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Issack FH, Hassen SM, Tefera AT, Teshome H, Gebreselassie KH, Mummed FO. Short-term recurrence rate of male urethral stricture and its predictors after treatment with optical internal urethrotomy: Prospective Cohort Study at a tertiary center in Ethiopia. Ann Med Surg (Lond) 2023; 85:4715-4719. [PMID: 37811100 PMCID: PMC10553156 DOI: 10.1097/ms9.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/19/2023] [Indexed: 10/10/2023] Open
Abstract
Abstract Background Although optical internal urethrotomy is popular among the urologists due to its simplicity and safety, urethroplasty is considered the gold standard treatment for urethral strictures. This study aims to determine the 1-year recurrence rate of urethral strictures after optical urethrotomy and identify predictors of recurrence in a tertiary center in Ethiopia. Methods A prospective observational cohort study was conducted on 80 male patients who underwent optical urethrotomy from November 2019 to August 2020 in a tertiary center in Ethiopia. Logistic regression was used to analyze the association between dependent and independent variables, with a P-value of <0.05 considered statistically significant. Results The mean and median age (±SD) of patients at the time of the procedure were 54.76 (±14.74) and 58 years with a range [20-78], respectively. Urethral discharge was the most common etiology identified in 39 (48.75%) of patients. Eleven (13.75%) patients had no identifiable etiology for their urethral stricture disease.The majority of patients presented with at least one voiding lower urinary tract symptoms.Sixty-eight (85%) patients out of the total had a single stricture and 12 (15%) had multiple strictures. The location of the stricture was in the bulbar urethra on cystourethrography in 83% of the patients. The 1-year recurrence rate of urethral stricture after optical urethrotomy was 35% in our study.The number of strictures and the presence of hypertension were independent predictors of recurrence of urethral stricture within 1-year after treatment with optical urethrotomy (AOR=15.35, 95% CI: 2.92-80.61, P=0.00; AOR=19.47, 95% CI: 2.11-178.98, P=0.01, respectively). Conclusions Our study identified that multiple strictures, and the presence of hypertension are associated with an increased recurrence rate in the first postoperative year.
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Affiliation(s)
- Feysel H. Issack
- Department of Surgery, St Paul’s Hospital Millennium Medical College, Swaziland Street, Addis Ababa, Ethiopia
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Rourke D, Bekkema J, Rourke KF. Prospective Assessment of Genital Pain in Patients With Urethral Stricture: Incidence, Associations, and Impact of Urethroplasty. Urology 2023; 171:221-226. [PMID: 36343864 DOI: 10.1016/j.urology.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/06/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the incidence of genital pain in patients with urethral stricture and examine the impact of urethroplasty. Genital pain is a common and challenging urological condition and potentially associated with urethral stricture. METHODS From 2011-2019, patients were offered enrollment in a prospective single-center study assessing patient-reported genital pain pre- and 6-months posturethroplasty. Genital pain was assessed with the question, "Do you experience genital (scrotum or penis) pain?" answered on a five-point scale ["Never" (1), "Occasionally" (2), "Sometimes" (3), "Most of the Time" (4) or "All of the Time" (5)]. Responses of 3, 4, or 5 were considered clinically significant. Wilcoxon signed-rank test was used to compare pre- and postoperative states and logistic regression was used to evaluate the association between genital pain and clinical variables. RESULTS Of the 387 patients completing enrollment, 36.4% (141/387) reported genital pain preoperatively. Patients with panurethral stricture reported higher rates (57.1%) of pain (Odds Ratio 2.93, 95%CI 1.32-6.50; P = .008). Posturethroplasty, pain scores improved with an incidence of 14.2% (P < .0001). In patients reporting preoperative pain, 88.7% (125/141) experienced improvement, 8.5% were unchanged and 2.8% reported worsening pain. On logistic regression, patients with penile strictures (O.R. 0.24, 95%CI 0.06-0.91; P = .04), hypospadias (O.R. 0.14, 95%CI 0.02-0.88; P = .04), and staged reconstruction (O.R. 0.22, 95%CI 0.05-0.90; P = .04) were less likely to report improvement. CONCLUSION Genital pain is common in patients with urethral stricture and improves in the majority of patients undergoing urethroplasty but less so in patients with penile strictures, hypospadias and staged reconstruction.
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Affiliation(s)
- Declan Rourke
- Department of Biological Sciences, University of Alberta, Edmonton, AB, Canada
| | - Jordan Bekkema
- Division of Urology, University of Alberta, Edmonton, AB, Canada
| | - Keith F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada.
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González-Espinosa C, Castro-Nuñez P, Averbeck MA, Gomez R, Castaño-Botero JC, Aparicio A, Moreno-Palacios J. Diagnosis and treatment of urethral stricture in men with neurogenic lower urinary tract dysfunction: A systematic review. Neurourol Urodyn 2022; 41:1248-1257. [PMID: 35686544 DOI: 10.1002/nau.24982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022]
Abstract
AIM To summarize available data focused on diagnosis and management of urethral stricture in men with neurogenic lower urinary tract dysfunction by a systematic review of the literature. MATERIALS AND METHODS A systematic review of the literature was carried out through an extensive electronic database search performed in PubMed/MEDLINE and Scopus databases for full texts, and International Continence Society, American Urology Association, and European Association of Urology abstracts for citations related to urethral structure. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. RESULTS A total of 316 articles were identified, 48 of which were selected for this review. Different strategies are currently being used for the management of urethral strictures, such as clean intermittent catheterization (CIC) which reduces stricture by up to 68%; direct vision internal urethrotomy which shows lower rates of renarrowing; urethroplasty which shows a success rate up to 70%; urinary diversion is the treatment of choice when reconstruction is not possible. CONCLUSIONS Further studies are needed in this population because of the heterogeneity of the outcomes and the lack of a standardized definition and classification of this population.
