Role of visual internal urethrotomy in pediatric urethral strictures

Posterior Sagittal Approach Provides Optimal Exposure for Urethral Reconstruction in Children With a History of Anorectal Malformations

OBJECTIVE

To present a unique series of children with previously repaired anorectal malformations (ARM) with subsequent urethral pathology repaired via a posterior sagittal exposure and highlight the associated technical advantages.

METHODS

Using a retrospective review of all procedures performed in our pediatric colorectal and pelvic reconstruction program from January 2020 through December 2022, we compiled a case series of patients with a history of ARM and prior posterior sagittal anorectoplasty (PSARP) who had urethral pathology and concurrent indication for redo-PSARP. Clinical features, operative details, and postoperative outcomes were collected.

RESULTS

Six male patients presented at a median age of 4.3 years, all born with an ARM of recto-urinary fistula type, of which 3 were recto-prostatic, 1 recto-bladder-neck, and 2 unknown type. In addition to redo-PSARP, 2 underwent remnant of the original fistula excision and 4 had urethral stricture repair. One required post-operative Heineke-Mikulicz anoplasty. Patients underwent cystoscopy 4-6 weeks post-reconstruction, and none showed urethral stricture requiring treatment. Post-procedurally, 5 patients were able to void urethrally and 1 required additional bladder augmentation/Mitrofanoff.

CONCLUSION

Redo-PSARP completely mobilizes the rectum, thereby providing excellent exposure to the posterior urethra for repair. This approach also allows the option of a rectal flap for augmented urethroplasty as well as harvest of an ischiorectal fat pad for interposition.

Interventional urethral balloon dilatation before endoscopic visual internal urethrotomy for post-traumatic bulbous urethral stricture: A case report

BACKGROUND

While several treatment options are available for pediatric urethral strictures, the appropriate treatment must be based on several factors. Although endoscopic visual internal urethrotomy (EVIU) could be a first-line treatment option for short pediatric urethral strictures, it is not feasible if the urethroscope cannot pass through the stricture point. Herein, we present a pediatric case of severe post-traumatic bulbous urethral stricture that was successfully treated by EVIU after securing the urethral route via interventional balloon dilatation.

CASE SUMMARY

A 12-year-old boy presented at our outpatient clinic with the inability to urinate. He had sustained a straddle injury three months prior. The post-void residual urine volume was 644 mL, and retrograde urethrography confirmed severe stricture of the bulbous urethra. EVIU was planned; however, the first attempt to treat the stricture failed because the urethroscope could not pass through the stricture point. The urethral route was subsequently secured via balloon dilatation of the stricture, which was performed in collaboration with specialists from the department of interventional radiology. The urethroscope was then able to pass, and the repeat EVIU was successful.

CONCLUSION

Interventional urethral balloon dilatation before EVIU may help secure the urethral route in the treatment of pediatric urethral strictures.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]

OBJECTIVE

The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology).

MATERIAL AND METHODS

These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables.

RESULTS

Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms.

CONCLUSION

Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

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.

Balloon dilation performs poorly as a salvage management strategy for recurrent bulbar urethral strictures following failed urethroplasty

BACKGROUND

The optimal management strategy for recurrent urethral stricture disease (USD) following urethroplasty remains undefined. We aim to evaluate the role and efficacy of endoscopic urethral balloon dilation in temporizing recurrent USD after failed urethroplasty.

METHODS

Between 2007-2018 at our institution, 80 patients underwent balloon dilation procedures for bulbomembranous urethral strictures. Balloon dilation was performed with an 8-cm, 24-French UroMax Ultra™ balloon dilator, under direct vision, guided by a 16-French flexible cystoscope. Patients who underwent concomitant open or endoscopic urethral procedures were excluded. Treatment failure was defined as the need for subsequent surgical intervention for stricture recurrence. Stricture characteristics including etiology, length, location, severity stage, and prior surgical procedures were compared between patients with and without treatment failure.

