A recurrent homozygous missense mutation in CCDC103 causes asthenoteratozoospermia due to disorganized dynein arms / 亚洲男科学杂志(英文版)

Asthenoteratozoospermia is one of the most severe types of qualitative sperm defects. Most cases are due to mutations in genes encoding the components of sperm flagella, which have an ultrastructure similar to that of motile cilia. Coiled-coil domain containing 103 (CCDC103) is an outer dynein arm assembly factor, and pathogenic variants of CCDC103 cause primary ciliary dyskinesia (PCD). However, whether CCDC103 pathogenic variants cause severe asthenoteratozoospermia has yet to be determined. Whole-exome sequencing (WES) was performed for two individuals with nonsyndromic asthenoteratozoospermia in a consanguineous family. A homozygous CCDC103 variant segregating recessively with an infertility phenotype was identified (ENST00000035776.2, c.461A>C, p.His154Pro). CCDC103 p.His154Pro was previously reported as a high prevalence mutation causing PCD, though the reproductive phenotype of these PCD individuals is unknown. Transmission electron microscopy (TEM) of affected individuals' spermatozoa showed that the mid-piece was severely damaged with disorganized dynein arms, similar to the abnormal ultrastructure of respiratory ciliary of PCD individuals with the same mutation. Thus, our findings expand the phenotype spectrum of CCDC103 p.His154Pro as a novel pathogenic gene for nonsyndromic asthenospermia.

Multimodal Intraoperative Neurophysiological Monitoring in Spine Surgeries: The Experience at a Spine Centre through Years

Methods@#This retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm. @*Results@#Of the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%. @*Conclusions@#Use of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.

experience with continent urinary diversion

Objective: to find out frequency of urinary continence and surgical complications of using cecum and right colon as reservoir with appendix as a continent catheterizable conduit in various urological conditions in adults

Study design: retrospective study

Place and Duration of study: department of Surgery, Hayatabad Medical Complex and Khyber Teaching Hospital, from January 2005 and December 2015

Methodology: this is a review of records of patients who underwent continent urinary diversion. Reservoir was constructed from cecum and right colon using Le Bag technique. Appendix was used as a catheterizable port applying Mitrofanoff principle. Patients were followed up for six months at two months interval

Results: a total of 85 patients underwent continent diversion and 78 patients completed the study protocol. Four patients were lost to follow up and three died. Out of 78 patients, 48 were males and 30 females, with age range from 05 year to 68 year. Thirty-eight [48.71%] patients presented with transitional cell carcinoma, and 12 [15.38 %] had exstrophyepispadias complex. Reservoir formation using right colon with appendix for Mitrofanoff was performed in 53[67.94%] patients. Eleven [14.10%] patients underwent bladder augmentation procedure with Mitrofanoff and in 14 [17.94%] patients appendix alone was used for diversion. Thirty-two [41.02%] patients developed complications which included incisional hernia [n=7 - 8.97%], calculous formation [n=1 - 1.28%] and subacute intestinal obstruction [n=2 - 2.56%]

Conclusion: use of appendix as a catheterizable conduit is a good option in achieving continent urinary diversion

Susceptibility of multidrug resistant pseudomonas aeruginosa to commonly used biocides and its association with Qac efflux pump genes

To assess the prevalence of qacE?1 and qacE genes and their correlation to antibiotic and biocides resistance in Pseudomonas aeruginosa isolated in Egypt. Susceptibility was assessed for 14 antibiotics in 136 Pseudomonas aeruginosa isolates using agar diffusion method. The minimum inhibitory concentration of 6 biocides, Savlon, Povidone-iodine, Phenol, Formalin and two Chlorine releasing agents were determined using macro-dilution method. Presence of qacE?1 and qacE genes was examined by polymerase chain reaction. There were 34.4 % of Pseudomonas aeruginosa isolates identified as multidrug resistant. Phenol and formalin displayed a higher antiseptic/disinfectant activity compared to other biocides tested. Savlon and Povidone-iodine displayed antibacterial activity when used in recommended dilutions. Minimum inhibitory concentration values of chlorine releasing agents were higher than the dilution prescribed by their manufactures. The qacE gene was only detected among multidrug resistant Pseudomonas aeruginosa. The qacE?1 gene was identified in 57.8% of multidrug resistant isolates and 21.4% in susceptible strains. The prevalence of qac genes among clinical Pseudomonas aeruginosa were 42.3%. Current study concluded thatthere was a correlation between multidrug resistance Pseudomonas aeruginosaandqacE?1 gene, whereas there was no correlation between increased MIC values of biocides and the presence of Qac genes

