Can proliferative hypertrophic scars of the median sternotomy incision predict the occurrence and characteristics of urethral stricture?

Huseyin Aydemir, Hasan S. Saglam, Salih Budak, Osman Kose, Ahmet Gokce


Objectives: To investigate the correlation between the characteristics of urethral stricture and incision scars in patients with urethral stricture and median sternotomy incision. 

Methods: We identified 368 patients who had undergone internal urethrotomy between January 2014 and December 2017. A total of 49 male patients with a median sternotomy scar and diagnosed with  urethral stricture were retrospectively evaluated. The median sternotomy incision scars were assessed using the Vancouver Scar Scale (VSS) and the patients were divided into 2 groups. Group I consisted of patients with a VSS score of less than 4 points, and those with ≥4 points constituted group II. The groups were compared in terms of age, smoking habit, body mass index, diabetes mellitus, hypertension, urethral stricture etiology, length and localization, and stricture relapse after intervention.

Results: The mean total VSS score was 2.0 points in group I and 7.46 points in group II. There was a significant correlation between the VSS total score and the urethral stricture length among the whole study population (correlation coefficient value=0.481; p less than 0.001). The urethral stricture was longer as the VSS score increased. 

Conclusion: A poorly healed median sternotomy incision scar can predict a poor wound healing in the urethra tissue. Further large scale, multi-center and prospective studies are needed to clarify this relationship.




Saudi Med J 2019; Vol. 40 (7): 701-706


How to cite this article:
Aydemir H, Saglam H, Budak S, Kose O, Gokce A. Can proliferative hypertrophic scars of the median sternotomy incision predict the occurance and characteristics of urethral stricture? Saudi Med J 2019; 40 (7): 701-706. doi:10.15537/smj.2019.7.24285


urethral strictures; hypertrophic scar; surgical incision; scar formation; wound healing

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Baskin LS, Constantinescu SC, Howard PS, McAninch JW, Ewalt DH, Duckett JW, et al. Biochemical characterization and quantitation of the collagenous components of urethral stricture tissue. J Urol 1993; 150: 642-647.

Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L. Contemporary urethral stricture characteristics in the developed world. Urology 2013; 81: 191-196.

Harraz AM, El-Assmy A, Mahmoud O, Elbakry AA, Tharwat M, Omar H, et al. Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures? Arab J Urol 2015; 13: 277-281.

Mundy AR, Andrich DE. Urethral strictures. BJU Int 2011; 107: 6-26.

Bhavsar S, Nimigan A, Hackam DG, O’Gorman DB, Gan BS, Spence JD. Keloid scarring, but not Dupuytren’s contracture, is associated with unexplained carotid atherosclerosis. Clin Invest Med 2009; 32: E95-E102.

Liao WT, Yu HS, Arbiser JL, Hong CH, Govindarajan B, Chai CY, et al. Enhanced MCP-1 release by keloid CD14+ cells augments fibroblast proliferation: role of MCP-1 and Akt pathway in keloids. Exp Dermatol 2010; 19: e142-e150.

Border WA, Noble NA. Transforming growth factor beta in tissue fibrosis. N Engl J Med 1994; 331: 1286-1292.

Kamath VV, Krishnamurthy S, Satelur KP, Rajkumar K. Transforming growth factor-β1 and TGF-β2 act synergistically in the fibrotic pathway in oral submucous fibrosis: An immunohistochemical observation. Indian J Med Paediatr Oncol 2015; 36: 111-116.

Zhang K, Chen J, Zhang D, Wang L, Zhao W, Lin DY, et al. microRNA expression profiles of scar and normal tissue from patients with posterior urethral stricture caused by pelvic fracture urethral distraction defects. Int J Mol Med 2018; 41: 2733-2743.

Atiyeh BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg 2007; 31: 468-492.

Jina NH, Marsh C, Than M, Singh H, Cassidy S, Simcock J. Keratin gel improves poor scarring following median sternotomy. ANZ J Surg 2015; 85: 378-380.

Li YH, Yang J, Liu JQ, Xie ST, Zhang YJ, Zhang W, et al. A Randomized, placebo-controlled, double-blind, prospective clinical trial of botulinum toxin type A in prevention of hypertrophic scar development in median sternotomy wound. Aesthetic Plast Surg 2018; 42: 1364-1369.

Sherris DA, Larrabee WF Jr, Murakami CS. Management of scar contractures, hypertrophic scars, and keloids. Otolaryngol Clin North Am 1995; 28: 1057-1068.

Sproat JE, Dalcin A, Weitauer N, Roberts RS. Hypertrophic sternal scars: silicone gel sheet versus Kenalog injection treatment. Plast Reconstr Surg 1992; 90: 988-992.

Nedelec B, Shankowsky HA, Tredget EE. Rating the resolving hypertrophic scar: comparison of the Vancouver Scar Scale and scar volume. J Burn Care Rehabil 2000; 21: 205-212.

Thompson CM, Sood RF, Honari S, Carrougher GJ, Gibran NS. What score on the Vancouver Scar Scale constitutes a hypertrophic scar? Results from a survey of North American burn-care providers. Burns 2015; 41: 1442-1448.

Li-Tsang CW, Lau JC, Chan CC. Prevalence of hypertrophic scar formation and its characteristics among the Chinese population. Burns 2005; 31: 610-616.

Wolfram D, Tzankov A, Pülzl P, Piza-Katzer H. Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009; 35: 171-181.

Truong PT, Abnousi F, Yong CM, Hayashi A, Runkel JA, Phillips T, et al. Standardized assessment of breast cancer surgical scars integrating the Vancouver Scar Scale, short-form McGill pain questionnaire, and patients’ perspectives. Plast Reconstr Surg 2005; 116: 1291-1299.

Jina H, Simcock J. Median sternotomy scar assessment. N Z Med J 2011; 124: 57-62.

Child FJ, Fuller LC, Higgins EM, Du Vivier AW. A study of the spectrum of skin disease occurring in a black population in south-east London. Br J Dermatol 1999; 141: 512-517.

Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol 2007; 177: 1667-1674.

Kinnaird AS, Levine MA, Ambati D, Zorn JD, Rourke KF. Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties. Can Urol Assoc J 2014; 8: E296-E300.

Ruutu M, Alfthan O, Heikkinen L, Järvinen A, Lehtonen T, Merikallio E, et al. “Epidemic” of acute urethral stricture after open-heart surgery. Lancet 1982; 1: 218.

Wilksch J, Vernon-Roberts B, Garrett R, Smith K. The role of catheter surface morphology and extractable cytotoxic material in tissue reactions to urethral catheters. Br J Urol 1983; 55: 48-52.

Buchholz NP, Riehmann M, Gasser TC. Absence of urethral strictures with suprapubic urinary drainage during extracorporeal circulation. J Urol 1993; 150: 337-339.

Ziyrek M, Şahin S, Acar Z, Şen O. The relationship between proliferative scars and endothelial function in surgically revascularized patients. Balkan Med J 2015; 32: 377-381.

Dustan HP. Does keloid pathogenesis hold the key to understanding black/white differences in hypertension severity? Hypertension 1995; 26: 858-862.

Nacey JN, Delahunt B. Urinary catheter toxicity. N Z Med J 1991; 104: 355-356.

Butzelaar L, Soykan EA, Galindo Garre F, Beelen RH, Ulrich MM, Niessen FB, et al. Going into surgery: Risk factors for hypertrophic scarring. Wound Repair Regen 2015; 23: 531-537.


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