{'fraction_non_alphanumeric': 0.030550089026333053, 'fraction_numerical': 0.018929809764783055, 'mean_word_length': 5.299881936245573, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 1, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Review on Management of Urethral Stricture Disease at Tertiary Care Centre

Introduction: Urethral stricture disease remains a common cause of morbidity among men. Many questions about the etiology of urethral stricture disease remain unanswered till now. This study was done in a tertiary care center along with a review of the literature to evaluate the etiology of urethral strictures and to determine the factors that may influence possible preventive or curative strategies. Materials and Methods: Data collected from Patients visiting the OPD &/or admitted in the IPD for urethral stricture during the August 2015 to December 2017 this period at tertiary care centre with the help of relevant history, clinical examination, appropriate investigation including and treatment which includes medical and surgical intervention. Results: In study iatrogenic (40%) was main etiological factor for which H/O catheterization was main contributory factor for about 41% among iatrogenic cause. Direct visual internal urethrotomy was common surgical procedure performed with success rate (58%). Anastomotic urethroplasty was associated with success rate of 87.5%. Conclusion: Avoiding unnecessary urethral catheterization and repeated urethral instrumentation can reduce these iatrogenic strictures. Contrast urethrogram was the most common imaging modalities followed by Urethroscopy. Anastomotic urethroplasty had higher success rate as compared to DVIU and Urethral dilatation.


Introduction
Urethral stricture disease is still a prevalent problem with an estimated incidence of 0.6% in susceptible populations 1 . It can result from a multitude of aetiological factors, with iatrogenic causes, infections, trauma and idiopathic strictures responsible for most cases in the contemporary world. A propensity toward recurrence necessitates repeated urethral instrumentation in many patients leading to significant impairment of quality of life. The surgical management of stricture disease can be complex and challenging due to the multiple factors that need to be considered including anatomical location, underlying patho-physiology as well as patient co-morbidity. Despite the prevalence of urethral strictures, there has been a remarkable lack of consensus on the optimal approach to evaluation and management. The recent International Consultation on Urological Disease (ICUD) panel on urethral strictures (2010) aimed to bring more consistency to the literature in terms of terminology, definitions and specific management recommendations 2 . In this article we review the recent literature on the evaluation and management of urethral strictures.

2.
To determine the results of the initial management procedures performed. 3. To determine the complications of all the management procedures performed. 4. To look at the follow-up after the initial management procedure.

Inclusion Criteria
1. Cases of urethral stricture, with or without previous history of any medical or surgical treatment for the same. 2. Cases which are regular for post treatment follow-up. 3. Patients willing to be part of this study.

