Urethral stricture is narrowing of the anterior urethra and it is generally referred to as anterior urethral stricture disease, or a process of scarring which involves the spongy erectile tissue of the corpus spongiosum, known as spongiofibrosis.^[1]

The scar causes destruction of the urethral lumen leading to weak or poor urine stream or subsequent cessation of urine flow and consequently acute urinary retention (AUR).The resultant scar can be of various depths, densities, and lengths, replacing certain portions of the corpora spongiosum and subsequent circular contraction of the lumen.^[2]

The main causes of urethral strictures can be classified as post traumatic, post infectious or inflammatory and iatrogenic.^[3] Post infectious/inflammatory strictures are most commonly secondary to inadequately treated or untreated gonococcal infection. Inflammatory strictures are caused by processes leading to chronic inflammation and eventually stricture formation.

The incidence of traumatic strictures is increasing due to increase in road traffic accidents and violence. Traumatic strictures tend to be short and occur almost exclusively in the bulbar urethra. These strictures are generally deeper due to extensive scarring and fibrosis.^[4]

The incidence of urethral stricture was estimated to be around 1% in the adult male population.^[5] Urethral stricture disease is one of the most common causes of morbidity among men. In developed countries the most common cause of urethral stricture is iatrogenic, which mainly involves the anterior urethra, in particular, the bulbar tract. In low to middle income countries including India post infectious strictures occur commonly followed by post traumatic strictures, which represent a large majority of cases of urethral strictures.^[6]

Patients become symptomatic only after the urethral caliber falls to less than 10 Fr (3.33mm) which occurs several years after initial insult in the case of infectious and inflammatory strictures. Urethroplasty is regarded as the gold standard treatment for surgical management of urethral strictures, with recurrence rates after long-term follow up ranging from 1.2% to 14% for anastomotic urethroplasty and up to 58% for substitution urethroplasty. ^[7,8] Urethral stricture has high morbidity due to a high recurrence rate and is a significant burden both for the patient and also for the health care providers.

The aim of the present study is therefore to examine the various factors that influence the occurrence of a re-stricture and to determine potential management techniques with favorable outcomes

This was a prospective interventional study done over a period of 18 months. The study population are those patients admitted in the Department of Urology in NRI Medical College andHospital. Fifty patients were taken into the study using non probability sampling method. All male patients with recurrent urethral stricture are included in the study whereas female patients with stricture urethra and those with recurrence after previous urethral dilatation are excluded. Data from the questionnaires was analysed with MS Excel and SPSS Software version 20for statistical analysis. Bivariate analysis was performed using chi-square test and p – value of less than 0.05 was considered as statistically significant.

A total of 50 patients were included in the study, who were satisfying the inclusion criteria, out of which 6 patients were lost to follow up and could not be assessed for post catheter removal evaluation. The remaining 4 patients refused postoperative follow up. Data analysis was therefore done in a total of 40 patients.

Majority of the patients in the present study belonged to 31 – 40 (32.5%) and 41-50 (37.5%) years of age group, followed by 51-60 years (15%). Only 2 cases were below 20 years (5%) and 1 patient had age more than 60 years (2.5%). Most of the patients are from urban area (72%) in the present study. Comparatively lower numbers of patients are from a rural area (28%).

Idiopathic strictures were the most common type observed among the study participants (40%) followed by traumatic strictures (27.5%) as represented in graph 1. The other causes are due to sexually transmitted infections in 7.5% of the patients, iatrogenic (catheterization, endoscopy, or urological procedures) causes in 20% of the patients. Strictures in 5% of the patients were due to lichen sclerosis. (Graph 1)

Graph 1: Etiology of Urethral Strictures

Graph 2: Frequency of complications (%)

Majority of the patients presented with LUTS (82%) where as 18% of the patients presented with AUR.

