Urethral strictures in boys

Presentation, treatment and outcomes of pediatric anterior urethral strictures: 28 years' experience from a referral center

BACKGROUND

Pediatric urethral strictures are an uncommon entity, with the anterior urethra being the most common affected location, similar to adults. The, literature on outcomes in these strictures is limited, especially in the non-traumatic group, as most of the studies have included hypospadias related "neourethral" strictures and posterior strictures, thereby making interpretation difficult. It is for these reasons we decided to search our database to identify the different surgical procedures used and analyze the outcomes of interventions in these children and adolescents with anterior urethral strictures.

OBJECTIVE

To report the treatment strategies and outcomes in a series of 119 pediatric anterior urethral strictures, identified in a 28-year period in a high-volume tertiary center.

MATERIALS AND METHODS

A retrospective case-note review of all cases of pediatric anterior urethral strictures was done. Data on the clinical presentation including age at presentation, characteristics of strictures identified, primary intervention and additional secondary procedures and outcomes were collected.

RESULTS

We identified 119 boys with anterior urethral strictures with commonest location being the bulbar urethra (60.5%). Sixty patients (50.4%) in this cohort underwent minimally invasive intervention in the form of dilatation or direct visual internal urethrotomy (DVIU) with the rest undergoing open intervention. The primary success rate was 87.1% (101/116) at a median follow-up of 29 (IQR 21-38) months. Idiopathic urethral stricture and iatrogenic strictures had better success rate of 92.5% and 82.1% than traumatic strictures (78.9%) and it was lowest for those traumatic strictures that were treated with DVIU (66.7%). Multifocal strictures had comparatively poorer outcomes (62.5%) compared with penile or bulbar strictures, with worst outcomes (44.4%) in those treated with substitution urethroplasty. Length >1 cm, multifocality and treatment with substitution urethroplasty were significantly associated with recurrence. Three boys with strictures associated with anorectal malformations were a particularly difficult group and needed multiple intervention and had poor outcomes.

CONCLUSION

Based on our study, we recommend a minimally invasive approach for short segment, bulbar strictures, especially of idiopathic etiology. For other locations and longer strictures, we recommend urethroplasty. Caution must be exercised to avoid underestimation of the actual pathology of the stricture. Caretakers of children with complete bulbar level blockage associated with anorectal malformations undergoing urethroplasty should be explained about the need for multiple interventions and possibility of poor voiding outcomes.

Childhood and adolescent idiopathic urethritis: what does the current literature say?

INTRODUCTION

Idiopathic urethritis (IU) is a known entity in the childhood and adolescent age groups and is described as blood spotting of the underwear in these populations. Typically, IU presents clinically as terminal void haematuria or blood spotting, accompanied with dysuria, occasional suprapubic pain and rarely constitutional symptoms. Sometimes IU may progress to formation of urethral strictures. It carries a high morbidity because of its chronicity and recurrent course, which often persists to puberty. In spite of no single aetiology being confirmed, several treatment approaches have shown some efficacy. Although no consensus has yet been established, the consideration of previous authors' experience and expertise may contribute to the development of a possible unified algorithm.

AIM

This article considers IU, collecting pertinent data and case series from the literature. The authors attempt to describe all presumptive aetiologies, endoscopic findings with established grading classifications and finally the various treatment modalities proposed. In addition, highlights from the senior's author experience regarding this entity including endoscopic, radiographic and histological images are mentioned.

METHODS

Retrospective review and analysis of all relevant articles present on PubMed, SCOPUS and Cochrane Library from the time of inception to the date of first submission.

RESULTS

A total of 19 series concerning IU have been reported since year 1971 to present time (Table 1). Many aetiologies have been postulated, but some have been refuted, including infectious pathogens. Children with dysfunctional voiding and meatal stenosis are more prone to exhibit IU. A variation in the urethral milieu during the prepubertal period, secondary to systematic hormonal alteration, may lead to squamous cell metaplasia resulting in IU and possible urethral strictures. Grading classifications for IU are described. Up to 20% of IU may develop urethral strictures. Various treatment approaches are discussed.

CONCLUSION

A summary of current understanding of the pathogenesis and spectrum of IU has been achieved. Successful treatment can be achieved with steroids and dysfunctional voiding protocols. It may be possible to develop a consensus unified management algorithm.

Etiology and characteristics of pediatric urethral strictures in a developing country in the 21st century

BACKGROUND

Urethral stricture disease in children is not uncommon as assumed; however, most of the information about the etiology, features, and natural history of pediatric strictures is extrapolations from adult series as the literature on this common entity is sparse, and most of the studies are small series.

