Short Strictures Research Articles

Endoscopic Internal Urethrotomy Outcomes in the Management of Male Urethral Strictures

Background: The aim of this study was to evaluate the outcomes of stricture treatment using endoscopic internal urethrotomy in the male urethra. Patients and Methods: We conducted a retrospective study from 2012 to 2017 at the Urology and Andrology Department of the University Hospital in Brazzaville, Congo. Medical records of 30 patients who underwent endoscopic internal urethrotomy for urethral stricture were analyzed. We studied the following variables: frequency of urethral stricture, age of patient, onset, cause and location of urethral stricture, duration of bladder catheterization, duration of hospitalization, and postoperative complications. The treatment outcome was assessed after a follow-up of 2.6 years (extreme: 2 and 4 years). Outcomes were considered successful or good when the patients had a normal urine flow and an unobstructed urethra at the Retrograde Urethrogram (RUG). Results: The mean age was 47.5 ± 9.7 years (range: 17 to 83 years). Dysuria was the most common symptom reported. We found that urethral stricture was mostly caused by infectious diseases (20 patients). The urethral stricture was located at the membranous urethra in 4 patients, the bulbar urethra in 25 patients, and the penile urethra in 1 patient. The mean duration of the bladder catheterization was 2.3 days. Hospitalization duration was 36 hours. We observed the following complications: urethrorrhagia in 3 patients, acute orchiepididymitis. We achieved good results in 23 patients. Conclusion: In our context where the practice of endoscopic internal urethrotomy is recent, it provides satisfactory results for the treatment of short urethral male stricture.

Visual internal urethrotomy in short segment bulbar stricture

Visual internal urethrotomy in short segment bulbar stricture

Direct Vision Internal Urethrotomy (DVIU) and Regular Clean Self Intermittent Catheterization (CSIC) For Short Bulbar Urethral Strictures: A Durable Solution

Background: To evaluate durability of DVIU results and recurrence of stricture if the CSIC was done regularly up to one year and weekly thereafter. Subjects and Methods: This retrospective study was conducted in the Department of Urology at tertiary care teaching hospital of Rajasthan, India. Files of all patients operated between January 2015 and July 2018 for single bulbar urethral strictures of less than 1-1.5cm size in length, iatrogenic, idiopathic, traumatic or inflammatory origins were evaluated. Patient with multiple or complicated strictures of post urethroplasty, post hypospadias repair, previous radiation or multiple DVIU were excluded from the study. Data of all patients who were on CSIC following direct vision internal urethrotomy were evaluated at 3, 6, 12 and 24 months. Results: Mean age of patients was 41.13 years with range in between 26-74 years. Most common cause of urethral strictures were idiopathic 66 (58.92%) followed by iatrogenic 27 (24.11%) causes. After 24 months of follow up 95 (84.82%) patients maintained urethral caliber up to 16 Fr. Failure or recurrence was found in 17 (15.18%) patients who required intervention. Conclusion: Direct vision internal urethrotomy (DVIU) with regular clean intermittent self-catheterization (CSIC) was found good success rate in bulbar urethral strictures upto 1 cm in selected patients.

Extended Primary Anastomosis With Penile Plication (EPAPP): A Promising New Alternative to Perineal Urethrostomy for Reconstruction of Long Urethral Strictures

At present, excision and primary anastomosis (EPA) urethroplasty is a highly reliable method of reconstruction for short bulbar urethral strictures. Longer strictures are often managed with grafting techniques to ensure a tension-free repair. Here we report our initial experience with a new, extended anastomotic technique for long bulbar strictures that incorporates plication of the ventral corporal bodies to reduce the distance between the urethral ends and obviates the need for grafting. We reviewed records for all urethroplasties performed by a single surgeon at our institution between January 2018 and February 2020. We identified a cohort of older patients with complex strictures who underwent Extended Primary Anastomosis with Penile Plication (EPAPP). Patient demographics, stricture characteristics, perioperative 75 parameters, and postoperative outcomes were evaluated. Of 346 urethroplasty records reviewed, 10 patients (2.9%) underwent EPAPP. Mean stricture length was 3.75 ± 1.4 cm. EPAPP patients were older than those repaired by other techniques (mean age 66.6 vs 55.6, P=.024), and most were not sexually active preoperatively. Postoperative voiding cystourethrogram confirmed urethral patency without extravasation in all patients. At a median follow up of 9.7 months (IQR 8.5-11.5) 8 patients remained asymptomatic after EPAPP alone and 2 patients required a single balloon dilation for stricture recurrence. EPAPP is a promising alternative option for the management of long bulbar strictures among appropriately selected patients.