The site of stricture was found to be penile and bulbar in 25% of the patients each and pan urethral in 22.5% of the patients and in 27.5% of the patients the site was membranous urethra, which was the most common site compared to others. (Table 1)Most of the patients were found to be having a stricture length varying between 1 to 2 cm (92.5%) while in 7.5% of the patients the length of the stricture was less than 1 cm. (Table 2)

The site of recurrent stricture was found to be penile and bulbar in 35% of the patients each and pan urethral in 2.5% of the patients and in 27.5% of the patients the site was bulbo - membranous urethra, which was the most common site compared to others. (Table 1)

Most of the patients with previous stricture were managed by BMG Urethroplasty (55%) followed by anastomoticurethroplasty in 27.5% of the patients. In 3 (7.5%) patients Prepuceal graft urethroplasty was done and in 4 (10%) patients DVIU was performed. (Table 3)The most common procedure performed in the present study was Dorsal BMG onlayurethroplasty which was done on 62.5% of the patients. Other procedures done were anastomotic urethroplasty, which was performed on 7.5% of the patients, composite graft in 5%, staged urethroplasty in 12.5%, augmentedperinealurethroplasty in 5% and non-transacting augmented urethroplasty in the remaining 5% of the patients. (Table 4)

Nearly half of the patients (45%) who had recurrent urethral stricture reported duration of 5-10 years followed by 30% of the patients with duration of more than 10 years and 20% with duration more than 1-5 years and 5% with < 1 year duration.All the patients came with an IPPS grade 3 score, out of which  2 patients had grade 2 even after surgery, and one had grade 3 after surgery, in follow-up. (Table 5)

Based on uroflowmetry and symptom scoring 3 patients were diagnosed with recurrence after 2^nd surgery, in 2 patients recurrence was seen after the 1^st year and the procedure performed was DVIU (67%) and in the remaining 1 patient, the recurrence was seen after the 18^th month, where the procedure performed was dilatation.  

Majority of the patients had post void dribbling as the primary complication (35.3%). The other most common complications noted were erectile dysfunction in 29.4% of the patients and also UTI in 29.4%. In one patient stoma narrowing after perinealurethrostomy has occurred as a complication.

Table 1: Site of previous and recurrent strictures

Table 2: Length of stricture

Table 3: Surgical management of previous stricture

Table 4: Type of surgery for recurrent stricture

Table 5: Symptom score after recurrence

Surgical photographs

Fig 1: Anastamotic Urethroplasty

Fig 2: Buccal mucosal graft urethroplasty

Fig 3: Staged Urethroplasty

Fig 4: Augmented perinealurethrostomy

In the present study, 37.5% of the patients belonged to 41-50 years of age group. 32.5% were in 31-40 years of age group and 15% belongs to 51-60 years of age group. The average age was found to be 40.9 years. Labib et al ^[9]in their study also reported a nearly similar age incidence of urethral strictures, with average age to be 38.04 years.Anger JT et al^[5]and Ferguson G et al ^[10] revealed a higher age incidence of urethral strictures in patients with age more than 60 years.

The higher incidence of urethral strictures in a relatively younger population in developing and poor countries was demonstrated to be due to infective and inflammatory conditions such as sexually transmitted infections, urethritis etc. This finding was established in a study done by Labib et al^[9].Mugalo.E et al in their study, reported that post infectious urethral strictures are common among younger population in low and middle income countries, due to increased high risk sexual behavior and inadequate treatment of STIs in this age group.^[11]

In the present study, idiopathic strictures were the most common type observed among the study participants (40%) followed by traumatic (27.5%) and iatrogenic strictures (15%). The etiology of strictures was sexually transmitted infections in 7.5% of the patients. Heyns et al in their study reported a higher incidence of post inflammatory strictures and sexually transmitted infections was the most common etiology.^[12]Ahidjo et al in their study also reported that post inflammatory strictures were the most common cause, the reason being either due sexually transmitted infections or previous catheterization.^[13] However Anger J et al reported that contrastingly in developed countries, the most common cause was found to be iatrogenic strictures, as post inflammatory or gonococcal strictures are becoming rare due to extensive use of broad spectrum antibiotics.^[14] Similar results were reported by a study done by Fenton. A et al, in which the authors described the most common etiology was due to iatrogenic causes, few cases were reported to be due to post inflammatory or traumatic causes.^[4]This significant difference in the pattern of etiology of urethral strictures between several regions was attributed to the widespread use of transurethral procedures for treatment of urological conditions in the developed world. In resource poor settings, the relatively lower incidence of iatrogenic strictures is mainly due to lack of various endoscopic facilities.

