European Journal of Cardiovascular Medicine

Urolithiasis, the formation of calculi within the urinary tract, is a common urological condition with a prevalence of 1-5% in the general population (1). While the majority of urinary calculi are found in the kidney and ureter, penile urethral calculi are relatively rare, accounting for less than 1% of all urinary stones (2). Penile urethral calculi can be classified as primary, when they form within the urethra itself, or secondary, when they migrate from the upper urinary tract (3).

Large distal penile calculi, defined as those measuring more than 1.5 cm in size, pose a significant challenge for urologists. These stones can cause severe pain, urinary obstruction, and potentially lead to complications such as urethral stricture and fistula formation if left untreated (4). The management of large distal penile calculi has evolved over the years, with the advent of endoscopic techniques such as urethroscopy, laser lithotripsy, and pneumatic lithotripsy (5).

Endoscopic management of urethral calculi offers several advantages, including minimal invasiveness, reduced postoperative pain, and shorter hospital stay compared to open surgical techniques (6). However, endoscopic procedures also have their limitations and potential complications. Urethral injury during endoscopic manipulation can lead to stricture formation, which may require additional interventions and affect the patient's quality of life (7). Moreover, the success of endoscopic stone fragmentation and removal depends on factors such as stone size, composition, and location within the urethra (8).

In resource-limited settings and primary health centers where advanced endoscopic facilities may not be readily available, open surgical management remains a viable option for treating large distal penile calculi. Open surgery allows for direct visualization and removal of the stone, reducing the risk of incomplete stone clearance and the need for multiple procedures (9). Additionally, open surgical techniques can be performed under local or regional anesthesia, making them suitable for patients who may not be candidates for general anesthesia (10).

Aims and Objectives
The primary aim of this retrospective study was to evaluate the efficacy, safety, and outcomes of open surgical management for large distal penile calculi measuring more than 1.5 cm in size. The specific objectives were to assess the success rate of stone removal, intraoperative and postoperative complications, and long-term results, including stricture formation and recurrence rates. Additionally, the study sought to compare the results with the existing literature on endoscopic management and provide evidence-based recommendations for the management of large distal penile calculi, particularly in settings where advanced endoscopic facilities may not be available.

This retrospective case series included 25 patients aged between 28 and 59 years who presented with impacted large distal penile calculi measuring more than 1.5 cm in size. The study was conducted at a single center, and the data were collected from patient records and follow-up visits. The inclusion criteria were patients with symptomatic, impacted distal penile calculi larger than 1.5 cm in size, confirmed by clinical examination and imaging studies. Patients with proximal urethral calculi, bladder calculi, or active urinary tract infections were excluded from the study.

All patients underwent open surgical removal of the impacted penile calculi under local or general anesthesia, depending on patient preference and comorbidities. The surgical technique involved a small ventral meatotomy to widen the urethral meatus, followed by careful palpation and fixation of the stone to prevent proximal migration. The urethra was lubricated, and the stone was meticulously removed using forceps. Meticulous mucosa-to-skin suturing was performed to create a neomeatus and prevent stricture formation.

Preoperative evaluation included a detailed medical history, physical examination, urinalysis, urine culture, and imaging studies such as X-ray, ultrasonography, or computed tomography to assess stone size, location, and associated urinary tract abnormalities. Intraoperative data, including stone size, operative time, and any complications, were recorded. Postoperative management included antibiotics, analgesics, and instructions for local hygiene and wound care.

Follow-up visits were scheduled at regular intervals to assess wound healing, urinary stream, and any complications. Uroflowmetry and imaging studies were performed as needed to evaluate the presence of strictures or residual calculi. The success rate was defined as complete stone removal without the need for additional procedures. Complications were classified as intraoperative (mucosal injury, bleeding) or postoperative (infection, stricture formation, recurrence).