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

Traumatic Bulbar Urethral Stricture: Improvised Reconstruction with Muscle and Nerve Sparing Approach

Bulbar urethra is the most common site of the stricture (46.9%). Meta-analysis of anterior urethral strictures showed etiology as iatrogenic (33%), idiopathic (33%) and, to a lesser extent, trauma (19%) and inflammation (15%). End-to-end anastomosis is the most valid treatment of choice for short bulbar traumatic urethral strictures, with cure rates close to 100% [1,2].

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 <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<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

Bulbomembranous Urethral Strictures Repair After Surgical Treatment of Benign Prostatic Hyperplasia. Experience From a Latin American Referral Centre

To evaluate stricture recurrence and urinary incontinence (UI) rates in patients who underwent bulbomembranous anastomosis for management of short (≤ 2cm) bulbomembranous urethral stricture (BMS) after benign prostatic hyperplasia (BPH) surgical treatment. In addition, we studied if there was any relation between post urethroplasty UI and the method employed for BPH surgical treatment. A retrospective study was conducted between January 2011 and October 2019. We included all patients who developed BMS after undergoing Transurethral Resection of the Prostate, Holmium Laser Enucleation of the Prostate or Open Simple Prostatectomy (OSP). We excluded patients with UI after BPH surgical treatment as well as patients who underwent a dorsal or ventral onlay oral graft urethroplasty for longer proximal bulbar strictures, and also patients with associated bladder neck contracture or other strictures locations. We defined failure as the need for any intervention to restore the urethral caliber. Overall, 77 patients were included in the study with mean age 70 years (sd 8). Median BMS length was 1.5 cm (IQR 1-2). Median follow-up was 53 months (IQR 24 to 82). Of the patients, 74/77 (96.1%) were classified as success and 3/77 (3.9%), as failure. Out of the 6/77 (7.8%) patients who had postoperative UI, 5 of them had been treated for their BPH with OSP (p 0.001). Bulbomembranous anastomosis is a suitable reconstructive option for short proximal bulbar urethral strictures after BPH surgical treatment. OSP was associated with postoperative UI more frequently than endoscopic treatments modalities.

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

S2337 Outcomes of Lumen-Apposing Metal Stents (LAMS) in the Management of Colonic Strictures, Leaks, and Fistulae

INTRODUCTION: Benign colonic strictures and fistulae are usually managed surgically. Surgical procedures are more invasive and are associated with significant morbidity and occasional mortality. Endoscopic management of colonic strictures involves balloon dilation, covered metal stent placement. Traditional covered metal stents are associated with high migration rate. Fistulae can be managed endoscopically by placement of over the scope clips (OVESCO) or endoscopic suturing. Endoscopic suturing is technically challenging when the lumen is narrow. Lumen apposing metal stents [LAMS] are short (1 cm long) covered metal stents with a unique shape. LAMS has several advantages, including varying diameter (10mm, 15mm, 20 mm), a saddle-shaped design that decreases migration risk, and an easy deployment system allowing high technical success. Use of LAMS in the management of the upper GI tract strictures has been reported. We aimed to study the safety and efficacy of using LAMS (AXIOS, Boston Scientific, Marlborough, USA) in the treatment of colonic strictures and fistulae. CASE DESCRIPTION/METHODS: We retrospectively reviewed data of 5 patients who had undergone LAMS placement in the colon for strictures, fistulae or leaks in the past one year. Patient demographics, location of the stricture/fistula, previous treatments, indication for the stent, size of the LAMS used, intraprocedural adverse events, post procedural adverse events, follow up data was collected. Our patient sample comprised 3 females and 2 males with an age range of 57 to 81 years. Of the 5 patients, 3 had an anastomotic leak/fistula (AF), while 2 had benign anastomotic strictures (S) in the sigmoid colon. The 20 mm AXIOS was deployed successfully in all patients without any evidence of bleeding or stent mal-deployment. Of the 5 patients, two had failed prior intervention with either an Ovesco clip closure (2 AF) or balloon dilatation (1 S). Follow up data is available in 4 patients (2 AF and 2 S): all had resolution of the strictures/fistulae. One is awaiting follow up. See Table 1 for details. DISCUSSION: LAMS can be successfully utilized as a safe and effective alternative in the management of short segment benign colon strictures and fistulae. Further prospective studies are needed to assess the outcomes of LAMS use in the colon.Table 1.: Patient demographics and Clinical information- AXIOS for management of Colon strictures and leaks.