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Affiliation(s)
- Carlos González-Espinosa
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
| | - Patricia Castro-Nuñez
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
| | - Marcio A Averbeck
- Neuro-Urology Department, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | - Reynaldo Gomez
- Urology Department-Hospital del Trabajador, Santiago, Chile
| | | | | | - Jorge Moreno-Palacios
- Urology Department, UMAE, Hospital de Especialidades "Dr. Bernardo Sepúlveda Gutiérrez", IMSS, Ciudad de México, México
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Madec FX, Karsenty G, Yiou R, Robert G, Huyghe E, Boillot B, Marcelli F, Journel NM. [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)]. Prog Urol 2021; 31:1055-1071. [PMID: 34620544 DOI: 10.1016/j.purol.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/17/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- F-X Madec
- Service d'urologie, hôpital Foch, 40, rue de Worth, 92150 Suresnes, France.
| | - G Karsenty
- Service d'urologie, hôpitaux universitaires de Marseille Conception, 147, boulevard Baille, 13005 Marseille, France
| | - R Yiou
- Service d'urologie, hôpital Henri-Mondor, CHU Paris est, 51, avenue du Marechal de Lattre de Tassigny, 94010 Créteil Cedex, France
| | - G Robert
- Service d'urologie, CHU de Bordeaux GH Pellegrin, 30000 Bordeaux, France
| | - E Huyghe
- Département d'urologie, transplantation rénale et andrologie, CHU de Toulouse, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
| | - B Boillot
- Service d'urologie et de la transplantation rénale, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
| | - F Marcelli
- Service d'urologie, CHRU-hopital huriez, rue Michel Polonowski, 59037 Lille, France
| | - N M Journel
- Service d'urologie, Centre Hospitalier Lyon Sud (HCL), chemin du Grand Revoyet, 69310 Pierre Benite, France
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Azab SS. Comparative study between Amplatz renal dilator vs visual internal urethrotomy (cold knife) for the treatment of male urethral stricture. Scand J Urol 2020; 54:431-437. [PMID: 32723114 DOI: 10.1080/21681805.2020.1798504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM The study aimed to assess and compare urethral stricture (US) management outcomes, efficiency, and complications, treated by either Amplatz renal dilator or visual internal urethrotomy (VIU). PATIENTS AND METHODS This prospective comparative study was carried out on 88 male patients with stricture urethra. All patients have performed a physical examination, ascending and micturition urethrography, urodynamic, and pelvic ultrasound. The patients were randomized divided into group 1 (Amplatz group) 44 patients treated with Amplatz dilator, and group 2 (VIU group) 44 patients treated with a cold knife. Patients were followed up at 15 days,3,6, and 12 months after the procedure. RESULT The mean age was 41.2 (22-73) years. The mean stricture length in group 1 and group 2 was 1.01 ± 0.40 and 1.04 ± 0.30, respectively (p = 0.421). The average IPSS score at baseline for group 1 and group 2 was 21.2 and 21.9 points, respectively. During the 12 months follow-up, IPSS improved, with average scores of 16.1 and 17.3 for group 1 and group 2, respectively (p > 0.05). The mean values of (Q max) between group 1 and group 2 at baseline, day 15, day 90 and 180 days showed no significant difference but at 12 months, (Q max) showed a higher significant difference in group 1 than group 2 (p = 0.003). The post-void residual (PVR) displayed a significant decline in both groups from baseline. After 1 year, PVR showed that group 2 was a little higher than group 1 (no significance) compared to baseline The procedures were found effective without recurrence in all patients (both groups) during the 12 months (Q max > 15m/s). However, group 2 reported (11.4%) intra-operative bleeding, and (6.8%) extravasations. CONCLUSION The guided urethral dilation and internal urethrotomy are safe, short time procedures, and offer satisfactory results with the advance to VIUD in Qmax at 12 months. No recurrence was documented in both groups after 12 months. VIU reported 18% intraoperative complication.
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Affiliation(s)
- Sherif Salah Azab
- Urology Department, Faculty of Medicine, October 6 University, Cairo, Egypt
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Topaktaş R, Ürkmez A, Tokuç E, Akyüz M, Kutluhan MA. Hematologic parameters and neutrophil / lymphocyte ratio in the prediction of urethroplasty success. Int Braz J Urol 2019; 45:369-375. [PMID: 30785704 PMCID: PMC6541144 DOI: 10.1590/s1677-5538.ibju.2018.0682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/15/2018] [Indexed: 11/21/2022] Open
Abstract
Objective: The pathophysiology of urethral stricture and its recurrence remains vague and one of the important causes is progressive inflammation. It has been shown in recent years that the neutrophil / lymphocyte ratio is a marker of systemic inflammation and is associated with prognosis in many cardiovascular diseases, malignancies and chronic inflammatory diseases. We assessed simple systemic inflammation markers preoperatively and surgical techniques for urethral stricture recurrence after urethroplasty. Patients and Methods: After exclusion criteria applied, a total of 117 male cases operated with urethroplasty in our clinic between January 2012 and June 2017 were included in the study and analyzed retrospectively. Localization and length of the strictures of the patients, neutrophil counts and percentages, lymphocyte counts and percentages, and neutrophil / lymphocyte ratios in preoperative peripheral blood samples were statistically analyzed. Recurrent stricture during first 12 months follow-up after the surgery has been assessed as recurrence. Results: The mean age of the patients was 54.12 ± 16.35 and the mean urethral stricture length was 3.44 ± 1.83 cm. Recurrence was observed in 30.1% of cases who received buccal graft, 30% in penile skin applied cases and 26.1% of cases treated with end-to-end anastomosis and there was no statistically significant difference between neutrophil, lymphocyte, neutrophil / lymphocyte ratio and average stricture segment length between recurrent and non-recurrent cases (p > 0.005). Conclusions: We consider that neutrophil, lymphocyte counts and their ratio prior to urethroplasty and the technique performed are not parameters that can be used to predict stricture recurrence. Prospective and randomized new trials with larger patient populations are needed to make more accurate judgments about the role of these inflammatory parameters.
