Background
Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised. The extent and quality of evidence guiding treatment choice for this condition are uncertain.  

Objectives
To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.  

Search methods
We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles.

Selection criteria
We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

Data collection and analysis
Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5).

Main results
Two randomised trials were identified. One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size.

Authors' conclusions
There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

What's known on the subject? and What does the study add?

The incidence of specific aetiologies of urethral stricture disease has been reported from a variety of series throughout the world.
Most reported urethral stricture series are from single institutions or from a specific region of the world. We provide a multi-centred series to compare aetiologic incidence between differing regional populations.




Objective

To better understand distinct regional patterns in urethral stricture aetiology and location among distinct regional populations.




Patients and Methods

Data on 2589 patients who underwent urethroplasty from 2000 to 2011 were collected retrospectively from three clinical sites, including 1646 patients from Italy, 715 from India and 228 from the USA.
Data from all sites were single-surgeon series. As the data from the Italian and US cohorts were similar in aetiology, location and demographics, we combined these data to form group 1, and compared this group with men in the Indian cohort, group 2.
Age, stricture site and primary stricture aetiology were identified for each patient. Stricture site and primary aetiology were determined by the treating surgeon. Primary aetiology was defined as iatrogenic, trauma including pelvic-fracture-related urethral injury (PFUI), lichen sclerosus (LS), infectious, congenital, or unknown.




Results

There were more penile strictures (27 vs 5%) and fewer posterior urethral stenoses (9 vs 34%) in group 1.
There were more iatrogenic strictures identified in group 1 (35 vs 16%). When comparing the aetiology of iatrogenic strictures alone, more strictures in group 1 were attributable to failed hypospadias repair (49 vs 16%).
More patients presented with LS (22 vs 7%) and external trauma (36 vs 16%) in group 2.
Prevalence of strictures of infectious aetiology was low (1%) with similar proportions between the two groups.




Conclusions

We have shown that significant regional differences in stricture aetiology exist in a large multicentre cohort study. Group 1 had a higher proportion of penile strictures, largely owing to more iatrogenic strictures and, in particular, failed hypospadias repair. Group 2 had a higher proportion of PFUI and LS-associated urethal stricture.
Identified infection-related urethral stricture was rare in all cohorts.
Significant regional differences in stricture aetiology exist and should be considered when analysing international outcomes after urethroplasty. These data may also help the development of international disease prevention and treatment strategies.

A geographic analysis of male urethral stricture aetiology and location

Introduction: Different types of grafts have been described in urethral reconstruction (UR), with penile skin graft (PSG) and buccal mucosa graft (BMG) as the most frequently used ones. It still remains unclear whether one graft is superior in terms of success when compared to the other. Material and Methods: A systematic review of the literature was performed searching the MEDLINE database with the following search strategy: ‘urethroplasty’ AND ‘penile skin’/ ‘urethroplasty’ AND ‘buccal mucosa’. 266 and 144 records were retrieved for urethroplasty with PSG and BMG, respectively. These records were reviewed to identify papers where PSG and BMG were used in UR and where individualized data on success were available within the same series. Results: 18 papers were found eligible for further analysis. In total, 428 and 483 patients were respectively treated with PSG or BMG. If available, follow-up duration was 64.1 versus 42.1 months (p Conclusions: Success of UR using BMG is significantly better compared to PSG. Results might be seriously biased by a longer follow-up duration and stricture length for PSG compared to BMG.

/pdf/urethral-reconstruction-using-buccal-mucosa-or-penile-skin-2j4a0d5qfn.pdf

Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis.

Urethral stricture disease is relatively common and is associated with a significant financial cost and potentially debilitating outcomes. Understanding urethral stricture epidemiology is important to identify risk factors associated with the etiology or progression of the disease. This understanding may lead to better treatments and preventative measures that could ameliorate disease severity, produce better health outcomes, and reduce expenditures. We performed a comprehensive review of urethral stricture disease based on available published case series, identified gaps in knowledge of this disease, and recommend future directions for research.

/pdf/epidemiology-of-urethral-strictures-31662aruwp.pdf

Epidemiology of urethral strictures.

