Urethral stricture disease is one of the oldest urological problem with an incidence of around 0.6%–0.9% in reported series [1,2]. It causes bothersome voiding symptoms leading to impaired patient's quality of life[2]. Anterior urethral stricture is defined as a pathological condition in which a fibrous tissue involves the corpus spongiosum resulting in narrowing of urethral calibre. Etiology has been changed in last few decades and trauma is the most common etiology of anterior urethral stricture, especially fall astride injury and other causes includes infective urethritis and iatrogenic trauma. Surgical modality available for the treatment of urethral stricture disease includes urethral dilatation, direct visual internal urethrotomy (DVIU), stent and reconstructive surgical techniques (Single or double stage urethroplasty). As there is no single surgical modality suitable for all stricture disease, choice of surgery depends on location, length, etiology of stricture, density of fibrous tissue as well as surgeon preference. Simple procedure that is durable and having acceptable success rate with minimal morbidity is preferred. The pre-operative and intraoperative decision-making process is very complex. Only few literature is available to support one procedure over another[3].

Preoperative assessment is essential. It helps in surgical decision making. Investigations like retrograde urethrography (RGU), uroflowmetry (UFR), and cystoscopy are the part of initial evaluation[4]. In the past few decades, urethral dilatation and DVIU were the surgical treatment of choice for short segment bulbar urethral stricture as they are simple, cost effective with minimal morbidity [5,6]. However endoscopic approach was associated with high recurrence rate necessitating multiple procedures with increasing financial burden for healthcare [1]. On follow up study, recurrence free rates with endoscopic approach are only 39%–73%; however multiple attempts of DVIU or dilatations have further decrease the success rate and hence are not cost effective[7-10]. Hence, Excision and primary anastomosis (EPA) also called as Excision and end to end anastomosis is the gold standard procedure for short segment isolated bulbar urethral strictures of less than two cm with low postoperative morbidity and overall high level of success [11-13]. Indications for EPA in patient with bulbar urethral stricture includes patient with previous failed endoscopic surgery like DVIU or urethral dilatation and those patients who does not fit into the criteria for DVIU or dilatation[10,11]. As most patients wants a cure, it is wise to straight over proceed to EPA in most of the cases.

Length of the stricture and the amount of associated spongiofibrosis play a key role in the management of bulbar urethral stricture. EPA is the straightway surgical option for simple uncomplicated bulbar urethral stricture. Substitution urethroplasty in the form of buccal mucosal graft urethroplasty might be suggested for patient diagnosed with long segment strictures on RGU to reduce recurrence rate and hence need for repeat procedure. Success rate of excision and end-to-end Anastomosis is more than 90% in various published literatures[14,15]. Finally, Double-stage urethroplasty (staged urethroplasty) is reserved for patients with strictures associated with local adverse conditions. Factors determining the outcome measures and hence the clinical effectiveness of urethroplasty includes clinician determined parameters like maximum flow rate (MFR), urethrography[16,17].

This prospective study was performed in our institution to assess various risk factors like age, etiology, previous surgery, type of stricture, associated comorbidity, preoperative voiding status, time to surgery, stricture length and operative time that determines the surgical outcome of excision and end to end anastomosis for bulbar stricture urethra.

AIM AND OBJECTIVES

To assess the factors affecting surgical outcome of excision and end to end anastomosis for bulbar urethral stricture.

OBJECTIVES

1. To study various preoperative factors (age, previous intervention, etiology, voiding status, associated comorbidity) and its impact on surgical outcome of surgery.
2. To study intra-operative factors (length of stricture, duration of surgery, time to surgery) and its impact on surgical outcome of surgery.

Study design: Prospective observational study

Duration of study: June 2023 - Jan 2025

Study subjects: The present study included 36 patients attending Urology OPD at GMC and Superspeciality Post Graduate Institute, Nagpur

Inclusion criteria:

• All patients of bulbar urethral stricture who needed surgical intervention and had given informed consent to participate in the study was included.
• Those patients who presented for primary consultation as well as those patients with previous failed repair was included.

Exclusion criteria:

• Patient who underwent combined procedure or augmented anastomotic urethroplasty.
• Medically unfit cases.
• Complicated stricture with urethrocutaneous fistula.
• Patients with associated benign prostatic hyperplasia on corticosteroids or uncontrolled diabetes which affect surgical outcome.
• Malignant urethral lesions.
• Patients who were unwilling or unable to undergo surgery.
• Patients with incomplete record.

