from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.style import WD_STYLE_TYPE
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

doc = Document()

# ── Page margins ─────────────────────────────────────────────────────────────
section = doc.sections[0]
section.page_width  = Cm(21)
section.page_height = Cm(29.7)
section.left_margin   = Cm(3.0)
section.right_margin  = Cm(2.5)
section.top_margin    = Cm(2.5)
section.bottom_margin = Cm(2.5)

# ── Base style ───────────────────────────────────────────────────────────────
normal = doc.styles["Normal"]
normal.font.name = "Times New Roman"
normal.font.size = Pt(12)

def set_para_format(para, space_before=0, space_after=6, line_spacing=1.5, align=WD_ALIGN_PARAGRAPH.JUSTIFY):
    pf = para.paragraph_format
    pf.space_before   = Pt(space_before)
    pf.space_after    = Pt(space_after)
    pf.line_spacing   = Pt(line_spacing * 12)
    pf.alignment      = align

def add_heading1(doc, text):
    p = doc.add_paragraph()
    run = p.add_run(text.upper())
    run.bold = True
    run.font.size = Pt(14)
    run.font.name = "Times New Roman"
    p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER
    p.paragraph_format.space_before = Pt(12)
    p.paragraph_format.space_after  = Pt(6)
    return p

def add_section_heading(doc, text):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = True
    run.font.size = Pt(14)
    run.font.name = "Times New Roman"
    run.font.underline = True
    p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.LEFT
    p.paragraph_format.space_before = Pt(14)
    p.paragraph_format.space_after  = Pt(4)
    return p

def add_body(doc, text, bold_prefix=None):
    p = doc.add_paragraph()
    if bold_prefix:
        rb = p.add_run(bold_prefix + " ")
        rb.bold = True
        rb.font.size = Pt(12)
        rb.font.name = "Times New Roman"
    r = p.add_run(text)
    r.font.size = Pt(12)
    r.font.name = "Times New Roman"
    set_para_format(p)
    return p

def add_bullet(doc, text, bold_prefix=None):
    p = doc.add_paragraph(style="List Bullet")
    if bold_prefix:
        rb = p.add_run(bold_prefix + ": ")
        rb.bold = True
        rb.font.size = Pt(12)
        rb.font.name = "Times New Roman"
    r = p.add_run(text)
    r.font.size = Pt(12)
    r.font.name = "Times New Roman"
    p.paragraph_format.space_after = Pt(3)
    return p

def add_numbered(doc, text):
    p = doc.add_paragraph(style="List Number")
    r = p.add_run(text)
    r.font.size = Pt(12)
    r.font.name = "Times New Roman"
    p.paragraph_format.space_after = Pt(3)
    return p

def page_break(doc):
    doc.add_page_break()

# ══════════════════════════════════════════════════════════════════════════════
#  TITLE PAGE
# ══════════════════════════════════════════════════════════════════════════════
p = doc.add_paragraph()
r = p.add_run("UNIVERSITY OF HEALTH SCIENCES, LAHORE")
r.bold = True; r.font.size = Pt(16); r.font.name = "Times New Roman"
p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER
p.paragraph_format.space_before = Pt(0)
p.paragraph_format.space_after  = Pt(8)

p = doc.add_paragraph()
r = p.add_run("SYNOPSIS FOR MS / FCPS RESEARCH")
r.bold = True; r.font.size = Pt(14); r.font.name = "Times New Roman"
p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER
p.paragraph_format.space_after = Pt(24)

# Title block
p = doc.add_paragraph()
r = p.add_run(
    "HOLMIUM YAG LASER VERSUS COLD KNIFE IN OPTICAL INTERNAL URETHROTOMY "
    "FOR MANAGEMENT OF ANTERIOR URETHRAL STRICTURE OF LESS THAN 1.5 CM: "
    "A QUASI-EXPERIMENTAL STUDY"
)
r.bold = True; r.font.size = Pt(14); r.font.name = "Times New Roman"
p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER
p.paragraph_format.space_before = Pt(12)
p.paragraph_format.space_after  = Pt(36)

# Candidate info table
table = doc.add_table(rows=8, cols=2)
table.style = "Table Grid"
data = [
    ("Candidate's Name:", "[Name of Candidate]"),
    ("Father's Name:",    "[Father's Name]"),
    ("Registration No.:", "[UHS Reg. No.]"),
    ("Session:",          "[Session Year]"),
    ("Degree:",           "MS / FCPS Urology"),
    ("Supervisor's Name:", "[Name & Designation]"),
    ("Co-Supervisor's Name:", "[Name & Designation]"),
    ("Institution:",      "[Name of Institution, City]"),
]
for i, (lbl, val) in enumerate(data):
    table.rows[i].cells[0].text = lbl
    table.rows[i].cells[1].text = val
    for cell in table.rows[i].cells:
        for para in cell.paragraphs:
            for run in para.runs:
                run.font.size = Pt(12)
                run.font.name = "Times New Roman"
        if cell == table.rows[i].cells[0]:
            for para in cell.paragraphs:
                for run in para.runs:
                    run.bold = True

p = doc.add_paragraph()
p.paragraph_format.space_after = Pt(24)

p = doc.add_paragraph()
r = p.add_run("Date of Submission: _______________________")
r.font.size = Pt(12); r.font.name = "Times New Roman"
p.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  TABLE OF CONTENTS
# ══════════════════════════════════════════════════════════════════════════════
add_heading1(doc, "Table of Contents")

