|Year : 2014 | Volume
| Issue : 4 | Page : 321-324
Relationship between development of urethral stricture after transurethral resection of prostate and glycemic control
Sükrü Kumsar, Hasan Salih Saglam, Osman Köse, Salih Budak, Oztug Adsan
Department of Urology, Sakarya University Training and Research Hospital, Sakarya, Turkey
|Date of Submission||01-May-2013|
|Date of Acceptance||11-Nov-2013|
|Date of Web Publication||18-Sep-2014|
Sakarya EAH, Uroloji Klinigi, Sakarya
| Abstract|| |
Objectives: The purpose of this study is to investigate the association of glycemic control prior to TUR-P and postoperative urethral stricture development.
Materials and Methods: Of the 168 patients with a diagnosis of urethral stricture, who underwent internal urethrotomy in our hospital were retrospectively analyzed for this study.
98 patients who underwent monopolar TUR-P in our hospital previously and were developed urethral stricture were divided into two groups as diabetic and nondiabetic. Based on their HbA1c concentrations, diabetics were allocated to two groups with good (HbA1c ≤ 6.5%) or poor (HbA1c > 6,5%) glycemic control. Time to internal urethrotomy and the other operative parameters were compared among groups.
Results: Time to internal urethrotomy after TUR-P was significantly shorter in diabetic patients with poor glycemic control than Group 1 and Group 2 (P = 0,02, P = 0,012) but no significant difference was found between Group 1 and Group 2 (P = 0,368). There was no significant difference in the mean diagnosed and resected prostate wight among groups There was no significant difference in the mean resection time and the mean time to urethral catheter removal among groups.
Conclusions: Especially in poor glycemic control patients, urethral stricture development was seen in the early period after TUR-P. For this reason, in the elective TUR-P scheduled poor glycemic controlled patients the operation should be done after glycemic control.
Keywords: Glycemic control, transurethral resection of prostate, urethral stricture
|How to cite this article:|
Kumsar S, Saglam HS, Köse O, Budak S, Adsan O. Relationship between development of urethral stricture after transurethral resection of prostate and glycemic control. Urol Ann 2014;6:321-4
|How to cite this URL:|
Kumsar S, Saglam HS, Köse O, Budak S, Adsan O. Relationship between development of urethral stricture after transurethral resection of prostate and glycemic control. Urol Ann [serial online] 2014 [cited 2019 Oct 16];6:321-4. Available from: http://www.urologyannals.com/text.asp?2014/6/4/321/140995
| Introduction|| |
The term "urethral stricture" refers to obstruction of the urethral lumen that causes slowing or cessation of urinary flow. 
Strictures stem predominantly from infectious disease (sexually transmitted diseases,
tuberculosis); today, most of the strictures are post-traumatic or iatrogenic and the main iatrogenic cause is transurethral surgery. , The true incidence of male urethral stricture disease is unknown; however, development of urethral stricture after transurethral resection of the prostate (TUR-P) is stated as 2-10% in the literature. 
Factors, which are responsible for development of urethral strictures after TUR-P, include large prostate volume, prolonged operation time, size and material of catheter, urinary tract infection, usage of thick shaft and high energy, and energy leakage from shaft. , Endoscopy and imaging modalities are used for diagnosis of strictures. The most common technique for management of urethral strictures is visual internal urethrotomy (VIU), because of being an easy and minimally invasive technique. 
Diabetes is a chronic metabolic disorder characterized by inappropriate hyperglycemia due to lack of or resistance to insulin. 
Plasma glycosylated hemoglobin A (HbA1c) is an established indicator of blood glucose control during previous 3 to 4 months  and was previously useful as a preoperative predictor of surgical outcomes in cardiac, vascular and colorectal patients. ,,
The purpose of the study is to investigate the effect of glycemic control before TUR-P on the development of postoperative urethral stricture. In order to achieve this purpose, we investigated the HbA1c levels prior to TUR-P with the time to internal urethrotomy after TUR-P and the other operative parameters retrospectively.
| Materials and methods|| |
A total of 168 patients, who underwent visual internal urethrotomy for urethral stricture, were evaluated retrospectively. Patients were identified from the practice computer database. Data of 150 patients were used for the study. Etiologies of urethral stricture, date of internal urethrotomy, date of TUR-P, diabetic conditions, preoperative HbA1c values, operating time of TUR-P, time of catheter removal, prostate weight measured through transvesical ultrasonography and resected prostate weight were noted. Men, who underwent previous urethra-related surgery before TUR-P, non TUR-P etiologies for urethral stricture and prostatic adenocarcinoma pathologies were excluded. Ninety eight patients with anterior urethral stricture shorter than 2 cm, who underwent visual internal urethrotomy in our hospital, were divided into two groups according to their diabetic conditions, and based on their HbA1c concentrations, diabetic patients were divided into two groups, as good (HbA1c ≤ 6.5%) and poor (HbA1c > 6.5%) glycemic control as previously described.  Group 1 was non-diabetic group (n = 40), group 2 was diabetic and good glycemic controlled group (n = 24) and group 3 was diabetic and poor glycemic controlled group (n = 34). Time to internal urethrotomies after TUR-P and operative parameters were statistically compared among groups.
