The management of anterior inflammatory urethral strictures
Claassen, Frederik Martinus
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Introduction: Inflammatory urethral stricture disease secondary to gonococcal urethritis is a major problem among male patients presenting with urethral strictures at urology clinics in central South Africa. The incidence of gonococcal urethritis is reported as being as high as 68% by the health authorities in central South Africa. These patients present with a variety of clinical scenarios, which vary between difficulty in voiding to necrotising fasciitis, which can be fatal. The exact incidence of urethral stricture disease is not known in the general population of central South Africa. The incidence of infective gonococcal related urethral strictures presents in 81% of patients with urethral strictures visiting the urology clinic. Patients often present with palpable urethral fibrosis and diseased perinea, which increase the risk for treatment failures. Literature regarding the treatment of infective urethral strictures is exceedingly limited. The literature reports typically focus on traumatic and iatrogenic urethral strictures. An additional hindrance, which makes research challenging, is the complexity of the anterior male urethra, which differs throughout its length in urethral lumen diameter and spongiosum thickness. Follow-up that exceeds five to ten years is necessary to determine the success rates of procedures because procedures do deteriorate over time. The necessity for long term follow-up made this research demanding and data of patients with urethral stricture disease who were treated at the Universitas Academic Hospital between 2005 and 2010 were collected. No existing database existed for these patients, hence the clinic files, radiology reports and the hospital records regarding the patients’ visits were collected and analysed. Procedure failure was defined as when the patient presented with symptoms suggestive of stricture recurrence, which necessitated a secondary procedure to treat the stricture. The primary aim of this research was to develop a treatment protocol for infective urethral strictures, which can be implemented at the teaching hospitals in central South Africa. The secondary objective was to determine the long term success rates of the different procedures used to treat urethral strictures. The third objective was to modify the anastomotic urethroplasty in order to remove the urethral catheter the following day, thus limiting the risk of catheter related stricture formation. The final objective was to determine the feasibility of incorporating the fibrotic urethra, rather than excising it as a two-stage procedure in patients with obliterated panurethral strictures. Methodology: Databases were created from the patient folders. This was used to do two retrospective analyses on patients who had a follow-up of four to seven years. The first retrospective cohort included 308 patients with a follow up of seven years. The second retrospective study included 326 patients with infective strictures with a minimum follow-up of four years. Two prospective studies were done. The first prospective study was with thirty-six patients. A randomised control trial comparing the double layer continuous running suture re-anastomosis with the interrupted suture re-anastomosis when doing an anastomotic urethroplasty. The second prospective study was a case series of seven patients where the fibrotic urethra was incorporated in the repair of pan-urethral strictures with obliterated lumens as a two-stage procedure. Results: The overall treatment success rates of infective urethral strictures were significantly lower than that of trauma related strictures. The stricture recurrence rate was 2.6 times higher in patients with infective strictures compared to patients with trauma related strictures. Infective urethral strictures were significantly longer than trauma related urethral strictures, mean lengths 2.3 cm versus 1.5 cm. Stricture length was the most significant cause for failure, with stricture lengths of in excess of 3.0 cm being a major risk factor and a reason for failure. Stricture location and obliterative urethral lumens did not affect the success rates of urethroplasty procedures. The seven-year success rate of the dorsal buccal mucosa onlay urethroplasty was 65%, being significantly higher than that of the 27% success rate of ventral buccal mucosa onlay urethroplasty in patients treated during this study. Urethral dilatation after direct vision internal urethrotomy was not beneficial in infective strictures but the time to stricture recurrence was longer compared to patients who had had direct vision internal urethrotomy only. The one-stage circular penile skin flap urethroplasty with a five-year success rate of 8% was considerably lower than the two-stage urethroplasty, where the fibrotic urethra was incorporated in the repair and showed a success rate of 71% in patients with infective urethral strictures. This research demonstrated that the urethral catheter can be removed twenty-four hours after anastomotic urethroplasty performed with a double layer continuous running suture anastomosis. The double layer continuous running suture re-anastomosis had a success rate of 90%, clinically significantly higher than the 71% success rate of the interrupted suture re-anastomosis. Conclusions: The findings of this research led to and support the following recommendations. In cases where substitution urethroplasty with buccal mucosa graft is done for strictures, the graft must be placed dorsal and not ventral. A two-stage urethroplasty combining the dorsal buccal mucosa onlay with a ventral fasciocutanous penile skin flap is the most suitable approach for the treatment of panurethral strictures in patients with infective urethral stricture. Urethral dilatation after direct vision internal urethrotomy adds no benefit to the treatment of infective urethral strictures. The double layer continuous running suture anastomosis after stricture excision ensures early removal of the urethral catheter, thus avoiding catheter related complications. A stricture treatment algorithm for infective urethral strictures was developed from this research, centered on stricture length.