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Affiliation(s)
- Ramazan Topaktaş
- Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Ürkmez
- Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Emre Tokuç
- Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Akyüz
- Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Musab A Kutluhan
- Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
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Browne BM, Vanni AJ. Management of Urethral Stricture and Bladder Neck Contracture Following Primary and Salvage Treatment of Prostate Cancer. Curr Urol Rep 2018; 18:76. [PMID: 28776126 DOI: 10.1007/s11934-017-0729-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This article discusses the incidence, evaluation, and treatment of bladder outlet obstruction from urethral stricture, vesicourethral anastomotic stricture, and bladder neck contracture following primary and salvage treatment of prostate cancer. RECENT FINDINGS Rates of stenosis after prostate cancer treatment appear similar across all primary treatment modalities including radical prostatectomy, radiation therapy, cryoablation, and high-intensity focused ultrasound in contemporary series. Urethral dilation and urethrotomy continue to report moderate patency rates. Urethroplasty achieves high patency rates even for long strictures, but more extensive reconstruction increases the risk of postoperative urinary incontinence. Recent AUA guidelines on urethral strictures provide new recommendations for management of these patients. All treatment options for prostate cancer carry a risk for bladder outlet obstruction, and intervention is often necessary to relieve long-lasting morbidity. Careful preoperative evaluation should be completed to assess location and extent of the stricture in order to choose optimal therapy. Endoscopic treatments, open reconstruction, and urinary diversion all play a role in relief of stenosis depending on stricture length, location, characteristics, and patient comorbidities.
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Affiliation(s)
- Brendan Michael Browne
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA.
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Protective effect of platelet‐rich plasma on urethral injury model of male rats. Neurourol Urodyn 2017; 37:1286-1293. [DOI: 10.1002/nau.23460] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/10/2017] [Indexed: 01/15/2023]
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9
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Benincasa A, Saita A, Pinto A, Pilerci C, Francesco L, Russo A, Benincasa G. Double Intracavernous Breakage of Sachse's Knife Blade: Management of a Rare Complication Performing Direct Vision Internal Urethrotomy. J Endourol Case Rep 2017; 3:126-129. [PMID: 29098193 PMCID: PMC5655839 DOI: 10.1089/cren.2017.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Although the breakage of a Sachse's knife blade is already a rare event while performing optical internal urethrotomy, a double failure appears to be at the same time a unique and a challenging complication to manage since no reference has emerged from literature review. Case Presentation: A male patient, 80 years of age, underwent retreatment of recurrent urethral stricture that occurred after transurethral resection of the prostate. The latter was complicated by severe intraoperative urethrorrhagia; this is the reason he was transferred from another institution where at first a suprapubic cystostomy was carried out, followed by urethral recanalization through internal urethrotomy and finally he underwent intracavernous Sachse's knife blade discharge. Preoperative evaluation included combined retrograde and voiding urethrography and CT to evaluate the complete resolution of the urethral stenosis and to establish the correct location of the blades inside the corpus cavernosum. A transperineal approach to the left corpus cavernosum was carried out with manageable removal of the foreign body and postoperative assessment showed no early considerable complications for the patient. Conclusion: To our knowledge, this is the first case of double breakage of Sachse's knife blade performing optical internal urethrotomy reported in literature. Although it may appear to be an easy procedure, close attention to its execution must always be paid to prevent major complications. A transperineal approach has proven to be effective and safe without creating any further outcomes to the patient.
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Affiliation(s)
- Alfonso Benincasa
- Department of Urology, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy
| | - Alberto Saita
- Department of Urology, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Italy
| | - Angelo Pinto
- Department of Urology, San Luca Hospital, Vallo della Lucania, Italy
| | - Carmine Pilerci
- Department of Urology, San Luca Hospital, Vallo della Lucania, Italy
| | | | - Aniello Russo
- Department of Urology, San Luca Hospital, Vallo della Lucania, Italy
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Gül M, Altıntaş E, Kaynar M, Buğday MS, Göktaş S. The predictive value of platelet to lymphocyte and neutrophil to lymphocyte ratio in determining urethral stricture after transurethral resection of prostate. Turk J Urol 2017; 43:325-329. [PMID: 28861306 DOI: 10.5152/tud.2017.14478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 02/01/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The pathology of urethral stricture disease is still unclear however progressive inflammation may contribute to the development of urethral stricture. The platelet-to- lymphocyte ratio (PLR) is a new and simple marker that indicates inflammation. In this study we aimed to investigate the predictive value of neutrophil to lymphocyte ratio (NLR) and PLR in patients with urethral stricture who underwent transurethral resection of prostate (TURP). MATERIAL AND METHODS A total of 208 patients who underwent bipolar-TURP were included in this study. Patients who had previously undergone surgery due to any urethral pathology, posterior urethral strictures, previous or ongoing treatment for any cancer, hematologic disorders, presence of an active infection at the time of surgical intervention, and prior blood transfusion were excluded. PLR, NLR and red cell distribution width (RDW) levels were measured. In order to investigate the predictive values of NLR and PLR variables, binary logistic regression analysis was performed. RESULTS No statistically significant differences were observed between the groups in terms of age, NLR, RDW, prostate size and operative times. Statistically significant differences were presented only in the median PLR- values. For predicting urethral stricture, the optimal cut-off value was 112.5, (sensitivity: 0.84, specificity: 0.64; AUC=0.762, 95% CI 0.684-0.84). CONCLUSION In this study we showed that PLR can be used to determine urethral stricture as a cost-effective, common, and simple biomarker in patients after TURP.