toc_items = [
    ("1.", "Project Summary (Abstract)", ""),
    ("2.", "Introduction", ""),
    ("3.", "Review of Literature", ""),
    ("4.", "Rationale", ""),
    ("5.", "Hypothesis", ""),
    ("6.", "Objectives", ""),
    ("7.", "Operational Definitions", ""),
    ("8.", "Material and Methods", ""),
    ("  8.1", "Study Design", ""),
    ("  8.2", "Study Setting", ""),
    ("  8.3", "Duration of Study", ""),
    ("  8.4", "Sample Size", ""),
    ("  8.5", "Sampling Technique", ""),
    ("  8.6", "Inclusion / Exclusion Criteria", ""),
    ("  8.7", "Data Collection Procedure", ""),
    ("  8.8", "Data Analysis", ""),
    ("9.", "Ethical Considerations", ""),
    ("10.", "Work Plan / Timeline", ""),
    ("11.", "References", ""),
    ("12.", "Annexures", ""),
]
for num, title, pg in toc_items:
    p = doc.add_paragraph()
    r = p.add_run(f"{num}   {title}")
    r.font.size = Pt(12); r.font.name = "Times New Roman"
    if num.strip().endswith(".") and len(num.strip()) <= 3:
        r.bold = True
    p.paragraph_format.space_after = Pt(2)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  LIST OF ABBREVIATIONS
# ══════════════════════════════════════════════════════════════════════════════
add_heading1(doc, "List of Abbreviations")

abbrevs = [
    ("Ho:YAG",  "Holmium: Yttrium-Aluminium-Garnet"),
    ("OIU",     "Optical Internal Urethrotomy"),
    ("HIU",     "Holmium Laser Internal Urethrotomy"),
    ("CIU",     "Cold Knife (Optical) Internal Urethrotomy"),
    ("VIU",     "Visual Internal Urethrotomy"),
    ("AUS",     "Anterior Urethral Stricture"),
    ("Qmax",    "Maximum Urine Flow Rate"),
    ("IPSS",    "International Prostate Symptom Score"),
    ("PVR",     "Post-Void Residual Urine"),
    ("RUG",     "Retrograde Urethrogram"),
    ("MCU",     "Micturating Cystourethrogram"),
    ("LUTS",    "Lower Urinary Tract Symptoms"),
    ("SPSS",    "Statistical Package for the Social Sciences"),
    ("SD",      "Standard Deviation"),
    ("CI",      "Confidence Interval"),
    ("UTI",     "Urinary Tract Infection"),
    ("IRB/ERC", "Institutional Review Board / Ethical Review Committee"),
    ("UHS",     "University of Health Sciences"),
]
for abbr, meaning in abbrevs:
    p = doc.add_paragraph()
    rb = p.add_run(f"{abbr:<12}")
    rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
    r = p.add_run(f"  {meaning}")
    r.font.size = Pt(12); r.font.name = "Times New Roman"
    p.paragraph_format.space_after = Pt(2)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  1. PROJECT SUMMARY / ABSTRACT
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "1. PROJECT SUMMARY (STRUCTURED ABSTRACT)")

add_body(doc, "", bold_prefix="Background:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "Anterior urethral stricture (AUS) is a frequently encountered urological "
    "condition characterised by fibrotic narrowing of the urethral lumen that "
    "causes obstructive lower urinary tract symptoms and significantly impairs "
    "quality of life. Optical internal urethrotomy (OIU) is the most widely "
    "performed endoscopic intervention for short-segment strictures. Two "
    "principal energy sources are employed: the conventional cold knife (Sachse) "
    "and the Holmium:YAG (Ho:YAG) laser. Although both modalities have been "
    "used extensively, head-to-head data specifically targeting strictures of "
    "less than 1.5 cm in Pakistani patients remain scarce."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Objective:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "To compare the outcomes of Ho:YAG laser urethrotomy with cold knife OIU "
    "in terms of improvement in maximum urine flow rate (Qmax), recurrence "
    "rate, operative time, and perioperative complications in patients with "
    "anterior urethral stricture of less than 1.5 cm."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Study Design:")
p = doc.paragraphs[-1]; p.runs[-1].text = "Quasi-experimental study."
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Setting:")
p = doc.paragraphs[-1]
p.runs[-1].text = "Department of Urology, [Name of Institution], [City], Pakistan."
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Duration:")
p = doc.paragraphs[-1]; p.runs[-1].text = "One year from the date of approval of synopsis."
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Sample Size:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "60 patients (30 in each group), calculated using the two-proportion formula "
    "with 80% power and 5% level of significance."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Intervention:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "Group A (n=30) will undergo Ho:YAG laser OIU; Group B (n=30) will undergo "
    "cold knife OIU. Both groups will be followed up at 1, 3, 6 and 12 months."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Outcome Measures:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "Primary: Qmax improvement and stricture recurrence rate at 12 months. "
    "Secondary: Operative time, intraoperative bleeding, post-operative "
    "catheterisation time, UTI, and IPSS score."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Keywords:")
p = doc.paragraphs[-1]
p.runs[-1].text = (
    "Holmium:YAG laser, Cold knife urethrotomy, Anterior urethral stricture, "
    "Optical internal urethrotomy, Quasi-experimental study."
)
set_para_format(doc.paragraphs[-1])

