Introduction

Urethral stricture is a progressive narrowing or occlusion, or loss of distensibility of any part of the urethra secondary to periurethral spongiofibrosis (1). The etiology is either infective or trauma (2). Previous transurethral endoscopic surgery is now a major cause of post-traumatic strictures with a pooled range of 2.2–11.6% (3, 4). Postgonococcal urethritis with complicating strictures has been on the decline with the advent of appropriate antibiotics (5–7).

Urethral bouginage/sounding has historically been used to treat these strictures, partly because of its low cost and the ease of carrying out the procedure. These measures are however short term at best, and at worst worsen the strictures, in both length and breadth (8). Urethroplasty is the only potentially curative modality. These methods are offered only by specialized urethral surgeons. In Kenya, such

specialists are few and are found mainly in large referral

hospitals located in the main cities (9,10). The two main types of reconstruction are anastomotic and substitutional; both aim to produce a high-caliber, stable and compliant urethra while resolving obstructive symptoms and related sequelae (11). Anastomotic reconstructions rely on apposition of well-mobilized, tension-free urethral ends. Substitution techniques rely on introduction of either free tissue (buccal mucosa) or of flaps obtained from elsewhere, to bridge urethral defects. Most flap techniques are complex with a steep learning curve, and are mostly two-stage procedures. Such complex procedures increase the possibility of complications. Two-stage procedures require close follow-up and introduce a burden to the patient of taking care of the initial surgical site. A second admission and surgery also increase the overall cost. Techniques such as the two-stage

Bracka urethroplasty have potentially poor outcomes because the initial buccal mucosal graft shrinks and becomes desiccated by the time 6 months elapse in time for the second-stage surgery. One-stage repair was historically suited for solitary, short (sub-centimeter) or multiple contiguous strictures. The indications have now been broadened to include longer strictures including panurethral strictures (12). One-stage procedures offer the benefits of reducing overall cost, better tolerance and reducing the general risk of anesthesia and surgery.

Urethral stricture constitutes significant morbidity at St Mary’s Hospital, Kenya. A large number of our patients come from Narok, a region with a high number of post-gonococcal urethritis and urethral stricture. These patients present with obstructive lower urinary symptoms, recurrent urinary tract infection, periurethral abscess and/or watering can phenomenon. At St Mary’s Hospital, obstructing symptoms have hitherto been resolved through dilatation (metal sounding). This has been occasioned by the cost implication, lack of a reconstructive urologist and rapid symptomatic relief of the intervention. The recurrence of symptoms has however been unacceptably high, ranging from as short as one month to three months. This recurrence could be attributed to the complex nature of some of these inflammatory strictures. A patient also has a potential likelihood of requiring this procedure for life.

We started carrying out urethroplasty in 2017, as an intervention with the potential to cure stricture disease as well as reduce physical deformity, prolonged follow-up and repeat procedures. This informed our decision to adopt one-stage urethroplasty as our procedure of choice. We audited our safety procedures and outcomes at this early stage to determine if our interventions were within internationally acceptable standards. 

​

Methods

All patients who underwent one-stage urethroplasty were entered into the study. One-stage urethroplasty is a reconstructive procedure for primary or recurrent urethral stricture that aims to achieve urethral continuity and patency without requiring a second procedure and includes simple anastomotic urethroplasty, non-transecting anastomotic urethroplasty, buccal mucosal graft (ventral, dorsal and long dorsal panurethral graft), and complex bulboprostatic anastomosis with or without inferior pubectomy. Excluded from this audit were urethral dilatations, suprapubic diversions, DVIU, hypospadias reconstruction.

All patients were operated in the exaggerated lithotomy under either spinal (no BMG required) or general anesthesia (BMG required). A detailed description of the individual procedures as done in our centre follows;

 

Simple anastomotic urethroplasty

For short (1–3cm) strictures we used the simple anastomotic urethroplasty method, especially for bulbar urethra. Exposure was via a midline perineal incision. The urethra was exposed after incising the dartos and bulbospongiosus layers, depending on the anatomical site. The strictured segment was excised completely; next the healthy stumps were spatulated. Six interrupted sutures (Vicryl 4.0) were placed at 12, 2, 4, 6, 8 and 10 o’clock positions. The bulbospongiosus and other layers were closed in a stepwise fashion. No drains were left. A pressure dressing was applied and was removed 24 hours later.

 

Buccal mucosal graft urethroplasty

The urethra was exposed in standard fashion, as explained in the simple anastomotic urethroplasty method. Using the dorsal buccal mucosal graft (BMG) urethroplasty, the urethra was dissected off the corpora carvenosa by creating a sub-urethral widow and extending the dissection both proximally and distally. A dorsal urethrotomy was performed over a guide wire. Buccal mucosa graft was harvested from the right cheek, in standard fashion. The graft was defatted, fenestrated and quilted on the carvenosal bed with Vicryl 4.0 continuous sutures. The urethral edges were stitched to the quilted graft over a size 16 silicon catheter. Standard closure followed the simple anastomotic urethroplasty method. For ventral BMG, a ventral urethrotomy was done, the graft stitched to the edges of the urethrotomy and a two-layered closure of the urethral sponge was done over a 16 Fr silicon catheter.