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Affiliation(s)
- Murat Gül
- Clinic of Urology, Van Training and Research Hospital, Van, Turkey
| | - Emre Altıntaş
- Department of Urology, Selçuk University School of Medicine Konya, Turkey
| | - Mehmet Kaynar
- Department of Urology, Selçuk University School of Medicine Konya, Turkey
| | | | - Serdar Göktaş
- Department of Urology, Selçuk University School of Medicine Konya, Turkey
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Akkoc A, Aydin C, Kartalmıs M, Topaktas R, Altin S, Yilmaz Y. Use and outcomes of amplatz renal dilator for treatment of urethral strictures. Int Braz J Urol 2017; 42:356-64. [PMID: 27256192 PMCID: PMC4871399 DOI: 10.1590/s1677-5538.ibju.2014.0578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 09/09/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Urethral stricture disease is still a major problem in men. Many procedures are available for the treatment of urethral strictures; urethral dilatation is one of the oldest. The blind dilatation of urethral strictures may be a difficult and potentially dangerous procedure. The purpose of this study was to describe safe urethral dilatation using amplatz renal dilator and to report outcomes. Materials and Methods From 2010 to 2014, a total of 26 men with primary urethral strictures were managed by urethral dilatation using amplatz renal dilators. The parameters analyzed included presentation of patients, retrograde urethrography (RGU) findings, pre-and postoperative maximum flow rate (Qmax) on uroflowmetry (UF) and post-void residual urine (PVR). Patients were followed-up at 1.6 and 12 months. The technique described in this paper enables such strictures to be safely dilated after endoscopic placement of a suitable guidewire and stylet over which amplatz renal dilators are introduced. Results The mean age of the patients was 57.6 (35–72) years. The median stricture length was 0.82 (0.6–1.5)cm. Pre-operative uroflowmetry showed Qmax of 7.00 (4–12) mL/sec and ultrasonography showed PVR of 75.00 (45–195)mL. Postoperatively, Qmax improved to 18.00 (15–22)mL/sec (p<0.001) at 1 month, 17.00 (13–21)mL/sec (p<0.001) at 6 months and 15.00 (12–17)mL/sec (p<0.001) at 12 months. The post-operative PVR values were 22.50 (10–60)mL (p<0.001), 30.00 (10–70)mL (p<0.001) and 30.00 (10–70) mL (p<0.001) at 1.6 12 months, respectively. The median procedure time was 15.00 (12–22) minutes. None of the patients had a recurrence during a 12-month period of follow-up. Conclusion Urethral dilatation with amplatz renal dilators avoids the risks associated with blind dilatation techniques. This tecnique is a safe, easy, well-tolerated and cost-effective alternative for treatment of urethral strictures.
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Affiliation(s)
- Ali Akkoc
- Department of Urology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Cemil Aydin
- Department of Urology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Mahir Kartalmıs
- Department of Urology, Selahaddin Eyyubi State Hospital, Diyarbakir, Turkey
| | - Ramazan Topaktas
- Department of Urology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Selcuk Altin
- Department of Urology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Yakup Yilmaz
- Department of Urology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
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12
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Johnsen NV, Penson DF, Reynolds WS, Milam DF, Dmochowski RR, Kaufman MR. Cost-effective management of pelvic fracture urethral injuries. World J Urol 2017; 35:1617-1623. [PMID: 28229209 DOI: 10.1007/s00345-017-2022-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/06/2017] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis. METHODS Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period. RESULTS PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored. CONCLUSIONS Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.
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Affiliation(s)
- Niels V Johnsen
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
| | - David F Penson
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - W Stuart Reynolds
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Douglas F Milam
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Roger R Dmochowski
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Melissa R Kaufman
- Department of Urological Surgery, A-1302 Medical Center North, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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Modified platelet-rich plasma with transforming growth factor β1 neutralization antibody injection may reduce recurrence rate of urethral stricture. Med Hypotheses 2016; 97:1-3. [PMID: 27876114 DOI: 10.1016/j.mehy.2016.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/18/2016] [Indexed: 01/15/2023]
Abstract
Urethral stricture is one of the most bothersome urologic disease among urologists and has a substantial impact on quality of life and healthcare costs. Although it can be cured with internal urethrotomy easily, post-surgery stricture recurrence is challenging. Several adjuvant therapies have been used in conjunction with internal urethrotomy but none of them are used routinely because the pathophysiology of the disease is still obscure. Fibrosis is the most accused hypothesis for the action. Platelet-rich plasma (PRP) is an autologous blood product containing a high concentration of platelets that is being used for a very wide range of clinical healing applications. It comprises a concentration of fundamental protein growth factors shown to be actively excreted by platelets to initiate accurate wound healing. Although PRP can play a critical role in wound healing and has been used in fibrotic diseases successfully, it has some deleterious cytokines such as transforming growth factor β1 (TGF β1) which can also cause fibrosis. The new hypothesis is that the subcutaneous injection of neutralized platelet-rich plasma with TGFβ1 antibody at the planned urethrotomy site may prevent recurrence and provide superior healing and long-term results.