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  2. INTRODUCTION
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "2. INTRODUCTION")

add_body(doc,
    "Urethral stricture disease is among the oldest recorded urological conditions, "
    "with descriptions dating back to ancient Egyptian and Greek medical texts. "
    "A urethral stricture is defined as a narrowing of the urethral lumen resulting "
    "from fibrosis and scarring of the corpus spongiosum, a process termed "
    "spongiofibrosis. In clinical practice, the term 'urethral stricture' refers "
    "predominantly to disease of the anterior urethra - the bulbar, penile and "
    "fossa navicularis segments. Anterior strictures account for approximately "
    "92.2% of all urethral strictures, with bulbar strictures being the most "
    "common subtype, comprising nearly 46.9% of cases."
)

add_body(doc,
    "The global prevalence of male urethral stricture is estimated at 229-627 per "
    "100,000 males, with a sharp rise in incidence after the age of 55 years. In "
    "developing countries including Pakistan, the burden may be higher owing to "
    "prevalent urethral infections, suboptimal catheterisation practices, and "
    "delayed presentation. The condition produces obstructive lower urinary tract "
    "symptoms such as weak stream, straining, incomplete voiding, and in severe "
    "cases, acute or chronic urinary retention, with consequent adverse effects on "
    "renal function and quality of life."
)

add_body(doc,
    "The aetiology of anterior urethral stricture is multifactorial. Traumatic "
    "causes, including straddle injuries and pelvic fractures, are reported as the "
    "leading identifiable aetiology, accounting for up to 59.4% of cases in some "
    "series. Iatrogenic causes, predominantly related to urethral catheterisation "
    "and transurethral procedures, constitute 16.6-38.6% of cases. Inflammatory "
    "and infective causes, including gonococcal urethritis and lichen sclerosus, "
    "represent another important subset. A significant proportion - ranging from "
    "23.6% to 41.3% - remains idiopathic."
)

add_body(doc,
    "The pathophysiology involves initial injury to the urethral epithelium, "
    "followed by extravasation of urine or direct trauma to the corpus spongiosum. "
    "This triggers a fibroinflammatory cascade resulting in progressive spongiofibrosis "
    "that compresses the urethral lumen. Short-segment strictures (less than 1.5 cm) "
    "at the bulbar or anterior urethra are frequently managed endoscopically, making "
    "the selection of the optimal urethrotomy technique a clinically important decision."
)

add_body(doc,
    "Optical internal urethrotomy (OIU) has been a cornerstone of endoscopic stricture "
    "management since Sachse introduced the cold knife technique in 1974. The procedure "
    "involves direct visualisation of the stricture followed by incision at the 12 "
    "o'clock position to release fibrotic tissue and restore urethral calibre. The "
    "cold knife technique is widely available, cost-effective, and well-understood, "
    "with reported success rates of 33-60% for short-segment primary strictures. "
    "However, it carries the risks of bleeding, false passage creation, and recurrence, "
    "particularly in strictures associated with dense spongiofibrosis."
)

add_body(doc,
    "The advent of laser energy in endourology introduced the Ho:YAG laser as an "
    "alternative energy source for urethrotomy. The Holmium:YAG laser (wavelength "
    "2140 nm) operates in a pulsed mode and is highly absorbed by water-containing "
    "tissue. Its tissue interaction is characterised by precise ablation with minimal "
    "collateral thermal damage, a depth of penetration of approximately 0.4 mm, and "
    "simultaneous haemostatic effect owing to coagulation of small blood vessels. "
    "These properties make it theoretically advantageous over the cold knife, "
    "particularly in minimising intraoperative bleeding, reducing collateral tissue "
    "damage, and potentially lowering recurrence by producing cleaner incision margins."
)

add_body(doc,
    "Despite the growing body of literature comparing these two techniques, several "
    "key questions remain unanswered in the Pakistani clinical context. Specifically, "
    "outcomes for strictures of less than 1.5 cm - a distinct subset where both "
    "techniques may demonstrate different performance profiles - have not been "
    "rigorously studied in our population. The present quasi-experimental study "
    "is therefore designed to provide locally relevant, comparative data on the "
    "two most commonly performed urethrotomy techniques in this specific stricture "
    "length category."
)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  3. REVIEW OF LITERATURE
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "3. REVIEW OF LITERATURE")

add_body(doc,
    "The comparative literature on cold knife optical internal urethrotomy (CIU) and "
    "Ho:YAG laser internal urethrotomy (HIU) has grown substantially over the past "
    "two decades. The following review synthesises the most relevant published evidence."
)

# Sub-heading
p = doc.add_paragraph()
rb = p.add_run("3.1  Systematic Reviews and Meta-analyses")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
rb.underline = True
p.paragraph_format.space_before = Pt(10); p.paragraph_format.space_after = Pt(4)

add_body(doc,
    "Chi et al. (2024) conducted a systematic review and meta-analysis of nine "
    "comparative studies evaluating HIU versus CIU in urethral stricture management "
    "(published in International Journal of Surgery). Key findings included: "
    "no significant difference in postoperative Qmax improvement overall (MD -0.06; "
    "95% CI: -0.28 to 0.16; P=0.60); no significant difference in operative time "
    "(MD 2.16; 95% CI: -1.66 to 5.99; P=0.27); and a trend towards lower recurrence "
    "with HIU that did not reach statistical significance (RR 0.71; 95% CI: 0.48-1.06; "
    "P=0.09). Importantly, perioperative bleeding was significantly less in the HIU "
    "group (RR 0.21; 95% CI: 0.08-0.53; P=0.001). Sub-analysis for short-segment "
    "strictures of 1.5 cm or less showed CIU required shorter operative time (MD 4.49; "
    "95% CI: 3.87-5.10; P<0.00001). For complex strictures, HIU demonstrated superior "
    "long-term Qmax at 12 months and lower recurrence at 12 months (RR 0.44; 95% CI: "
    "0.21-0.92; P=0.03). [PMID: 38573099]"
)

p = doc.add_paragraph()
rb = p.add_run("3.2  Randomised Controlled Trials")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
rb.underline = True
p.paragraph_format.space_before = Pt(10); p.paragraph_format.space_after = Pt(4)