Prevalence of HBsAg and anti-HCV antibodies in poly-transfused- beta-thalassaemia major children in Lahore

To determine the prevalence of HBsAg and Anti-HCV antibodies in polytransfused thalassaemic children at two different Thalassaemia Centres i.e. The Institute of Haematology and Blood Transfusion Service [IHBTS] Punjab, Lahore and The Thalassaemia Centre at Sir Gangaram Hospital, Lahore. To compare the prevalence of these markers between two centres. To determine association of sero-positivity with number of transfusions. It is a cross sectional study. All information was gathered by questionnaire. Blood samples of 150 thalassaemic patients were collected from two different thalassaemia centres and sera were screened for HBsAg and Anti-HCV antibodies by ELISA technique. SPSS version 16 was used to analyze the data. Chi-square was applied to determine the association between number of transfusions and sero-positivity. The prevalence of HBsAg and Anti-HCV antibodies was 0% and 68% respectively among the patients of IHBTS. 1% and 43% patients were positive for HBsAg and Anti-HCV antibodies respectively at Thalassaemia Centre at Sir Gangaram Hospital. The overall prevalence of HBsAg and Anti-HCV antibodies was 0.66% and 51.3% respectively. Prevalence of anti-HCV was more at IHBTS. An association was observed in increasing number of transfusions and increasing positivity of patients for Anti-HCV [p-value = 0.018]. There is a need to focus on our health safety managements. A higher prevalence of Anti-HCV was observed due to weak infrastructure of health care centres or blood banks

Open haemorrhoidectomy versus rubber band ligation

To assess the results of open haemorrhoidectomy and rubber band ligation in terms of post operative pain and bleeding in 3rd degree haemorrhoids. A comparative study. Surgical unit Hayatabad Medical Complex Peshawar, from July 2009 to June 2010. A total of 100 patients were included. These were randomly divided in two groups; A and B and each group had 50 patients. Group A patients underwent open haemorrhoidectomy while group B patients had rubber band ligation procedure. Post operative complications like pain and bleeding between the two groups were compared. Out of 50 patients in group A, 72% [n=36] had pain and 20% [n=10] had post operative bleeding, while in group B pain was present in 08% [n=4] and post operative bleeding in 04% [n=2] patients. P values for pain [0.007] and bleeding [0.04] were significant in favour of group B. Rubber band ligation is a safe and quick procedure. It is associated with less intensity postoperative pain and bleeding as compared to open haemorrhoidectomy

Abdominal transpubic perineal urethroplasty for complex posterior urethral strictures: an experience of 10 years

To document the outcome of abdominal transpubic perineal urethroplasty for complex posterior urethral strictures. Descriptive case series Surgical unit Hayatabad Medical Complex and Khyber Teaching Hospital Peshawar, from March 1999 to February 2009. Abdominal transpubic perineal urethroplasty is an acceptable surgical approach in patients with complex posterior urethral stricture. Patients with complex posterior urethral stricture were included in this study. Pre operative evaluation included history, physical examination and laboratory investigations. Antegrade/retrograde urethrograms and cystourethroscopy were performed to evaluate bladder neck, and stricture site and length. Surgery was performed in lithotomy position through lower abdominal and perineal approaches. Patients were followed for 2 years. At each visit, ascending and descending urethrograms were performed and post operative complications were recorded. Results were graded as successful and failure based on stricture free rate at the end of 2 years A total of 28 patients were managed The age range was 14-36 year with a mean age of 27.3 + 2.4 year. Urethral stricture was associated with false passages in 17.88% cases, periurethral cavity in 10.71% and urethrocutaneous fistula in 7.14% cases. Mean operation time was 3.5 hours and mean hospital stay was 6 days. Postoperative complications were recurrent stricture [17.86%], urethrocutaneous fistula [7.14%], perineal haematoma [7.14%], impotence [10.71%] and wound infection [10.71%]. During follow up 89.29% patients were stricture free at the end of 2 years Abdominal transpubic perineal urethroplasty is an acceptable surgical approach in patients with complex posterior urethral stricture