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Yürük E, Yentur S, Çakır ÖO, Ertaş K, Şerefoğlu EC, Semerciöz A. Catheter dwell time and diameter affect the recurrence rates after internal urethrotomy. Turk J Urol 2016; 42:184-9. [PMID: 27635294 DOI: 10.5152/tud.2016.90490] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cold-knife direct vision internal urethrotomy (DVIU) is frequently used as the first-line treatment for urethral stricture disease. Although the steps of the procedure are defined in detail, the duration of catheterization and the diameter of the catheter to be used after the operation are not clearly defined. The aim of this study is to evaluate the effects of catheter dwell time and diameter on recurrence rates of urethral stricture disease after DVIU. MATERIAL AND METHODS Data of 193 consecutive treatment naïve bulbar urethral stricture patients who underwent DVIU between January 2009 and June 2013 were retrospectively analyzed. Patient demographics and stricture characteristics were noted. Catheter dwell times were grouped as <5 and ≥5 days. The diameters of catheters used were 16, 18 and 22 Fr. The association between recurrence rates, catheter dwell times, and diameter were evaluated with Tukey's test and Pearson's correlation test, respectively. RESULTS Overall 193 patients with a mean age of 64.51±12.99 (range: 17 to 85) years were enrolled in the study. Urethral stricture disease recurred in 45 (23.31%) patients within the first year after DVIU. Mean duration of catheterization was 7.47±4.03 and 4.79±1.94 days in patients with and without recurrences, respectively (p=0.0001). Catheter dwell times for ≥5 days were also associated with increased recurrence (p=0.0001). Of the patients with recurrent strictures, 16, 18 and 22Fr catheters were placed in 22.22%, 20% and 57.78% of the patients, respectively. Increased catheter diameter was also associated with higher recurrence rates (p=0.004). CONCLUSION Shortening the postoperative duration of catheterization and decreasing the catheter size may result in improved recurrence rates after DVIU. Further prospective randomized trials are necessary to confirm these findings.
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Affiliation(s)
- Emrah Yürük
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Serhat Yentur
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Ömer Onur Çakır
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Kasım Ertaş
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Ege Can Şerefoğlu
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Atilla Semerciöz
- Clinic of Urology, Bağcılar Training and Research Hospital, İstanbul, Turkey
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Djordjevic ML. Treatment of Urethral Stricture Disease by Internal Urethrotomy, Dilation, or Stenting. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2015.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vyas JB, Ganpule AP, Muthu V, Sabnis RB, Desai MR. Balloon dilatation for male urethral strictures "revisited". Urol Ann 2013; 5:245-8. [PMID: 24311903 PMCID: PMC3835981 DOI: 10.4103/0974-7796.120296] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 10/02/2012] [Indexed: 12/03/2022] Open
Abstract
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 (Qmax), 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. Qmax 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.
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Affiliation(s)
- Jigish B Vyas
- Department of Urology, Muljibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad, Gujarat, India
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Hennessey DB, Thomas AZ, Forde JC, McDermott TED. Management of recalcitrant urethral strictures with self-dilatation balloon catheter. Ir J Med Sci 2012. [PMID: 23184533 DOI: 10.1007/s11845-012-0866-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.
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Affiliation(s)
- D B Hennessey
- Department of Urological Surgery, St. James Hospital, James Street, Dublin 8, Ireland.
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The Clinical Spectrum of the Presenting Signs and Symptoms of Anterior Urethral Stricture: Detailed Analysis of a Single Institutional Cohort. Urology 2012; 79:1163-7. [DOI: 10.1016/j.urology.2012.01.044] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 01/20/2012] [Accepted: 01/23/2012] [Indexed: 11/19/2022]
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Heyns C, van der Merwe J, Basson J, van der Merwe A. Etiology of male urethral strictures-Evaluation of temporal changes at a single center, and review of the literature. AFRICAN JOURNAL OF UROLOGY 2012. [DOI: 10.1016/j.afju.2012.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Metalloproteinase-1 usefulness in urethral stricture treatment. Int Urol Nephrol 2011; 43:763-9. [DOI: 10.1007/s11255-011-9909-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 02/02/2011] [Indexed: 12/17/2022]
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21
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Gücük A, Tuygun C, Burgu B, Öztürk U, Dede O, İmamoğlu A. The Short-Term Efficacy of Dilatation Therapy Combined with Steroid After Internal Urethrotomy in the Management of Urethral Stenoses. J Endourol 2010; 24:1017-21. [DOI: 10.1089/end.2009.0233] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adnan Gücük
- Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Can Tuygun
- Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Berk Burgu
- Department of Urology, University of Ankara School of Medicine, Ankara, Turkey
| | - Ufuk Öztürk
- Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Onur Dede
- Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Abdurrahim İmamoğlu
- Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Predictors of recurrence of urethral stricture disease following optical urethrotomy. Int J Surg 2009; 7:361-4. [DOI: 10.1016/j.ijsu.2009.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 05/07/2009] [Accepted: 05/22/2009] [Indexed: 11/16/2022]
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O’Riordan A, Narahari R, Kumar V, Pickard R. Outcome of dorsal buccal graft urethroplasty for recurrent bulbar urethral strictures. BJU Int 2008; 102:1148-51. [DOI: 10.1111/j.1464-410x.2008.07763.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weidlich P, Adam C, Sroka R, Lanzl I, Assmann W, Stief C. [Low-dose rate brachytherapy with locally integrated beta emitters after internal urethrotomy. A pilot project using an animal model]. Urologe A 2007; 46:1231-5. [PMID: 17609925 DOI: 10.1007/s00120-007-1386-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The treatment of urethral strictures represents an unsolved urological problem. PATIENTS AND METHODS The effect of a (32)P-coated urethral catheter in the sense of low-dose rate brachytherapy to modulate wound healing will be analyzed in an animal experiment. RESULTS Unfortunately it is not possible to present any results because this is being studied for the first time and there are no experiences with low-dose rate brachytherapy and this form of application in the lower urinary tract. Furthermore the animal experiment will only start in the near future. Both decade-long experiences with radiotherapy to treat benign diseases and our own results of previous studies in otolaryngology and ophthalmology let us expect a significantly lower formation of urethral strictures after internal urethrotomy. CONCLUSION This study will contribute to improving the treatment of urethral strictures as demanded in previous papers.