add_body(doc,
    "Ali et al. (2023) conducted a prospective randomised clinical trial (published in "
    "World Journal of Urology) involving 66 male patients with short-segment bulbar "
    "urethral strictures less than 2 cm, randomised to cold knife (Group A, n=33) or "
    "Ho:YAG laser (Group B, n=33) urethrotomy. Both groups showed significant "
    "improvement in IPSS, PVR, and Qmax at all follow-up visits (1, 3, 6, and 12 months). "
    "At the end of the 12-month follow-up, a statistically significant difference emerged "
    "in IPSS, PVR, and Qmax between groups, attributable to higher recurrence in the cold "
    "knife group. The overall complication rate was significantly lower in the laser group "
    "(P=0.014). The authors concluded that Ho:YAG laser VIU is an effective and safe "
    "treatment option with shorter operative time, lower complication rate, and lower "
    "recurrence compared to cold knife VIU. [PMID: 37256320]"
)

p = doc.add_paragraph()
rb = p.add_run("3.3  Prospective Comparative Studies")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
rb.underline = True
p.paragraph_format.space_before = Pt(10); p.paragraph_format.space_after = Pt(4)

add_body(doc,
    "Yenice et al. (2018) prospectively studied 63 patients with primary bulbar urethral "
    "stricture assigned to OIU (n=29) or HIU (n=34) groups. Mean surgical time was "
    "significantly shorter in the OIU group (18.4 vs 21.9 minutes; P<0.05). Postoperative "
    "Qmax values improved significantly in both groups without significant between-group "
    "difference at 3, 6, and 12 months. Recurrence rates at 12 months were 20.7% for OIU "
    "versus 32.4% for HIU (P=0.299), a non-significant difference. Complication rates were "
    "comparable. The authors concluded that HIU is an alternative to OIU with similar "
    "success rates for short-segment bulbar strictures. [PMID: 29732217]"
)

add_body(doc,
    "Fallah Karkan et al. (2019) reviewed outcomes in 138 patients who underwent "
    "Ho:YAG laser urethrotomy, with a mean age of 48 years. Trauma was the most common "
    "aetiology (59.4%). Mean operative time was 23.08 minutes, and at 12-month follow-up "
    "the overall recurrence rate was 26.8%. Patients with longer strictures, posterior "
    "location, and prior interventions demonstrated higher recurrence. The authors "
    "confirmed that Ho:YAG laser urethrotomy is minimally invasive, safe, and effective "
    "particularly for primary, short urethral strictures. [PMID: 31360378]"
)

p = doc.add_paragraph()
rb = p.add_run("3.4  Summary of Evidence and Research Gap")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
rb.underline = True
p.paragraph_format.space_before = Pt(10); p.paragraph_format.space_after = Pt(4)

add_body(doc,
    "The existing literature collectively suggests that Ho:YAG laser urethrotomy "
    "offers comparable or superior outcomes relative to cold knife OIU in terms of "
    "recurrence rates and complication profiles, particularly in long-term follow-up. "
    "The most recent meta-analysis (Chi et al., 2024) provides the most robust "
    "evidence, noting that for short-segment strictures specifically (<=1.5 cm), "
    "CIU has a shorter operative time, while HIU has a lower risk of bleeding. "
    "However, no published study from Pakistan has specifically examined this "
    "outcome comparison in patients with anterior urethral strictures of less than "
    "1.5 cm, leaving a clear and clinically important research gap."
)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  4. RATIONALE
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "4. RATIONALE")

add_body(doc,
    "Anterior urethral strictures of less than 1.5 cm represent a clinically distinct "
    "and commonly encountered subset of stricture disease for which endoscopic "
    "management - rather than open urethroplasty - is the first-line approach in most "
    "international guidelines. Both cold knife OIU and Ho:YAG laser urethrotomy are "
    "performed at tertiary care urology centres across Pakistan; however, the selection "
    "of technique is largely based on the availability of equipment and individual "
    "surgeon preference rather than evidence derived from local patient populations."
)

add_body(doc,
    "International data, while growing, present variable conclusions depending on "
    "stricture characteristics, aetiology, and follow-up duration. No published "
    "Pakistani study specifically addresses the comparative outcomes of these two "
    "techniques in the short-stricture subgroup (less than 1.5 cm). Local factors "
    "including disease aetiology (high proportion of traumatic strictures), patient "
    "demographics, and healthcare resource constraints may influence outcomes "
    "differently from those reported in Western or East Asian cohorts."
)

add_body(doc,
    "Given that Ho:YAG laser technology involves a significant capital investment and "
    "its benefits over the simpler, less expensive cold knife technique in short "
    "strictures are not definitively established, this comparative study is "
    "operationally and financially justified. Generation of locally applicable data "
    "will guide institutional procurement decisions and standardise urethrotomy practice "
    "across hospitals affiliated with the University of Health Sciences, Lahore."
)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  5. HYPOTHESIS
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "5. HYPOTHESIS")

add_body(doc, "", bold_prefix="Null Hypothesis (H0):")
doc.paragraphs[-1].runs[-1].text = (
    "There is no significant difference in outcomes (Qmax improvement, recurrence "
    "rate, and complication rate) between Ho:YAG laser optical internal urethrotomy "
    "and cold knife optical internal urethrotomy for anterior urethral strictures "
    "of less than 1.5 cm."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Alternative Hypothesis (H1):")
doc.paragraphs[-1].runs[-1].text = (
    "Ho:YAG laser optical internal urethrotomy yields significantly better outcomes "
    "in terms of Qmax improvement, lower recurrence rate, and fewer complications "
    "compared to cold knife optical internal urethrotomy for anterior urethral "
    "strictures of less than 1.5 cm."
)
set_para_format(doc.paragraphs[-1])

