Direct vision cold knife urethrotomy

Collagen--emerging collagen based therapies hit the patient

The choice of biomaterials available for regenerative medicine continues to grow rapidly, with new materials often claiming advantages over the short-comings of those already in existence. Going back to nature, collagen is one of the most abundant proteins in mammals and its role is essential to our way of life. It can therefore be obtained from many sources including porcine, bovine, equine or human and offer a great promise as a biomimetic scaffold for regenerative medicine. Using naturally derived collagen, extracellular matrices (ECMs), as surgical materials have become established practice for a number of years. For clinical use the goal has been to preserve as much of the composition and structure of the ECM as possible without adverse effects to the recipient. This review will therefore cover in-depth both naturally and synthetically produced collagen matrices. Furthermore the production of more sophisticated three dimensional collagen scaffolds that provide cues at nano-, micro- and meso-scale for molecules, cells, proteins and bulk fluids by inducing fibrils alignments, embossing and layered configuration through the application of plastic compression technology will be discussed in details. This review will also shed light on both naturally and synthetically derived collagen products that have been available in the market for several purposes including neural repair, as cosmetic for the treatment of dermatologic defects, haemostatic agents, mucosal wound dressing and guided bone regeneration membrane. There are other several potential applications of collagen still under investigations and they are also covered in this review.

Traitement endoscopique des sténoses de l'urètre

The present article reviews the literature regarding the endoscopic treatment of urethral strictures. Only few prospective randomised clinical trials with sufficient power have been performed and most of the literature provides evidence of only level 3 and 4. Since length, location, extent and calibre of the urethral stricture have an important impact on prognosis, diagnosis and the role of ultrasonography are discussed. Pathophysiology of wound healing is discussed in relation to urethrotomy, as it explains the outcomes of the procedure. Operative techniques using cold knife and laser, use of endoprostheses, indications, complications, results and postoperative management are described. The possible role of urethral catheters, hydraulic dilatations and corticosteroid applications are discussed.

Endoscopic antegrade laser incision in the treatment of urethral stricture

OBJECTIVES

To examine the possibility of antegrade incisions at varying stricture lengths. We have developed a new method of using a ureteroscope and holmium:yttrium-aluminum-garnet (YAG) laser to make an antegrade incision without using a guidewire. Endoscopic internal urethrotomy involves the use of a guidewire or ureteral catheter that is passed through the stricture as an indicator for retrograde incision.

METHODS

An antegrade incision was performed in 31 procedures for 28 patients with urethral strictures. We used a semirigid ureteroscope with an outer diameter of 6F at the tip. The ureteroscope was inserted into the urethra and passed through the stricture into the bladder under direct vision. The ureteroscope was pulled distally while an incision was made using the holmium:YAG laser at the 10-o'clock and 2-o'clock positions to a diameter of 17F. The endoscope was then replaced by a 17F panendoscope and an antegrade incision was similarly made up to 21F to 22F.

RESULTS

An antegrade incision without the use of a guidewire was possible in all cases. Of the 31 incisions, restenosis appeared in 11 (35%). Of the 11 cases, re-incision was performed in 4 cases, and urethral sounding was conducted in the other 7 cases. Of the 4 re-incision cases, restenosis recurred in only 1 case. Of the 31 incisions, 23 (74%) were eventually successful.

CONCLUSIONS

Antegrade incision using the narrow-diameter ureteroscope and holmium:YAG laser is a safe and easy method. This method is especially effective in cases of long strictures.

A bioabsorbable self-expandable, self-reinforced poly-L-lactic acid urethral stent for recurrent urethral strictures: long-term results

BACKGROUND AND PURPOSE

Biodegradable urethral stents have been used clinically for some years mainly in order to prevent postoperative urinary retention after minimally invasive thermotreatment of benign prostatic hyperplasia. We previously reported a 15-month-follow-up pilot study of a bioabsorbable self-expandable, self-reinforced poly-L-lactic acid (SR-PLLA) urethral stent in combination with optical urethrotomy in the treatment of recurrent urethral strictures. The present aim was to evaluate the long-term results of this new treatment modality.

PATIENTS AND METHODS

A series of 22 patients with severe urethral strictures (mean number of earlier urethrotomies 2.5) were involved. An SR-PLLA spiral stent with a bioabsorption time of 10 to 12 months was inserted into the urethra at the stricture site immediately after optical urethrotomy. Uroflowmetry, measurement of postvoiding residual urine, urine culture, and urethroscopy were performed preoperatively and at 1 and 3 months and then every 3 months up to 12 months, with subsequent follow-up visits every 6 months. The mean follow-up was 46 months.

RESULTS

The treatment was successful in 8 of the 22 patients (36%). Six recurrences were found within the stented area and 15 outside. Patients with failure have since been treated with several urethrotomies and repeat self-dilatations or free skin urethroplasties.