RESEARCH METHODOLOGY:

The approval by the Thesis Protocol Approval Committee and Institutional Ethics Committee of our institution was taken for the procedure of the current study and informed consent was obtained from all patients. From June 2023 to January 2025, data from 36 patients of bulbar stricture urethra who underwent excision and end to end anastomosis surgery were prospectively analyzed.

PREOPERATIVE WORKUP:

All the patients with suspected stricture urethra from a thorough history and physical examination were subjected to investigations to establish the diagnosis and aid in surgery. These include Surgical profile (Renal function Test, Complete Hemogram, Coagulation Profile, Blood grouping and typing, Urine Culture Sensitivity) and special investigations to confirm the diagnosis. The latter included Uroflowmetry, Retrograde Urethrogram, Ultrasonography abdomen, Urethrocystoscopy (in cases of diagnostic dilemma).

PREPARATION AND PROCEDURE:

Once the diagnosis of Bulbar stricture urethra was established patient was subjected to definitive surgical procedure which includes excision and end to end anastomosis considering the various local and general factors of patient.

Local factors include - cause of stricture, length of stricture, site of stricture.

General factors include - general condition of patient, age of patient, other comorbidities, surgical fitness of patient.

Operative time and blood loss were taken as surrogates of intra-operative complexity. Surgery was performed by the same team of operating urologists.

The standard surgical technique of anastomotic urethroplasty was applied while the patient was positioned in a slightly hyperextended lithotomy position. After mobilization of the bulbar urethra, the area of fibrosis was completely excised and the healthy ends of the urethra was spatulated. Urethral mobilization was required, extending in some cases to the penoscrotal junction distally and perineal body proximally. Full thickness including mucosa was sutured with interrupted 4-0 or 5-0 polyglactin 6 - 8 interrupted sutures. At the end of the procedure, a 14-Fr silastic Foley urethral catheter was exclusively placed and a small drain was kept under the bulbospongiosus muscle for 2 to 3 days if needed.

POSTOPERATIVE:

Patients had been discharged with oral antibiotics for 2 weeks. The urethral catheter was removed at 1 month during first follow up. Uroflowmetry was performed at 1 and 3 months after surgery. Patients underwent retrograde urethrography or urethroscopy if they developed voiding symptoms, such as slow or splayed stream.

TREATMENT SUCCESS:

Was defined as freedom of postoperative instrumentation or dilatation.

TREATMENT FAILURE:

Was defined as the need for any postoperative intervention including urethral dilation.

STATISTICAL ANALYSIS:

Statistical analysis was performed using SPSS package (version 26). After compiling all the data, statistical analysis had been performed. The sample size required was calculated using the formula

n= z² × p (1-p)

d²

n=required sample size

z=confidence level at 95% (standard value of 1.96) p=estimated prevalence

d=margin of error at 5% (standard value of 0.05) Calculated sample size using above formula is n= 35

Fisher exact test was used to assess the significance of categorical risk factors for surgical failure like etiology, previous surgery or preoperative voiding status and Student t-test was used to assess significance in continuous factors, e.g., age, stricture length or operation time. Values has been expressed as mean ± standard deviations.

Statistical significance was considered statistically significant at p＜0.05.

REGULATORY APPROVALS:

The study was conducted after obtaining approvals by the institutional thesis protocol approval committee and institutional ethics committee.

FINANCIAL ISSSUES:

No financial burden was imposed on the participant of the study.

ETHICAL ISSUES:

In the present study routine investigations were performed during the diagnostic evaluation, pre-operative and post-operative periods. There was no ethical issues pertaining to the study. A written informed consent was obtained from all the patients participating in the study.

There was no additional risks to subjects in this study. Excision and end to end anastomosis was the standard surgical procedure for bulbar urethral stricture as published in many literature. No additional tissue or blood was removed from patient because of study protocol.

Principal investigator has been in contact with subjects during study period and monitor data throughout study.

ETIOLOGY:

Table 8: Etiology in our study cases.

In our present study, most common etiology was traumatic including 23 cases accounting 63.89% whereas remaining 13 cases were non-traumatic.

In non-traumatic cases, 7 cases were iatrogenic, 4 cases were idiopathic and 2 cases were of infectious etiology.

