Urethral stricture is a common and challenging disease in urology. Currently, there are numerous surgical procedures to treat this disease. However, the diversity of treatment modalities reflects the scarcity of an optimal technique [1]. Data from Medicare and Medicaid Services (for patients older than 65 years) confirmed an increased incidence of stricture disease at 9.0/100,000 for 2001 compared to 5.8/100,000 in patients younger than 65 years [2]. In addition, outpatient hospital visits for Medicare patients was 21/100,000 in 2001, which is half the number of urolithiasis visits in the same population, emphasizing the importance of this disease in the elderly population [3]. With 1600 stricture urethra patients, a study, presents the largest number of patients ever reported from Pakistan. The actual number of patients was even more, and with the introduction of newer modalities of treatment, the number of patients treated has increased tremendously in recent years [4].

The exact frequency of stricture urethra among urologic patients is unknown, but in our recent practice (2009) it was estimated to be 4% of all urologic indoor patients. Similarly, the exact incidence and prevalence of disease in the community is unknown in Pakistan [5]. The male urethra can be divided into two parts, the posterior urethra which consists of the membranous and prostatic urethra, and the anterior urethra which includes bulbar and the penile urethra. The bulbar urethra is enclosed by the bulbo spongiosus muscle and the penile urethra runs from the distal margin of the bulbospongiosus to the fossa navicular is and external meatus [6]. The main causes of urethral strictures consist of congenital anomalies of the mucosal membrane, infection, traumatic scarring after blunt pelviperineal trauma, urethral instrumentation, catheterization, hypospadias failures, and inflammatory disease of the corpus spongiosum caused by lichensclerosus [7]. Idiopathic and iatrogenic etiology are the main causes of urethral strictures in developed countries. Trauma remains the most common etiology of urethral strictures in the developing and Third World countries. About 90% of men with urethral stricture disease present with complications [8]. Before clinical treatment, a precise diagnosis and preoperative evaluation of anterior urethra stricture are necessary. While the American Urological Association symptom index captures the most common voiding complaint of men with urethral stricture, including lower urinary tract symptoms (LUTS) or acute urinary retention (AUR), 22.3% of patients have different presenting complaints [9]. As urethral stricture causes progressive narrowing of the urethral lumen, symptoms and signs of urinary obstruction arise [10]. Patients experience weak stream, straining to urinate, incomplete emptying, post-void dribbling, urinary retention, and recurrent urinary tract infections. The symptoms resemble those of other causes of bladder outlet obstruction such as benign prostatic hyperplasia [11]. The presence of obstructed ejaculation also points to urethral stricture and is a cause of infertility. Urethral stricture needs to be ruled out in patients presenting with Fournier’s gangrene, especially when there is urinary extravasation, and in young patients with recurrent epididymitis or prostatitis [12]. In cases of meatal stenosis, the urinary stream will be splayed or deviated. On examination, associated spongiofibrosis may be palpated periurethrally [13].

Objective:

To determine the efficacy of Mitomycin C in reducing Recurrence of Anterior Ureteral Stricture

This descriptive case series study was conducted at Department of Urology, Shaikh Zayed Hospital, Lahore during--------------------------------------------. Sample size of 60 cases is calculated with 95% confidence level, 4% margin of error and taking expected percentage of reduced recurrence in 86% patients. Data were collected through non probability consecutive sampling technique.

Inclusion Criteria:

• Male patients, age between 20 to 60 years of age.
• Patients with newly diagnosed anterior urethral stricture and had urethral strictures of a maximum length of 2 cm. (with in last 1 month)
• Patients with a maximal flow rate (MFR) of less than 12 mL/s.

Exclusion Criteria:

• Patients with blind urethral strictures, multiple urethral strictures and urethrocutaneous fistula
• History of recurrent stricture after failed IOU
• History of urethroplasty.

Data Collection Procedure:

60 patients meeting the inclusion and exclusion criteria was included in the study through wards of Department of Urology, Shaikh Zayed Hospital, and Lahore. Informed consent was taken. Basic demographics like name, age, gender was noted. A complete history, examination, and relevant investigations was completed in all patients. Later on, 0.1% mitomycin C was injected after IOU at the site in the 1, 5, 7, and 11 o'clock positions with a TLA needle using a straight working channel pediatric cystoscope. SCIC was not offered. Patients was regularly followed up for 1 months at 3 months. The follow-up was consisting of history, examination, and uroflowmetry at 3rd month. Efficacy of the mitomycin was noted as per operational definition.

Data Analysis:

Data was entered and analyzed with IBM-SPSS version 21. Mean ±SD was presented for quantitative variables like age. Frequency and percentage was computed for qualitative variables like efficacy of the mitomycin. Effect modifiers like age, size of stricture, flow rate was controlled by stratification. Post-stratification, chi-square test was applied with p ≤0.05 taken as significant

The mean age of the study patients was 43.53±9.5 years. The maximum flow rate was 28.56 with standard deviation of 12.33. The efficacy of the procedure was noted in the 46(76.7%) cases and absent tin the 14(23.3%). On stratification, it was noted that there was no significant difference for the age groups in the procedural cases as 6(75%) show efficacy with age <30 year and 40(76%) with age >30 year. Significant difference was noted with maximal flow rate with respect to efficacy.

Table 01: Distribution of the Efficacy of the Treatment in the Study Participants

Table 02: Stratification of the Efficacy for the Age of the Patients

Urethral strictures are relatively common in men. The most common etiology is idiopathic in developed countries and trauma in developing countries [14]. Iatrogenic injuries, such as oversized resectoscope at the time of transurethral surgery and traumatic placement of indwelling urinary catheters, account for 45 percent of all cases. Other causes of urethral strictures include infection (including sexually transmitted disease), hypospadias, skin conditions (most commonly lichen sclerosus), trauma (most commonly pelvic fracture), and radiation therapy [15,16]. The urethra conveys urine from the bladder to the exterior of the body. The anatomy is important here because male urethral strictures differ in etiology, diagnosis, and management based upon stricture locations. The male urethra is divided into two major segments: the anterior urethra and the posterior urethra. By convention, the surfaces of the penis are defined with the penis extended cranially and the urethra located ventrally [17,18].

The etiology of urethral stricture disease mainly involves the following: idiopathic, iatrogenic, external trauma, infection, and lichen sclerosus. In 2013, a comparative analysis showed that urethral strictures in India are proportionally more caused by an external trauma and less by an iatrogenic cause, when compared to the USA and Italy [19]. Meanwhile, in the Western World, the most important stricture etiology is iatrogenic and developing countries primarily face infectious strictures after venereal infections or after a nonspecific urethritis [20]. As regards lichen sclerosus, a skin condition with an important predilection for the anogenital region, its urethral involvement is a well-known aspect of the disease and potentially gives rise to urethral strictures at the penile or bulbar site [21-23]. Furthermore, it must be underlined that a substantial amount of stricture etiologies remains unknown, even after thorough evaluation of the patient’s history.

Mitomycin-C could be used as a potential additional treatment for anterior urethral strictures. However, further studies are required to investigate the safety and efficacy of this method for treating anterior urethral strictures, as only a limited number of studies presently exist.

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