CONCLUSIONS

The results of the use of a bioabsorbable SR-PLLA urethral stent for the treatment of recurrent strictures were encouraging. Without this additional therapy, the recurrence rate of strictures might have been much higher. The main problem was sudden collapse of the stent, possibly induced by outer compression. A new generation of bioabsorbable stents is already under development.

Optical urethrotomy for anterior urethral stricture under a new local anesthesia: intracorpus spongiosum anesthesia

OBJECTIVES

To determine the feasibility of routinely performing internal urethrotomy for anterior urethral stricture under intracorpus spongiosum anesthesia in an outpatient setting.

METHODS

In a consecutive series of 23 patients with anterior urethral stricture, a dosage of 3 mL of 1% lidocaine was slowly injected into the glans penis. Next, optical urethrotomy was performed immediately with a cold-cutting knife. The effect of this anesthetic technique was evaluated by questionnaire.

RESULTS

Internal urethrotomy was successfully completed in all the patients. Twenty-two patients (95.7%) had no pain or discomfort. One patient reported minimal but tolerable discomfort while the tissue above the stricture was being cut. The anesthesia lasted for about 1.5 hours and was very satisfactory without any complications.

CONCLUSIONS

Under intracorpus spongiosum anesthesia, optical urethrotomy can be routinely performed in an outpatient setting. With this new local anesthesia, internal urethrotomy is a safe, effective, simple, and inexpensive procedure for treatment of anterior urethral stricture.

Sachse urethrotomy versus endoscopic urethrotomy plus transurethral resection of the fibrous callus (Guillemin's technique) in the treatment of urethral stricture

OBJECTIVES

Advances in endoscopic instrumentation and technique have expanded the urologist's armamentarium for effective and safe treatment of urethral strictures. This prospective study included 80 patients who presented with single, iatrogenic, annular strictures of the bulbar urethra. The length of the stricture was 1 to 2 cm, with an average of 1.5 cm.

METHODS

Patients were randomly divided into two groups: group A, 40 patients who underwent direct-optical endoscopic urethrotomy with a guide catheter via cold-knife incision at the 12 o'clock position (Sachse urethrotomy), and group B, 40 patients who underwent double direct-optical endoscopic urethrotomy with a guide catheter via cold-knife incisions at the 11 and 1 o'clock positions, followed by transurethral resection of all scar tissues (Guillemin's technique). The results obtained were analyzed and compared at 6 months, 12 months, 24 months, 3 years, and 5 years postoperatively by clinical evaluation, uroflowmetry, and retrograde and voiding urethrographies.

RESULTS

Group A obtained 95% good results at 6 months, 85% at 12 months, 55% at 24 months, 45% at 3 years, and 25% at 5 years. Group B obtained 98% good results at 6 months, 95% at 12 months, 90% at 24 months, 80% at 3 years, and 70% at 5 years.

CONCLUSIONS

The differences between the two groups are not significant at 6 and 12 months (P > 0.05). They are statistically significant after 24 months, 3 years, and 5 years (P < 0.05).

Alternative endoscopic management in the treatment of urethral strictures

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.

Recurrence of urethral stricture after single internal urethrotomy

Recurrence of urethral stricture after single internal urethrotomy was investigated in 66 patients with special reference to some factors which would influence restricturing. In the present study, recurrence rate was 16.7% (11 patients). Recurrences occurred within an average of 11.9 months. Factors that had no influence on restricturing were age, aetiology, site of the stricture and duration of indwelling catheterization. On the other hand, stricture length appeared to influence the outcome (chi 2, p < 0.001). Short stricture (< or = 10 mm) showed only 4.4% recurrence rate, while 42.9% in long stricture (> 10 mm). Internal urethrotomy appeared to be effective particularly when the stricture was short, while it seemed difficult to treat long strictures by single internal urethrotomy.

Endoscopic treatment of posttraumatic urethral obliteration: experience in 396 patients

Of 396 patients with posttraumatic posterior urethral strictures treated endoscopically during 10 years 352 had no vesical displacement (group 1) and 44 had marked displacement (group 2). Group 1 patients were treated by suprapubic diversion and delayed optical urethrotomy. Exploration and railroad alignment to the urethra were done in group 2 and followup internal urethrotomy was performed in 33 patients. Eleven patients in group 2 and 68 in group 1 were considered failures due to complete short segment urethral obliteration. These 79 patients who failed initial visual urethrotomy underwent endoscopic resection of the stricture, that is core through optical urethrotomy. After 6 to 55 months (average 2 years) 46 patients (58.2%) were voiding satisfactorily (4 had stress incontinence). The 33 patients (41.8%) with failed minor or major endoscopic treatment due to persistent obstruction were treated with open urethroplasty. We conclude that posttraumatic posterior urethral obliteration can be treated by simple or major endoscopic techniques and that core through optical urethrotomy is a reasonable alternative to urethroplasty in patients with an impassable short stricture.