 

Non-transecting anastomotic bulbar urethroplasty

The urethra was exposed in standard fashion as per the simple anastomotic method. A 2-cm longitudinal ventral urethrotomy was done over a guide wire. This was closed in a transverse Heineke-Mikulicz fashion. Standard skin closure followed.

 

Complex bulboprostatic anastomosis

One case of a pelvic floor urethral distraction defect (PFUDD) warranted this approach. A long, midline incision was made and the distal stump of urethra exposed in standard fashion. Transection was done at the most proximal point of the urethra that could admit a Fr 22 bougie. Using a modified Hey Groove dilator (we curved a catheter introducer into a C shape and affixed a Foley catheter) advanced through the suprapubic cystostomy; the proximal urethral impression was palpated and mobilized to access a segment of anastomosable healthy urethra. Incision of the perineal membrane was necessary to facilitate prostatic urethra mobilization. We did not do inferior pubectomy. A tension-free bulbo-prostatic anastomosis was done at 12, 2, 4, 6, 8 and 10 o’clock positions with absorbable 4.0 sutures. Standard skin closure was performed.

Data was prospectively entered into a spreadsheet. The data included the following parameters: biodata, pre-operative adverse factors (high PFUDD, severe spongiofibrosis, watering can perineum, age >70 years, prolonged untreated obstructive uropathy), stricture etiology and characteristics (site, caliber, length, and recurrence), type of surgery (transecting anastomotic, non-transecting anastomotic, dorsal graft, ventral graft), hospital stay and complications (hematoma, site infection, recurrence, fistula, incontinence, ED). Successful short-term outcome was defined as subjective improvement of obstructive symptoms and not requiring a repeat procedure (catheter, dilatation, repeat urethroplasty) within 6 months (13).

 

Results

Between January and December 2017, 23 urethroplasties were carried out. The mean age of the patients was 52.5 years, and 83% presented primarily. The range of stricture length was 2–7 cm with a mean of 3 cm. Nine strictures were inflammatory (40%), nine were traumatic (40%) while three were recurrent strictures and two (9%) were unspecified. Majority (63%) of patients were aged 30–50 years presented post-trauma while the 63% of those between 50–70 years presented post inflammatory. The main clinical presentation was poor urine stream (ten patients, 43%). The predominant location of the stricture was the bulbar urethra (83%). Nine patients (40%) had preoperative adverse risk factors.

Of the 23 urethroplasties, 13 were simple anastomosis (57%), 5 were dorsal BMG urethroplasty (22%), 2 were non-transecting anastomotic urethroplasty, and 1 case each of ventral BMG urethroplasty, Johanson’s and Kulkarni’s panurethroplasty (Table 1). The overall complication rate was 39% (nine patients). Four patients (17%) had recurrence, two had fistula and one case each had persistent UTI, erectile dysfunction and

periurethral abscess. Three of the four recurrences had undergone BMG urethroplasty. All cases of simple anastomosis had no recurrence.

 

Discussion

Urethral stricture is one of the leading causes of urine obstruction worldwide. A shift in the etiology from inflammatory to trauma occurred with the advent of effective

 

Click To View Table 1

 

antibiotics to treat sexually transmitted diseases (STD). The study sample was drawn from a rural region in Kenya where gonorrhea has been prevalent. Post-gonococcal urethritis sequelae are worsened by stigma associated with seeking care for STD. The finding of an equal number of trauma and inflammatory strictures was surprising. This could, however, be explained by the selection bias of those patients most suitable for one-stage urethroplasty. Many other patients who present with urethral stricture disease are treated using urethral dilatation.

 

A predominance of bulbar strictures is well documented for both traumatic and, especially, inflammatory strictures. Infective bacteria predominantly affect the periurethral skene glands which are concentrated in the bulbar urethra, resulting in these strictures. In addition, the parts of a male urethra most vulnerable to trauma are the penobulbar and the bulbomembranous junctions. Our study concurred with prior studies from Africa and elsewhere (14, 15). Our mean urethral stricture length was 3 cm, which

was on the higher side. Again, this is a reflection of the selective bias for longer strictures which were not treated by simple dilatation. Dedicated urethroplasty centers have an average stricture length of 4–5 cm (16); this also likely reflects a selection bias towards referral of the most complex strictures.

The ease and reproducibility of simple anastomotic reconstruction makes it the mainstay of short urethral stricture surgery (11, 14, 15, and 17). It is mainly recommended for sub-2–3cm strictures. This study achieved tension-free anastomosis of even up to 4–5 cm with reasonably good short-term results. Indeed, all 57% of the simple anastomosis done did not have complications. In a country with a dearth of specialized urological surgeons, this technique is encouraged for use by general surgeons and those with interest in urology to avoid long delays and unnecessary or costly referrals to urban centers. Our overall short-term success rate of 61% was in sharp contrast to a similar study in Tanzania that showed a 90.8% one-year success rate (18). The Tanzanian study further found 100% success in substitution urethroplasty. The study site being a large tertiary hospital with better equipment and several specialists, these impressive results are not surprising.

