethroplasty

Urethral stricture disease continues to be a prevalent condition with significant morbidity. Oral mucosal graft augmentation urethroplasty for long segment bulbar urethral strictures is an established management option. Here the authors outline the results of their pilot study designed to evaluate the efficacy of using two innovative steps for graft augmentation.

Efficacy of oral steroids after optical internal urethrotomy in reducing recurrence of urethral strictures.

Optical internal urethrotomy is a feasible modality of treatment for short segment bulbar urethral strictures. Recurrence is an important problem after urethrotomy. This study aimed at evaluating the efficacy of oral steroid (deflazocort) in reducing the recurrence of strictures after urethrotomy. Up to date, no study has evaluated the role of oral steroids after urethrotomy. In this case-control study, patients undergoing urethrotomy (bulbar urethral strictures <2 cm) were divided into two groups according to patients receiving (Group 1) or not receiving (Group 2) oral steroid (deflazocort 6 mg tablets) after operation. Both groups were controlled at 1, 3 and 6 months after catheter removal (usually 5-6 days after operation) with uroflowmetry, and the flow rates were statistically compared. Deflazocort was given after catheter removal, at first 6 mg twice daily for two weeks, then 6 mg once daily for another two weeks (self-obturation was not performed). A total of 72 patients were selected for the study as per inclusion criteria. They were divided into 2 groups as those receiving (Group 1: deflazocort group; n=36) or not receiving (Group 2; n=36) deflazocort. Median postoperative maximum flow rates in the deflazocort group were 26.2, 22.3 and 18.2 mL/sec, and in the control group was 24.4, 17.1 and 13.7 mL/sec at postoperative 1., 3. and 6. months, respectively. Lesser patients in the deflazocort group had recurrence. The difference was statistically significant only at postoperative 3 (p value=0.03), and 6. months (p value=0.02) (p value=0.15). Oral steroids can be used after internal urethrotomy to reduce the recurrence of urethral strictures.

Comparison of cold-knife optical internal urethrotomy and holmium:YAG laser internal urethrotomy in bulbar urethral strictures.

IntroductionTo compare the results of cold-knife optical internal urethrotomy (OIU) and Holmium:YAG laser internal urethrotomy (HIU) in primary bulbar urethral strictures.Material and methodsA total of 63 patients diagnosed with primary bulbar urethral stricture between August 2014 and September 2015 were assigned to the OIU (n = 29) and HIU (n = 34) groups. The demographic variables, biochemistry panels, and preoperative and postoperative uroflowmetry results including the maximum flow rate (Qmax) and mean flow rate (Qmean) values, retrograde urethrography, and diagnostic flexible urethroscopy findings were recorded prospectively. Demographic features and preoperative values were not statistically different between groups (p >0.05). Mean surgical times were 18.4 ±2.3 min for OIU and 21.9 ±3.8 min for HIU groups, which was statistically significant (p <0.05). There was no significant difference in complication rates in both groups (p = 0.618).ResultsPostoperative Qmax values were increased in both groups even though postoperative Qmax values were not significantly different between the two groups in the short- and long-term results at 3, 6, and 12 months (p >0.05). There was no recurrence in the first 3 months in either group. The urethral stricture recurrence rate up to month 12 was not statistically significant for the OIU group (n = 6, 20.7%) as compared to the HIU group (n = 11, 32.4%; p = 0.299).At follow-up, the SFR and IFR was 96% and 88% at 3-months, and 82% and 71% at 12-months, respectively (p <0.001). While almost three-quarters of patients were stone and infection free at 12-months, the majority of those with stones recurrence also had recurrence of their UTI.ConclusionsHIU is an alternative method to OIU, and it has similar success rates in the treatment of short segment bulbar urethral strictures.

Does site of buccal mucosa graft for bulbar urethra stricture affect outcome? A comparative analysis of ventral, dorso-lateral and dorsal buccal mucosa graft augmentation urethroplasty.

To compare long- term outcomes of buccal mucosa graft (BMG) augmentation urethroplasty for long segment bulbar urethral strictures done by placing the graft ventrally, dorso-laterally and dorsally. We conducted a single institution retrospective study on 112 who underwent BMG augmentation urethroplasty for non-traumatic bulbar urethral strictures between January 2005 to December 2014. The cases were divided into three groups based on the site of placement of BMG graft i.e. (a) Ventral (n=44), (b) Dorso-lateral (n=48) and (c) Dorsal (n=20). Follow-up period was from one year to five years. Patients with failed outcomes underwent urethroscopy or retrograde urethrogram to note the site of recurrence of stricture. Out of 112 cases 91 (81%) were successful and 21 (19%) failed. The success rates for ventral, dorso-lateral and dorsal BMG augmentation procedures were 89%, 79% and 70%, respectively (p=0.18). Among 21 failed cases, 12 cases (57%) had stricture at proximal anastomotic site, 4 cases (19%) at graft and 5 cases (24%) at distal anastomotic site (p=0.01). The overall success rate for BMG augmentation urethroplasty is equal for all techniques. Ventral onlay urethroplasty provides better exposure of proximal anastomotic site thus it is associated with minimum proximal anastomotic site recurrence rates. Patients with extensive spongiofibrosis and long segment strictures had higher rates of failure.