SPSS software (The Statistical Package for the Social Sciences, Version 15.0, SPSS Inc., Chicago, Illinois, USA) was used to analyze the data. While normally distributed variables were described using means with standard deviations, non-normally distributed variables were described using medians with interquartile ranges.
Student t test was used to compare two groups and non-normally distributed data were analyzed using Mann-Whitney U test. P < 0.05 were considered as statistically significant.
| Results|| |
The strictures developed after TUR-P in 98 (65.3%) of 150 patients. The mean age of 98 TUR-P patients was 68.47 ± 7.8. The mean age of non-diabetic group (Group 1) (n = 40) was 65.95 ± 8.06, mean age of diabetic and good glycemic controlled group (Group 2) (n = 24) was 71.58 ± 9.84 and mean age of diabetic and poor glycemic controlled group (Group 3) (n = 34) mean age was 69.23 ± 6.86. There was no significant difference between groups in terms of the mean age of patients [Table 1].
The mean resection time during TUR-P and the mean time to urethral catheter removal were 44 ± 14.2 min and 2.4 ± 0.68 day in Group 1, 38 ± 11.4 min and 2.5 ± 0.79 day in Group 2 and 40 ± 18.4 min and 2.35 ± 0.6 day in Group 3. There was no significant difference between groups in terms of the mean resection time and the mean time to urethral catheter removal [Table 1].
Mean measured and resected prostate weight were 48.4 ± 18.8 and 17.4 ± 7.6 in group 1, 52.2 ± 21.1 and 19.2 ± 7.6 in group 2, and 50.5 ± 19.3 and 17.9 ± 6.9 in group 3. There was no significant difference between groups in terms of the mean measured and resected prostate weight [Table 1].
Median value of time to internal urethrotomy after TUR-P was found to be 12 months (2-60) in Group 1, 10 months (2-48) in Group 2 (HbA1c ≤ 6.5%), and 4 months (2-24) in Group 3 (HbA1c > 6.5%). Time to internal urethrotomy after TUR-P was significantly lower in diabetic patients with poor glycemic control compared to patients in Group 1 and Group 2 (P = 0.02, P = 0.012) but no significant difference was found between Group 1 and Group 2 (P = 0.368) [Table 1].
| Discussion|| |
Transurethral resection of the prostate (TUR-P) has been the dominant and definitive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS-BPH), but some of the late complications such as urethral stricture, which is the main late complication, can be frustrating.
Urethral stricture is a major late complication of TUR (2.2-9.8%), as well as radical (8.4%)  and simple (1.9%) prostatectomy. ,,,
The development of a urethral stricture is most likely secondary to instrumentation, technique, or postoperative catheterization. However, a higher stricture rate associated with larger resection sheaths was previously reported. ,
It was suggested that routine urethral dilation made before insertion of the resection sheath may reduce this incidence. Other factors have also been suggested in the literature as contributing to an increased incidence of urethral strictures. These include a high cutting current and use of lubrication.  Decreasing the cutting current and increasing the lubrication are thought to help minimizing the stricture rate.
In our study, all operations were conducted using a 26F continuous resectoscope and the urethral dilatation was not performed as a routine procedure in these TUR-P patients.
In addition to these general recommendations, we demonstrated that preoperative glycemic control is important on the development of urethral stricture after TUR-P in this study.
However, while there are some studies showing that age of the patient is an important risk factor for the development of urethral stricture after TUR-P,  there was no correlation between age and the development of stenosis in our study.
Some studies reported that duration of resection during TUR-P and time to urethral catheter removal after TUR-P were effective on development of postoperative stricture; ,, however, the relationship between these factors and the development of urethral stricture was not detected in our study.
HbA1c is a highly reliable measure of long-term glycemic control often used to follow ongoing adjustments to medications in patients with diabetes mellitus.  More recently in the surgical data, HbA1c has been demonstrated to be a preoperative predictor of postoperative outcomes. For example, in cardiac surgery, an elevated preoperative HbA1c has been associated with increased acute kidney injury and mortality.  Also, in vascular surgery, elevated HbA1c levels are associated with wound infections and overall 30-day morbidity.  Finally, elevated preoperative HbA1c levels in colorectal patients are associated with more infectious complications, such as pneumonia and urinary tract infection. 
To our knowledge, there has been no other study in the literature which investigates the development of urethral stricture after TUR-P associated with glycemic control prior to TUR-P; however, this study had some limitations; it was a retrospective study and numbers of patient were limited, ultimately restricting the statistical power of this study. Therefore, additional prospective and randomized studies are needed to demonstrate this relationship.