PREVIOUS SURGERY:

Table 9: History of previous surgery in our study.

VOIDING STATUS:

Table 10: Voiding status in our study

DISEASE ASSOCIATED COMORBIDITY:

Table 11: Stricture related comorbidity associated in our study.

TYPE OF STRICTURE:

Table 12: Type of stricture in our study.

TIME TO SURGERY:

Table 13: Time to surgery in our study.

OPERATIVE PARAMETERS:

All of the 36 bulbar urethral stricture cases included in our study underwent excision and end to end anastomosis. No technical difficulty was faced during the operative procedure.

Three cases were required corporal separation whereas two cases were required inferior pubectomy intraoperatively in order to facilitate tension free end to end anastomosis.

No blood transfusion was required in any of the cases.

DURATION OF SURGERY:

Table 14: Duration of surgery in our study.

Average duration of surgery in our study was 131.25 min (± 25.39). Shortest duration of surgery was 90 min whereas longest duration of surgery was 200 min.

LENGTH OF STRICTURE:

Table 15: Mean length of stricture in our study.

FOLLOW UP:

All the cases were followed upto the end of study period.

Periurethral urethrogram was done in five cases before per-urethral catheter removal.

One patient shows minimal extravasation at surgical site on pericatheter urethrogram. Patient was managed conservatively. Delayed catheter removal was done in this case.

MAXIMUM FLOW RATE:

Table 16: Maximum flow rate in our study.

All patients were subjected to uroflowmetry on follow up. Mean of maximum flow rate noted in our patients was 20.5194 ml/sec (±3.6402).

Lowest maximum flow rate was 13.4 ml/sec whereas highest maximum flow rate was 28.8 ml/sec.

COMPLICATIONS:

Table 17: Complications in our study.

SURGICAL OUTCOME:

Table 18: Surgical outcome in our study.

COMPARISION BETWEEN SUCCESS AND FAILURE GROUP:

Table 19: Comparision between success and failure group in our study.

We have compared various parameters against success and failure group and data were subjected to statistical analysis to find out the significant relation between parameter and surgical outcome of the surgery. It has been observed that only etiology and stricture length determines the surgical outcome of excision and primary anastomosis in patient of bulbar urethral stricture disease.

Bulbar urethral stricture disease management is a major challenge to both the patient and the treating surgeon as it mainly affects the productive sector of the population. Various factors like length of stricture, etiology of stricture and associated spongiofibrosis determines the surgical selection. Although for short segment incomplete bulbar urethral stricture, DVIU is recommended as first choice of treatment, it is associated with high recurrence rate and need for subsequent procedure. Excision and end to end anastomosis is a simple procedure with high success rate as high as 95% in published literature.[11]

We have included total 36 cases of bulbar urethral stricture disease in our study who underwent excision and primary anastomosis by single operative surgeon. All patients were analysed prospectively upto the end of study period and data were collected. Data were subjected to statistical analysis to derive a significant conclusion. Findings were compared with related studies published in the literature.

In our present study, 33 cases who underwent EPA for bulbar urethral stricture disease fall under "Success group" as they did not require any intervention postoperatively and hence considered as success. Three patients falls into the "Failure group" as they required repeat surgical intervention due to recurrence of symptoms.

AGE:

Table 20: Mean age comparision with other studies.

Mean age of the patient in our study is 41years (± 11.64) with maximum of 68 years and minimum of 18 years. This corresponds to previous studies such as Obi AO et al[56], Barbagli G et al[13] and Santuchi et al[11] where average age was 37.46, 39 and

38.0 years respectively.

This age group belongs to productive section of the population. This is highly mobile group that get more easily prone to trauma which is common etiology of bulbar urethral stricture disease. Mean age in success group and failure group patient is 40.55±11.73 and 46±11.38 years respectively. However, difference is not statistically significant at P value 0.2206. (Table 19) Thus, as per our study age is not a factor in the success rate and surgery should not be withheld for patient on the basis of age.

ETIOLOGY:

Table 21: Etiology comparision with other studies.

Most common etiology of bulbar urethral stricture disease in our study is trauma accounting for 63.89% similar to other published study like Suh JG et al[55] and Obi AO et al[56]. Most common form of trauma is straddle injury in which bulbar urethra is crushed against the undersurface of pubic symphysis. In our eight cases of iatrogenic etiology, two patients were having history of prolonged catheterisation whereas remaining six underwent surgical intervention before.

