Surgical management of urethral stricture in the male

Comparative study between Amplatz renal dilator vs visual internal urethrotomy (cold knife) for the treatment of male urethral stricture

AIM

The study aimed to assess and compare urethral stricture (US) management outcomes, efficiency, and complications, treated by either Amplatz renal dilator or visual internal urethrotomy (VIU).

PATIENTS AND METHODS

This prospective comparative study was carried out on 88 male patients with stricture urethra. All patients have performed a physical examination, ascending and micturition urethrography, urodynamic, and pelvic ultrasound. The patients were randomized divided into group 1 (Amplatz group) 44 patients treated with Amplatz dilator, and group 2 (VIU group) 44 patients treated with a cold knife. Patients were followed up at 15 days,3,6, and 12 months after the procedure.

RESULT

The mean age was 41.2 (22-73) years. The mean stricture length in group 1 and group 2 was 1.01 ± 0.40 and 1.04 ± 0.30, respectively (p = 0.421). The average IPSS score at baseline for group 1 and group 2 was 21.2 and 21.9 points, respectively. During the 12 months follow-up, IPSS improved, with average scores of 16.1 and 17.3 for group 1 and group 2, respectively (p > 0.05). The mean values of (Q max) between group 1 and group 2 at baseline, day 15, day 90 and 180 days showed no significant difference but at 12 months, (Q max) showed a higher significant difference in group 1 than group 2 (p = 0.003). The post-void residual (PVR) displayed a significant decline in both groups from baseline. After 1 year, PVR showed that group 2 was a little higher than group 1 (no significance) compared to baseline The procedures were found effective without recurrence in all patients (both groups) during the 12 months (Q max > 15m/s). However, group 2 reported (11.4%) intra-operative bleeding, and (6.8%) extravasations.

CONCLUSION

The guided urethral dilation and internal urethrotomy are safe, short time procedures, and offer satisfactory results with the advance to VIUD in Qmax at 12 months. No recurrence was documented in both groups after 12 months. VIU reported 18% intraoperative complication.

Use and outcomes of amplatz renal dilator for treatment of urethral strictures

Introduction

Urethral stricture disease is still a major problem in men. Many procedures are available for the treatment of urethral strictures; urethral dilatation is one of the oldest. The blind dilatation of urethral strictures may be a difficult and potentially dangerous procedure. The purpose of this study was to describe safe urethral dilatation using amplatz renal dilator and to report outcomes.

Materials and Methods

From 2010 to 2014, a total of 26 men with primary urethral strictures were managed by urethral dilatation using amplatz renal dilators. The parameters analyzed included presentation of patients, retrograde urethrography (RGU) findings, pre-and postoperative maximum flow rate (Q_max) on uroflowmetry (UF) and post-void residual urine (PVR). Patients were followed-up at 1.6 and 12 months. The technique described in this paper enables such strictures to be safely dilated after endoscopic placement of a suitable guidewire and stylet over which amplatz renal dilators are introduced.

Results

The mean age of the patients was 57.6 (35–72) years. The median stricture length was 0.82 (0.6–1.5)cm. Pre-operative uroflowmetry showed Q_max of 7.00 (4–12) mL/sec and ultrasonography showed PVR of 75.00 (45–195)mL. Postoperatively, Q_max improved to 18.00 (15–22)mL/sec (p<0.001) at 1 month, 17.00 (13–21)mL/sec (p<0.001) at 6 months and 15.00 (12–17)mL/sec (p<0.001) at 12 months. The post-operative PVR values were 22.50 (10–60)mL (p<0.001), 30.00 (10–70)mL (p<0.001) and 30.00 (10–70) mL (p<0.001) at 1.6 12 months, respectively. The median procedure time was 15.00 (12–22) minutes. None of the patients had a recurrence during a 12-month period of follow-up.

Conclusion

Urethral dilatation with amplatz renal dilators avoids the risks associated with blind dilatation techniques. This tecnique is a safe, easy, well-tolerated and cost-effective alternative for treatment of urethral strictures.

Long-Term Followup of Visual Internal Urethrotomy for Management of Short (Less Than 1 Cm) Penile Urethral Strictures Following Hypospadias Repair

PURPOSE

We reviewed the results of direct vision urethrotomy for short (less than 1 cm) penile urethral strictures following hypospadias surgery.

MATERIALS AND METHODS

Patients with less than 1 cm anterior penile urethral strictures located proximal to the meatus underwent direct vision urethrotomy. Based on the type of initial urethroplasty patients were randomly divided into treatment with direct vision urethrotomy vs direct vision urethrotomy plus clean intermittent catheterization for 3 months. Success was defined as absent obstructive voiding symptoms and a normal urine flow 2 years following the last patient instrumentation.