Preoperative glycemic control before TUR-P in diabetic patients has an important role on development of urethral stricture which is the most important late complication of TUR-P. Especially in poor glycemic control patients, urethral stricture development was seen in the early period after TUR-P. For this reason, the operation should be done after glycemic control in the elective TUR-P scheduled poor glycemic controlled patients.
| References|| |
|1.||Perez RP, Llinares MA. Male urethral stenosis: Review of complications. Arch Esp Urol 2004;57:485-511. |
|2.||Hodonou R, Hounnasso PP, Gbessi DG, Akpo C. Penileperineal-scrotal gangrene. Epidemiologic, diagnostic, and therapeutic features. Report of 32 cases. Prog Urol 2000;10:271-6. |
|3.||Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck W. Etiology of urethral stricture disease in the 21 st century. J Urol 2009;182:983-7. |
|4.||Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of Transurethral Resection of the Prostate (TURP) incidence, management, and prevention. Eur Urol 2006;50:969-80. |
|5.||Kallenberg F, Hossack TA, Woo HH. Long term followup after electrocautery transurethral resection of the prostate for benign prostatic hyperplasia. Adv Urol 2011:2011:359478. |
|6.||Schultheiss D, Truss MC, Jonas U. History of direct vision internal urethrotomy. Urology 1998;52:729-34. |
|7.||Kolluru KG, Bir SC, Kevil CG. Endothelial dysfunction and diabetes: Effects on angiogenesis, vascular remodeling, and wound healing. Int J Vasc Med 2012:2012:918267. |
|8.||Koenig RJ, Peterson CM, Jones RL, Saudek C, Lehrman M, Cerami A. Correlation of glucose regulation and hemoglobin AIc in diabetes mellitus. N Engl J Med 1976;295:417-20. |
|9.||O′Sullivan CJ, Hynes N, Mahendran B, Andrews EJ, Avalos G, Tawfik S, et al. Haemoglobin A1c (HbA1c) in non-diabetic and diabetic vascular patients: Is HbA1c an independent risk factor and predictor of adverse outcome? Eur J Vasc Endovasc Surg 2006;32:188-97. |
|10.||Gustafsson UO, Thorell A, Soop M, Ljungqvist O, Nygren J. Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. Br J Surg 2009;96:1358-64. |
|11.||Halkos ME, Lattouf OM, Puskas JD, Kilgo P, Cooper WA, Morris CD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg 2008;86:1431-7. |
|12.||International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-34. |
|13.||Elliott SP, Meng MV, Elkin EP, McAninch JW, Duchane J, Carroll PR, et al. Incidence of urethral stricture after primary treatment for prostate cancer: Data From CaPSURE. J Urol 2007;178:529-34. |
|14.||Varkarakis I, Kyriakakis Z, Delis A, Protogerou V, Deliveliotis C. Long-term results of open transvesical prostatectomy from a contemporary series of patients. Urology 2004;64:306-10. |
|15.||Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: A randomized prospective trial in 200 patients. J Urol 2004;172:1012-6. |
|16.||Tefekli A, Muslumanoglu AY, Baykal M, Binbay M, Tas A, Altunrende F. A hybrid technique using bipolar energy in transurethral prostate surgery: A prospective, randomized comparison, J Urol 2005;174:1339-43. |
|17.||Balbay MD, Ergen A, Sahin A, Lekili M, Ulucay S, Karaaðaoðlu E. Development of urethral stricture after transurethral prostatectomy: A retrospective study. Int Urol Nephrol 1992;24:49-53. |
|18.||Logie JR, Keenan RA, Whiting PH, Steyn JH. Fluid absorption during transurethral prostatectomy. Br JUrol 1980;52:526-8. |
|19.||Schultz A, Bay-Nielsen H, Bilde T, Christiansen L, Mikkelsen AM, Steven K. Prevention of urethral stricture formation after transurethral resection of the prostate: A controlled randomized study of Otis urethrotomy versus urethral dilation and the use of the polytetrafluoroethylene coated versus the uninsulated metal sheath. J Urol 1989;141:73-5. |
|20.||Hart AJ, Fowler JW. Incidence of urethral stricture after transurethral resection of prostate. Effects of urinary infection, urethral flora, and catheter material and size. Urology 1981;18:588-91. |
|21.||Kelly TN, Bazzano LA, Fonseca VA, Thethi TK, Reynolds K, He J. Systematic review: Glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med 2009;151:394-403. |
|22.||Hudson CC, Welsby IJ, Phillips-Bute B, Mathew JP, Lutz A, Chad Hughes G, et al. Glycosylated hemoglobin levels and outcome in non-diabetic cardiac surgery patients. Can J Anaesth 2010;57:565-72. |
|23.||O′Sullivan CJ, Hynes N, Mahendran B, Andrews EJ, Avalos G, Tawfik S, et al. Haemoglobin A1c (HbA1c) in non-diabetic and diabetic vascular patients: Is HbA1c an independent risk factor and predictor of adverse outcome? Eur J Vasc Endovasc Surg 2006;32:188-97. |
|24.||Gustafsson UO, Thorell A, Soop M, Ljungqvist O, Nygren J. Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. Br J Surg 2009;96:1358-64. |