Newly diagnosed bulbar urethral strictures: etiology and outcome of various treatments

A retrospective review was performed of 199 consecutive patients who were evaluated at this institution between 1976 and 1990 because of a newly diagnosed bulbar urethral stricture. Mean patient age at diagnosis was 64 years (range 10 to 96) and most patients presented with obstructive symptoms. The stricture etiology was primarily iatrogenic (47%), secondary to a transurethral procedure. The strictures were usually short (less than 2 cm., 96%), single (99%) and located in the proximal bulb (57%). Of the 151 patients receiving treatment at the time of initial diagnosis 101 (67%) underwent urethral dilation, 39 (26%) were managed with direct vision internal urethrotomy and in 11 (7%) a cystotomy tube was placed. With a median followup of 3.5 years (range 0 to 16), there was an estimated retreatment rate of 2.4 treatments per 10 person-years. The probability of not requiring retreatment within 3 years was 65 +/- 5% for urethral dilation and 68 +/- 8% for direct vision internal urethrotomy. When compared to urethral dilation, direct vision internal urethrotomy resulted in a higher incidence of postprocedure cystitis (5% versus 3%), epididymitis (5% versus 3%) and penile hemorrhage (8% versus 2%). These findings indicate that both conservative therapies were equally efficacious as an initial treatment of bulbar urethral stricture. However, direct vision internal urethrotomy did have a slightly higher complication rate. No specific patient or stricture characteristics could be identified that were reliable for predicting therapeutic outcome.

Erectile dysfunction following direct vision internal urethrotomy

A total of 104 evaluable patients 20-90 years old treated by direct vision internal urethrotomy a.m. Sachse for urethral strictures reported retrospectively via a questionnaire their sexual potency before and after internal urethrotomy. Eleven patients (10.6%) experienced partial or total erectile dysfunction following the operation, most of whom had distal and long strictures. Eight were evaluated for impotence and on grounds of a comprehensive history, physical examination, penile Doppler investigations, and papaverine tests it was concluded that 3 patients might have achieved an abnormal communication between the corpus cavernosum and corpus spongiosum. In two of the patients cavernosographies were carried out and in one total opacification of the corpus spongiosum was demonstrated, but the exact location of the leak could not be pinpointed, and surgical treatment therefore not rendered feasible. Possible factors in the development of erectile dysfunction following internal urethrotomy are analyzed.

Urethral stricture following transurethral prostatectomy

Urethral stricture is the most common late complication of transurethral prostatectomy. Uroflowmetry is recommended as the routine screening procedure for strictures postoperatively. If maximal urinary flow rate (Qmax) is below 10 mL/second the patients should be investigated further. The etiology of urethral stricture is still unclear. Further studies are necessary to evaluate the possible etiologic role of infected urine pre- and/or postoperatively, urethral catheterization pre- and postoperatively, catheter material, and the type and size of the resectoscope. A narrow urethra is probably a predisposing factor for stricture formation, but this is not definitively clarified. Only few randomized studies have been performed to evaluate the different prophylactic methods against development of strictures postresection. Resection via perineal urethrotomy, perhaps preceded by urethral calibration, seems to be a way to avoid anterior urethral strictures. The effects of internal urethrotomy preoperatively on stricture formation are conflicting. Further randomized studies are necessary.

Optical internal urethrotomy as the treatment of choice for primary stricture of the urethra

Seventy-five patients with primary urethral strictures were treated by optical urethrotomy with catheter drainage for 7 days. Good results were obtained in 66% of cases, which were all post-traumatic in nature; 34% had to undergo further procedures such as dilatation or repeat internal urethrotomy.

Endoscopic reconstruction of traumatic membranous urethral transection

Newer endoscopic techniques derived from percutaneous renal manipulations are well suited for endoscopic reconstruction of traumatic short total membranous urethral transections. Four men and 1 child underwent successful endoscopic membranous urethral reconstruction. All 4 men are voiding with good flow and normal control more than 1 year after any endoscopic manipulation.

Urethral strictures in boys

While common in adult males, urethral strictures are comparatively rare in boys. We report our experience with this condition in 19 boys. Ten of the strictures were iatrogenic, seven traumatic, and three inflammatory in origin. Dilation is reportedly unsatisfactory for the management of most urethral strictures in children. In our series, however, 9 patients (47.3%) underwent urethral dilation as the only definitive form of treatment, while urethroplasty was successfully performed in the other 10 cases.

