Vidyadhar P Kelkar^1*, Aashish Ramesh Chavan², Sachin Kanakapur^3, Boda Raju⁴

¹Associate Professor, ²Assistant Professor, ^3,4Junior Resident, Department of General Surgery, Dr Shankarrao Chavan Government Medical College Vishnupuri Nanded, Maharashtra. INDIA.

Email: drvidu24@gmail.com, aashish.chavan85@gmail.com, sachinkanakapur16@gmail.com, bodaraju2063@gmail.com

Table 1: Age wise Distribution of patients according to sex.

In this current study the causes of urethral stricture in most of the patients were infections (30%) and trauma (50%). Followed by iatrogenic / instrumentation (10%). Balanitis xerotica obliterans / spongiofibrosis (10%) was also seen in some of the patients.

Table 2: Etiology distribution

In current study 80 % patients presented with the symptom of sense of incomplete evacuation of urine other symptoms were straining and dribbling during micturition pain, fever and hematuria. In current study 11 patients are vegetarian diet [22%] and 39 patient have non-vegetarian diet [78%]. 46 patients (92%) normal KFT profile and most of the patients had hemoglobin more than or equal to 10 gm%. (96%)

Table 3: Symptoms and diet distribution with percentage

All the patients are ope4ated under Local / Spinal / Intravenous sedation anesthesia. Most of the patients requiring urethral dilatation and visual Internal Urethrotomy were operated under local anaesthesia and intravenous sedition (84%). Remaining 16% of patients who underwent BMG urethroplasty were given spinal anaesthesia. Most patients are treated by the serial urethral dilatation (58%). Other procedures were visual internal urethrotomy (VIU) (26%) and surgery including buccal mucosal graft (BMG) urethroplasty (16%).

Post-operative complications affect the hospital stays of patients. In current study, 42 patients including 31 male and 11 females stayed for less than 5 days while only 8 male patients stayed for more than 5 days.

Table 4: Operative characteristics

In the study, out of 50 patients,1 female and 5 males noted to require 30 min while 6 males and 4 females required 45 min for operation. 60 min time was utilized for the surgery of 5 female and 23 males

Table 5: Time required for operation

In current study intraoperative complications occurred are mucosal injury and urethral bleeding and poor vision during cystoscopy. Bleeding was managed by normal saline irrigation during the surgery. No patient had urethral perforation. Postoperatively out of 50 patients 7 patients experienced Pain [14%] and 43 patients doesn‘t have pain in postoperative period. [86%]. About 8 patients have fever in postoperative period [16%] and hematuria is seen in 18 patients [36%]

Table 6: complications

DISCUSSION

Almost all urethral strictures for which a cause can be identified are acquired8,9. The largest group (45%) are iatrogenic and result from urethral manipulations (traumatic indwelling catheter, transurethral interventions, correction of hypospadias, prostatectomy, brachytherapy).^7,8 Another cause of urethral stricture is traumatic urethral rupture associated with pelvic fracture. Bacterial urethritis can also lead to stricture (around 20% of cases); classically, these are cases of untreated gonorrhea. Another inflammatory disease associated with (distal) urethral stricture is balanitis xerotica obliterans, a chronic inflammatory disease whose exact etiology is unknown.⁹ Around 30% of urethral strictures are idiopathic8. In these cases the most likely trigger is considered to be some forgotten minor trauma that occurred a long time in the past (e.g., perineal injury while riding a bicycle).¹⁰ In present study, gender distribution in the current study was 78% males and 22% females. Male to female ratio in this study was 3.55:1. In study done by O.N. Ekeke et.al,¹¹ there was a male preponderance with a male-to-female ratio 31.3:1 in 194 patients. A study done by Nyongole Obadia Venance¹² found that out of 111 patients, 39% were above 60 years, while 27% were patients in age group 45-60years and mean age of the patients was 48 ± 9.24 years. Similar findings were noted in present study. In the present study, Most of the patients are treated by the serial urethral dilatation (58%). Followed by visual internal urethrotomy (26%) and urethroplasty (16%). A study done by Nyongole Obadia Venance¹², DVIU constituted 64% of the provided treatments followed by primary (one stage) urethroplasty (26%) then multistage urethroplasty (6%), while dilatation accounted 2%. Dr. K. Subramaniyan¹³ noted that out of 40 patients, 4 underwent Optical internal urethrotomy, 30 underwent Perineal end to end urethroplasty and 6 patients underwent transpubic urethroplasty. In study by O.N. Ekeke et.al,¹¹ urethroplasty (48.98%) was most common procedure followed by direct vision internal urethrotomy (DVIU) (31.44%), serial urethral dilatation (19.07%) had and 1 patient with malignant urethral stricture had total penectomy. In current study intraoperative complications occurred are mucosal injury and urethral bleeding and poor vision during cystoscopy. Bleeding occurred was overcome by normal saline irrigation during the surgery. No patient had urethral perforation. K. Subramaniyan¹³ 2 patients had associated bladder injuries, repaired and SPC diversion was done. 2 patients had only urethral injuries with huge retropubic pelvic hematoma, , managed by only SPC diversion and later planned for definitive repair. In present study postoperatively out of 50 patients 7 patients experienced Pain [14%] and 43 patients doesn‘t have pain in postoperative period. [86%]. About 8 patients have fever in postoperative period [16%] and hematuria is seen in 18 patients [36%] And no patient have reported for post- operative stricture formation. O.N. Ekeke et.al,¹¹ noted that 21.64% patients had various types of post-operative complications. 11.3% had re-stricture and 3.6 % patients (epididymoorchitis in 2 patients who had DVIU while 5 patients had surgical site infection following urethroplasty). Bleeding occurred in 6.70% patients (in 4.12% patients who had DVIU). Also 4 patients had bleeding after urethral dilatation though these were minimal and 4 patients had re-stricture due to poor compliance with dilatation schedule. Post-operative complications affect the hospital stays of patients. In current study, 42 patients including 31 male and 8 females stayed for less than 5 days while only 8 male patients stayed for more than 5 days. Thus, the data demonstrated that urethral dilatation and the Visual internal urethrotomy is good option to minimize the operation time and also the post-operative hospital stay of these patients than the open surgery. Most patients can be discharged from the hospital on the second or third postoperative day with the indwelling catheter in place. At that moment, instructions for wound care should be provided, which are specifically important in patients with a perineal wound.¹⁴ K.Subramaniyan¹³ noted 50% success rate in Optical internal urethrotomy, 83.33% success rate in Perineal end to end urethroplasty and 83.33% success rate in Transpubic urethroplasty. According to MM Koratim et al.¹⁵ the success rate of perineal urethroplasty was 95%. For transpubic urethroplasty the success rate was 95- 98%. DVIU represents the basis of endoscopically treating urethral strictures, involves an intervention which is guided by the direct vision of the surgeon. The sole indication for DVIU is a primary, isolated, short (<1.5 cm), bulbar urethral stricture.^16,17 DVIU for primary urethral strictures <1.5 cm entails the best surgical outcome, with success rates ranging up to 80% in case of strictures <1 cm¹⁸ Limitations of present study were small sample size and short follow up. Larger sample studies with adequate follow-up are required to confirm findings.

CONCLUSION

Trauma and infections were the leading cause of urethral stricture. Visual Internal Urethrotomy and urethroplasty were the mainstay of treatment with satisfactory outcome. Direct visual internal urethrotomy is relatively new, and has been gaining acceptance for single, short segment urethral stricture. The use of uroflowmetry and other imaging studies have provided objective assessment of the success rate.

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