Exclusion Criteria:
1. Cases which will not come for regular follow-up and who did not get complete or receive any medical or surgical treatment. 2. Patients not willing to be part of this study. 3. Patients who were not followed up in the urology clinic for at least 6 months after the Initial procedure. 4. Patients with posterior urethral valves.
In the present study, Iatrogenic (40%) ( Table 2) was the most common etiology amongst study population followed by Idiopathic (30%), Bacterial urethritis (20%), External Trauma (6.7%) and Lichen sclerosis (3.3%). There are several explanations for the so called idiopathic stricture. It may be the delayed manifestation of unrecognized (childhood) trauma 3 , congenital in origin 4 (possibly due to an incomplete rupture of the urogenital membrane and related to what is called Cobb's collar 5 by some and Moorman's ring 6 by others) or mainly ischemic in origin, especially in elderly men 7 .
Patient age is also relevant in deciding on the cause of a stricture: In patients younger than 45 years, hypospadias correction and pelvic trauma are most commonly defined as the cause, while transurethral interventions are most common in those aged over 45 8 .
In the present study, amongst Iatrogenic causes post catheterization (41%) was the most common etiology amongst study population followed by transurethral prostate resection (25%), Hypospadias correction (25%) and Post cystolithotripsy (8.3%) ( Table 3). These findings correlated well with the study conducted 9 in which urethral ca theterization contributed 35.9% of total iatrogenic causes in both age subgroups. It may typically occur at the junction of the bulbar and penile urethra or in the proximal bulbar urethra. But penile urethra, pan urethra, and multifocal anterior urethral involvement are also common. Improper urethral catheter insertion causes 3.2 urethral injuries per 1,000 patients 10 . Prolonged catheterization leads to urethral inflammation and ischemia, and leads ultimately to urethral stricture 11 . Leaching of toxic compounds from poor quality catheters and microvascular disease (as in smokers and in diabetics) may increase the risk 10,12 . Adequate and strict indications for urinary catheterization, skilled urethral catheter insertion, and the consideration of suprapubic catheter placement in prolonged catheterization may decrease the incidence of these iatrogenic strictures.
Iatrogenic strictures occur at any age, commonly involving the membranous urethra and urethral sphincter mechanism, after Trans-Urethral Resection of the Prostate (TURP) (so-called "sphincter strictures") 13 . Similarly in the study conducted 14,15 the incidence of iatrogenic stricture by TURP (2.2 to 9.8%) or radical (8.4%) or simple prostatectomy (1.9%) are higher in the older group patients. The probable causes of stricture after TURP are traumatic insertion of the resectoscope with perforation of the bulbous urethra, instrument friction at the penoscrotal angle (as the instrument moves up and down within the urethra some 800 times), and monopolar current leakage due to insufficient resectoscope insulation 14,16 . In younger patients, hypospadias surgery is the most important iatrogenic cause. Urethral stricture incidence after hypospadias surgery varies from 2.5% to 11% of patients 17,18 .
In the present study, Contrast urethrogram (70%) was the most common investigations amongst study population followed by Urethroscopy (30%) and Urine cultures (26.7%). Urethrogram has been the gold standard for urethral stricture diagnosis 21 .
The goal of treatment of a urethral stricture is a patent, continent urethra without jeopardizing any sexual function present. Accordingly, the results were classified as good and poor outcome. Good was when the urine stream was good, no incontinence, retention and no recurrence of symptoms within 6 months. Poor was when there was a poor urine stream after the procedure or incontinence of urine or acute retention of urine.
In the present study, DVIU (43.3 %) was the most common surgery amongst study population followed by Anastomotic urethroplasty (26.7%), Urethral dilatation (20%), and Substitution urethroplasty (6.7%) and Staged urethroplasty (3.3%). Direct Visual Internal Urethrotomy (DVIU) treats the stricture directly by incision. Patients who have superficial spongiofibrosis may benefit from DVIU when the incision is carried out through all depths of the scar 22 . Predictors of success include stricture length and degree of spongiofibrosis 22 . According to American urological association 23 that DVIU or urethral dilatation has a long success rate of 50-60% if the above criteria are Vol 6 (1) | January-June 2019 | www.informaticsjournals.com/index.php/mvpjms Sudhir Bhamre and Ravikumar Phad met. DVIU success can be improved if urethral dilation is performed greater than 1 year. DVIU can offer an overall stricture free rate of approximately 55% in short, soft bulbar strictures. These have the most favourable outcome, and the likely success rate declines with longer strictures and those in the penile urethra. Whilst these success rates are: significantly lower than those demonstrated by EPA (90%-95%) (Figure 3, Table 5).
In the present study, result of initial management procedure like good urine stream, poor urine stream and acute urine retention was observed in 80%, 13.3% and 6.7% respectively amongst study population (Table 6).
In the present study, Success rate of Anastomotic urethroplasty, DVIU, Urethral dilatation, Staged urethroplasty and Substitution urethroplasty was observed in 87.5%, 58.3%, 50%, 100%, respectively amongst study population. Staged urethroplasty is usually reserved for long strictures especially full length, after previous unsuccessful repair attempts, strictures due to balanitis xerotica obliterans 24 . This could explain why it was performed as an initial procedure in only 1 patients (Figure 4, Table 7).
The success rate for anastomotic urethroplasty was higher (87.5%) as compared to DVIU (58.3%). This is consistent with previous studies 23,25 . Urethroplasty is the most effective method for definitive correction of urethral stricture disease and this approach is generally considered to be the gold-standard treatment 26,27 . This is due to the fact that in DVIU the wound contraction tries to approximate the edges before epithelization is complete while in anastomotic urethroplasty the area of fibrosis is totally excised and anastomosis is widely spatulated creating a large ovoid anastomosis. Urethral dilatation had a poor outcome as expected 23 . Its outcome is usually improved by serial dilatations but in this study many of the patients came back for repeat dilatations only after the recurrence of the symptoms 28 .

Conclusion
Urethral stricture disease is common and accounts for substantial morbidity and cost to the medical system. Our results showed that iatrogenic and idiopathic strictures are surprisingly common. Avoiding unnecessary urethral catheterization and repeated urethral instrumentation can reduce these iatrogenic strictures. Diagnosis and planned repair of strictures involves the use of imaging modalities, amongst which contrast urethrogram was the most common imaging modalities followed by Urethroscopy. Several methods are available for managing strictures, including Anastomotic urethroplasty, DVIU, Urethral dilatation, Staged urethroplasty and Substitution urethroplasty. Anastomotic urethroplasty had higher success rate as compared to DVIU and urethral dilatation.