ORIGINAL ARTICLE

Results of End to End Anastomotic Uethroplasty In Adult

Patients of Stricture Urethera
ARIF QAYYUM, MUHAMMAD KALEEM, SAFDAR HUSSAIN BALOCH, SOHAIL HASSAN, ADIL KHURSHEED

ABSTRACT
Objective: To see the results of stricture excision and end to end anastomosis of urethra after
spatulation in patients with blind urethral stricture.
Patients and methods: This study was carried out from September 2006 to November 2010 in the
Department of Urology, Nawaz Sharif Social Security Teaching Hospital Lahore. Twenty male patients,
age above 16 years having blind stricture of bulbar or membranous urethra equal to or less than 2cm
were included in the study. Patients with stricture >2cm, patients of stricture with neurogenic bladder
and patients with malignant strictures were excluded from the study. Median follow-up was 2.5 years
and minimum follow-up was one year.
Results: Twenty patients of blind urethral stricture with age range 20-44 years were treated. There was
good result in 14 patients (70%), fair in 4 patients (20%) and in 2 patients (10%) urethroplasty failed.
Overall success rate was 90%.
Conclusion: Excellent results can be expected from anastomotic urethroplasty in patients with blind
stricture of bulbar or membranous urethra.
Key words: Stricture, Urethra, End to end urethroplasty

INTRODUCTION PATIENTS AND METHODS

Urethral stricture is a narrowing of the calibre of This prospective study was conducted at the
urethra caused by the presence of a scar tissue Department of Urology, Nawaz Sharif Social Security
consequent on infection or injury.1 Urethral dilatation Teaching Hospital, Lahore from September, 2006 to
with metal or wooden dilators has been practised November, 2010 on twenty patients of completely
since ancient time.2 It has been the only treatment for obliterating stricture (blind stricture) of bulbar or
centuries starting from 600 BC in India.3 At the end of membranous urethra. The study was limited to male
17th century, an operation called “La Buttoniere” was patients with age above 16 years. Patients having
devised in France which consisted of creating a stricture ≤2cm in size were included in the study.
button hole in the dilated urethra proximal to Patients with malignant stricture, stricture more than
stricture.4 In 18th century, Civiale and Otitis started 2 cm in size or patients of stricture with neurogenic
blind internal urethrotomy but the results were poor.3 bladder were excluded from the study. Any case in
The introduction of chloroform anaesthesia in 1857 which end to end anastomosis could not be
and knowledge of aseptic and anti-septic measures accomplished without grafting was also excluded
ten years later, gave a confidence to the surgeon. At from the study. Twenty patients who satisfied the
the end of 19th century, excision of stricture and end inclusion criteria presented during study period were
to end anastomosis of urethra was performed but due evaluated by detailed history, history of previous
to frequent failure, the technique was abandoned. treatment for stricture, physical examination and
Thereafter the treatment continued to be periodic investigations. Investigations carried out included
urethral dilatation, blind internal urethrotomy, perineal complete blood count, urine routine examination,
urethrostomy and the only addition was suprapubic blood urea, serum creatinine, screening for hepatitis
5 th
cystostomy to divert urine. In the second half of 20 B and C, blood grouping and cross-matching, ECG,
century, famous English urethrologist Richard Turner X-ray chest, retrograde urethrogram and antigrade
Warwick revitalized urethroplasty based on the cystourethrogram in selected cases. Surgery was
excision of stricture and primary urethral anastomosis performed under general or spinal anaesthesia. After
6
with good results. In the present study, we have anaesthesia patient was placed in exaggerated
evaluated the results of urethroplasty based on lithotomy position. Midline incision in the perineum
excision of stricture and anastomosis of normal was applied. Incision was deepened to cut
urethral ends after spatulation in patients with blind subcutaneous fat and bulbocavernous muscle in the
urethral stricture of bulbar or membranous urethra. midline to expose the bulbar urethra. A metallic
---------------------------------------------------------------------- bougie was passed per urethra upto the stricture to
Department of Urology, Nawaz Sharif Social Security Hospital, facilitate the dissection. A window was created
Lahoree
Correspondence to Dr. Arif Qayyum Email:
between the urethra and deeper structure, and
[email protected] urethra was dissected away from the corpora