S2012 Esophageal Lichen Planus: Making the Diagnosis with History and Endoscopy With Histopathologic Evaluation

INTRODUCTION: Esophageal lichen planus (ELP) is a rare manifestation of lichen planus, an inflammatory disease of unknown etiology that commonly affects mucocutaneous membranes. Diagnosing ELP can be challenging because of nonspecific endoscopic or histologic findings, variable symptoms and lack of clear diagnostic criteria. CASE DESCRIPTION/METHODS: A 67-year-old female with a past medical history of gastroesophageal reflux disease and hypertension presented to clinic with two years history of dysphagia to solids, odynophagia, and 30lbs weight loss. Symptoms began with oral ulcers, bleeding gums, and hypogeusia. Her medications included a thiazide diuretic. Physical examination was negative for skin or oropharyngeal lesions and abdominal exam was benign. Laboratory results were negative for antinuclear antibody, anti-Ro/La, and hepatitis C antibody. Patient was started on a proton pump inhibitor and proceeded to esophagogastroduodenoscopy, which revealed an upper esophageal web that was dilated. The mucosa was diffusely inflamed throughout the length of the esophageal body, making the identification of the boundary between squamous and columnar epithelium difficult. A short distal stricture 2 cm above the top of the hiatal hernia was also dilated. Biopsy of proximal esophagus revealed squamous mucosa with basilar lymphocytic infiltrate and scattered apoptotic squamous cells (Civatte bodies) (Figure 1), consistent with a diagnosis of ELP. Distal esophageal biopsy revealed intestinal metaplasia without dysplasia and squamous mucosa with predominantly lymphocytic mixed inflammatory infiltrate and rare apoptotic squamous cells. Patient tolerated endoscopic dilation without complications and patient’s thiazide diuretic was held. Patient re-presented to clinic 6 months after EGD without dysphagia and 9lbs weight gain since previous visit. DISCUSSION: Lichen planus is an inflammatory disease of unknown etiology that commonly affects mucocutaneous membranes but can also involve the esophagus. ELP should be suspected in any patient who has history of lichen planus. Dysphagia and odynophagia are two primary symptoms associated with ELP. A comprehensive endoscopic, radiologic and histopathologic evaluation aid in the diagnosis. ELP is treated with systemic steroids and endoscopic dilation. Endoscopic dilation with discontinuation of potential culprit medications (i.e. thiazides) is a reasonable first step management, as in our case.Figure 1.: Biopsy specimens showing inflammatory infiltration of basal mucosa and scattered apoptotic squamous cells, also known as Civatte bodies (arrow).