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Affiliation(s)
- P Weidlich
- Urologische Klinik und Poliklinik, Klinikum der Universität München-Grosshadern, Marchioninistrasse 15, 81377 München.
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25
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Ayyildiz A, Akgül T, Nuhoğlu B. Re: Hamid Mazdak, Iraj Meshki and Fatemeh Ghassami. Effect of mitomycin C on anterior urethral stricture recurrence after internal urethrotomy. Eur Urol 2007;51:1089-92. Eur Urol 2007; 52:929. [PMID: 17499429 DOI: 10.1016/j.eururo.2007.04.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 04/30/2007] [Indexed: 10/23/2022]
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Husmann DA, Rathbun SR. Long-Term Followup of Visual Internal Urethrotomy for Management of Short (Less Than 1 Cm) Penile Urethral Strictures Following Hypospadias Repair. J Urol 2006; 176:1738-41. [PMID: 16945637 DOI: 10.1016/s0022-5347(06)00617-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE We reviewed the results of direct vision urethrotomy for short (less than 1 cm) penile urethral strictures following hypospadias surgery. MATERIALS AND METHODS Patients with less than 1 cm anterior penile urethral strictures located proximal to the meatus underwent direct vision urethrotomy. Based on the type of initial urethroplasty patients were randomly divided into treatment with direct vision urethrotomy vs direct vision urethrotomy plus clean intermittent catheterization for 3 months. Success was defined as absent obstructive voiding symptoms and a normal urine flow 2 years following the last patient instrumentation. RESULTS Of patients with urethral strictures following hypospadias repair 44% (32) had previously undergone tubularized graft urethroplasty and 56% (40) had previously undergone flap urethroplasty, including a tubularized island flap in 18, an onlay flap in 11 and urethral plate urethroplasty in 11. Direct vision urethrotomy alone was performed in 51% of patients (37), and direct vision urethrotomy and clean intermittent catheterization were performed in 49% (35). Success with the 2 methods was similar, that is 24% (9 of 37 patients) vs 22% (8 of 35). Following direct vision urethrotomy all patients with tubularized graft urethroplasty showed failure (0 of 32). Success was noted in 11% of patients (2 of 18) with tubularized island flap urethroplasty compared to 72% (8 of 11) with onlay urethroplasty and 63% (7 of 11) with urethral plate urethroplasty (each p <0.05). CONCLUSIONS The addition of clean intermittent catheterization to direct vision urethrotomy does not improve the likelihood of success. Direct vision urethrotomy for short (less than 1 cm) urethral stricture usually fails following any type of tubularized graft or flap urethroplasty but it had moderate success following onlay flap and urethral plate urethroplasties.
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Affiliation(s)
- D A Husmann
- Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN 55906, USA.
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Wright JL, Wessells H, Nathens AB, Hollingworth W. What is the most cost-effective treatment for 1 to 2-cm bulbar urethral strictures: societal approach using decision analysis. Urology 2006; 67:889-93. [PMID: 16698347 DOI: 10.1016/j.urology.2005.11.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Revised: 10/07/2005] [Accepted: 11/02/2005] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Direct vision internal urethrotomy (DVIU) and urethroplasty are the primary methods of managing urethral stricture disease. Using decision analysis, we determine the cost-effectiveness of different management strategies for short, bulbar urethral strictures 1 to 2 cm in length. METHODS A decision tree was constructed, with the number of planned possible DVIUs before attempting urethroplasty defined for each primary branch point. Success rates were obtained from published reports. Costs were estimated from a societal perspective and included the costs of the procedures and office visits and lost wages from convalescence. Sensitivity analyses were conducted, varying the success rates of the procedures and cost estimates. RESULTS The most cost-effective approach was one DVIU before urethroplasty. The incremental cost of performing a second DVIU before attempting urethroplasty was $141,962 for each additional successfully voiding patient. In the sensitivity analysis, urethroplasty as the primary therapy was cost-effective only when the expected success rate of the first DVIU was less than 35%. CONCLUSIONS The most cost-effective strategy for the management of short, bulbar urethral strictures is to reserve urethroplasty for patients in whom a single endoscopic attempt fails. For longer strictures for which the success rate of DVIU is expected to be less than 35%, urethroplasty as primary therapy is cost-effective. Future prospective, multicenter studies of DVIU and urethroplasty outcomes would help enhance the accuracy of our model.