RESULTS

Failure cases were more likely to have strictures following urethroplasty (21/27, 78%) [vs. the no-failure group (27/53, 51%)]. Among the 27/80 (33.8%) failures with a median follow-up of 8.4 months (IQR, 3.9-22.5 months), median time to recurrence was 4 months (IQR, 2-12 months). These patients had a greater incidence of prior stricture intervention in general (P=0.01) and prior urethroplasty specifically (P=0.03). On multivariable analysis, the number of prior treatments specifically independently remained associated with treatment failure. Complications of balloon dilation were uncommon (6/80, 7.5%) and minor in nature.

CONCLUSIONS

Endoscopic balloon dilation performs poorly as a salvage strategy after failed open urethral reconstruction in addition to prior urethral dilations.

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.

Comparison between cold knife and laser urethrotomy for urethral stricture: a systematic review and meta-analysis of comparative trials

BACKGROUND

Previous study compared limited number of parameters post the treatment of cold knife and laser urethrotomy for urethral stricture and controversy about the superiority of those two techniques still remains. This study aims to update the evidence and provide better clinical guidance.

METHOD

We systematically searched Pubmed, Embase, ClinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials for articles comparing cold knife and laser urethrotomy for urethral stricture. Parameters including maximum urinary flow (Q_max), recurrence, reoperation, complications, operation time, and Visual Analog Scale (VAS) pain score were compared using RevMan 5.3.

RESULTS

Seven articles involving 453 patients were eventually included. The cold-knife group had better 6-month Q_max (MD - 0.95, 95% CI - 1.49 to - 0.41) and similar 3-month and 12-month Q_max compared with the laser group. No significance was observed regarding the comparison of recurrence rate. The laser group had lower risk of bleeding (OR 0.08, 95% CI 0.01-0.43), lower rate of reoperation (OR 0.39, 95% CI 0.19-0.81) and longer operation time (MD 4.09, 95% CI 3.35-4.82). There was no significant difference in terms of other complications and VAS pain score.

CONCLUSION

Cold knife and laser urethrotomy had similar efficacy regarding short-term and long-term recurrence rate and Q_max, except that the cold-knife group had slightly better 6-month Q_max. However, the laser group had less risk of bleeding and lower rate of reoperation but also longer operation time.

Anterior Urethral Strictures in Children: Disease Etiology and Comparative Effectiveness of Endoscopic Treatment vs. Open Surgical Reconstruction

Pediatric anterior urethral strictures are rare and recommendations regarding treatment strategies derive from small monocentric case series. In 2014, a collaborative effort of the Société Internationale d'Urologie and the International Consultation on Urological Diseases drafted the first systematic and evidence-based guideline for diagnosis and treatment of urethral strictures in children. Against this backdrop, we performed an updated literature review to provide a comprehensive summary of the available evidence and contemporary outcomes with a focus on comparative effectiveness of endoscopic treatment (dilation or urethrotomy) vs. open surgical reconstruction. Overall, 22 articles reporting on children with anterior urethral strictures were included into the review. Most strictures were iatrogenic (48%) and traumatic (34%), whereas congenital (13%), inflammatory (4%), or postinfectious strictures (1%) were rather rare. The cumulative success rate of endoscopic treatment and urethroplasty was 46% (range: 21-75; N = 334) and 84% (range: 25-100; N = 347), respectively. After stratifying patients according to urethroplasty technique, success rates were 82% (range: 25-100; N = 206) for excision and primary anastomosis, 94% (range: 75-100; N = 40) for graft augmentation, 97% (range: 87-100; N = 30) for flap urethroplasty, and 70% (one study; N = 20) for pull-through urethroplasty. In conclusion, endoscopic approaches are rather ineffective in the long-term and open surgical reconstruction via urethroplasty should be preferred to avoid multiple, repetitive interventions. Future research may involve multi-institutional, collaborative, and prospective studies, incorporating well-defined outcome criteria and assessing objective surgical endpoints as well as patient-reported functional outcomes.