Use of circumferential fasciocutaneous penile skin flap in the reconstruction of complex urethral strictures

To find out stricture free rate of penile circumferential fasciocutaneous skin flap use in complex urethral strictures Descriptive case series. Surgical Unit Khyber Teaching Hospital and Hayatabad Medical Complex Peshawar, from January 2000 to December 2009. All patients with complex urethral strictures, more than 4 cm long, were included. Patients were followed-up for two years and on each visit ascending urethrogram was performed. A total of 48 patients with complex urethral strictures were managed. The average length of the stricture was 06 cm [range 04-12cm]. Total operation time was 01-03 hours [mean 02 hours]. Late postoperative complications included recurrent strictures [25%], urethrocutaneous fistula [4.2%], erectile dysfunction [8.3%] and mild postmicturition dribbling [8.3%]. The overall success rate at the end of two years follow-up was 75%[n=36]. Circumfrential fasciocutaneous penile skin flap for urethroplasty is a good option for managing complex urethral strictures with acceptable postoperative morbidity

Frequency of incidental gallbladder carcinoma following cholecystectomy for symptomatic gallstone disease

To determine the frequency of incidental carcinoma of the gallbladder in specimens following routine cholecystectomy. Descriptive case series. Department of Surgery, Hayatabad Medical Complex Peshawar, from February 2008 to January 2011. All patients with symptomatic gallstone disease of either gender having age range between 12-70 year were included. Patients with diagnosed gallbladder malignancy, gallbladder mass, empyema gallbladder and gallstones associated with obstructive jaundice were excluded. Following cholecystectomy all the specimens were sent for histopathological examination. Two hundred and sixty patients including 65 males and 195 females [M: F ratio 1:4] aged 12-70 year and having a mean age of 41.7 year [ +/- SD 2.4], were studied. Commonest presentations were pain right hypochondrium and a positive Murphy's sign [87.71%] followed by dyspepsia[55%], nausea, vomiting [40%], pyrexia [31.92%] and weight loss [05%]. Eleven [4.23%] patients had a diagnosis of malignancy of gallbladder at histopathology examination. Mean age for patients with malignancy was 55.25 year with a male to female ratio of 01:10. Well differentiated adenocarcinoma was reported in 45.45% cases, moderately differentiated in 36.36%, poorly differentiated in 09.09% and undifferentiated in 09.09% patients. Routine histopathology of gallbladder following cholecystectomy is helpful in early detection of carcinoma gallbladder

Experience of rubber band ligation for haemorrhoidal disease

To assess symptomatic relief in haemorrhoidal disease using rubber band ligation. Surgical unit, Hayatabad Medical Complex, Peshawar from July 2007 to June 2009. All patients presenting with rectal bleeding or prolase underwent proctoscopy to determine the cause of bleeding. Only patients with 1[st], 2[nd] and 3[rd] degree haemorrhoids [bleeding and prolapse] were selected for the study and they underwent rubber band ligation in two sessions, 6 weeks apart. Patients were followed in the OPD at 3 months and one year when their subjective and objective symptoms were noted followed by rectal examination and proctoscopy. Therapeutic response was assessed by symptomatic improvement in bleeding and prolapse of hemorrhoids and any complications. A total of 105 patients underwent rubber band ligation. There were 65[62%] males and 40[38%] females with a male to female ratio of 1.6:1. Age of the patients ranged from 21-65 years [ +/- 2.4SD]. Twenty three [21.9%] patients had 1[st] degree, 50[47.6%] had 2[nd] degree and 32[30.5%] had 3[rd] degree haemorrhoids. Forty-eight patients [45.7%] presented with prolapse, 33[31.4%] had both bleeding and prolapse and 23[21.9%] had bleeding only. At 3 months of follow up rubber band ligation cured 76[72.4%] patients, improved 13[12.4%] and failed in 7[6.7%] patients. At one year follow up, recurrence of bleeding and prolapse occurred in 16[15.2%] patients having 3rd degree haemorrhoids. Overall success was achieved in 89[84.8%] cases. Complications were seen in 20[19.1%] patients which were of mild to moderate nature and no serious/ life threatening complications were noted. Rubber band ligation is a rapid and safe non operative procedure for treating 1[st], 2[nd] and early 3[rd] degree haemorrhoids on out patient basis