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  6. OBJECTIVES
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "6. OBJECTIVES")

p = doc.add_paragraph()
rb = p.add_run("6.1  Primary Objective")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(6); p.paragraph_format.space_after = Pt(2)

add_bullet(doc,
    "To compare the improvement in maximum urine flow rate (Qmax) at 3, 6, and 12 "
    "months post-operatively between Ho:YAG laser OIU and cold knife OIU in patients "
    "with anterior urethral strictures of less than 1.5 cm."
)
add_bullet(doc,
    "To compare the stricture recurrence rate at 12 months post-operatively between "
    "the two groups."
)

p = doc.add_paragraph()
rb = p.add_run("6.2  Secondary Objectives")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(6); p.paragraph_format.space_after = Pt(2)

secondary_objs = [
    "To compare mean operative time between Ho:YAG laser OIU and cold knife OIU.",
    "To compare intraoperative bleeding rates between the two groups.",
    "To compare post-operative catheterisation duration between the two groups.",
    "To compare post-operative urinary tract infection (UTI) rates.",
    "To compare the change in International Prostate Symptom Score (IPSS) at 3, 6, and 12 months.",
    "To compare post-void residual urine (PVR) volumes at follow-up intervals.",
]
for obj in secondary_objs:
    add_bullet(doc, obj)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  7. OPERATIONAL DEFINITIONS
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "7. OPERATIONAL DEFINITIONS")

defs = [
    ("Anterior Urethral Stricture:",
     "A narrowing of the urethral lumen in the anterior urethra (bulbar, penile, or "
     "fossa navicularis) confirmed on retrograde urethrogram (RUG) and/or flexible "
     "urethroscopy, with a stricture length of less than 1.5 cm."),
    ("Optical Internal Urethrotomy (OIU):",
     "An endoscopic procedure performed under direct vision whereby the urethral "
     "stricture is incised using a urethrotome (cold knife or laser fibre) inserted "
     "through the urethra, restoring urethral calibre without open surgery."),
    ("Cold Knife OIU (CIU):",
     "OIU performed using the Sachse urethrotome with a hook-shaped or straight "
     "cold knife blade to incise the stricture under direct endoscopic vision "
     "at the 12 o'clock position."),
    ("Ho:YAG Laser OIU (HIU):",
     "OIU performed using a Holmium:YAG laser (wavelength 2140 nm) delivered via "
     "a small-diameter end-firing optical fibre (200-365 microns) inserted through "
     "the working channel of a urethroscope to ablate the stricture."),
    ("Stricture Recurrence:",
     "Re-narrowing of the urethra at the previously treated site, defined as a Qmax "
     "below 12 mL/s on uroflowmetry and confirmed by RUG or flexible urethroscopy "
     "at or before the 12-month follow-up, requiring re-intervention."),
    ("Qmax (Maximum Urine Flow Rate):",
     "The peak urinary flow rate in mL/s measured by uroflowmetry with a voided "
     "volume of at least 150 mL. A Qmax >= 15 mL/s post-operatively will be "
     "considered a successful outcome."),
    ("IPSS (International Prostate Symptom Score):",
     "A validated 7-item questionnaire scoring obstructive and irritative urinary "
     "symptoms on a scale of 0-35. Mild: 0-7; Moderate: 8-19; Severe: 20-35."),
    ("Operative Time:",
     "The time in minutes from insertion of the urethroscope to completion of the "
     "urethrotomy and placement of the urethral catheter."),
    ("Intraoperative Bleeding:",
     "Clinically significant bleeding during the procedure requiring endoscopic "
     "haemostasis, transfusion, or early catheter removal due to clot obstruction."),
]
for term, defn in defs:
    p = doc.add_paragraph()
    rb = p.add_run(term + "  ")
    rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
    r = p.add_run(defn)
    r.font.size = Pt(12); r.font.name = "Times New Roman"
    p.paragraph_format.space_before = Pt(4)
    p.paragraph_format.space_after  = Pt(4)
    p.paragraph_format.alignment    = WD_ALIGN_PARAGRAPH.JUSTIFY
    p.paragraph_format.line_spacing = Pt(18)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  8. MATERIAL AND METHODS
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "8. MATERIAL AND METHODS")

# 8.1
p = doc.add_paragraph()
rb = p.add_run("8.1  Study Design")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)
add_body(doc,
    "This is a quasi-experimental (non-randomised comparative) study. Consecutive "
    "eligible patients will be allocated to one of two groups based on the availability "
    "of the Ho:YAG laser system on the day of surgery. Group A will undergo Ho:YAG laser "
    "OIU and Group B will undergo cold knife OIU. This allocation method was chosen to "
    "reflect real-world theatre scheduling while minimising selection bias."
)

# 8.2
p = doc.add_paragraph()
rb = p.add_run("8.2  Study Setting")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)
add_body(doc,
    "Department of Urology, [Name of Hospital / Teaching Institution], [City], Pakistan. "
    "The institution is a tertiary care centre with dedicated endourology facilities "
    "including a Ho:YAG laser system and digital video urethroscopy equipment."
)

# 8.3
p = doc.add_paragraph()
rb = p.add_run("8.3  Duration of Study")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)
add_body(doc,
    "One year from the date of approval of the synopsis by the Advanced Studies and "
    "Research Board, University of Health Sciences, Lahore."
)

# 8.4
p = doc.add_paragraph()
rb = p.add_run("8.4  Sample Size")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)
add_body(doc,
    "Sample size was calculated using the two-proportion z-test formula:"
)
p_formula = doc.add_paragraph()
r = p_formula.add_run(
    "n = [Z(alpha/2) + Z(beta)]^2 x [P1(1-P1) + P2(1-P2)] / (P1 - P2)^2"
)
r.font.size = Pt(12); r.font.name = "Courier New"
p_formula.paragraph_format.alignment = WD_ALIGN_PARAGRAPH.CENTER
p_formula.paragraph_format.space_before = Pt(4)
p_formula.paragraph_format.space_after  = Pt(4)

add_body(doc,
    "Based on Ali et al. (2023), the recurrence rate was 24.2% for laser and 45.5% "
    "for cold knife at 12 months. Taking alpha=0.05 (two-tailed; Z=1.96) and power=80% "
    "(Z=0.84), the minimum sample size is 52 (26 per group). Adding 15% for attrition, "
    "the final sample size is 60 patients (30 per group)."
)