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Affiliation(s)
- Jonathan L Wright
- Department of Urology, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington, USA
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Rourke KF, Jordan GH. Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture. J Urol 2005; 173:1206-10. [PMID: 15758749 DOI: 10.1097/01.ju.0000154971.05286.81] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Treatment for urethral stricture disease often requires a choice between readily available direct vision internal urethrotomy (DVIU) and highly efficacious but more technically complex open urethral reconstruction. Using the short segment bulbous urethral stricture as a model, we determined which strategy is less costly. MATERIALS AND METHODS The costs of DVIU and open urethral reconstruction with stricture excision and primary anastomosis for a 2 cm bulbous urethral stricture were compared using a cost minimization decision analysis model. Clinical probability estimates for the DVIU treatment arm were the risk of bleeding, urinary tract infection and the risk of stricture recurrence. Estimates for the primary urethral reconstruction strategy were the risk of wound complications, complications of exaggerated lithotomy and the risk of treatment failure. Direct third party payer costs were determined in 2002 United States dollars. RESULTS The model predicted that treatment with DVIU was more costly (17,747 dollars per patient) than immediate open urethral reconstruction (16,444 dollars per patient). This yielded an incremental cost savings of $1,304 per patient, favoring urethral reconstruction. Sensitivity analysis revealed that primary treatment with urethroplasty was economically advantageous within the range of clinically relevant events. Treatment with DVIU became more favorable when the long-term risk of stricture recurrence after DVIU was less than 60%. CONCLUSIONS Treatment for short segment bulbous urethral strictures with primary reconstruction is less costly than treatment with DVIU. From a fiscal standpoint urethral reconstruction should be considered over DVIU in the majority of clinical circumstances.
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Affiliation(s)
- Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Olschewski T, Kröpfl D, Seegenschmiedt MH. Endourethral brachytherapy for prevention of recurrent urethral stricture following internal urethrotomy—first clinical experiences and results. Int J Radiat Oncol Biol Phys 2003; 57:1400-4. [PMID: 14630279 DOI: 10.1016/s0360-3016(03)00779-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the therapeutic effect of endourethral brachytherapy for prevention of recurrent urethral stricture after internal urethrotomy. MATERIALS AND METHODS Endourethral high-dose-rate (HDR) brachytherapy was performed in 10 male patients with recurrent urethral strictures after radical prostatectomy or transurethral resection of prostatic adenoma. Brachytherapy commenced on the day of the actual intervention and continued over 3 days; the radiotherapy dose was 4 x 3 = 12 Gy for the first 3 patients and 4 x 4 Gy = 16 Gy for the following 7 patients. RESULTS During follow-up (range: 8-27 months, mean: 14.8 months), 9 of 10 patients remained relapse-free, i.e., without recurrent strictures or requiring another urethrotomy. In 1 patient with a restricture after endourethral brachytherapy, a second brachytherapy course was performed; nevertheless, he experienced a further restricture 12 months after the second intervention. No radiation-induced acute toxicity occurred, but 1 patient developed incontinence after the current urethrotomy. Overall, patient satisfaction and compliance with the therapeutic procedures was high. CONCLUSIONS Endourethral HDR brachytherapy proved to be a safe method that can reduce urethral restricture. Further follow-up is needed to prove long-term efficacy of this treatment. Further investigations are planned to evaluate the adequate fractionation and possible late treatment sequelae.
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Affiliation(s)
- Thomas Olschewski
- Department of Radiotherapy and Radiation Oncology, Alfried Krupp Krankenhaus, Essen, Germany
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Hsiao KC, Baez-Trinidad L, Lendvay T, Smith EA, Broecker B, Scherz H, Kirsch AJ. Direct vision internal urethrotomy for the treatment of pediatric urethral strictures: analysis of 50 patients. J Urol 2003; 170:952-5. [PMID: 12913749 DOI: 10.1097/01.ju.0000082321.98172.4e] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE In an attempt to evaluate our experience with the treatment of pediatric urethral stricture disease we performed a retrospective review of patients undergoing direct vision internal urethrotomy (DVIU). MATERIALS AND METHODS The computerized surgical logs at 2 pediatric hospitals were reviewed to identify patients who underwent DVIU between 1992 and 2001. Hospital and clinical charts were then reviewed. Many variables were analyzed, including patient age, etiology of stricture, technique and clinical outcomes. Minimum followup to be included in clinical outcome analysis was 12 months. RESULTS A total of 50 patients were identified (mean age 7.7 years, range 6 months to 17 years). The most common etiology for stricture formation was previous hypospadias repair (20 patients [40%]). Forty patients met the 12-month minimum followup requirement for clinical outcome analysis. Of these patients 20 (50%) had no symptoms to suggest recurrent stricture at a median of 2.0 years (mean 2.7 years, range 12 months to 7 years). Seventeen patients (42.5%) had symptoms of recurrent stricture at a median of 8 months (mean 13 months, range 2 months to 5 years). Technical factors did not influence the ultimate success or failure of the procedure. CONCLUSIONS DVIU provides a therapeutic option that successfully treats approximately half of the patients with a reasonably low complication rate. Complications following DVIU should not preclude its use as a therapeutic modality for the treatment urethral strictures in children. If the child fails the initial DVIU, repeat attempts at endoscopic correction of urethral stricture should be abandoned in favor of definitive urethroplasty.
