What is the Optimal Surgical Strategy for Bulbous Urethral Stricture in Boys?

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.

Oral Mucosa vs. Penile Skin Flap in Substitution Urethroplasty for Anterior Urethral Strictures: A Systematic Review and Meta-Analysis

Background: The purpose of this study is to compare the effectiveness and safety of oral mucosa and penile skin flaps in the treatment of anterior urethral stricture. Methods: This meta-analysis was carried out according to the principle of preferred reporting items for systematic reviews and meta-analysis (PRISMA) and registered at PROSPERO (CRD42021277688). The Cochrane Library, PubMed, Embase, CKNI databases were searched and reviewed up to Sep 2021. Quality evaluation was performed with Newcastle-Ottawa Scale (NOS) system for non-randomized studies and Cochrane stools for randomized studies. Data synthesis was conducted with RevMan 5.4 software (Cochrane) and a Stata 15.0 environment (Stata Corpor, College Station, TX, USA). Results: After the research screening, eight studies (comprising 445 patients) were finally included in the quantitative analysis. In the success rate comparison, there was no significant difference between oral mucosa and penile skin flaps (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.80, 95% CI: 0.47-1.34, P = 0.39). There was no significant difference in the post-operative complication comparison (oral mucosa vs. penile skin flap, Mantel-Haenszel statistic [M-H] fixed model, OR: 0.68, 95% CI: 0.40-1.16, P = 0.15). However, considering that the site of oral mucosa is far from the anterior urethra, it may have advantages in operation time through simultaneous operations (oral mucosa vs. penile skin flap, MD: -40.05, 95% CI: -79.42, -0.68, P = 0.046). Conclusion: When the oral mucosal graft was used in the anterior urethra urethroplasty, it had a similar success rate and post-operative complication rate, and oral mucosa substitution had a shorter operation time. This evidence-based medical research further supports the view that oral mucosa is the preferred substitution material for the anterior urethra urethroplasty.

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.

Delayed primary end-to-end anastomosis for traumatic long segment urethral stricture and its short-term outcomes

BACKGROUND:

The purpose of this study is to evaluate the aetiology of posterior urethral stricture in children and analysis of results after delayed primary repair with extensive distal urethral mobilisation.

MATERIALS AND METHODS

This was a retrospective study carried out in a tertiary care centre from January 2009 to December 2013.

RESULTS:

Eight children with median age 7.5 years (range 4-11 years), underwent delayed anastomotic urethroplasty: Six through perineal and two through combined perineal and transpubic approach. All the eight children had long-segment >2 cm stricture: Three posterior and five anterior urethral stricture. On a mean follow-up period of 33 months (range 24-48 m), all were passing urine with good flow and stream.

CONCLUSION:

End-to-end anastomosis in post-traumatic long segment posterior urethral stricture between prostatic and penile urethra in children is possible by perineal or combined perineal and transpubic approach with good results without any urethral replacement.

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.

Role of visual internal urethrotomy in pediatric urethral strictures

PURPOSE

To evaluate the efficiency of visual internal urethrotomies (VIUs) in pediatric patients.

PATIENTS AND METHODS

Thirty-four patients aged 0.2-16.3 years were treated with VIUs as a primary treatment for urethral stricture at our institution during 1980-2010. The stricture characteristics and need for repeat treatments as well as the results of repeat VIUs or dilatations were evaluated in a long-term follow-up.

RESULTS

Each time first VIUs or repeat treatments were carried out there was a 22-33% success rate at 5 years. Twenty-four patients (71%) were treated successfully after repeat VIUs or dilatations at a median of 6.6 years' follow-up. None of the five patients with strictures longer than 2 cm were successfully treated, compared with 24 of 29 patients with shorter strictures (p = 0.001). However, stricture etiology or location did not have an impact on success. Currently four patients have undergone an open operation because of stricture and six patients are on a home dilatation program.

CONCLUSION

Single VIU is successful for about one-quarter of pediatric patients with a urethral stricture. With repeated VIUs or dilatations 71% of the patients can achieve success. In strictures less than 2 cm, up to three VIUs can be attempted, but longer strictures need open correction if the patient does not wish to follow the home dilatation program.

Etiology and outcome of the perineal repair of posterior and bulbar urethral strictures in children: a single surgeon experience

OBJECTIVE

To evaluate the etiology of posterior and/or bulbar strictures in children in an industrialized country and assess the outcome of its repair by perineal approach. Urethral strictures in children are rare and often challenging to treat. Trauma is the main etiology in developing countries. However, data for industrialized countries are sparse.

MATERIAL AND METHODS

Retrospective analysis of 17 patients treated with perineal urethroplasty 2001-2010. Data were assessed by chart review and non-validated standardized questionnaire. Hypospadias cases were excluded. Reconstruction was performed by stricture excision and primary anastomosis, or a single-staged or two-staged buccal mucosa graft.

RESULTS

Mean age at surgery was 7.9 years (range 1-13) and mean follow-up was 42.6 months (4-115). Eight patients (47.1%) had post-traumatic strictures, five (29.4%) had a history of posterior valves, and previous transurethral catheterization and irradiation each accounted for one patient (5.9%). In the remaining two (11.8%), the etiology was unknown. The success rate was 88.9%. All but one patient were continent postoperatively.

CONCLUSIONS

Most common etiology for open urethral reconstruction in children was trauma and previous valve treatment. In our hands the perineal approach for stricture repair is safe and successful. Stricture recurrence rate is low, and incontinence is only associated with additional bladder neck trauma.

Sonourethrogram to manage adolescent anterior urethral stricture

PURPOSE

Accurate measurement of anterior urethral stricture length is critical to determine the appropriate surgical approach. Retrograde urethrogram is often used to determine stricture location and length. However, the adult literature shows that retrograde urethrogram may underestimate stricture length. We investigated the role of sonographic urethrogram in the preoperative evaluation of adolescent urethral stricture disease.

MATERIALS AND METHODS

Between June 2008 and February 2009 we retrospectively evaluated 12 pediatric patients with urethral stricture disease using retrograde and sonographic urethrogram. Stricture length was categorized by 2 radiologists as I-less than 1, II-1 to 3 and III-greater than 3 cm. On sonographic urethrogram stricture length was measured as the longest extent of the urethral abnormality.

RESULTS

Mean patient age was 16.9 years (range 9.5 to 20.8). Retrograde urethrogram classified 7 cases as category I, 4 as category II and none as category III stricture, and 1 with no evidence of stricture. Sonographic urethrogram revealed strictures greater than 1 cm in all 7 category I cases and 2 of the 4 category II cases had strictures longer than 3 cm. One patient in whom retrograde urethrogram showed a category II stricture was stricture-free on sonographic urethrogram. One patient with a negative retrograde urethrogram had a stricture on sonographic urethrogram. Sonographic urethrogram upgraded stricture length in 10 of the 12 patients and outperformed retrograde urethrogram in 11.

CONCLUSIONS

Sonographic urethrogram is effective for evaluating adolescent urethral stricture disease. It may provide more accurate measurement of stricture length and improve preoperative planning.