Urethroplasty is considered the gold standard for the treatment of urethral stricture disease, with a success rate of more than 93% in terms of stricture recurrence. The objective of this study is to compare the outcomes of excision and primary anastomosis (EPA) urethroplasty, a transecting urethroplasty technique, and tunica vaginalis graft (TVG) urethroplasty, a non-transecting urethroplasty technique, in patients with bulbar urethral strictures up to 2 cm in length.
This will be a randomized controlled trial (RCT) involving 94 patients admitted to Sahiwal Teaching Hospital, Sahiwal. The patients will be divided into two equal groups. Randomization will be performed using a computer-generated random sequence. Group A patients will undergo excision and primary anastomosis (EPA) urethroplasty, while Group B patients will undergo tunica vaginalis graft (TVG) urethroplasty. Non-probability convenience sampling will be used.
A detailed history of urinary symptoms, sexual function, catheterization, instrumentation, urinary tract infection, and trauma will be obtained to determine the cause of the stricture. Demographic information, including name, age, and contact number, will be recorded. Preoperative investigations will include complete blood count, renal function test, liver function test, urine complete examination, ultrasonography of the kidneys, ureters, and bladder with post-void residual volume (PVR), uroflowmetry, and retrograde urethrogram for the diagnosis and measurement of stricture length.
Other study parameters will include length of hospital stay and postoperative complications, such as graft failure, wound infection, urinary tract infection, and fistula formation. Data will be collected using a structured proforma and entered into the Statistical Package for the Social Sciences (SPSS) version 26.0 for analysis. For quantitative variables, the mean and standard deviation will be calculated. For qualitative variables, frequencies and percentages will be calculated. Data will be presented in tables and graphs for both quantitative and qualitative variables. The chi-square test will be used to assess the association between qualitative variables, while the independent samples t-test will be applied to quantitative variables. A p-value of less than 0.05 will be considered statistically significant.
It is anticipated that tunica vaginalis graft (TVG) urethroplasty will provide better outcomes than excision and primary anastomosis (EPA) urethroplasty.
Patients with diagnosis of bulbar urethral stricture upto 2cm in length.
Patients aged between 18-50 years.
Patients with non-traumatic bulbar urethral stricture.
Isolated short (≤ 2 cm) bulbar urethral stricture
Urethral stricture which is completely obliterated stricture.
Patients with history of hypospadias or previous open urethral surgery.
Patients with uncontrolled diabetes or Immunocompromised patients.
Patients unwilling for the follow-up.
Parallel
Excision and Primary Anastomosis Urethroplasty
Procedure/SurgeryIn Excision and Primary anastomosis urethroplasty patients, an incision will be made down onto the urethra at the level of stricture in the ventral midline. Urethra will be divided with scissors proximally and distally until healthy urethra is entered. Stay sutures will be placed. The scarred urethra will be excised, and the healthy proximal urethral segment will be spatulated dorsally so that it accommodates a 30Fr bougie and the distal urethra will then be spatulated ventrally. The anastomosis will be done using interrupted sutures of 4-0 polydioxanone (PDS).
Tunica Vaginalis Graft Urethroplasty
Procedure/SurgeryIn Tunica Vaginalis Graft Urethroplasty patients, an incision will be made onto the urethra in the ventral mid-line along the stricture length, opening into healthy proximal and distal urethra and stay sutures will be positioned. Tunica vaginalis graft is harvested by making a small vertical or transverse hemiscrotal incision. The dartos fascia is divided to expose the tunica vaginalis. The testis is gently delivered through the incision.The tunica vaginalis graft outlined and harvested. The tunica vaginalis defect is approximated and testis is placed back into the scrotum. The dartos and skin are closed in layers using absorbable sutures. The graft will be laid as a ventral onlay graft onto the opened urethral defect and sutured to the urethral mucosal edges using absorbable sutures. Quilting or anchoring sutures may be placed to reduce graft dead space and enhance take. Ventral urethrotomy is closed over the catheter using absorbable sutures.
Stricture Recurrence
Defined as the presence of a recurrent stricture on retrograde urethrogram (RUG) or the need for any secondary intervention (e.g., dilatation, direct visual internal urethrotomy, or repeat urethroplasty) within 12 months of the initial surgery.
Maximum Urine Flow Rate (Qmax)
The highest rate of urine flow in milliliters per second (mL/s) as measured by uroflowmetry. The primary analysis will compare the mean change in Qmax postoperatively.
Erectile Dysfunction
Erectile dysfunction (ED) has been defined as the inability to attain or maintain penile erection sufficient for successful sexual intercourse. The severity of erectile dysfunction is often described as mild, moderate, or severe according to International Index of Erectile Function (IIEF5) questionnaire, with a score of 1-7 indicating severe ED, 08-11 moderate ED, 12-16 mild-moderate ED, 17-21 mild ED, and 22-25 no ED.
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