Post catheterization strictures also contribute to significant proportion of iatrogenic stricture formation, and in most cases the reason for catheterization was found to be due to non urological reasons. In a study done by Popoolaet al various factors related to indwelling catheter were found to influence the formation of a stricture.^[15]

In a study done by Heyns et al post infective strictures were reported to be most common among sexually active men, who engage in high risk sexual behavior and are also less compliant to complete treatment for STIs.^[12]Mugalo et al also reported a similar higher prevalence of post infectious strictures in younger men and the reason cited was due to incomplete treatment of  STIs.^[11] Several other studies done in low income and developing countries also reported a higher incidence of post infectious strictures among men, and also concluded that more attention is needed in adequate treatment of STIs to prevent future formation of stricture.

In a retrospective study done by Harraz.A et alit was observed that most strictures were idiopathic followed by iatrogenic in 51.6% and 26.3% of patients, respectively.^[16] The authors also reported that, most patients in the study presented with obstructive lower urinary tract symptoms (68.9%) and strictures were bulbar. These results are congruent with the findings observed in the present study.

RTAs were reported to be the other most common etiology for stricture formation by different studies and this was attributed to multiple traumatic injuries leading to pelvic fractures and consequent urethral injury.Congruent findings were observed in the present study where traumatic strictures were the second most common (27.5%) after idiopathic strictures. Stein DM et alin their study on the geographic analysis of male urethral stricture aetiology revealed that in India traumatic strictures were more common compared to the western countries.(36% vs 16%).^[17] The results from the present study are almost comparable.Strictures in 5% of the patients in the presents study were due to lichen sclerosus. Lichen scelorus strictures were reported to be common in India (22%) in a study done by Stein DM et al. ^[17]

Clinically, in the present study. 82% of the patients presented with lower urinary tract symptoms and 18% presented with acute urinary retention. In a study done by Harraz, A et almost patients presented with obstructive lower urinary tract symptoms (68.9%).^[16]Mathur.R et alin their study, established a significant association between the etiological factors and outcome of urethral strictures.^[18] The study revealed that all of the patients who had acute urinary retention had an identifiable etiological factor. This association was also found to be statistically significant (p<0.05).

A high proportion of patients (92.5%) in the present study were found to be having a stricture length varying between 1 to 2 cm. Evidence from several studies point to the fact that, stricture length is found to be directly proportional to recurrence. Pansadoro V in their study demonstrated that recurrence rates were higher in patients in whom the length of stricture was greater than 1 cm.^[19] They also also noted that the success rate was 71% in case of strictures which are less than 1 cm and only 18% in case of strictures more than 1 cm or longer. Similarly in a study done by Albers P et al also found a higher recurrence rate of 51% in patients with strictures more than 1 cm compared to only 28% in case of strictures less than 1 cm.^[20]Ishigooka M et al and Zehri AA et al in their studies also demonstrated that, the recurrence rates were higher with increasing stricture length. ^[21,22]

The recurrence rate in the present study was found to be 7.5%. In a prospective cohort study done by Labib.M et alshowed that dilatation had the highest rate of recurrence (28%) in comparison with the other treatment modalities. Naude.AM et al in their study revealed that overall, internal urethrotomy (IU) has a lower success rate (60%) than urethroplasty (80–90%), but if used for selected strictures, the success rate of IU could approach that of urethroplasty.^[23]In a retrospective study done by Harraz.A et alit was observed that idiopathic strictures were independent predictors of recurrence and were found to have higher failure rates.^[16] Various stricture characteristics were analysed and it was established that location (penile and membranous strictures), length (>2 cm), site (multiple strictures), aetiology (untreated perioperative urethritis) and depth (extensive periurethralspongiofibrosis) were risk factors for poor outcomes.