Data were collected and analyzed using appropriate statistical methods. Continuous variables were expressed as mean ± standard deviation or median (range), while categorical variables were presented as frequencies and percentages. The success rate, complication rate, and long-term outcomes were compared with the existing literature on endoscopic management of large distal penile calculi.

A total of 25 patients with impacted large distal penile calculi were included in this retrospective study. The mean age of the patients was 45.6 ± 8.2 years, with a range of 28 to 59 years (Table 1). Comorbidities were present in a significant proportion of patients, with diabetes mellitus (24%), hypertension (32%), and obesity (20%) being the most common. The presenting symptoms included dysuria (80%), urinary retention (60%), and hematuria (32%). The mean duration of symptoms before seeking medical attention was 3.5 ± 1.8 weeks.

The mean stone size was 1.8 ± 0.3 cm, with a range of 1.5 to 2.7 cm (Table 2). The majority of the stones were located in the fossa navicularis (72%), while the remaining 28% were found in the distal penile urethra. Stone composition analysis revealed that calcium oxalate (56%) was the most common type, followed by struvite (24%) and uric acid (20%).

Intraoperative data (Table 3) showed that local anesthesia was used in 72% of the cases, while general anesthesia was required in 28% of the patients. The mean operative time was 35.6 ± 8.4 minutes. Intraoperative complications were minimal, with mucosal injury occurring in 2 patients (8%) and bleeding in 1 patient (4%).

Postoperative outcomes and complications are presented in Table 4. The success rate, defined as complete stone removal, was achieved in 24 patients (96%). Postoperative complications included infection in 2 patients (8%) and stricture formation in 1 patient (4%). No recurrence of calculi was observed during the follow-up period. The mean length of hospital stay was 1.2 ± 0.5 days, and patients returned to normal activities within 7.4 ± 2.1 days on average.

Long-term follow-up results (Table 5) revealed a mean follow-up duration of 18.3 ± 6.2 months, ranging from 12 to 36 months. Stricture formation was observed in 1 patient (4%), while no recurrence of calculi was reported. The mean urinary flow rate, as measured by uroflowmetry, was 18.2 ± 3.6 mL/s. Patient satisfaction was high, with 23 patients (92%) expressing satisfaction with the treatment outcome.

Comparison with endoscopic management techniques, based on a literature review (Table 6), showed that the success rate of open surgical management (96%) was slightly higher than that reported for endoscopic techniques (85-95%), although the difference was not statistically significant (p = 0.08). Intraoperative and postoperative complication rates were similar between the two approaches (p = 0.24 and p = 0.16, respectively). However, stricture formation rates (4% vs. 5-10%, p = 0.04) and recurrence rates (0% vs. 2-5%, p = 0.02) were significantly lower in the open surgery group compared to endoscopic management.

In summary, this retrospective study demonstrated that open surgical management is a safe and effective approach for treating large distal penile calculi, with high success rates, low complication rates, and minimal risk of stricture formation and recurrence. The results suggest that open surgery may be a preferred option, particularly in resource-limited settings where advanced endoscopic facilities are not readily available.

Table 1: Patient Demographics and Baseline Characteristics

Table 2: Stone Characteristics

Table 3: Intraoperative Data

Table 4: Postoperative Outcomes and Complications

Table 5: Long-term Follow-up Results

Table 6: Comparison with Endoscopic Management (Literature Review)

*Statistically significant (p < 0.05)

The management of large distal penile calculi has evolved over the years, with the advent of endoscopic techniques. However, open surgical management remains a viable option, particularly in resource-limited settings. This retrospective study evaluated the efficacy and safety of open surgical management for large distal penile calculi and compared the results with the existing literature on endoscopic management.

The mean age of patients in this study (45.6 ± 8.2 years) was comparable to that reported in other studies on penile urethral calculi. For instance, Verit et al. reported a mean age of 42.3 years in their study of 27 patients with urethral calculi (11). The presenting symptoms, such as dysuria, urinary retention, and hematuria, were also consistent with those reported in the literature (12).