Etiology of stricture urethra varied from region to region and period to period. In between 1961 and 1981, most common cause of urethral stricture was urethritis however after that there was considerable shift towards iatrogenic causes of urethral stricture. In 2002, Jordan and Schlossberg[59] have suggested that most urethral strictures result from external trauma.

On statistical analysis, it has been observed that success rate in traumatic group is more than non-traumatic group in our study with significant p value 0.0401. (Table 19) All failure cases have non-traumatic etiology. Two cases were iatrogenic whereas remaining one case has infectious etiology. Inflammatory strictures are generally more extensive involving more of the urethra and corpus spongiosum and are less likely to yield a successful result.[60] Similarily, Lindell et al[61]. reported highest failure rate in patients with strictures due to prolonged indwelling catheter drainage.

Hence, etiology determines the surgical outcome of EPA in patient of bulbar urethral stricture disease in our study. Most likely reason for the better result in traumatic group is that spongiofibrosis developed from outside to inside, which makes it easier to identify the extent of stricture. On the contrary, spongiofibrosis propogated from inside to outside in urethral strictures of nontraumatic causes, especially those with iatrogenic or infectious causes.

PREVIOUS SURGERY:

Table 22: History of previous surgery compared with other studies.

In our present study, 20 patients were having history of previous surgical intervention for bulbar urethral stricture disease. Suh JG et al[55], Pieter D'hulst et al[57] and Barbagli G et al[13] noted similar findings in their studies. 13 patients were having history of single surgical intervention whereas 07 patients were operated multiple times before. Among three failure patients, two patients were having history of previous surgical intervention.

On statistical analysis, history of previous surgical intervention does not correlate significantly with surgical outcome of the patient in our study with p value

1. (Table 19) Literature suggests that the influence of previous treatment on surgical outcome is controversial.[11-13,62,63] Santucci et al[11] and Eltahawy et al[12] had history of failed previous surgical intervention in 55% and 69.2% of the patient respectively however surgical outcomes were equally excellent. In contrast, Barbagli et al[13] reported lower success rate (78.6%) in patient who had undergone multiple treatments.

VOIDING STATUS:

Table 23: Voiding status compared with other studies.

In our study, most of the patients (19 patients) were on SPC preoperatively whereas 13 patients were having slow stream of urine similar to study of Suh JG et al[55]. Out of three failure cases, one case was on SPC whereas remaining two patients were on slow stream. On statistical analysis, there was no significant association between preoperative voiding status and surgical outcome with p value 0.5929. (Table 19) Hence, in our study preoperative voiding status do not affect surgical outcome of EPA.

DISEASE ASSOCIATED COMRBIDITY:

Table 24: Disease associated comorbidity comparision with other studies.

Presence of disease associated comorbidity was noted in 28 (77.78%) patients. Thus most of the patients were having disease associated comorbidity similar to study of Obi AO et al[56] (79.2%). Some patients had combinations of comorbidities. Among three failure cases, two patients were having disease associated comorbidities but this did not impact negatively on the outcome of surgery in our study, p = 0.5412. (Table 19)

TYPE OF STRICTURE:

Table 25: Type of stricture compared with other study.

14           patients (38.89%) had complete stricture as opposed to 22 patients (61.11%) with incomplete stricture in our study. In contrast, in study of Obi AO et al[56] most of the patients (60.4 %) were having complete stricture. All three failure cases in our study were having incomplete stricture however relation with outcome of surgery is not statistically significant. p = 0.2667. (Table 19) In our study, type of stricture did not determine the surgical outcome of the surgery.

TIME TO SURGERY:

Table 26: Time to surgery compared to other study.

15           patients (41.67 %) underwent surgery in less than 6 months in our study as opposed to 21 patients (58.33%) who underwent surgery more than 6 months similar to study of Obi AO et al[56]. Among three failure cases, two patients had been operated more than 6 months whereas remaining one case had operated less than 6 months from onset of symptoms. However, time to surgery does not impact negatively on the surgical outcome of the patient in our study. p = 1(Table 19)

DURATION OF SURGERY:

Table 27: Duration of surgery compared to other study.

