Endoscopic internal urethrotomy for treatment of urethral strictures: midterm survey

Urethral Balloon Dilatation: Factors Affecting Outcomes

Background/Aims/Objectives: The study aims to review our experience with balloon dilatation of urethral strictures and retrospectively analyze predictors of improved success rates.

METHODS

One hundred and forty-four cases were analyzed from January 2011 to December 2012. Patients underwent balloon dilatation using 6-Fr Balloon dilator set (Cook Urological, Spencer, Ind., USA). Patients analyzed with respect to demography, uroflowmetry (Qmax) and need for auxiliary procedures in the immediate postoperative period, at 6 months and at 1 year. Comparisons were made between those who performed self-calibration against those who did not.

RESULTS

Overall success rate of balloon dilatation in our study was 84.4%. Procedural failure was observed with 3 patients (2.1%). Auxiliary procedure was required in 21 cases (15.6%) during follow-up. The mean Qmax (ml/s) in those who regularly performed self-calibration (n = 73) and in those who did not perform self-calibration (n = 39) in the immediate postoperative period, at 6 months and at 1 year were 24.2 ± 10.5, 16.5 ± 7.5, 14.4 ± 6.3 and 21.2 ± 10.6, 14.5 ± 7, 10.8 ± 5.6, respectively. Statistical significance was noted at 1 year (p = 0.003). Lesser re-treatments were required in those who performed self-calibration (12.3 vs. 20.5%). Improved success rates were noted with focal and bulbar strictures. Iatrogenic strictures and pan-anterior urethral strictures had poor outcomes despite self-calibration.

CONCLUSIONS

Balloon dilation with self-calibration significantly improves flow rates at 1 year and lessens auxiliary procedures required. It is simple, easy to perform under local anesthesia and repeatable in case of re-strictures.

Balloon dilatation for male urethral strictures "revisited"

Aims:

To analyze the results of balloon dilatation for short segment male urethral strictures.

Materials and Methods:

Retrospective analysis was done of 120 patients undergoing urethral balloon dilatation since January 2004 to January 2012. The inclusion criteria for analysis was a short segment (less than 1.5 cm) stricture, exclusion criteria were pediatric, long (more than 1.5 cm), traumatic, malignant strictures. The parameters analyzed included presentation of patients, ascending urethrogram (AUG) and descending urethrogram findings, pre- and postoperative International prostate symptoms score (IPSS), uroflowmetry (Q_max), and post-void residue (PVR). Need for self calibration/ancillary procedures were assessed. Failure was defined as requirement for a subsequent endoscopic or open surgery. A urethral balloon catheter (Cook Urological, Spencer, Indiana) is passed over a guide wire after on table AUG and inflated till 180 psi for 5 minutes under fluoroscopy till waist disappears. Dilatation is followed by insertion of a Foley catheter. Patients were followed up at 1, 3, and 6 months.

Results:

Mean age was 49.86 years. Mean follow-up was 6 (2–60) months. IPSS improved from 21.6 preoperative to 5.6 postoperatively. Q_max increased from 5.7 to 19.1 and PVR decreased from 90.2 to 28.8 (P < 0.0001*) postoperatively. At 1, 3, and at 6 monthly follow-up, 69.2% (n = 82) patients were asymptomatic.

Conclusions:

Balloon dilation is a safe, well-tolerated procedure with minimal complications. Further randomized studies comparing balloon dilatation with direct internal visual urethrotomy are warranted.

Endoscopic incision of short (<3 cm) urethral strictures after phallic reconstruction

INTRODUCTION

Urethral stricture formation is a frequent complication after phallic reconstruction, but little is known about the treatment. Endoscopic cold-knife incision has long been applied for short urethral strictures. Can this treatment be used for strictures in the phalloplasty patients as well?

MATERIALS AND METHODS

Thirty-two endoscopic urethrotomies were done in 22 patients with a phalloplasty. Only noncomplicated strictures shorter than 3 cm were considered appropriate for endoscopic incision. The stricture was treated by a cold-knife incision. The urethral catheter was maintained for at least 2 weeks. Follow-up was done every 3 months during the first year and annually thereafter. Comparing failures with successful cases, prognostic factors for success are assessed.