MODERN METHODS OF TREATING DISEASES OF THE BULBO-MEMBRANOUS PART OF URETHRA

Strictures of the bulbous-membranous urethra are a common cause of obstructive urination disorder. Modern trends in the development of medicine lead to a wider application of endoscopic method, a more frequent cause of iatrogenic injury of the urethra. At present, conservative, endourologic and reconstructive methods of care are used to treat urethral strictures. There are several conservative, endourological and reconstructive methods for treating patients with urethral stricture. Conservative methods include interventions that do not involve the destruction of urethral stricture or its reconstruction, such as stenting, blind dilatation, and recanalization of the urethra. Performing blind dilatation strictures of the bulbo-membranous urethra is not recommended because of the high risk of false path formation and low efficiency. Endourological operations refer to surgical methods of care and suggest the natural restoration of urethral tissues after the destruction of stricture. Because of the low effectiveness of correction of strictures of the posterior urethra (more than 90 % of relapses in five years), this method is a variant of temporary or palliative care. Currently, two approaches to the reconstruction of the bulbo-membranous urethra are used: anastomotic and replacement operations. Anastomotic surgery involves excision of the affected area and juxtaposition of healthy urethral tissues without tension. Replacement plastic allows to restore patency of the urethra by increasing the diameter of the lumen due to the implantation of various grafts. The article shows that, based on international clinical studies, the most effective method of reconstructing the bulbomembranous urethra is reconstructive surgical methods.

Development of novel prognostic models for predicting complications of urethroplasty

INTRODUCTION AND OBJECTIVE

To identify predictors of thirty-day perioperative complications after urethroplasty and create a model to predict patients at increased risk.

METHODS

We selected all patients recorded in the National Surgery Quality Improvement Program (NSQIP) from 2005 to 2015 who underwent urethroplasty, determined by Current Procedural Terminology (CPT) codes. The primary outcome of interest was a composite 30-day complication rate. To develop predictive models of urethroplasty complications we used random forest and logistic regression with tenfold cross-validation employing demographic, comorbidity, laboratory, and wound characteristics as candidate predictors. Models were selected based on the receiver operating characteristic (ROC) curve, with the primary measure of performance being the area under curve (AUC).

RESULTS

We identified 1135 patients who underwent urethroplasty and met inclusion criteria. The mean age was 53 years with 84% being male. The overall incidence of complications was 8.6% (n = 98). Patients who experienced a complication more commonly had diabetes, a preoperative blood transfusion, preoperative sepsis, lower hematocrit and albumin, as well as a longer operative time (p < 0.05). LASSO logistic and random forest logistic models for predicting urethroplasty complications had an AUC (95% CI) 0.73 (0.58-0.87), and 0.48 (0.33-0.68), respectively. The variables that were determined to be most important and included in the predictive models were operative time, age, American Society of Anesthesiologists (ASA) classification and preoperative laboratory values (white blood cell count, hematocrit, creatinine, platelets).

CONCLUSION

Our predictive models of complications perform well and may allow for improved preoperative counseling and risk stratification in the surgical management of urethral stricture.

Visual internal urethrotomy for management of urethral strictures in boys: a comparison of short-term outcome of holmium laser versus cold knife

PURPOSE

To compare efficacy and safety of visual internal urethrotomy (VIU) using holmium laser (Ho:YAG) (group A) versus cold knife (group B) in children with urethral strictures. It may be the first comparative study on this issue in children.

METHODS

This study compared Ho:YAG group, which was evaluated prospectively from January 2014 till January 2016, versus cold knife group, which was a historical control performed from March 2008 till February 2010. Children ≤ 13 years old with urethral strictures ≤ 1.5 cm were included successively. Recurrent cases, congenital obstructions and cases with complete arrest of dye in voiding cystourethrography were excluded. Scar tissue was incised at twelve o'clock. Outcome was compared using Student's t, Mann-Whitney, Chi-square or Fisher exact tests as appropriate.

RESULTS

Each group included 21 patients. Mean age was 6.27 ± 3.23 (2-13) years old. Mean stricture length was 1.02 versus 1 cm in group A versus B, respectively (p = 0.862). Ten cases of penile/bulbous strictures and another 11 cases of membranous strictures were found in each group. There was no significant difference between both groups in preoperative data. Success rate for initial VIU was 66.7% in group A versus 38% in group B (p = 0.064). This was associated with significantly higher Q_max in group A (mean 16.52 vs 12.09 ml/s; p = 0.03). Success rate after two trials of VIU was 76.2% for group A and 47.61% for group B (p = 0.057). No complications were reported in both groups.

CONCLUSION

Laser VIU has a higher success rate than cold knife VIU for urethral strictures ≤ 1.5 cm in children with significantly higher Q_max. Both are easy to perform, low invasive and safe.