Average duration of surgery in our case study is 131 ± 25.39 min whereas it is 151 min in a study of Suh JG et al[55]. In success and failure group, average duration of surgery is 131.0606 ± 26.47 min and 133.33 ± 7.6376 min. However, it does not impact significantly surgical outcome of surgery in our study at p = 0.4443. (Table 19)

LENGTH OF STRICTURE:

Table 28: Length of stricture comparision with other studies.

Mean excised stricture length in our study is 13.0278 ± 4.5134 mm corresponding to previous study of Suh JG et al[55] Stricture length was less than 1 cm in eight patients (22.22%), 1 to 2 cm in 25 patients (69.45%) and more than 2 cm in three patients (8.33%). Mean stricture length in success and failure group is 12.33 ± 3.9896 and 20.6667 ± 2.5166 mm respectively. Difference is statistically significant. Stricture length in our study negatively impact surgical outcome of the patient at p = 0.0001(Table 19)

In order to achieve a good success rate, both complete excision of abnormal urethral mucosa with associated spongiofibrosis and tension free anastomosis is important. There is continuous controversy regarding ideal length for EPA.

Guralnick and Webster[25] suggested that surgery should be limited to stricture less than one centimeter because excision of 1cm urethral segment with opposing 1cm proximal and distal spatulation result in 2cm urethral shortening. There is also additional risk of chordee and penile shortening on excision of long urethral segment. [25] In general, ideal stricture length for successful EPA is less than or equal

to 2 cm[12,65] however in selected patients stricture longer than 2cm can be manged successfully with EPA. [11-13] Morey and Kizer[66] in his report of 22 patients of bulbar urethral strictures longer than 2.5cm that were treated with EPA suggested that the ability of the urethra to be reconstructed is proportional to the length and elasticity of the distal urethral segment, They reported a 91% success rate, concluding that defects upto 5 cm can be successfully excised and primarily reconstructed in select young men with proximal bulbar stricture.

In our study, majority of patients (91.67%) had an excised stricture length less than two cm. Out of three failure cases, two cases were having stricture length more than 2cm. We consider strictures upto 2 cm to be suitable for EPA.

MAXIMUM FLOW RATE:

Table 29: Comparision of MFR against age group.

Mean of maximum flow rate in our study is 20.5194 ± 3.6402 ml/sec (Range 13.4 - 28.8). In success and failure group, Mean MFR after surgery was 20.5970 ± 3.6627 and 19.667 ± 4.0067 ml/sec respectively and hence does not impact outcome of surgery in our study significantly at p = 0.3409 (Table 19).

Patient aged less than 50 years (N = 29) showed better MFR with mean of 21.68 ± 2.9696 ml/sec (Range 17.7 - 28.8) than did those aged 50 years or more (N=07) who had mean MFR of 15.7 ± 1.5822 ml/sec. Difference is statistically significant in our study with p value 0.0001 (Table 19).

COMPLICATIONS:

Table 30: Complications compared with other studies.

Complications after AU is few and limited. Early complications were minor and included urinary tract infections, epididymo-orchitis and wound infection whereas major complications were scrotal pain, decreased ejaculatory force, erectile dysfunction and urinary incontinence. Complications were present in total 12 patients in our study. Early complications were easily treated with short course of antibiotic. Most common complication is scrotal pain seen in six patients (16.67%) corresponding to study of Suh JG et al[55]. Most patients feel satisfied with the surgical outcome despite some minor postoperative complications[13].

In three patients who had erectile dysfunction preoperatively, condition persisted postoperatively. No patient had new onset of ED postoperatively. No patient complained of penile shortening or chordee. Yucel and Baskin[69] reported that surgical damage to perineal nerve that innervates bulbospongiosus muscle and sends branches to corpus spongiosum may have role in determining the loss of efficient bulbar urethral contraction, thus causing difficulties in expelling semen and urine. Although urologists mostly concentrate on surgical success in terms of voiding efficiency, patient may be concerned more about adverse effect related to sexual performance. Al-Qudah[68] and Santucci[11] suggested that complications including chordee and ED occured in 18% of patients after AU. Complications do not affect the surgical outcome of the patients in our study. p = 0.5361. (Table 19)

PERICATHETER URETHROGRAM:

In our institute, we perform pericatheter urethrogram (PCU) in selected cases. In our study, we have done PCU in five patients out of which one patient shows mild extravasation at surgical site which was managed conservatively with delayed PUC removal. Santucci et al[11] have noted low yield of urethrography and suggested that postoperative evaluation should be kept minimal in resource poor countries without compromising patient outcome.