OBJECTIVE

The current etiology and clinical features of urethral stricture disease in the pediatric population in the developing world were determined.

MATERIALS AND METHODS

The data of children with urethral stricture disease, who had undergone treatment in the tertiary center from 2001 to 2017, were retrospectively analyzed. After excluding girls, the database was analyzed for clinical presentation, possible causes of stricture, site and number of strictures, and length of stricture and for previous interventions. Subanalysis was performed for stricture etiology by patient age, stricture length, site, previous treatments, and presentation with paraurethral abscess.

RESULTS

A total of 195 boys with strictures were identified. The common causes of pediatric urethral stricture were traumatic (36.9%), iatrogenic (31.8%), and idiopathic (28.7%). The anterior urethra was the location of the stricture in 141 patients (72.3%). Iatrogenic causes (due to catheterization, hypospadias repair, and valve fulguration) accounted for the majority of anterior urethral strictures (61/141 or 43.2%). Younger children had a tendency to have an iatrogenic and idiopathic cause for strictures, whereas older children had a traumatic etiology; 18.6% of strictures in children younger than 10 years were secondary to trauma, whereas 44.9% of the strictures in patients older than 10 years were traumatic in origin. Trauma was the major cause of posterior urethral strictures (53/54 or 98.1%) and was always associated with pelvic fracture. Strictures due to lichen sclerosus or infectious cause were rare (5 patients or 2.6%). The length of strictures was longer in pan anterior urethral strictures (mean: 82.0 mm) than that of those due to lichen sclerosus (mean: 42.5 mm) and in patients who had undergone previous treatment (mean: 28.7 mm).

CONCLUSION

Iatrogenic causes such as catheterization and hypospadias repair account for the majority of anterior urethral stricture disease in the pediatric population, especially the younger age-group. However, as the child grows, there is a gradual preponderance of traumatic urethral strictures, including posterior urethral strictures.

Free tubularised vesical mucosa graft for congenital stenosis of the urethra in children

BACKGROUND

Reconstruction of urethral strictures in children remains a challenge to the pediatric surgeon as these are often related to different rare congenital anomalies with various clinical presentations that endanger renal function and should be repaired in young children. Multiple techniques have been described for their repair. We aimed to determine whether the use of a free tubularised bladder mucosal graft associated to a prior tubeless vesicostomy was feasible and sure, as this technique of reconstruction using tubularised grafts has not been described yet in young children.

RESULTS

Two newborn male patients were referred to our department. Both presented a congenital stenosis of the urethra as a part of a complex urethral malformation. Surgery involved prior tubeless vesicostomy, free bladder mucosal graft for urethral reconstruction, and vesicostomy closure for both children. Postoperative evolution was satisfying in both children and cystourethroscopy showed permeable urethra. Satisfying cosmetic and functional results have been obtained in the two cases.

CONCLUSIONS

The prior vesicostomy prevents kidney damage in the context of complex genital and urinary malformations. Bladder mucosa's immunohistological properties are the most similar to those of the urethral tissue, and are appropriate for this type of correction, making our technique feasible and sure.

LEVEL OF EVIDENCE

5.

Post-traumatic urethral strictures in children: what have we learned over the years?

BACKGROUND

Urethral stricture presents an uncommon but difficult urological problem in the pediatric population. Treatment protocols are different from in adults due to anatomical considerations.

MATERIAL AND METHODS

A thorough manual and Medline search was conducted to review the existing literature on post-traumatic pediatric urethral strictures, with key words: stricture, children, post-traumatic, urethroplasty, pediatric.

RESULTS

Opinion early on was that, due to the confined perineum, high incidence of supramembranous injury resulting in less predictable distraction defects of the posterior urethra and a high incidence of prostatic displacement, transperineal urethroplasty is technically more difficult than in adults and thus the transpubic approach is more feasible. Recent reports revealed that both approaches resulted in almost the same clinical outcomes for children with post-traumatic posterior urethral strictures.

CONCLUSION

The ideal reconstruction for the treatment of post-traumatic posterior urethral strictures in children is bulboprostatic anastomosis. This procedure should be initially attempted through the perineum in every case. A transpubic procedure should be done only when tension-free anastomosis cannot be accomplished through the perineum.

Pediatric and adolescent transperineal anastomotic urethroplasty

PURPOSE

Pediatric urethral stricture disease represents a significant surgical challenge because of smaller pelvic confines, decreased caliber and increased tissue fragility. Operative series of pediatric urethral reconstruction usually involve small numbers. In this study, we examined the outcome of open reconstructive techniques for pediatric and adolescent patients with posterior urethral distraction injuries.