RESULTS

Median follow-up is 51 months (range, 8-95 months). In 14 patients, no previous intervention was done. Mean stricture length is 1 cm (range, 0.5-2.5 cm). Endoscopic incision was successful in 14/32 cases (43.8%). First incision was successful in 10/22 cases (45.5%), a second incision was successful in 4/7 cases (57.1%), but three or more incisions were never successful (0/3). The only significant difference between failures and successful cases is the interval between phalloplasty and endoscopic incision (32 vs. 9.9 months; p = 0.00008).

CONCLUSIONS

Endoscopic incision for short (<3 cm) urethral strictures after phallic reconstruction can solve the problem in about half of the cases. Three or more incisions seem to be useless. Endoscopic incision is significantly better when performed with a long-term interval after phalloplasty, indicating that a well-healed phallic urethra is more prone to a successful endoscopic incision.

Traitement endoscopique des sténoses de l'urètre

The present article reviews the literature regarding the endoscopic treatment of urethral strictures. Only few prospective randomised clinical trials with sufficient power have been performed and most of the literature provides evidence of only level 3 and 4. Since length, location, extent and calibre of the urethral stricture have an important impact on prognosis, diagnosis and the role of ultrasonography are discussed. Pathophysiology of wound healing is discussed in relation to urethrotomy, as it explains the outcomes of the procedure. Operative techniques using cold knife and laser, use of endoprostheses, indications, complications, results and postoperative management are described. The possible role of urethral catheters, hydraulic dilatations and corticosteroid applications are discussed.

Holmium laser ablation of recurrent strictures of urethra and bladder neck: preliminary results

BACKGROUND

The management of patients with recurrent urethral strictures represents a challenge for the practicing urologist.

PATIENTS AND METHODS

We used holmium:yttrium-aluminum-garnet (Ho:YAG) laser in the management of recurrent urethral strictures in 13 patients. The energy level was set at 1.0 at a frequency of 10 pulses/sec. No treatment complications were observed. The mean preoperative maximum flow rate by uroflowmetric analysis was 3.8 mL/sec.

RESULTS

Nine patients (69%) continue to do well with no symptoms at a median follow-up of 27 months with a mean maximum flow rate of 19 mL/sec. Of the four patients in whom treatment failed, three were retreated with the Ho:YAG laser. One of them was managed by insertion of a permanent urethral stent, another continues to do well without any further treatment, and the other is managed with dilation by self-catheterization. One of the four failures underwent open reconstructive urethroplasty after recurrence following his first treatment with the Ho:YAG laser.

CONCLUSION

Our preliminary results suggest that Ho:YAG laser ablation of urethral strictures is safe and might be a reasonable alternative endoscopic treatment for recurrent urethral strictures.

Assessment of a new transurethral balloon dilation catheter in the treatment of urethral stricture disease

OBJECTIVES

To assess a newly designed balloon dilation catheter for the treatment of urethral stricture disease. The dilating capability of the catheter, the tolerability and safety of the procedure, and its short-term efficacy were evaluated.

METHODS

Fifty-one patients with urethral strictures underwent dilation with the UrethraMax or a coude tip balloon dilation catheter. Efficacy parameters included measurement of the American Urological Association symptom score and maximum urinary flow rate 3, 6, and 12 months after treatment. The adequacy of dilation and the degree of mucosal trauma and hematuria were assessed endoscopically, and patient pain was measured using a visual analog scale.

RESULTS

Forty-three patients (84.3%) were successfully dilated, achieving a urethral caliber of 20F or greater. Dilation resulted in statistically significant improvements in both the mean American Urological Association symptom score and mean maximum urinary flow rate at 3 and 6 months. Mucosal trauma was mild in all but 4 cases, and no patient developed significant hematuria. The mean visual analog pain score was 3.9 (range 0.1 to 9.4).