Intraoperative breakage of Sachse’s knife blade: a rare complication of optical internal urethrotomy (one case managing experience)

ABSTRACTOptical internal urethrotomy (OIU) is the most common procedure performed for short segment bulbar urethral stricture worldwide. This procedure most commonly performed using Sachse’s cold knife. Various perioperative complications of internal urethrotomy have been described in literature including bleeding, urinary tract infection, extravasation of fluid, incontinence, impotence, and recurrence of stricture. Here we report a unique complication of breakage of Sachse knife blade intraoperatively and its endoscopic management.

Short segment bulbar urethral strictures: Review of 48 cases managed in a resource-poor setting.

To share our experience on the presentation and management of short segment bulbar urethral strictures (BUSs) in a resource-poor center. Short segment bulbar urethral strictures (BUSs) managed from January 2009 to December 2014 were analyzed. Patients'age, stricture aetiology, mode of presentation, stricture characteristics, time to surgery, associated morbidity, operative procedure, and post-operative outcome were reviewed. All patients had bulbar anastomotic urethroplasty (BAU). Total 42 bulbar anastomotic urethroplasties (BAUs) were done. The mean age of the patients in years was 37.46 (± 13.80). Fall astride injuries accounted for most strictures, 39(89.3%) of cases. The mean stricture lenght was 1.04 cm ± 0.49 and was longer in patients who had prior instrumentation,1.45 cm (± 0.37) versus 0.70 cm (± 0.26), P = 0.000. Associated lower urinary tract comorbidities were noted in 38 (79.2%) patients. Mean time to surgery was 10.20 (± 4.96) months. Patients operated on after 6 months of presentation had more associated comorbidities, 24/26 patients (92.3%), compared to those operated on within 6 months; 8/16 cases (50%), P = 0.003. However, this did not impact negatively on the outcome of surgery (P = 0.275). Patients with complete strictures tended to accept surgery earlier than those with incomplete strictures, 29 patients (60.4%) versus 19 patients (39.6%), P = 0.208,with no difference in outcome between the two groups, P = 0.581.The overall success rate was 92.9%. Fall astride injuries are the commonest cause of short segment BUSs. Prior urethral instrumentation is associated with recurrence and longer stricture lenght. Suprapubic catheter-related associated comorbidity increases with the duration of catheterization but does not impact negatively on the surgical outcome. BAU has low morbidity and high success rate of 92.7%. It should be the first line treatment for short segment BUS in low-resource countries.

COMPARISON OF SEXUAL DYSFUNCTION BETWEEN END-TO-END ANASTOMOSIS AND BUCCAL MUCOSA GRAFT

Objective: The aim of this study was to compare long term follow-up of sexual dysfunction between end-to-end anastomosis or buccal mucosa graft in short segment bulbar urethral stricture. Material &amp; Method: We performed a meta analysis of cohort study. The data sources was MEDLINE from 1980 through 2011. A fixed effects model with Mantel-Haenszel method was used to calculate the pooled Risk Ratio (RRs) and 95% Confidence Interval (CIs). We assessed the heterogeneity by calculating the I2 statistic. All analyses were performed with Stata statistical software, version 10.0 (Stata Corp). Results: We analyzed 6 cohort studies. End-to-end anastomosis and buccal mucosa graft patients who complained about sexual dysfunction were 24.6% (45/183) and 9.1% (11/122) respectively, with overall RR 2.54 (95% CI, 0.22-0.69, p = 0.001). Conclusion: Buccal mucosa graft showed a superior outcome compared to end-to-end anastomosis, based on sexual dysfunction in ≤ 3 cm bulbar urethral stricture treatments.Keywords: Sexual dysfunction, end-to-end anastomosis, buccal mucosa graft, anterior urethral stricture.

Expanded Use of a Dorsal Onlay Augmented Anastomotic Urethroplasty With Buccal Mucosa for Long Segment Bulbar Urethral Strictures: Analysis of Outcomes and Complications

To evaluate the results of a dorsal onlay augmented anastomosis using buccal mucosa to reconstruct long segment bulbar urethral strictures. The ideal treatment of long segment bulbar urethral strictures remains controversial. Urethroplasty with tissue transfer is typically required, but the optimal technique is unknown. A prospective cohort of 163 patients with complete follow-up data underwent dorsal onlay augmented anastomosis using buccal mucosa for long segment bulbar urethral strictures from November 2003 to March 2011. All patients underwent preoperative urethrography and cystoscopy. The follow-up protocol consisted of cystoscopy and subjective symptom assessment at 6 months and symptom assessment at 12 months, with repeat cystoscopy, if indicated. Annual symptom assessments were performed thereafter as required. Stricture recurrence was defined as a segment<16F on cystoscopy or the presence of intractable voiding symptoms. The secondary outcome measure was the incidence of postoperative complications using a nonvalidated questionnaire. Fisher's exact test was used to evaluate the patency and complication rates between patient age and stricture length. The median follow-up period was 31.0 months (range 6-91). Of the 163 patients, 157 (96.9%) had no evidence of stricture recurrence. Postoperative complications included postvoid dribbling (41.7%; 68 of 163), urinary tract infection (3.7%; 6 of 163), erectile dysfunction (3.1%; 5 of 163), orchalgia (10.4%; 17 of 163), and donor site morbidity (4.3%; 7 of 163). Age was not associated with recurrence, but stricture length≥5 cm was associated with a lower patency rate (P= .010). Dorsal onlay augmented anastomosis using buccal mucosa demonstrated a 96.9% patency rate in our single-center prospective study and should be considered for reconstruction of long segment bulbar urethral strictures, especially with a focal segment of obliteration. Strictures≥5 cm are prone to recurrence but are still amenable to dorsal onlay augmented anastomosis using buccal mucosa.