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Affiliation(s)
- Kenneth C Hsiao
- Department of Urology, Division of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, 1901 Century Boulevard, Atlanta, GA, USA
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Affiliation(s)
- TRACEY S. WILSON
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
| | - GARY E. LEMACK
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
| | - ROGER R. DMOCHOWSKI
- From the Department of Urology, University of Texas Southwestern Medical Center, Dallas and The North Texas Center for Urinary Control, Fort Worth, Texas
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NAGLER ARNON, GOFRIT OFER, OHANA MEIR, PODE DOV, GENINA OLGA, PINES MARK. THE EFFECT OF HALOFUGINONE, AN INHIBITOR OF COLLAGEN TYPE I SYNTHESIS, ON URETHRAL STRICTURE FORMATION: IN VIVO AND IN VITRO STUDY IN A RAT MODEL. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67105-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- ARNON NAGLER
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
| | - OFER GOFRIT
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
| | - MEIR OHANA
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
| | - DOV PODE
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
| | - OLGA GENINA
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
| | - MARK PINES
- From the Departments of Bone Marrow Transplantation and Urology, Hadassah University Hospital, Jerusalem and Institute of Animal Science, Agricultural Research Organization, The Volcani Center, Bet Dagan, Israel
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THE EFFECT OF HALOFUGINONE, AN INHIBITOR OF COLLAGEN TYPE I SYNTHESIS, ON URETHRAL STRICTURE FORMATION: IN VIVO AND IN VITRO STUDY IN A RAT MODEL. J Urol 2000. [DOI: 10.1097/00005392-200011000-00100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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MacDiarmid SA, Harrigan CT, Cottone JL, McIntyre WJ, Johnson DE. Assessment of a new transurethral balloon dilation catheter in the treatment of urethral stricture disease. Urology 2000; 55:408-13. [PMID: 10699622 DOI: 10.1016/s0090-4295(99)00541-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- S A MacDiarmid
- Department of Urology, University of Arkansas College of Medicine and John L. McClellan Memorial Veterans Affairs Hospital, Little Rock, Arkansas, USA
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TREATMENT OF MALE URETHRAL STRICTURES. J Urol 1998. [DOI: 10.1097/00005392-199808000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J Urol 1998; 160:356-8. [PMID: 9679876 DOI: 10.1016/s0022-5347(01)62894-5] [Citation(s) in RCA: 227] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- C F Heyns
- Department of Urology, Faculty of Medicine, University of Stellenbosch and Tygerberg Hospital, South Africa
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Abstract
PURPOSE We determined the efficacy of adjuvant home balloon self-dilation as an alternative to office dilation and to reduce the likelihood of recurrence in patients with recalcitrant urethral strictures. MATERIALS AND METHODS A total of 31 men participated in a urethral self-dilating protocol following phallic construction, urethroplasty or visual internal urethrotomy, or as conservative management in 2 nonoperative candidates. Uroflow data and subjective information obtained by blinded questionnaire were reviewed. RESULTS The 31 patients were followed for a mean of 18.7 months (range 3 to 45) after initial balloon dilation, and 25 (81%) were available for followup interviews. Of the 25 patients 24 (96%) found no difficulty in learning the technique and 21 (84%) thought they received adequate training with 1 office visit. Most patients noted improvement in voiding with balloon dilation, and peak uroflowmetry rates were preserved or improvement with long-term followup. Six patients (19%) complained of discomfort with balloon placement, 3 (10%) noticed minor bleeding with dilation and 4 (13%) had urinary tract infections during followup. Following visual internal urethrotomy, no stricture recurrences were noted in 9 patients. Strictures recurred in 2 of 13 (15%) urethroplasty patients following balloon dilation. After radial forearm free flap phallic construction, a technique known to have a high re-stricture rate, 5 of 7 patients (71%) had recurrent urethral stricture. CONCLUSIONS Preliminary results indicate that adjuvant outpatient urethral self-dilation following surgical correction of urethral strictures in patients at high risk for recurrence is inexpensive and safe, as well as a potentially effective option in reducing stricture recurrence and maintaining urethral patency.
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Affiliation(s)
- L A Levine
- Department of Urology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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Levine LA, Engebrecht BP. Adjuvant Home Urethral Balloon Dilation for the Recalcitrant Urethral Stricture. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64326-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Laurence A. Levine
- From the Department of Urology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
| | - Brian P. Engebrecht
- From the Department of Urology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
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Steenkamp J, Heyns C, de Kock M. Internal Urethrotomy Versus Dilation as Treatment for Male Urethral Strictures: A Prospective, Randomized Comparison. J Urol 1997. [DOI: 10.1016/s0022-5347(01)65296-0] [Citation(s) in RCA: 194] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J.W. Steenkamp
- Department of Urology, Faculty of Medicine, University of Stellenbosch and Tygerberg Hospital, Tygerberg, South Africa
| | - C.F. Heyns
- Department of Urology, Faculty of Medicine, University of Stellenbosch and Tygerberg Hospital, Tygerberg, South Africa
| | - M.L.S. de Kock
- Department of Urology, Faculty of Medicine, University of Stellenbosch and Tygerberg Hospital, Tygerberg, South Africa
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Affiliation(s)
- Peter Albers
- Departments of Urology, Bonn University Medical Center, Bonn, and Mainz University Medical Center, Mainz, Germany
| | - Jan Fichtner
- Departments of Urology, Bonn University Medical Center, Bonn, and Mainz University Medical Center, Mainz, Germany
| | - Peter Bruhl
- Departments of Urology, Bonn University Medical Center, Bonn, and Mainz University Medical Center, Mainz, Germany
| | - Stefan C. Muller
- Departments of Urology, Bonn University Medical Center, Bonn, and Mainz University Medical Center, Mainz, Germany
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