The most common site of stricture was found to be membranous urethra (27.5%) in the present study followed by penile and bulbar in 25% of the patients. In a study done by Dubey D et al lower recurrence rates were seen in bulbar urethral strictures, compared to those that are located distally.^[24] This has been attributed to better vascularity of bulbar urethra than the pendulous urethra.

Dorsal BMG on lay Urethroplasty was the most common procedure performed in the present study (62.5%). Javali, T et al in their study on the management of recurrent anterior urethral strictures following BMG mucosal graft urethroplasty reported that the success rate of this redo surgery was 85.7%.^[25] The authors concluded that redo BMG mucosal graft urethroplasty is safe and a feasible surgical technique with intermediate term outcome. In the present study, short term success rate for anastamoticurethroplasty was more than 90%. However they need further follow up to access for long term recurrence.

Buccal mucosal graft substitution urethroplasty was proven to be a useful procedure with less donor site morbidity and fewer complications. Gupta NP et al in their study on the minimal access approach for anterior urethral stricture reported that the procedure was successful in 11 out of the 12 patients.^[26] In a prospective study done by Barbagli G et al to evaluate the effectiveness of bulbar urethroplasty reported that penile skin grafts used as dorsal on lay deteriorate over time compared to buccal mucosa.^[27] Although the study reported to be successful in 73% of the patients, it was a failure in 27% of the patients requiring further postoperative intervention.

In a multicentre study done by Kane CJ et albuccal mucosal grafts used as ventral on lay for bulbar urethral reconstruction, yielded consistently successful results which reported average symptom scores to be decreased from 21.2 pre-operatively to 5.4 post-operatively and these differences were also found to be statistically highly significant (p<0.01) and the peak flow rate increased from7.9ml to 30ml/sec.^[28]

Anastamotic Urethroplasty was done in 7.5% of the patients. Andrich DE et al and several other studies done in the past, recommend Anastamotic Urethroplasty as the preferred surgical procedure due its high success rate, which was reported to be almost over 90% in different centers all around the world.^[29]In present study short term results (18 months follow up) for re do anastamoticurethroplasty was more than 90 %. However, they need further follow up to access for long term recurrence.

DVIU was done in 17.5% of the patients in the present study.  Pansadoro et al also reported in their study that, multiple urethrotomies have no role in the management of stricture recurrence as has been demonstrated in their study.^[19]Naude.AM et al highlighted that long term outcome for DVIU is extremely poor.^[23]

Staged Urethroplasty was performed on 12.5% (5) of the patients in the present study. This procedure was generally reserved for strictures with longer length, previous unsuccessful repair techniques, and strictures due to balanitisxeroticaobliterans and in cases with other associated complications such as perineal fistula and periurethral abscesses.

Mild Post void dribbling was the predominant complication (35.3%) observed in the present study. The other most common complication noted were UTI and erectile dysfunction seen in 29.4% of the patients each.. In a study done by Martinez et althe most common post – operative complications reported were wound infection (1.3%), incontinence (1.3%), hematoma formation (1.3%) and erectile dysfunction (4.7%) which were almost comparable with the present study.^[30] In an another study done by Blandy JP et al the complications observed after management of urethral strictures were bleeding (6%), extravasation of urine (1.9%) and infection (6.4%).^[31]

Somerville et al in their review gave a detailed description of the complications that occur after staged urethroplasty.^[32] Complications of first stage include stoma stenosis (24%), bridging (7%) incontinence(7%).Others includes orchitis, impotence, deep vein thrombosis. The main complication following second stage is post-micturition dribbling in upto 33% due to a tendency to oversize the neourethra which results in a troublesome urinary pooling after voiding. Others include incontinence (25%), perineal fistula (13%), urinary infection (13%), urethral stone (8%), urethral diverticulum (8%) and recurrence of the stricture (8%).

The most common strictures observed in the present study were idiopathic strictures followed by traumatic strictures in the age group of 30-60 years being most common. The common clinical presentation was obstructive lower urinary tract symptoms more thanacute urinary retention.BMG Urethroplasty was the most common surgical procedure done for recurrent urethral strictures. Most of the recurrent strictures can be managed with Dorsal BMG urethroplasty.

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