PATIENTS AND METHODS

Between February 2002 and September 2005, 15 patients from Kasr ElAini hospital presenting with posterior urethral distraction defects due to motor vehicle accidents were included in our study. Their age ranged between 5 and 17 years (mean 12.5). We used the progressive perineal approach to achieve a tension-free spatulated anastomosis.

RESULTS

Mean follow-up was 28.4 months. Initial and ultimate success rates were 80 and 86.6%, respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No penile curvature, shortening or urethral diverticulae were noted during follow-up.

CONCLUSION

Using the appropriate modern guidelines of urethroplasty, consistent success can be achieved in pediatric and adolescent patients with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. Urethral reconstruction is strongly recommended as the primary treatment option, especially in the pediatric urethral stricture population, because of the repair durability.

LONG-TERM OUTCOME OF VISUAL INTERNAL URETHROTOMY FOR THE MANAGEMENT OF PEDIATRIC URETHRAL STRICTURES

PURPOSE

We evaluated the long-term results of visual internal urethrotomy for pediatric urethral strictures to evaluate the efficacy and final outcome of this procedure in children and to evaluate the risk factors for stricture recurrence.

MATERIALS AND METHODS

The computerized surgical records of our hospital were reviewed to identify children who underwent visual internal urethrotomy between 1980 and 2001. Hospital and followup clinical charts were then reviewed. Many variables were analyzed, including age, etiology, length and site of the strictures, and catheter duration. Only patients with a minimum followup of 2 years were included. Regular self-catheterization was not used by any child.

RESULTS

A total of 31 patients (mean age 11.2 years, range 2 to 18) were identified. Followup ranged from 2 to 20 years, with a mean of 6.6 years. The most common etiology for stricture formation was failed previous urethroplasty and post instrumentation (35.5% and 32.3%, respectively). The success rate after initial urethrotomy was 35.5% (11 of 31 patients). Mean interval to first recurrence was 26 months. A second urethrotomy improved the success rate of 58.1%. Eight patients required 2 or more urethrotomies, of whom half required open urethroplasty. Among the evaluated variables only stricture length shorter than 1 cm was associated with good results.

CONCLUSIONS

Visual internal urethrotomy provides a safe first line therapeutic option for pediatric urethral strictures shorter than 1 cm, independent of etiology and location. For patients with more than 1 recurrence or with strictures longer than 1 cm, who are at high risk for recurrence after internal urethrotomy, open urethroplasty remains the treatment of choice.

Perineal anastomotic urethroplasty for managing post-traumatic urethral strictures in children: the long-term outcome

OBJECTIVE

To evaluate the long-term results of one-stage perineal anastomotic urethroplasty for post-traumatic paediatric urethral strictures.

PATIENTS AND METHODS

Thirty-five boys who had a perineal anastomotic urethroplasty for post-traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6-132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto-urethrography.

RESULTS

The mean (range) age of the patients was 11.9 (6-18) years. The estimated radiographic stricture length before surgery was 2.6 (1-5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow-up.

CONCLUSIONS

The overall success of a one-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino-perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

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.

Open reconstruction of pediatric and adolescent urethral strictures: long-term followup

PURPOSE

Pediatric urethral stricture disease represents a significant surgical challenge. Published operative series of pediatric urethral reconstruction include small numbers or lack long-term followup. We examined the long-term outcome of open reconstructive techniques for pediatric urethral strictures.

MATERIALS AND METHODS

From March 1987 through August 2002, 17 boys 7 to 17 years old underwent open urethral reconstruction with followup. Trauma was the etiology in 88% of cases. Nine patients had anterior urethral stricture and 8 had traumatic posterior urethral disruption. Strictures secondary to failed hypospadias correction were not included in analysis. In 10 patients (59%) previous management with open or endoscopic procedures had failed. Followup in all patients consisted of symptomatic evaluation, voiding cystourethrography and flexible urethroscopy.

RESULTS

One-stage perineal urethral reconstruction was performed in all patients without retropubic or transpubic dissection. All patients were stricture-free and continent at a mean followup of 67 months. A total of 18 open surgical procedures were needed. A patient with posterior urethral disruption required reoperation for recurrent stricture disease but had excellent long-term results after the second operation. Chordee, penile shortening and urethral diverticula were not noted during followup.

CONCLUSIONS

Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. When considering the importance of repair durability in the pediatric urethral stricture population, urethral reconstruction should be strongly considered the primary treatment option. Endoscopic procedures should be reserved for patients with short bulbar strictures associated with minimal spongiofibrosis. As in the literature, we do not advocate repeat direct vision internal urethrotomy.