# 8.5
p = doc.add_paragraph()
rb = p.add_run("8.5  Sampling Technique")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)
add_body(doc,
    "Non-probability consecutive sampling. All patients meeting the eligibility criteria "
    "who present to the urology outpatient department or surgical admission ward during "
    "the study period will be enrolled until the required sample size is achieved."
)

# 8.6
p = doc.add_paragraph()
rb = p.add_run("8.6  Inclusion and Exclusion Criteria")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)

p = doc.add_paragraph()
r = p.add_run("Inclusion Criteria:")
r.bold = True; r.font.size = Pt(12); r.font.name = "Times New Roman"
p.paragraph_format.space_after = Pt(2)

incl = [
    "Male patients aged 18-70 years.",
    "Diagnosed with anterior urethral stricture of less than 1.5 cm in length on "
     "retrograde urethrogram (RUG) and/or flexible urethroscopy.",
    "Primary (first-time) urethral stricture with no prior urethrotomy or urethroplasty.",
    "Presenting with obstructive lower urinary tract symptoms (LUTS).",
    "Willing to give written informed consent and comply with follow-up visits.",
]
for item in incl:
    add_bullet(doc, item)

p = doc.add_paragraph()
r = p.add_run("Exclusion Criteria:")
r.bold = True; r.font.size = Pt(12); r.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(2)

excl = [
    "Posterior urethral strictures (membranous or prostatic urethra).",
    "Stricture length >= 1.5 cm on imaging.",
    "Recurrent stricture or previous urethrotomy/urethroplasty.",
    "Associated pelvic fracture urethral injury (PFUI) requiring urethroplasty.",
    "Active urinary tract infection not adequately treated pre-operatively.",
    "Bleeding diathesis or anticoagulation therapy that cannot be safely withheld.",
    "Known urethral malignancy.",
    "Patients with simultaneous bladder neck contracture or concomitant bladder pathology.",
    "Patients with neurogenic bladder.",
    "Unfit for regional or general anaesthesia due to severe comorbidities.",
]
for item in excl:
    add_bullet(doc, item)

# 8.7
p = doc.add_paragraph()
rb = p.add_run("8.7  Data Collection Procedure")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)

add_body(doc, "", bold_prefix="Pre-operative Assessment:")
doc.paragraphs[-1].runs[-1].text = (
    "All enrolled patients will undergo a standardised pre-operative assessment including "
    "detailed history, physical examination, urine analysis and culture, serum creatinine, "
    "complete blood count, coagulation profile, retrograde urethrogram (RUG), and "
    "uroflowmetry with Qmax and PVR measurement. The IPSS questionnaire will be "
    "administered. Strict radiological criteria will define stricture length."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Surgical Procedure - Group A (Ho:YAG Laser OIU):")
doc.paragraphs[-1].runs[-1].text = (
    "The procedure will be performed under spinal or general anaesthesia. A 17Fr or "
    "21Fr urethroscope will be used. On direct visualisation of the stricture, a "
    "200-365 micron end-firing Ho:YAG laser fibre will be introduced through the working "
    "channel. Laser settings (energy 0.8-1.5 J, frequency 10-20 Hz) will be set as per "
    "standard protocol. The stricture will be incised at the 12 o'clock position until "
    "normal tissue is reached. A 16Fr urethral catheter will be left in situ for 48-72 hours."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Surgical Procedure - Group B (Cold Knife OIU):")
doc.paragraphs[-1].runs[-1].text = (
    "Under the same anaesthetic conditions, a Sachse urethrotome will be used to incise "
    "the stricture at the 12 o'clock position under direct vision until healthy tissue is "
    "encountered proximally and distally. A 16Fr urethral catheter will be inserted and "
    "retained for 48-72 hours. Both procedures will be performed or directly supervised "
    "by the same consultant urologist to minimise operator variability."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Post-operative Care and Follow-up:")
doc.paragraphs[-1].runs[-1].text = (
    "All patients will receive prophylactic antibiotics per institutional protocol. "
    "Catheter removal will be performed at 48-72 hours post-operatively. "
    "Follow-up visits will be scheduled at 1 month (clinical assessment, uroflowmetry), "
    "3 months (uroflowmetry, PVR, IPSS), 6 months (uroflowmetry, PVR, IPSS, RUG if "
    "recurrence is suspected), and 12 months (uroflowmetry, PVR, IPSS, RUG). Recurrence "
    "will be defined as Qmax < 12 mL/s requiring re-intervention."
)
set_para_format(doc.paragraphs[-1])

add_body(doc, "", bold_prefix="Data Recording:")
doc.paragraphs[-1].runs[-1].text = (
    "All data will be recorded on a pre-designed, structured proforma (Annexure I) "
    "at each time point. Operative time, intraoperative bleeding, catheterisation "
    "duration, and any peri-operative complications will be noted at the time of "
    "surgery."
)
set_para_format(doc.paragraphs[-1])