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Results of End to End Anastomotic Uethroplasty In Adult Patients of Stricture Urethera

cavernosa distally upto penoscrotal junction. impotent before surgery and out of remaining 19
Proximally dissection was carried upto the stricture cases, 1 patient (5.3%) developed impotence (Table
and then more proximally approaching the normal 5). In 14 patients (70%) results were good, 4 patients
part of urethra. In bulbar stricture at this point (20%) results were fair and 2 patients (10%) results
stricture was excised. Both normal ends were were poor. Overall success rate was 90% (Table 6).
spatulated and four interrupted sutures of 4/o
Table 3: Location of stricture
polyglycolic acid were applied over Foly catheter 18
Location n= %age
Fr. Urethra was transected at the stricture Bulbar urethra 14 70.0
level.Bougie was passed into the prostatic urethra Membranous Urethra 6 30.0
through cystostomy opening and adjusted in such a
position that the tip of the bougie was projected into Table 4: Previous history of treatment for stricture
the perineum .Incision was made at the projecting tip History of treatment n= %age
of bougie to create an opening into the proximal Urethroplasty 2 10.0
urethra. Optical internal urethrotomy 16 80.0
Urethral dilatation 20 100.0
RESULTS
Table 5: Frequency of complications
Twenty patients with blind bulbar or membranous Complication =n %age
urethral stricture were included in the study. Age of Wound infection 2 10.0
the patients ranged between 20-44 years. Mean age Re-stricture 2 10.0
was 32 years (Table 1). In majority of our cases Impotence 1 5.3
cause of the stricture was trauma. Eleven patients Incontinence - -
(55%) had history of fall astride and direct hit to the Deep venous thrombosis - -
perineum, six patients (30%) had road traffic accident Table 6: Results of end to end anastomotic uethroplasty
with pelvic fracture and injury to the posterior urethra. Result n= %age
Two patients (10%) had infective strictures and in Good 14 70.0
one patient (5%) cause of stricture could not be Fair 4 20.0
ascertained (Table 2). Poor 2 10.0
Table 1: Age of the patients at the time of presentation
Age (Years) n= %age
DISCUSSION
20 – 29 10 50.0 Urethral stricture remains a difficult surgical problem
30 – 39 4 20.0 for men since known medical history.7 For many
40 – 44 6 30.0 centuries there was not much difference among the
Table 2: Etiology treatment of urethral stricture of any aetiology. At
Etiology n= %age present different treatment options are periodic
Fall astride 11 55.0 urethral dilatation, optical internal urethrotomy and
Road Traffic accident 6 30.0 urethroplasty with or without grafting. After the
Infective 2 10.0 introduction of optical system by Hopkins in 1960 and
Unknown 1 5.0 later Sachse in 1970, optical internal urethrotomy has
been widely practised. It is easy to use and has low
In 14 patients (70%) stricture was involving the bulbar rate of complications.8 This resulted in continuing
urethra and in 6 patients (30%) stricture was in the debate about how best to treat urethral stricture,
membranous urethra (Table 3). All patients had especially as urologist tend to choose the simplest
previous history of treatment for stricture Sixteen and least invasive solution10. However, the results of
patients (80%) had history of internal urethrotomy. different series raised doubt about the efficacy of this
Two patients (10%) had history of urethroplasty. All procedure and mentioned high recurrence rate
patients (100%) had history of urethral dilatation approaching 80% in five years.10-15 Optical internal
(Table 4). In all patients, stricture was excised and urethrotomy is only curative for short stricture (<1 cm)
overlapping end to end anastomosis of urethra with that are not having significant spongiofibrosis.11 For
good spatulation was performed. Operative time was all other strictures it is only a palliative management.
1
between ninety minutes to one hundred and eighty Moreover its role is very limited in the management of
minutes. Blood transfusion was required in six (30%) blind urethral stricture. The standard treatment of
patients. Wound infection was developed in two blind stricture of bulbar and membranous urethra is
(10%) patients which was managed successfully. excision of stricture and overlapping anastomosis of
Minimum follow-up period was one year. Mean the spatulated urethral ends3 This anastomosis is
follow-up was 2.5 years. Four (20%)patients technically demanding because of narrow space and
developed stricture at the site of anastomosis. They difficult position. For good results, segment of fibrosis
were managed by optical internal urethrotomy and should be totally excised and urethral ends should be
two of them were put on CISC. One patient was

182 P J M H S VOL.5 NO.1 JAN – MAR 2011

 Arif Qayyum, Muhammad Kaleem, Safdar Hussain Baloch et al

adequately spatulated to permit bougie of 28/32 results in patients with blind stricture of bulbar or
easily. This spatulation is important because any membranous urethra less than 2 cm.
contraction of anastomosis after surgery would not
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