SURGICAL OUTCOME:

Table 31: Surgical outcome compared with other studies.

The success rate of anastamotic urethroplasty varied between studies. Eltahawy et al[12] published their series of 260 patients with bulbar stricture who underwent end-to-end anastomosis over 10 years with a mean follow-up of 50.2 months. The mean stricture length was 1.9 cm, and the authors described a success rate of 98.8%. On the other hand, Gupta et al. [64] published the results of 114 patients who underwent end-to-end anastomosis in their center with a mean follow-up of 26.7 months and an average stricture length of 2.2 cm. The success rate of the procedure was 82.6%. While analyzing the long-term results of end-to-end anastomosis for bulbar urethral stricture of varied etiologies in 153 patients, Barbagli et al.[13] had a success rate of 90.8%. The success rate of anastamotic urethroplasty in our study was 91.67% with followup upto end of study period and an average length of 1.3 cm.

We have experienced stricture recurrence in three patients. All the recurrences occurred in first 6 months. Two patients were managed with VIU whereas one patient was managed with dilatation. All three patients were having incomplete stricture with non-traumatic etiology with two patients were having history of previous surgical intervention.

 It is difficult to make direct comparisons of success rates between studies because patients characteristics, follow-up periods, and method of follow up often differ considerably. Our sample population was small such that every unsuccessful case adversely affected the overall success rate. To get the best results for EPA, complete excision of unhealthy urethra and accompanying spongiofibrosis and tension free anastomosis are essential. Failure to remove all abnormal urethra is thought to be the primary cause of surgical failure and stricture recurrence.[60] Unfortunately, accurate identification of spongiofibrosis is not possible with the technology at hand. RGU often combined with MCU is a conventional preoperative tool for evaluation of the extent of urethral involvement. However, static RGU image can both underestimate or overestimate the length of the stricture.[70] Intraoperative urethrocystoscopy can be used as an adjunct to RGU to estimate the extent of stricture.[12] Some advocate urethral sonography to accurately determine stricture length[11,70].

COMPARATIVE ANALYSIS OF PREVIOUS INTERVENTION AND STRICTURE LENGTH:

Table 32: Comparative analysis between previous intervention and stricture length in our study.

Mean stricture length (15.10 ± 3.66 cm) in patients having history of previous surgical intervention (N = 20) was longer than patients (N =16) with no history of any surgical intervention. (10.25 ± 3.89 cm). Relation is statistically significant at p = 0.0001. Similar findings noted in study of Obi AO et al[56]. It has been noted that repeated instrumentation of urethral stricture is associated with recurrence and increase stricture complexity. Hence, we observed in our study that history of previous surgical intervention determines the stricture length.

COMPARATIVE           ANALYSIS OF TIME TO SURGERY AND COMORBIDITY:

Table 33: Comparative analysis between time to surgery and comorbidity in our study.

In our study, we have observed that patient with incomplete stricture tended to accept surgery earlier than those with complete stricture 50% versus 26.67% in contrast to study of Obi AO et al[56]. It is due to fact that most of the patient with complete stricture in our study was on SPC whereas patients with incomplete stricture continued to void through their urethra. However, relation is not statistically significant at p = 0.3021.          

STRENGTH AND LIMITATIONS:

• Key strength of this study is its prospective nature and availability of preoperatve data.
• It is a single tertiary care centre study with relatively low sample size and short follow up.
• Sample size was not enough to obtain statistical significance in the multivariate analysis.
• Small sample size impacted negatively on the success rate and positively on complication rates.

The follow up period in our study was limited and longer follow up would shed better insights of disease 

• In our study, Excision and end to end anastomosis for short bulbar urethral stricture has an acceptable success rate of 91.67% with minimal complications.
• Stricture etiology determines the surgical outcome of the surgery in our study. Recurrence rate was significantly higher in the patients with nontraumatic causes than in the patients with traumatic etiology.
• Stricture length determines the surgical outcome of the surgery in our study. We consider strictures upto 2 cm to be suitable for EPA.
• Prior surgical intervention is associated with longer stricture length in our study. However, this did not impact negatively on the outcome of surgery.
• Patient aged less than 50 years in our study showed better MFR postoperatively than did those aged 50 years or more.
• Delay in undergoing surgery is common observation in our study, however it further adds on disease associated comorbidity.

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