CONCLUSIONS

Balloon dilation is a safe, well-tolerated, office-based procedure that theoretically offers several advantages over sequential rigid dilation and internal urethrotomy. It is associated with minimal complications, and its short-term efficacy is acceptable. We regard this as the dilation procedure of choice and first-line therapy for most strictures.

Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful?

PURPOSE

We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures.

MATERIALS AND METHODS

Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments.

RESULTS

Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001).

CONCLUSIONS

Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.

Newly diagnosed bulbar urethral strictures: etiology and outcome of various treatments

A retrospective review was performed of 199 consecutive patients who were evaluated at this institution between 1976 and 1990 because of a newly diagnosed bulbar urethral stricture. Mean patient age at diagnosis was 64 years (range 10 to 96) and most patients presented with obstructive symptoms. The stricture etiology was primarily iatrogenic (47%), secondary to a transurethral procedure. The strictures were usually short (less than 2 cm., 96%), single (99%) and located in the proximal bulb (57%). Of the 151 patients receiving treatment at the time of initial diagnosis 101 (67%) underwent urethral dilation, 39 (26%) were managed with direct vision internal urethrotomy and in 11 (7%) a cystotomy tube was placed. With a median followup of 3.5 years (range 0 to 16), there was an estimated retreatment rate of 2.4 treatments per 10 person-years. The probability of not requiring retreatment within 3 years was 65 +/- 5% for urethral dilation and 68 +/- 8% for direct vision internal urethrotomy. When compared to urethral dilation, direct vision internal urethrotomy resulted in a higher incidence of postprocedure cystitis (5% versus 3%), epididymitis (5% versus 3%) and penile hemorrhage (8% versus 2%). These findings indicate that both conservative therapies were equally efficacious as an initial treatment of bulbar urethral stricture. However, direct vision internal urethrotomy did have a slightly higher complication rate. No specific patient or stricture characteristics could be identified that were reliable for predicting therapeutic outcome.

Spermatic cord for onlay coverage of urethral defect

Segmental urethral necrosis may accompany scrotoperineal gangrene, and primary closure of the urethral defect may unacceptably reduce urethral dimensions. This dilemma has been managed successfully in 5 patients by application of the intact spermatic cord to the urethral defect and approximation to its margins. A representative case is described.

Congenital stricture of the urethra

Three patients with presumed congenital urethral strictures are presented. The strictures were all in the bulbar urethra and were demonstrated by micturating cysto-urethrography. A further child is described with a normal urethra in whom the appearances mimicked a proximal bulbar stricture.

Excisional repair of urethral stricture. Follow-up of 90 patients

One hundred five patients with urethral stricture of various causations were treated with excision of the stricture and oblique end-to-end anastomosis. Fifty-two patients (49%) had had one or more previous operations and dilatations, respectively. The immediate postoperative complication rate was 9 per cent. Ninety patients could be followed for one to eight years. The success rate was 93 per cent. Five patients had recurrent strictures. The failures were due to abscess formation, perineal hematoma, and excessive length of stricture.

Optical urethrotomy as ambulatory procedure

Optical urethrotomy is a relatively new means of treating urethral stricture. We performed the procedure on 100 ambulatory patients using only topical anesthesia and sedation in some. The patients were followed a minimum of one year. Our success rate for cure following one procedure was 66 per cent; however, those patients not cured required less frequent dilations after urethrotomy. We believe that this is a safe and effective means of treating urethral strictures in the outpatient setting with little morbidity and discomfort and with considerable economic savings.

Visual internal urethrotomy in management or urethral strictures

Visual internal urethrotomy was used in the treatment of urethral strictures in 103 patients. The procedure was performed mostly under local anesthesia. Urethral catheter for forty-eight hours or urethral splinting for two weeks was used as complementary treatment in some cases. We obtained an overall success rate of 95.1 per cent.

Post-prostatectomy infection: to treat or not to treat?

A prospective study of bacteriuria in 100 prostatectomies is analysed. The author states that an antibiotic policy which treats only patients with fever, clinical discomfort, or isolated bacteriuria after the first postoperative month does not enhance morbidity, and lowers hospital costs.