Use of Multiple Urolume Endourethral Prostheses in Complex Bulbar Urethral Strictures

Management of restenosis after urethral stent placement

PURPOSE

We describe our experience with the management of restricture after urethral stent placement, including endoscopic and open surgical treatment.

MATERIALS AND METHODS

We surveyed our prospectively collected database for patients with restenosis after urethral stent insertion. We reviewed patient age, comorbidities, indications for stent placement, restricture length, management of restricture, postoperative complications and the further restenosis rate.

RESULTS

Overall we have treated 22 patients with failed urethral stents with a median followup of 30 months (range 1 to 96). All stents were initially placed for urethral stricture management. Stricture etiology included prostate cancer therapy in 9 cases, idiopathic causes in 6, urethral instrumentation in 2, trauma in 2, simple prostatectomy in 2 and gender reassignment/phalloplasty in 1. Ten patients had anterior urethral stricture, 11 had posterior stricture and 1 patient had each type. Of the 22 patients with stenosis after stent placement 13 underwent urethroplasty. Of the 18 patients with indwelling stents at treatment the stent was removed in 8 intraoperatively and in 10 the stent was left in situ. Ten of the 11 anterior strictures were treated with urethroplasty. Only 4 of the 12 posterior strictures were treated with urethroplasty, while 8 were managed endoscopically. Our overall success rate for treatment after stent failure was 67% (8 of 12 cases) for posterior urethral strictures and 82% (9 of 11) for anterior strictures.

CONCLUSIONS

Urethral stent failure requires complex intervention. A failed posterior urethral stent can often be managed endoscopically. Conversely we have managed failed anterior urethral stents by urethroplasty.

Management of recurrent urethral strictures with covered retrievable expandable nitinol stents: long-term results

OBJECTIVE

The purpose of this study was to evaluate the long-term clinical efficacy of temporary placement of covered retrievable stents in the management of recurrent urethral strictures.

MATERIALS AND METHODS

During the period December 1998-December 2005, 32 men and one adolescent boy (mean age, 48.6 years; range, 16-73 years) with recurrent urethral strictures underwent fluoroscopically guided insertion of a total of 68 stents. Patients without complications underwent elective stent removal 2 or 4 months after stent insertion. Rates of clinical success (long-term clinical and radiographic resolution of urethral strictures) were assessed. The Mann-Whitney U test was used to compare the duration of stent placement in patients with long-term clinical resolution with that in patients with stricture relapse.

RESULTS

Clinical success was achieved in 18 (55%) of the 33 patients. The mean duration of stent placement in patients with clinical success was significantly different from that in patients who had recurrences (p < 0.0001). Stricture relapse did not occur in only four (20%) of 20 cases of stent placement for 2 months. All 14 stent placements lasting at least 4 months resulted in long-term resolution after a mean follow-up period of 3.6 years. The most common complications necessitating early stent removal were stent migration (33.8% of stents) and tissue hyperplasia (20.6% of stents).

CONCLUSION

Placement of a covered retrievable stent for a minimum of 4 months is effective in inducing long-term resolution of refractory urethral strictures. Stent migration remains the largest obstacle in achieving adequate duration of stent placement.

Preservation of lower urinary tract function in posterior urethral stenosis: selection of appropriate patients for urethral stents

PURPOSE

We describe our experience with urethral stents to manage iatrogenic posterior urethral stenosis.

MATERIALS AND METHODS

We surveyed our retrospective database for patients in whom we placed a urethral stent for posterior urethral stricture disease. We reviewed patient age, comorbidities, indications for stent placement, stricture length, postoperative complications and the repeat stenosis rate.

RESULTS

Overall we placed urethral stents in 13 patients, of whom 12 presented with posterior urethral stenosis and 1 presented with anterior and posterior stricture. The etiology of urethral stricture was prostate cancer therapy in 11 of 13 cases and simple prostatectomy in 2. Urethral stenting was chosen instead of urethral reconstruction largely due to prior radiation for prostate cancer and avoidance of the morbidity of surgery. Overall 6 of 13 patients required additional procedures for stricture recurrence, including 5 in previously irradiated patients. Two patients had stents removed due to migration or pain. Genitourinary infections developed in 5 of 13 patients. Eight of 13 patients with a posterior urethral stricture were incontinent, as expected after stent placement. Incontinence was managed by an artificial urinary sphincter in willing patients with 9 of 13 continent.

CONCLUSIONS

Urethral stents provide reasonable treatment for patients with posterior urethral stenosis when attempting to preserve lower urinary tract function caused by stricture disease after prostate cancer therapy. Prior radiation seems to increase the failure rate. Continence can be maintained after posterior urethral stenting in select patients.

One-stage urethral reconstruction for stricture recurrence after urethral stent placement

PURPOSE

We report our 8-year experience with 1-stage open urethral reconstruction in 10 patients with recurrent bulbar and/or membranous strictures after UroLume urethral stent placement.