S2491 Small Duct Primary Sclerosing Cholangitis: An Atypical Presentation

INTRODUCTION: Primary sclerosing cholangitis (PSC) is a chronic progressive disease of the liver and biliary tract causing cholestasis, fibrosis, and strictures in intra and extrahepatic bile ducts. Patients are often asymptomatic, but as the disease progress, complications occur and include: recurrent cholangitis, portal hypertension, cirrhosis of the biliary tract, end-stage liver disease, and hepatobiliary malignancies, namely cholangiocarcinoma. Within the entity of PSC, there are two distinct variants: small duct PSC and large duct PSC. Here we present a case of small duct PSC presenting atypically with chronic portal vein thrombosis and a hilar mass. CASE DESCRIPTION/METHODS: 36- year old Pakistani man presented with right upper quadrant abdominal pain, jaundice, and fever. He reported a history of chronic abdominal pain and recurrent jaundice, as well as chronic portal vein thrombosis (PVT) since childhood. The patient was recently hospitalized in another institute for the same complaint for which he had a Computerized tomography (CT) of the abdomen that revealed marked splenomegaly together with evidence of portal vein occlusion with cavernous transformation as well as Intrahepatic biliary ductal dilation with a transition in the common hepatic duct and a hilar mass. The patient underwent endoscopic retrograde cholangiography (ERC) with biopsies obtained through cholangioscopy that were unremarkable. Liver biopsy showed findings consistent with primary sclerosing cholangitis with acute cholangitis and changes secondary to portal vein thrombosis. DISCUSSION: Primary sclerosing cholangitis is a chronic, incurable disease in which the liver and biliary tract become fibrosed, and strictures form in the intra and extrahepatic biliary ducts causing obstruction, portal hypertension, and eventual liver cirrhosis necessitating a liver transplant. MRC is the most frequently used diagnostic tool due to its high specificity and sensitivity. Although ERC is more sensitive, there are added risks and complications (i.e., pancreatitis and bacterial cholangitis) with this technique. When ERC is performed, findings typically include multifocal short annular strictures, which create a "beaded" pattern. Although most patients are shown to have intra and extrahepatic bile duct involvement, a small subset presents with only intra or extrahepatic bile duct involvement. Only a few small duct PSC cases were reported in the literature, and it rarely presents with an inflammatory mass as well as PVT, as in our case.Figure 1.: Portal fibrosis with mild to focal moderate ductular reaction, accompanied by neutrophils.Figure 2.: A Coronal contrast-enhanced CT image through the abdomen shows intrahepatic beading (red arrow) with intervening sites of alternating strictures, mildly dilated, and normal ducts. There is compensatory hypertrophy of the right lobe and caudate lobe of the liver (green arrows).Figure 3.: A Coronal MRCP Image through the liver shows multiple multifocal diffuse intrahepatic and extrahepatic strictures (red arrows) and severely dilated intrahepatic ducts (blue arrows), with a branching-tree appearance. There is extrahepatic beading with intervening sites of a normal, narrow stricture (long red arrow), and mildly dilated extrahepatic ducts (yellow arrow).

S0395 Outcomes of Benign Corrosive Esophageal Stricture Dilation—Single Center Experience

INTRODUCTION: The strictures secondary to caustic ingestion is a debilitating condition causing long-term nutritional challenges. This retrospective study investigates the outcomes of endoscopic dilation in patients with benign esophageal strictures secondary to corrosive ingestion. METHODS: A retrospective study that included patients with esophageal strictures due to caustic injury under follow-up was performed at a tertiary care center. These patients at the centre underwent endoscopic dilation by both Endoscopic Balloon Dilation (EBD) and Gilliard Savary (GS) dilators based on endoscopist comfort (P.K.). Symptomatic relief within 2 months of intervention was considered a successful response. RESULTS: The study included 39 patients including 31 patients with acid ingestion and 8 with alkali ingestion (Figure 1). Of patients with acid ingestion, 32.3% (10/31) underwent EBD and 67.7% (21/39) underwent GSD with only 50% (5/10) and 38.1% (8/21) respectively having symptom relief. Of patients with alkali ingestion, 50% (4/8) underwent EBD and 50% (4/8) underwent GSD with 75% (3/4) and 50% (2/4) respectively having symptom relief. Irrespective of caustic etiology, the composite success for EBD and GSD sub-groups were 61.5% and 38.5% respectively. Short stricture length was associated with successful outcomes among patients with acid ingestion (P = .003) but not among patients with alkali ingestion. Patients with failed outcomes had higher percentages of grade 2B and 3 mucosal injury at time of initial caustic exposure and warranted repeated endoscopic dilations for symptom management. This however did not reach significance in patients with either alkali (P = 0.19) or acid ingestion (likelihood ratio; P = 0.14). In the study population, seven patients had concomitant stomach involvement with three (7.7%) developing gastric outlet obstruction (GOO), all of whom underwent surgical intervention. Other than GOO, no other sequelae like achlorhydria, mucosal metaplasia, carcinoma or protein losing enteropathy were diagnosed during follow up. CONCLUSION: Overall success of endoscopic dilation for caustic esophageal stricture is limited and newer modalities like stent placement or endoscopic incision therapy may play a role in management of refractory strictures. Primary prevention of such injuries should be the preferred approach in managing this public health issue.Figure 1.: Flow diagram describing the endoscopic dilations among the patients with benign strictures.