RESULTS

Of patients with urethral strictures following hypospadias repair 44% (32) had previously undergone tubularized graft urethroplasty and 56% (40) had previously undergone flap urethroplasty, including a tubularized island flap in 18, an onlay flap in 11 and urethral plate urethroplasty in 11. Direct vision urethrotomy alone was performed in 51% of patients (37), and direct vision urethrotomy and clean intermittent catheterization were performed in 49% (35). Success with the 2 methods was similar, that is 24% (9 of 37 patients) vs 22% (8 of 35). Following direct vision urethrotomy all patients with tubularized graft urethroplasty showed failure (0 of 32). Success was noted in 11% of patients (2 of 18) with tubularized island flap urethroplasty compared to 72% (8 of 11) with onlay urethroplasty and 63% (7 of 11) with urethral plate urethroplasty (each p <0.05).

CONCLUSIONS

The addition of clean intermittent catheterization to direct vision urethrotomy does not improve the likelihood of success. Direct vision urethrotomy for short (less than 1 cm) urethral stricture usually fails following any type of tubularized graft or flap urethroplasty but it had moderate success following onlay flap and urethral plate urethroplasties.

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

PURPOSE

The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.

METHODS

The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.

RESULTS

Thirty-two patients were included. They have been followed up for up to 2(1/2) years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.

CONCLUSIONS

Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.

Recurrence of urethral stricture after single internal urethrotomy

Recurrence of urethral stricture after single internal urethrotomy was investigated in 66 patients with special reference to some factors which would influence restricturing. In the present study, recurrence rate was 16.7% (11 patients). Recurrences occurred within an average of 11.9 months. Factors that had no influence on restricturing were age, aetiology, site of the stricture and duration of indwelling catheterization. On the other hand, stricture length appeared to influence the outcome (chi 2, p < 0.001). Short stricture (< or = 10 mm) showed only 4.4% recurrence rate, while 42.9% in long stricture (> 10 mm). Internal urethrotomy appeared to be effective particularly when the stricture was short, while it seemed difficult to treat long strictures by single internal urethrotomy.

Sachse optical urethrotomy, a modified technique: 6 years of experience

Urethrotomy with the Sachse optical urethrotome has radically modified our management of strictures of the male urethra. A total of 143 patients underwent 210 procedures during 6 years. The strictures resolved in 85 per cent of the patients and they required no further treatment, including 52 patients followed for more than 6 years. A modified surgical technique using a pediatric cystoscope is described to inspect, traverse and cannulate the urethral stricture before optical urethrotomy, thus, enabling successful management of even the most difficult strictures. Our results confirm that the best prospects of cure were short and single urethral strictures, and that optical urethrotomy is the treatment of choice for strictures of the male urethra.

Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection

We performed 100 urethroplasties for urethral strictures that fulfilled our criteria for surgical intervention. Strictures were located in the pendulous urethra in 14 cases, bulbar urethra in 33 and membranous urethra in 32, while the entire urethra or multiple adjacent areas were strictured in 21. The etiology of the strictures was traumatic in 47 patients and inflammatory in 22, and no cause was identified in 31. One-stage repairs were performed in 76 cases. Anastomotic repairs were optimal for short traumatic strictures, with 1 failure among 29 cases. Full thickness skin graft repairs were performed for more lengthy inflammatory strictures in 34 cases, with 5 failures. Mitigating against success in these patients were extrapenile skin donor sites, tubed grafts and poor graft beds. Vascularized island flap repairs were performed in 13 patients with 1 failure but there was an associated problem of redundant repairs. Two-stage repairs were reserved primarily for long or multiple strictures, with 2 failures in 24 cases. We conclude that procedure selection should be determined by stricture characteristics, including location, etiology, length and the presence of local adverse factors. An over-all rate free of stricture of 91 per cent was achieved.

Factors influencing recurrence of urethral strictures after endoscopic urethrotomy: the role of infection and peri-operative antibiotics

One hundred patients who had undergone 162 urethrotomies were reviewed. Factors which influenced the outcome of the procedure are discussed. Peri-operative infection occurred in 38% of cases and significantly increased the recurrence rate unless the patients were treated with antibiotics.

Long-term results of optical urethrotomy

In a 7-year period 137 men with urethral stricture underwent optical urethrotomy. Over 91% were relieved of their stricture symptoms and required no further treatment, including 41 patients in whom the follow-up period exceeded 4 years. The surgical technique is outlined. Strictures with the best prospect of cure were short and single. Optical urethrotomy is confirmed as the treatment of choice in strictures of the male urethra.