MATERIALS AND METHODS

Ten consecutive referral patients underwent preoperative contrast imaging and urethroscopy followed by primary anastomotic repair or substitution urethroplasty, with concomitant open UroLume removal (when the stent was still present). Postoperative evaluation included contrast imaging 3 weeks after surgery, urethroscopy 4 months after surgery, uroflowmetry, and American Urological Association symptom score assessment.

RESULTS

At a medium followup of 51.2 months all patients remain free of bulbar or membranous stricture recurrence. No patient has required dilation or any other intervention.

CONCLUSIONS

One-stage open reconstruction with stent extraction offers a definitive treatment option with a high success rate for patients with recurrent bulbar and/or membranous strictures following urethral stent placement.

Recurrent traumatic urethral strictures near the external sphincter: treatment with a covered, retrievable, expandable nitinol stent--initial results

PURPOSE

To investigate the clinical effectiveness of a covered, retrievable, expandable nitinol stent in treating traumatic urethral strictures near the external sphincter.

MATERIALS AND METHODS

The stent was 10 mm in diameter when fully expanded and 40-50 mm long. To make it removable, two nylon drawstrings were attached to its lower inner margin. Twelve consecutive men (19-67 years; mean age, 47 years) with traumatic urethral strictures near the external sphincter that were refractory to endoscopic urethrotomy were treated. With fluoroscopic guidance, a stent was placed to completely bridge the external sphincter. The stent was electively removed with a retrieval hook wire 2 months after placement. Stent placement and removal were successful in all patients, with no procedural complications.

RESULTS

Mean maximum urine flow rate was 5 mL/sec (range, 3-7 mL/sec) before stent placement and 27 mL/sec (range, 16-40 mL/sec) at 1 week after placement. During the mean follow-up of 20 months (range, 2-37 months) after the first stent removal, strictures recurred in eight of 12 patients. For the eight patients with recurrence, a second stent was placed and 4 months later was removed from seven of the eight patients. During the mean follow-up of 18 months (range, 4-32 months) after the second stent removal, strictures recurred in two patients, in whom a third stent was placed and then removed 4 months later, with good results. Four (33%) of 12 patients, five (62%) of eight patients, and two (100%) of two patients were successfully treated with placement of the first stent, the second stent, and the third stent, respectively. In the remaining patient, the second stent remains in place.

CONCLUSION

Placement of a covered, retrievable, expandable nitinol stent seems to be effective in treating urethral strictures near the external sphincter and warrants further investigation.

Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients

PURPOSE

We reviewed our experience with anastomotic urethroplasty for anterior urethral stricture.

MATERIALS AND METHODS

A chart review revealed 168 patients 6 to 82 years old (mean age 38) with at least 6 months of followup (mean 70, range 6 to 291) after anastomotic urethroplasty.

RESULTS

Average stricture length was 1.7 cm. Of the 168 patients stricture recurred in 8 (5%) but was managed by direct vision internal urethrotomy or a single dilation in 5, while repeat urethroplasty was required in 3 (2%). In these 3 cases extenuating circumstances included patient dislodgment of the catheter with attempts to replace it that disrupted repair, a history of urethrocutaneous fistula and periurethral abscess, and previous irradiation complicating the stricture in 1 each. Other complications were uncommon, such as transient thigh pain or numbness in 3 patients (2%), small wound dehiscence in 2 (1%), and scrotal hematoma, erectile dysfunction and self-limited pulmonary edema in 1 (less than 1%) each.

CONCLUSIONS

Anastomotic urethroplasty for anterior stricture has a high success rate of 95%. It is technically straightforward and complications are uncommon. Cure by anastomotic urethroplasty should be strongly favored over long-term management by direct vision internal urethrotomy or dilation.

The use of self-expanding metallic urethral stents in the treatment of recurrent bulbar urethral strictures: long-term results

OBJECTIVE

To evaluate the effectiveness and long-term results of using a self-expanding metallic urethral stent (Urolumetrade mark, American Medical Systems, Minnetonka, MI, USA) to treat recurrent bulbar urethral strictures.

PATIENTS AND METHODS

Between 1990 and 1999, 65 stents were placed in 60 men (mean age 45.2 years, range 20-71) with a urethral stricture (mostly caused by trauma and present for a mean of 4.3 years, range 0.16-26) and who had previously undergone different unsuccessful treatments.

RESULTS

During a mean (range) follow-up of 3.8 (1-9) years the strictures in 52 of the 60 patients (87%) were treated successfully. All patients initially had postvoid dribbling incontinence, but this resolved in most within one week; 19 patients remain incontinent.

CONCLUSION

The Urolume is a cost-effective alternative to other treatments for recurrent bulbar urethral strictures of whatever cause.