Surgical management of carcinoma caecum

To determine the magnitude of carcinoma caecum and its surgical management in the department of Surgery, Hayatabad Medical Complex Peshawar-Pakistan. This case series study was conducted at surgical Unit Hayatabad Medical Complex Peshawar from July 2006 to June 2009. A total of 32 patients of carcinoma of caecum were included that were admitted either through OPD as elective cases [22 patients] or in emergency [10 patients]. In elective cases, diagnosis was made on colonoscopic biopsy while those who presented in emergency either with intestinal obstruction or with the suspicion of acute appendicitis, were diagnosed on the resected specimen histopathology. Out of 32, 25 patients [78%] were male and 7 [22%] female, with a male to female ratio of 3.6:1. Their mean age at the time of presentation was 65 +/- 2.8 years. Right hemicolectomy with side to side or end to end ileotransverse anastomosis was performed in 23 cases [71.89%]. In 3 cases [9.37%] ileotransverse bypass without resection was carried out as the tumour was locally advanced. In 3 other cases [9.37%], only omental biopsy was taken as the carcinoma was so advanced that any curative or palliative resection was not possible. In emergency situation, right hemicolectomy with exteriorization of bowel ends was done in 3 cases [9.37%]. Postoperative morbidity included wound infection 12.50%, faecal fistula 9.37% and intraabdominal collection 6.25%. Majority of the patients were having operable disease, however late presentation is very common. Surgical intervention may prove to be a better option in such cases

Postoperative outcome of mesh hernioplasty under local anaesthesia as a day case procedure

To evaluate the outcomes of inguinal hernia mesh repair under local anaesthesia as a day case surgery. Descriptive case series. Surgical unit, Hayatabad Medical Complex Peshawar, from September 2007 to August 2008. Patients having direct/indirect inguinal herniae of either side who underwent Lichtenstein repair under local anaesthesia as a day case procedure were included. Patients below 20 years of age were excluded. Similarly those patients having acute complications of hernia like obstruction and strangulation were also excluded. Patients were followed up in the OPD for 02 years and any positive findings noted during this time period, recorded. All 135 patients were male with mean age of 52.5 years [ +/- 2.4 years SD]. Fifty-eight [42.96%] patients had direct inguinal hernia [right side 35 cases and left side 23 cases]. Seventy-seven had indirect inguinal hernia [right side 45 cases and left side 32 cases]. Postoperative complications included urinary retention in 08 [5.93%] cases, seroma formation in 06 [4.44%], wound infection in 10 [7.41%], scrotal oedema in 07 [5.19%] and chronic neuralgic pain in 02 [1.48%] cases. Three [2.94%] patients developed recurrence during the follow up period. Inguinal hernia mesh repair can be performed safely and effectively under local anaesthesia with minimal postoperative complications and acceptable results