Stricture Urethra in Children: An Indian Perspective

Background:

Pediatric urethral stricture and its treatment have functional implications in the growing child.

Subjects and Methods:

A retrospective study of records on urethral strictures encountered in our institution between January 2005 and May 2016 yielded 23 boys against a backdrop of 19,250 admissions during the same period; stenosis and strictures after hypospadias repair were not included in this study. Demographic data were collected from the charts, and the success of repair was assessed clinically by success of repair was assessed clinically by observing for presence or absence of symptoms such as dribbling, straining at voiding, adequacy of urinary stream and radiologicaly by assessing the micturition phase of voiding cystourethrogram. Success was defined as successful initiation, flow, and completion of voiding with radiological evidence of reestablishment of urethral continuity.

Results:

The most common cause of urethral stricture was perineal or pelvic trauma (56.5%). Three after surgery for anorectal malformation (13.04%) and 2 (8.6%) followed otherwise unspecified urethritis. Transperineal and transpubic anastomotic routes were used for surgery. Redo surgery was required in 47.8%. The overall success rate was 82%. A self-catheterizable mitrofanoff channel was created as part of the primary procedure in 63.6% (7/11) or after the failure of the first procedure in 36.3% (4/11).

Conclusion:

The majority of urethral strictures are long-segment strictures or those with complete disruption not amenable to endoscopic techniques. The aim of the surgery is to obtain end-to-end opposition of healthy proximal and distal urethra. The route – transperineal or transpubic – which will give the best access to the ends of the urethra is determined by the location and extent of the stricture and the alteration in anatomy as a consequence of the pelvic fracture. Even after the introduction of laser and endoscopic techniques, surgical repair is required to tackle the majority of urethral strictures in children.

Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up

BACKGROUND

Our objective is to report a comparative review of recently released guidelines for the evaluation, management, and follow-up of urethral stricture disease.

METHODS

This is an analysis of the American Urologic Association (AUA) and Société Internationale d'Urologie (SIU) guidelines on urethral stricture. Strength of recommendations is stratified according to letter grade that corresponds to the level of evidence provided by the literature.

RESULTS

Although few, the discrepancies between the recommendations offered by the two guidelines can be best explained by varying interpretations of the literature and available evidence on urethral strictures. When comparing the AUA guidelines and the SIU guidelines on urethral stricture, there are very few discrepancies. Perhaps the most notable difference is in the use of repeat DVIU or urethral dilation after an initial failed attempt. SIU guidelines state that there are instances where repeat DVIU or urethral dilation can be indicated, and they give a range of time at which stricture recurrence post procedure mandates an urethroplasty (less than 3 to 6 months). The AUA guidelines definitively state that repeat endoscopic procedures should not be offered as an alternative to urethroplasty, and they do not mention time of stricture recurrence as a factor. SIU guidelines allow for management of urethral stricture with indwelling urethral stenting.

CONCLUSIONS

Overall there is a need for more high quality research in the work up, management, and follow up care of urethral stricture.

Male Urethral Stricture: American Urological Association Guideline

PURPOSE

The purpose of this Guideline is to provide a clinical framework for the diagnosis and treatment of male urethral stricture.

MATERIALS AND METHODS

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional guidance is provided as Clinical Principles and Expert Opinion when insufficient evidence existed.

RESULTS

The Panel identified the most common scenarios seen in clinical practice related to the treatment of urethral strictures. Guideline statements were developed to aid the clinician in optimal evaluation, treatment, and follow-up of patients presenting with urethral strictures.

CONCLUSIONS

Successful treatment of male urethral stricture requires selection of the appropriate endoscopic or surgical procedure based on anatomic location, length of stricture, and prior interventions. Routine use of imaging to assess stricture characteristics will be required to apply evidence based recommendations, which must be applied with consideration of patient preferences and personal goals. As scientific knowledge relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Use of holmium laser for urethral strictures in pediatrics: A prospective study

INTRODUCTION

The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions.

OBJECTIVE

To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures.

PATIENTS AND METHODS

From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation.

RESULTS

The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six.

DISCUSSION

One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study.

CONCLUSION

HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.