A significant number of complications were noted in our study with the substitution urethroplasties (overall 39%); seven of the cases were major complications. As one of the aims of this interim study was to assess the safety of complex urethral surgery in a new urethroplasty centre, these complications were not unexpected. A 62-month study done in Chicago, Illinois, found an 18% long-term recurrence rate of anastomotic urethroplasty compared with31% recurrence with substitution urethroplasty (19). The general long-term recurrence ranges from 1.2% to 14% for anastomotic urethroplasty and up to 58% for substitution urethroplasty (20, 21). Being a new centre of reconstruction, these high

figures serve as a wake-up call to review our systems and especially on patient and technique selection.

The major weakness of our study was the short-term follow-up. At one year, no robust inferences can be made on any of the major outcome measures for urethroplasty. This interim study was a safety and effectiveness audit not designed for long-term outcome. In addition, our centre was unable to proceed with further patient follow-up due to circumstances beyond our control.

 

Conclusion

Complex urethroplasty has a clinically significant complication rate but our recurrence rate for simple urethroplasty is low. A high recurrence was noted in substitution urethroplasties, suggesting the need for careful patient selection, an improvement in technique and possible early referral of these cases to specialized centers.

 

REFERENCES

1. Mundy AR, Andrich DE. Urethral strictures. BJU Int. 2011;107(1):6–26.

2. Eshiobo I. A 10‑year review of urethral stricture management in Irrua, Nigeria. 2017;23(2):119–24.

3. Balbay MD, Ergen A, Sahin A, et. al. Development of urethral stricture after transurethral prostatectomy: a retrospective study. IntUrolNephrol. 1992;24(1):49–53.

4. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. Eur Urol. 2006;50(5):969–79.

5. Alwaal A, Blaschko SD, McAninch JW, Breyer BN. Epidemiology of urethral strictures. TranslAndrol Urol. 2014;3(2):209–13.

6. Osoba AO, Alausa O. Gonococcal urethral stricture and watering can perineum. Br J Vener Dis. 1976;52(6):387–93.

7. McMillan A, Pakianathan M, Mao JH, MacIntyre CCA. Urethral stricture and urethritis in men in Scotland. Sex Transm Infect. 1994;70(6):403–5.

8. Kamande L, Owilla F (UoN). A review on management procedures for urethral stricture disease at Kenyatta National Hospital. Unpublished dissertation, University of Nairobi, 2003.

9. Oliech JS. One-stage repair of urethral strictures at the Kenyatta National Hospital (1978–1984). East Afr Med J. 1988;65(1):39–47.

10. Adwok JA. Urethral strictures at the Kenyatta National Hospital. East Afr Med J. 1986;63(3):175–81.

11. Dakum NK, Ramyil VM, Amu CO. Outcome of urethroplasty for urethral stricture at Jos University Teaching Hospital. Niger J ClinPract. 2008;11(4):300–4.

12. Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of panurethralstricture. UrolClin North Am. 2017;44(1):67–75.

13. Jackson MJ, Chaudhury I, Mangera A, Brett A, Watkin N, Chapple CR, et al. A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. Eur Urol. 2013;64(5):777–82.

14. Hussain A, Pansota MS, Rasool M, Tabassum SA, Ahmad I, Saleem MS. Outcome of end-to-end urethroplasty in post-traumatic stricture of posterior urethra. J Coll Physicians Surg Pakistan. 2013;23(4):272–5.

15. Eziyi AK, Olajide AO, Etonyeaku AC, Ojewuyi OO, Eziyi JAE, Adeyanju T, et al. One-stage urethroplasty for urethral strictures at the LadokeAkintola University of Technology Teaching Hospital, Osogbo, South Western Nigeria. World J Surg. 2013;37(11):2529–33.

16. Kinnaird AS, Levine MA, Ambati D, Zorn JD, Rourke KF. Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties. J Can Urol Assoc. 2014;8(5–6):296–300.

17. Aghaji AE, Odoemene CA. One-stage urethroplasty for strictures: Nigerian experience. Int J Urol. 2001;8(7):380–5.

18. Musau P, Mteta AK. Urethral strictures in a tertiary care hospital in Tanzania. East Afr Med J. 2009;86(1):3–6.

19. Han JS, Liu J, Hofer MD, Fuchs A, Chi A, Stein D, et al. Risk of urethral stricture recurrence increases over time after urethroplasty. Int J Urol. 2015;22(7):695–9.

20. Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of urethroplasty. J Urol. 2003;170(1):90–2.

21. Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA JG. Long-term follow-up for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007;177:1803–6.