Post operative outcomes of open versus closed haemorrhoidectomy

To compare the therapeutic results of open haemorrhoidectomy with closed one in terms of post operative pain, bleeding and wound healing. This experimental study was carried out in the surgical unit, at Hayatabad Medical Complex Peshawar from March to August 2009. Fifty patients of 2[nd], 3[rd] and 4[th] degree haemorrhoids having no systemic illnesses were included in this study. Patients were randomly divided in two equal groups. Group A included patients undergoing open haemorrhoidectomy and group B catered for patient with closed haemorrhoidectomies. Post operatively these patients were followed up in the OPD for 02 months and were evaluated for post operative pain, bleeding and wound healing in addition to other complications like urinary retention and anal fissure. The mean age of the sample was 45.5 +/- 2.3 years. In group B, 08 [32%] patients had mild pain, 10 [40%] had moderate and 02 [08%] had sever pain post operatively as compared to 13 [52%] patients with mild, 11[44%] with moderate and 06 [24%] with severe pain in group A [p < 0.05]. Similarly early post operative bleeding was noted in 15 [60%] patients in group A and 06 [24%] patients in group B [p < 0.05]. Wound healing time was just over 02 weeks in group B as compared to more than 04 weeks in group A [p < 0.05]. Closed haemorrhoidectomy technique is much better than open technique for 2[nd], 3[rd] and 4[th] degree haemorrhoids

Causes of mechanical intestinal obstruction in adults

To investigate the causes of mechanical intestinal obstruction in adults at surgical C unit Lady Reading Hospital Peshawar. This case series study was conducted at surgical C unit, of Lady Reading Hospital Peshawar, Pakistan from July 2006 to June 2007. In this study a total of 93 patients were included; who underwent exploratory laprotomy. These patients were diagnosed on the basis of clinical history, examination and radiological findings. After resuscitation, exploratory laprotomy was performed to confirm the diagnosis and relieve the obstruction. Laprotomy findings were recorded and where necessary specimen was sent for histopathology for definitive diagnosis. In this study of 93 cases, 100% patients presented with pain and abdominal distension. Other symptoms were less frequent. Males were 50 [53.76%] and females 43 [46.24%] with a male to female ratio of 2:1. 72. Tuberculosis [36.55%] was the leading cause of mechanical intestinal obstruction followed by carcinoma of the large gut [22.58%] and postoperative adhesions [21.51%]. Five [5.37%] patients had obstructed herniae and four [4.31%] had malignancy of the small gut. Three [3.22%] patients were with Meckle's diverticulum while 2 [2.15%] each had appendicular adhesions, intussusception and sigmoid volvulus. The causes of intestinal obstruction are variable in different parts of the world. Tuberculosis was the leading cause of dynamic intestinal obstruction in this study

Intermittent urethral self dilatation for prevention of recurrent stricture

To find out the role of clean intermitting self dilatation [CISD] for the prevention of recurrent urethral stricture. This comparative study of patients undergoing optical urethrotomy for anterior urethral stricture was conducted in Surgical Unit Hayatabad Medical Complex, Khyber Medical Centre and Khyber Teaching Hospital Peshawar from July 2004 to June 2008. A total of 146 male patients were included in the study. They were divided into two groups of 73 each on alternate basis. Group A was control group and group B with clean intermitting self dilatation and were followed upto 8 months. Study results showed a high rate of recurrence in control group A i.e. 42 patients [57.53%] in comparison to self dilatation group B i.e. 26 patients [35.61%]. Clean intermitting self dilatation is an effective procedure in the prevention of recurrent urethral strictures for primary strictures and deep strictures between 0.5-1.5cm length after optical urethrotomy

Early outcome of operative fixation of tibial pilon fractures

To evaluate the outcome of operative fixation of pilon fracture. It was descriptive, non randomized uncontrolled study. It was conducted at Civil Hospital Quetta. Study included 41 patients out of which 10 patients were excluded from study due to various reasons at the end of study 31 patients were available, whose results were analyzed. A total number of 31 patients entered the study between 15 June 2007 June 20, 2008. The patients that were lost in follow up were not included in the study. Out of the 31 cases in 11 the fibula was fixed with 1/3rd tubular plate with 3 patients having good, 4 fair and 5 poor result. Four cases where ORIF with spoon plate was done on tibia and maintaining fibula length by 1/3 tubular plate had good results [100%]. In 3 cases tibia was fixed by screw only and fibula length was maintained by 1/3 tubular plate one had good one fair and poor results. In cases where tibia was stabilized by external fixator either combined or in single one patients had good 5 fair and 12 poor results

Combined ilioinguinal block and local infiltration anaesthesia for inguinal hernia repair