Comparative Study Between Outcomes of Early Primary Endoscopic Realignment Versus Suprapubic Cystostomy With Delayed Reconstruction in the Management of Posterior Urethral Injury

Objectives: To compare the outcomes of early primary endoscopic realignment and suprapubic cystostomy with the outcomes of delayed reconstruction in the management of posterior urethral injury. Methods: This is a quasi-experimental prospective study Conducted in the Urology department Dhaka medical college and hospital from January 2009 to December 2010. Atotal of 60 consecutive patients were selected for this study and inclusion criteria, male patients and age 18years and above. Posterior urethral injury resulting in distraction defect and urethral injury with pelvic fracture. Group-A, 28 patients underwent early primary endoscopic realignment after initial suprapubic urinary diversion and Group-B, 32 patients underwent primary suprapubic urinary diversion and delayed urethral reconstruction after 3 months of injury. Results: After procedure 21(75%) out of 28 patients in Group-A developed stricture 12(42.9%) had simple and short segment stricture and 7(32.1%) had simple and long segment stricture, while in Group-B 12(37.5%) patients developed simple and short segment stricture. All of the patients in Group-A had minimum blood loss during operation. While, majority (81.3%) of patients in Group-B had a history of maximum blood loss. None of the patients in Group-A developed incontinence throughout the observations period (from removal of catheter to 9 months), while 15.6% of the patients in Group-B had incontinence at removal of catheter after anastomotic urethroplasty and at 3 month. The incontinence further increased to 18.8% at 6 and 9 months. Complaints of impotence were significantly less in Group-A than that in Group-B throughout the period of observation (14.3% vs. 37.5%, p = 0.042; 14.3% vs. 37.5%, p = 0.042 and 14.3% vs. 37.5%, p = 0.042). At removal of urethral catheter, stricture formation was observed and statistically there was no difference in Group-A and Group-B (14.3% vs. 21.9% in Group-B, p = 0.448). At month 3, stricture formation was significantly higher in Group-A than that in Group-B (42.9% vs. 15.6%, p = 0.020). At month 6, about 18% of patients in Group-A had stricture, but none of patients in Group-B was found so (p = 0.018). Conclusions: Early primary endoscopic realignment of traumatic posterior urethral disruption is a simple, less traumatic, safe, and rapid technique. It provides a low morbidity and less postoperative complications. Though recurrent stricture formation is higher but the strictures are simple and short and amenable to be corrected endoscopically. It may be considered as initial therapy in the management of posterior urethral distraction defect over suprapubic cystostomy with delayed reconstruction. Bangladesh Journal of Urology, Vol. 17, No. 1, Jan 2014 p.29-35

VeSpAR trial: a randomized controlled trial comparing vessel-sparing anastomotic repair and transecting anastomotic repair in isolated short bulbar urethral strictures

BackgroundVessel-sparing anastomotic repair (vsAR) has been developed as a less traumatic alternative to transecting anastomotic repair (tAR) to treat isolated short bulbar urethral strictures. This vessel-sparing technique could result in improved functional outcomes without jeopardizing the excellent surgical outcome after (transecting) anastomotic repair. The purpose of this study is to directly compare vsAR and tAR for both surgical and functional outcomes.MethodsThis trial is a prospective, interventional, multi-center, single-blinded, 1:1 randomized, controlled, non-inferiority, phase II trial. Sample size calculation resulted in a required sample size of 100 patients (50 patients per arm). Trial participants will be randomized by an independent third party using a computer-based random sequence generator with permuted blocks of variable size. The primary objective of this trial is to show that vsAR is non-inferior to tAR in terms of failure-free survival after 24 months of follow-up, considering a non-inferiority limit of 10%. Failure is defined as the inability to pass a 16-Fr flexible cystoscope through the reconstructed area without damaging the urethral mucosa. Secondary end-points mainly include differences in postoperative complications and changes in functional outcome parameters, which will be assessed with validated questionnaires. All participants are scheduled for follow-up at 3, 12, and 24 months postoperatively.DiscussionThis trial will provide level Ib evidence about the differences in both surgical and functional outcome between vsAR and tAR, which may importantly scape the future of bulbar urethral reconstruction. Depending on the trial results, this phase II trial may generate a larger phase III trial with more statistical power and a lower alpha value.Trial registrationThis trial is registered at clinicaltrials.gov (NCT03572348) and in the Belgian Clinical Trial Registry (B670201837335). The trial was registered prospectively. Registered on 28 June 2018.