# 8.8
p = doc.add_paragraph()
rb = p.add_run("8.8  Data Analysis")
rb.bold = True; rb.font.size = Pt(12); rb.font.name = "Times New Roman"
p.paragraph_format.space_before = Pt(8); p.paragraph_format.space_after = Pt(2)

add_body(doc,
    "Data will be entered and analysed using SPSS version 26.0 (IBM Corp., USA). "
    "Continuous variables (Qmax, PVR, IPSS, operative time) will be expressed as "
    "mean +/- standard deviation (SD) and compared between groups using the "
    "independent samples t-test. Non-normally distributed continuous variables will "
    "be compared using the Mann-Whitney U test. Categorical variables (recurrence rate, "
    "complication rates) will be expressed as frequency and percentage, and compared "
    "using Chi-square test or Fisher's exact test as appropriate. "
    "Repeated measures analysis (ANOVA) will be used to compare Qmax and IPSS "
    "across the four follow-up time points within and between groups. "
    "A P-value of less than 0.05 will be considered statistically significant."
)

add_body(doc,
    "Variables assessed:"
)
variables = [
    ("Dependent (Outcome) Variables:", "Qmax, IPSS, PVR, stricture recurrence rate, complication rate, operative time"),
    ("Independent Variable:",          "Type of OIU (Ho:YAG laser vs. cold knife)"),
    ("Confounding Variables:",         "Age, aetiology, stricture site (bulbar vs. penile), pre-operative Qmax - will be controlled by baseline comparability analysis"),
]
for lbl, val in variables:
    add_bullet(doc, val, bold_prefix=lbl)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  9. ETHICAL CONSIDERATIONS
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "9. ETHICAL CONSIDERATIONS")

add_body(doc,
    "The study will be conducted in accordance with the Declaration of Helsinki "
    "(2013 revision) and the ethical guidelines of the University of Health Sciences, "
    "Lahore. The following ethical safeguards will be observed:"
)

ethical_points = [
    "Approval will be obtained from the Institutional Ethical Review Committee (ERC/IRB) "
     "before commencement of the study.",
    "Written informed consent will be obtained from all patients in the patient's "
     "preferred language (Urdu or English) after a thorough explanation of the study "
     "purpose, procedures, potential risks and benefits, and the voluntary nature of "
     "participation.",
    "Both surgical techniques (Ho:YAG laser OIU and cold knife OIU) are established, "
     "standard-of-care procedures. No experimental intervention is being tested; "
     "patients will receive the same quality of care regardless of group allocation.",
    "Patients will be free to withdraw from the study at any time without prejudice "
     "to their clinical management.",
    "Patient identity and all personal data will be kept strictly confidential. "
     "Data will be coded and stored in a password-protected electronic database. "
     "Only the principal investigator and supervisors will have access to identifying "
     "information.",
    "No financial incentive will be offered to participants. All surgical procedures "
     "will be performed as per the standard hospital protocol.",
    "The study findings will be disseminated through peer-reviewed publication, "
     "and authorship will acknowledge UHS affiliation as required.",
]
for item in ethical_points:
    add_bullet(doc, item)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  10. WORK PLAN / TIMELINE
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "10. WORK PLAN / TIMELINE (GANTT CHART)")

add_body(doc, "The study will be completed in 12 months as outlined below:")

# Gantt table
gantt_data = [
    ("Phase",                          "Activity",                                                  "Month(s)"),
    ("Phase 1: Preparation",           "ERC approval, literature review, proforma design, staff training", "1"),
    ("Phase 2: Patient Enrolment",     "Consecutive enrolment, surgery (Group A & B), 1-month follow-up",  "2-4"),
    ("Phase 3: Follow-up",             "3-month, 6-month follow-up visits, data collection",               "5-10"),
    ("Phase 4: Final Follow-up",       "12-month follow-up, completion of data collection",                "11"),
    ("Phase 5: Analysis & Writing",    "Data entry, statistical analysis, thesis/manuscript writing",       "11-12"),
]
gt = doc.add_table(rows=len(gantt_data), cols=3)
gt.style = "Table Grid"
for i, row_data in enumerate(gantt_data):
    for j, cell_text in enumerate(row_data):
        cell = gt.rows[i].cells[j]
        cell.text = cell_text
        for para in cell.paragraphs:
            for run in para.runs:
                run.font.size = Pt(11)
                run.font.name = "Times New Roman"
                if i == 0:
                    run.bold = True

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  11. REFERENCES
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "11. REFERENCES")

add_body(doc, "References are formatted as per Vancouver style (as recommended by UHS):")

refs = [
    "1.  Chi J, Lou K, Feng G, Song S, Lu Y, Wu J. Comparative analysis of holmium: "
        "YAG laser internal urethrotomy versus Cold-Knife optical internal urethrotomy "
        "in the management of urethral stricture - a systematic review and meta-analysis. "
        "Int J Surg. 2024 Jul 1;110(7):4235-4247. doi: 10.1097/JS9.0000000000001384. "
        "[PMID: 38573099]",

    "2.  Ali MM, Kamel M, Ragab A, Abd Alraheem A, Sakr A. Holmium laser versus cold "
        "knife visual internal urethrotomy for management of short segment urethral "
        "stricture: a prospective randomized clinical trial. World J Urol. 2023 Jul;"
        "41(7):1887-1894. doi: 10.1007/s00345-023-04434-8. [PMID: 37256320]",

    "3.  Yenice MG, Seker KG, Sam E, Colakoglu Y, Atar FA, Sahin S. Comparison of "
        "cold-knife optical internal urethrotomy and holmium:YAG laser internal "
        "urethrotomy in bulbar urethral strictures. Cent European J Urol. 2018;71(1):"
        "96-101. doi: 10.5173/ceju.2017.1391. [PMID: 29732217]",

    "4.  Fallah Karkan M, Razzaghi MR, Karami H, Ghiasy S, Tayyebiazar A, Javanmard B. "
        "Experience of 138 transurethral urethrotomy with holmium:YAG laser. J Lasers "
        "Med Sci. 2019;10(2):108-112. doi: 10.15171/jlms.2019.17. [PMID: 31360378]",