To evaluate the benefit of adding ilioinguinal block to local infiltration anaesthesia for intraoperative analgesia in inguinal hernia repair. We performed a singled blinded randomized study on 232 patients. They had inguinal hernia repair using proline Darn under local infiltration anaesthesia, with or without additional ilioinguinal block. Intra operative and three hour post operative pain was accessed using visual analogue pain scale. Pain during operation was better controlled in patient who had local infiltration anaesthesia with the addition of ilioinguinal block, showing significant P value of .0009. Similarly duration of operation was significantly shorter in these patients with the P value of .005. Combination of ilioinguinal blockade improves the intraoperative analgesia and shortens the duration of operation

Diuretic radionuclide renography in assessing Anderson-Hynes pyeloplasty in unilateral pelvi-ureteric junction obstruction

To analyze the functional outcome of unilateral Anderson Hynes [AH] Pyeloplasty using DTPA renography in patients with symptomatic pelvi- ureteric junction [PUJ] obstruction. This study included 48 patients with PUJ-obstruction who underwent stentless AH pyeloplasty. Their record was analyzed for age, clinical presentation, pre and postoperative IVU and preoperative and postoperative DTPA renography finding. The out come of the pyeloplasty was evaluated by comparing preoperative and postoperative symptomatic improvement and DTPA renography split function result. The age range from 3yrs 25yrs with mean age 19.68 yrs. The were 35 [72.9%] male and 13[27.1%] female. The left side was involved in 31[64.58%], right side in 10[20.83%] and 7 [14.58%] patients had bilateral PUJ -obstruction. The predominant clinical presentation was pain in 36[75%], urinary tract infection in 4[8.33%], haematuria in 2[4.16%], while in 8[16.66%] patients it was an incidental finding. The patients were divided into 3 groups based on the renography split function. Group A: 20-30% function, 16 [33.33%] patients; Group B: 31-40% function, 12[25%] patients and Group C: >40% function, 20 [41.66%] patients. Post pyeloplasty scan revealed stable renal function in 19[39.58%] patients, while improvement was noticed in 21[43.75%] patients. The remaining 8[16.66%] had deterioration in renal function. Anderson-Hynes Pyeloplasty is an effective treatment for PUJ-obstruction. 99mT-DTPA renal scan is an important investigation in diagnosing PUJ-obstruction and evaluating the outcome of surgical intervention

Frequency of carcinoma in specimens of clinically benign enlarged prostate

To determine the frequency of carcinoma prostate on histology.in specimens obtained from patients with clinically benign enlarged prostate. Descriptive study. This study was carried out in Khyber Teaching Hospital [KTH]Surgical ward D and Lady Reading Hospital [LRH] surgical ward A. Peshawar from January 2004 to December2004. A total of 107 patients who presented to Surgical OPD with bladder outflow obstruction and fulfilled the inclusion and exclusion criteria of the study were included in the study. After an informed consent history.clinically examination and related investigations were carried out. All the patients underwent transvesical prostatectomy [TVP] and their prostate specimens were subjected to histopathology. Total number of patients was 107. Most of the patients [58.88%] with benign prostatic hypertrophy [BPH] were in age range of 56 - 60 years. The common presenting complaints were prostatism [57.94%] and acute retention [34.58%]. All patients underwent trans vesical prostatectomy [TVP]. On histopathology 3.74% turned out as adenocarinoma prostate while 96.26% biopsies showed BPH. The mean age of presentation with carcinoma [Ca] prostate was 65 years.In this study the frequency of Ca prostate in specimens of clinically benign enlarged gland was 3.74%. Therefore all specimens must be submitted for histopathology after prostatectomy

Role of internal urethrotomy in transurethral resection of prostate [TURP]

To see the benefit of internal urethrotomy before TURP for preventing urethral stricture formation. The study was conducted on two hundred patients undergoing TURP. Half of them had internal urethrotomy at 12 o'clock position before the insertion of resectoscope sheath. These patients were followed for 1 year for evidence of Urethral Stricture formation. Sixteen patients in Group A who did not have OTIS-Urethrotomy prior to TURP develop Urethral stricture with in 1 year compared to only 5 patient in Group-B. Routine use of internal Urethrotomy is beneficial in reducing the incidence of urethral stricture formation after TURP