Introduction: Urethral strictures remain a reconstructive dilemma, due to high incidence of recurrence and less than satisfactory outcomes. Even experienced surgeons following strict surgical principles have not achieved optimal results, leading us to think whether the etiology of strictures dictate the outcome . We evaluated this “cause-effect” relationship highlighting the significance of the etiology on the overall prognosis of urethral strictures. Materials and Methods: A total of 302 males with urethral strictures were assessed (both retrospectively and prospectively) over a period of ten years. The preoperative evaluation was performed by retrograde urethrogram, urethrosonogram, and uroflowmetry and categorized, based on etiology: a) as post traumatic, b) post infective, c) iatrogenic or d) unknown. Traumatic strictures were subjected to pelvic X-ray and sub-categorized into grades A, B and C, following the TILE classification. Patients were operated; with tunica albuginea urethroplasty for anterior strictures and U shape prostato-bulbar anastomosis for posterior strictures. Results: Traumatic strictures accounted for 54% of cases. 127 of the 302 patients were treated using Tunica Albuginea Urethroplasty, while U shaped Prostatobulbar Anastomosis was performed on others. Post traumatic strictures had best outcome whereas post infective strictures had the worse outcome. Among strictures following pelvic fractures, TILE grades A and B had a better post operative course as compared to TILE C. Overall complication rate was 13.24%. Conclusion: Our study demonstrated that etiology of urethral strictures may play a vital role for the overall prognosis of urethral strictures. Clinical Urology

/pdf/comprehensive-analysis-of-etiology-on-the-prognosis-of-33ds4v87qe.pdf

Comprehensive analysis of etiology on the prognosis of urethral strictures

Prognosis of urethral strictures following pelvic fracture urethral distraction defects--a single centre study.

Context: Scoring systems have been an important tool of clinical decision making in medicine. As scoring systems like Glasgow Coma scale have made a revolutionary change in stratifying the patient, in particular, clinical scenario. Wiegand et al. in 2012 proposed UREThRAL Score a novel method to quantify anterior urethral stricture. Aims: The aim was to validate urethral stricture score (USS) for evaluating the efficacy of operative procedures. Settings and Design: Study was done in a retrospective manner and includes patients operated for anterior urethral stricture by a single surgeon in tertiary care center over the period of 2008–2014. Subjects and Methods: A total of 57 cases were included in this study who met the inclusion criteria, of these cases 7 underwent excision and primary anastomosis (EPA), 20 underwent preputial flap urethroplasty (PFUP), 22 underwent tunica albuginea urethroplasty (TAU), and rest 8 underwent scrotal flap urethroplasty (SFUP). Procedures were assigned different complexity level, and USS was compared with the particular procedure to see the relation between both. Statistical Analysis Used: Data were analyzed using ANOVA on SPSS software. Results: Mean USS for EPA, PFUP, TAU, and SFUP in our study group was found to be 6.57, 8.95, 9.00, and 10.00, respectively, with an overall USS of 9.03, with a standard deviation of 1.56. USS was significantly associated with complexity. Conclusions: Mean USS increased with increase in surgical complexity indicating that higher USS correlates with more complex surgery. Strongest association between complexity and the individual parameter was found with location and length.

Evaluating efficacy of various operative procedures done in anterior urethral stricture using urethral stricture score

Aim: The aim of this study is to identify the common urinary problems in Indian females, their etiology and symtomatology. Material and Methods: This is a prospective epidemiological study of 703 female patients with urinary problems, who attended the surgery and gynecology OPD (outpatient department) in our institution which is a tertiary referral centre in central India. Result: 58% of patients were middle age (31 - 55) yrs. Burning micturition was the most common urinary complain (607 patients) followed by increased frequency of micturition (309 patients). 68% females took months or even years to take first consultation after appearance of their symptoms. 14% percent of patients suffered from urinary incontinence (stress, urge and mixed). 86% of women had education level below fifth standard. About 58% of females gave birth to 3 or more than 3 issues. About 254 (36%) patients had one or more unassisted delivery at home. Thirty eight percent of patients still remained undiagnosed. More than 50% of undiagnosed females lie in middle age group. 68% of undiagnosed patients took consultation months or years after their symptoms first appeared. Irritative symptoms are the most common presenting complains of these undiagnosed patients followed by pain in abdomen. Around 60% of patients had history of either mental distress, domestic violence or any neuropschiatric disease. This study only gives us an idea about the urinary problems faced by females and their probable causative factors. Many more studies need to be done involving multidisciplinary approach in order to benefit this section of our society.

/pdf/study-of-common-urinary-problems-of-females-at-a-government-4v522r2b3i.pdf

Fareed Khan

Papers

Comprehensive analysis of etiology on the prognosis of urethral strictures

Prognosis of urethral strictures following pelvic fracture urethral distraction defects--a single centre study.

Evaluating efficacy of various operative procedures done in anterior urethral stricture using urethral stricture score

Study of Common Urinary Problems of Females at a Government Hospital in Central India