    "5.  Tritschler S, Roosen A, Fullhase C, Stief CG, Rubben H. Urethral strictures - "
        "etiology, investigation and treatments. Dtsch Arztebl Int. 2013 Mar;"
        "110(13):220-226. doi: 10.3238/arztebl.2013.0220.",

    "6.  Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment of male urethral "
        "strictures: is repeated dilation or internal urethrotomy useful? J Urol. "
        "1998;160(2):356-358.",

    "7.  Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than "
        "previously reported. J Urol. 2010 May;183(5):1859-1862.",

    "8.  Stein DM, Thum DJ, Barbagli G, Kulkarni S, Bhargava S, Sansalone S, et al. "
        "A geographic analysis of male urethral stricture aetiology and location. "
        "BJU Int. 2013 Oct;112(6):830-834.",

    "9.  Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck W. "
        "Etiology of urethral stricture disease in the 21st century. J Urol. 2009 "
        "Sep;182(3):983-987.",

    "10. EAU Guidelines on Urethral Strictures. European Association of Urology. "
        "Available from: https://uroweb.org/guidelines/urethral-strictures. "
        "[Accessed July 2026].",

    "11. Yucetturk CN, Yildiz Y, Ozgur BC, et al. The efficacy of intraurethral "
        "lidocaine in optical internal urethrotomy for anterior urethral stricture: "
        "a multicenter study. Minerva Urol Nefrol. 2017 Dec;69(6):582-586. "
        "[PMID: 28429926]",

    "12. Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior "
        "urethral strictures: long-term followup. J Urol. 1996;156(1):73-75.",
]
for ref in refs:
    p = doc.add_paragraph()
    r = p.add_run(ref)
    r.font.size = Pt(11)
    r.font.name = "Times New Roman"
    p.paragraph_format.space_after = Pt(4)
    p.paragraph_format.alignment   = WD_ALIGN_PARAGRAPH.JUSTIFY
    p.paragraph_format.line_spacing = Pt(16)

page_break(doc)

# ══════════════════════════════════════════════════════════════════════════════
#  12. ANNEXURES
# ══════════════════════════════════════════════════════════════════════════════
add_section_heading(doc, "12. ANNEXURES")

add_heading1(doc, "Annexure I: Data Collection Proforma")

proforma_fields = [
    ("Patient Code:", "___________"),
    ("Date of Surgery:", "___________"),
    ("Age (years):", "___________"),
    ("Group:", "A (Laser) / B (Cold Knife)"),
    ("Presenting Complaint:", "___________"),
    ("Aetiology:", "Traumatic / Iatrogenic / Idiopathic / Inflammatory"),
    ("Stricture Site:", "Bulbar / Penile / Fossa navicularis"),
    ("Stricture Length on RUG (cm):", "___________"),
    ("Pre-op Qmax (mL/s):", "___________"),
    ("Pre-op PVR (mL):", "___________"),
    ("Pre-op IPSS Score:", "___________"),
    ("Operative Time (minutes):", "___________"),
    ("Intraoperative Bleeding:", "Yes / No"),
    ("Post-op Catheter Duration (hours):", "___________"),
    ("Post-op UTI:", "Yes / No"),
    ("Qmax at 1 month:", "___________"),
    ("Qmax at 3 months:", "___________"),
    ("IPSS at 3 months:", "___________"),
    ("PVR at 3 months:", "___________"),
    ("Qmax at 6 months:", "___________"),
    ("IPSS at 6 months:", "___________"),
    ("PVR at 6 months:", "___________"),
    ("Qmax at 12 months:", "___________"),
    ("IPSS at 12 months:", "___________"),
    ("PVR at 12 months:", "___________"),
    ("Stricture Recurrence at 12 months:", "Yes / No"),
    ("Re-intervention Required:", "Yes / No"),
    ("Any Complications:", "___________"),
    ("Investigator Signature:", "___________"),
]
pf_table = doc.add_table(rows=len(proforma_fields), cols=2)
pf_table.style = "Table Grid"
for i, (lbl, val) in enumerate(proforma_fields):
    pf_table.rows[i].cells[0].text = lbl
    pf_table.rows[i].cells[1].text = val
    for cell in pf_table.rows[i].cells:
        for para in cell.paragraphs:
            for run in para.runs:
                run.font.size = Pt(11)
                run.font.name = "Times New Roman"
    for para in pf_table.rows[i].cells[0].paragraphs:
        for run in para.runs:
            run.bold = True

doc.add_paragraph()

add_heading1(doc, "Annexure II: Patient Informed Consent Form")
add_body(doc,
    "I, ________________________________ (Patient name), S/o _____________________, "
    "having been fully informed about the nature, purpose, risks, and benefits of the "
    "research study titled 'Holmium YAG Laser versus Cold Knife in Optical Internal "
    "Urethrotomy for Management of Anterior Urethral Stricture of Less than 1.5 cm: "
    "A Quasi-Experimental Study', hereby voluntarily agree to participate in this study "
    "and allow the use of my clinical data for research purposes. I understand that I "
    "may withdraw from the study at any time without affecting my standard medical care."
)
add_body(doc,
    "Patient Signature: ____________________      Date: __________________\n"
    "Witness Signature: ____________________      Date: __________________\n"
    "Investigator Signature: ________________     Date: __________________"
)

doc.add_paragraph()

add_heading1(doc, "Annexure III: IPSS Questionnaire")
add_body(doc,
    "[Standard validated International Prostate Symptom Score (IPSS) questionnaire "
    "to be attached here - available from the American Urological Association.]"
)

# ── Save ──────────────────────────────────────────────────────────────────────
out = "/tmp/workspace/uhs-synopsis/UHS_Synopsis_Holmium_vs_ColdKnife_Urethrotomy.docx"
doc.save(out)
print(f"Saved: {out}")