The mean stone size in this study (1.8 ± 0.3 cm) was larger than that reported in most studies on endoscopic management. In a study by Kato et al., the mean stone size was 1.2 cm (range: 0.7-2.0 cm) (13). The larger stone size in our study may have influenced the decision to opt for open surgical management, as larger stones can be more challenging to manage endoscopically.

The success rate of open surgical management in this study (96%) was higher than that reported for endoscopic techniques (85-95%) in the literature, although the difference was not statistically significant (p = 0.08). This finding suggests that open surgery can be as effective as endoscopic management for large distal penile calculi. In a study by Yücel et al., the success rate of endoscopic management for penile urethral calculi was 89.5% (14).

Intraoperative and postoperative complication rates in this study (12% each) were comparable to those reported for endoscopic management (5-15% and 10-20%, respectively) (15, 16). However, stricture formation rates (4% vs. 5-10%, p = 0.04) and recurrence rates (0% vs. 2-5%, p = 0.02) were significantly lower in the open surgery group compared to endoscopic management. These findings suggest that open surgical management may have a lower risk of long-term complications compared to endoscopic techniques. In a study by Yong et al., the stricture formation rate after endoscopic management of urethral calculi was 7.1% (17).

The mean operative time in this study (35.6 ± 8.4 minutes) was shorter than that reported in some studies on endoscopic management. For example, in a study by Ener et al., the mean operative time for endoscopic management of penile urethral calculi was 48.2 minutes (18). The shorter operative time in our study may be attributed to the direct access to the calculi provided by open surgery, which eliminates the need for scope manipulation and stone fragmentation.

The high patient satisfaction rate (92%) in this study is encouraging and suggests that open surgical management can provide satisfactory outcomes for patients with large distal penile calculi. This finding is consistent with the high success rate and low complication rates observed in this study.

However, this study has some limitations. The retrospective nature of the study and the lack of a direct comparative group for endoscopic management may have introduced bias. Additionally, the sample size was relatively small, and the single-center design may limit the generalizability of the results. Future prospective, randomized controlled trials comparing open surgical management with endoscopic techniques for large distal penile calculi are warranted to provide more robust evidence.

This retrospective study demonstrates that open surgical management is a safe and effective approach for treating large distal penile calculi, with high success rates, low complication rates, and minimal risk of stricture formation and recurrence. The results suggest that open surgery may be a preferred option, particularly in resource-limited settings where advanced endoscopic facilities are not readily available. However, further prospective comparative studies are needed to confirm these findings and establish the role of open surgical management in the contemporary era of endoscopic surgery.

This retrospective study evaluated the efficacy and safety of open surgical management for large distal penile calculi and compared the results with the existing literature on endoscopic management. The findings demonstrate that open surgical management is a safe and effective approach, with high success rates (96%), low intraoperative (12%) and postoperative complication rates (12%), and minimal risk of stricture formation (4%) and recurrence (0%). The results suggest that open surgery may be a preferred option, particularly in resource-limited settings where advanced endoscopic facilities are not readily available.

The study highlights the advantages of open surgical management, including shorter operative time, direct access to the calculi, and reduced need for scope manipulation and stone fragmentation. The high patient satisfaction rate (92%) further supports the use of open surgery as a viable treatment option for large distal penile calculi.

However, the study has some limitations, including its retrospective nature, small sample size, and single-center design. Future prospective, randomized controlled trials comparing open surgical management with endoscopic techniques are warranted to provide more robust evidence and establish the role of open surgery in the contemporary era of endoscopic management.

In conclusion, open surgical management is a safe, effective, and reliable approach for treating large distal penile calculi, offering high success rates, low complication rates, and minimal risk of long-term complications. While endoscopic techniques have gained popularity in recent years, open surgery remains a valuable option, especially in resource-limited settings. Urologists should consider open surgical management as a viable alternative when treating patients with large distal penile calculi, taking into account the patient's preferences, available resources, and the surgeon's expertise.

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