Endoscopic stricturotomy for a refractory complex esophageal stricture.

Benign esophageal strictures present a frequent endoscopic challenge [1] [2] [3] [4]. Endoscopic stricturotomy using an electrocautery technique is effective for simple or short strictures (< 1 cm) [5]; however, there are few reports of its application for complex or long (> 1 cm) esophageal strictures.

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BackgroundCaustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not. MethodsWe retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program. ResultsThe patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program. ConclusionA length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures. Level of EvidenceLevel II.

Iso-peristaltic colonic loop interposition for the treatment of benign oesophageal stricture: a case report with review of literature

Corrosive oesophageal strictures are a common and debilitating condition in India. Patients generally have dysphagia, cachexia, drooling of saliva, aspiration pneumonitis, and lung abscess. Though endoscopic dilatations are done in cases of short segment strictures, surgical oesophageal by pass is the permanent solution for this condition. A 24 years female presented with complaints of dysphagia and cachexia, due to corrosive stricture. Patient had a history of poison ingestion 2 years back. Intra-operatively stricturous mucosa is excised and an iso peristaltic colonic loop by pass was carried out. Post operatively patient had a complication of anastomotic leak which was treated conservatively, excepting which patient is symptom free and gaining weight on a follow up period of 1 year. Ever since first described by Kelling and Vuillet in 1911 colonic interposition is mostly used around the globe for oesophageal bypass in both benign and malignant conditions. Stomach and jejunum are the other conduits that can be used. Iso peristaltic loop is mostly used to reduce the incidence of reflux. Right colon or transverse colon graft based on the mid colic artery or the left colic artery owing to the reliable blood supply and less diameter. This procedure has a high complication rate of around 27% most of which are due to the vascular comprise of the graft.

446 - Comparison of a sheath dilator and cold knife internal urethrotomy for the treatment of male short segment urethral stricture

446 - Comparison of a sheath dilator and cold knife internal urethrotomy for the treatment of male short segment urethral stricture

Трансуретральная эндопиелотомия с помощью тулиевого волоконного лазера

Transurethral endopyelotomy is an alternative treatment method for short stricture of ureteropelvic junction (UPJ). to evaluate the efficiency of transurethral thulium laser endopyelotomy. A total of 94 patients with UPJ obstruction during the period from December 2016 to December 2018 were prospectively enrolled in the study. Pelvic size did not exceed 3 cm in 31 patients, and it was in the range from 3 to 4 cm and more than 4 cm in 35 and 28 cases, respectively. Depending on the treatment, all patients were divided into 2 groups. The main group included 48 patients who underwent retrograde thulium fiber laser endopyelotomy. In the control group (n = 46), patients underwent Anderson-Hynes laparoscopic pyeloplasty. In the main group, there were significantly more patients with more preserved ipsilateral kidney function, with short (less than 1 cm) and recurrent UPJ strictures and less severe hydronephrosis compared to the control group. In addition, there were no patients with crossing vessel in the main group. Postoperatively, an internal stent of 6-8 Fr was put in all patients for a period of 6-8 weeks. After stent removal, all patients underwent a follow-up examination, including an ultrasound examination and, if pelvic size was more than 3 cm, contrast-enhanced CT-urography was performed. In all patients, after stent removal, a decrease in the pelvic size was noted. The operation time in the main and control group was 24+/-14 minutes and 82+/-26 minutes, respectively. In all cases, ureteropyeloscopy was performed prior to laparoscopy to determine the exact length of stricture and to exclude narrowing of other parts of the ureter. After follow-up of 24 months, an examination in 36 patients of the main group and 29 patients of the control group was performed. There was 1 recurrence after laparoscopic pyeloplasty and 1 recurrence after endopyelotomy. In other patients of both groups, there were neither stricture, nor impaired renal function. The first experience of using a thulium fiber laser for transurethral endoscopic treatment of UPJ obstruction is presented in the article. Indications for the transurethral thulium endopyelotomy are the presence of primary or secondary UPJ obstruction (with a decrease in kidney function by no more than 40%), length of up to 1 cm, absence of an additional vessel and pelvic dilatation of no more than 4 cm.