Direct vision internal urethrotomy. A prospective study of 81 primary strictures treated with a single urethrotomy

The post-operative treatment of urethral strictures as well as the criteria of success have varied considerably. In order to find a solution to this problem, we undertook a prospective evaluation of 81 men treated for their first urethral stricture with a single urethrotomy. Fifty-one patients with a stricture 5 mm or less in length were catheterised post-operatively for 3 days. Patients with strictures longer than 5 mm were catheterised for 3 weeks (14 patients) or 6 weeks (16 patients). All were followed up for a minimum of 24 months. The stricture recurred in 33 patients (41%). We found that 3 days' catheter drainage was sufficient for patients with short strictures. Whether strictures measuring more than 5 mm might be treated similarly needs further investigation.

Core-through optical internal urethrotomy in management of impassable traumatic posterior urethral strictures

During a 2 1/2-year period 10 patients with a traumatically obliterated posterior urethra underwent core-through optical internal urethrotomy 3 to 6 months after pelvic fracture. After 6 to 24 months of followup the peak urine flow rate was more than 15 ml. per second in 6 patients and 8 to 15 ml. per second in 2. Six patients were continent and 2 had transient stress urinary incontinence. Of the 10 patients 2 were failures because of peak urinary flow rates less than 8 ml. per second and/or urinary incontinence. Subsequently, 1 patient underwent successful scrotal flap urethroplasty. Core-through optical internal urethrotomy is an attractive alternative to urethroplasty when the impassable stricture is short.

Excisional repair of urethral stricture. Follow-up of 90 patients

One hundred five patients with urethral stricture of various causations were treated with excision of the stricture and oblique end-to-end anastomosis. Fifty-two patients (49%) had had one or more previous operations and dilatations, respectively. The immediate postoperative complication rate was 9 per cent. Ninety patients could be followed for one to eight years. The success rate was 93 per cent. Five patients had recurrent strictures. The failures were due to abscess formation, perineal hematoma, and excessive length of stricture.

Free full thickness (patch) graft urethroplasty: long-term follow-up

Thirty-two patients underwent free, full thickness skin (patch) graft urethroplasties between September, 1974, and May, 1978. Sixty-five per cent of the 23 patients available for five-year follow-up had good results from grafts ranging from 3 to 14 cm in length. In patients with good one-year results strictures did not develop during the review period, suggesting the need for only short-term follow-up in this group.

Direct vision internal urethrotomy in the treatment of urethral fistulas due to urethral strictures

Five cases of urethral fistula--three with single and two with multiple fistulous tracts--were treated by optical urethrotomy. All of the fistulas healed completely.

Optical urethrotomy as ambulatory procedure

Optical urethrotomy is a relatively new means of treating urethral stricture. We performed the procedure on 100 ambulatory patients using only topical anesthesia and sedation in some. The patients were followed a minimum of one year. Our success rate for cure following one procedure was 66 per cent; however, those patients not cured required less frequent dilations after urethrotomy. We believe that this is a safe and effective means of treating urethral strictures in the outpatient setting with little morbidity and discomfort and with considerable economic savings.

Direct Vision Internal Urethrotamy. A Critical Review of 365 Operations

Internal urethrotomy under direct vision for urethral strictures in the male was employed on 369 occasions in 225 patients during a 4-year period. A retrospective review of results showed an overall cure rate of 77% but the cure rate after each individual operation was less than 50%. Operations for recurrence carried a significantly lower cure rate than initial operations but even after several recurrences there were reasonably good results considering the relatively minor procedure. An active post-operative follow-up employing routine urethroscopy showed significantly better results than mictiographic follow-up. The post-operative period of catheterisation and positive urine culture at the time of follow-up had no significant influence on the results.

Treatment of urethral stricture by urethroplasty or direct vision urethrotomy. A comparative retrospective study

The outcome of treatment for urethral stricture is evaluated in two groups of patients in a retrospective study: 51 patients were treated with urethroplasty and 41 with direct vision urethrotomy. The groups did not differ greatly as regards primary success. It was 59% in the urethroplasty group and 61% in the urethrotomy group. This favours the view that the primary treatment of a urethral stricture should be direct vision urethrotomy whenever possible.

Visual internal urethrotomy with postoperative cystostomy or urethral catheter

Visual internal urethrotomy is nowadays considered by many to be a very useful method of treating urethral strictures. There is still controversy, however, about how long the postoperative urethral catheter should be left in situ. A prospective randomised study was therefore performed to evaluate the influence on the results of urethral catheterisation versus a suprapubic cystostomy for 5 weeks. After 12-36 months of follow-up (mean 25 months) there was a significant difference in result in favour of the urethral catheter. In the catheterised group, 13 out of 20 patients were without recurrence, compared to 4 out of 17 patients in the cystostomy group. Of the total number of 76 patients treated by postoperative urethral catheterisation, 37 (48%) had a normal or slightly subnormal flow-rate 12-60 months after the urethrotomy. Young patients and patients with stricture treated for the first time showed significantly better results than older patients or patients who had previously been treated twice or more. The stricture diameter-prestenotic urethral diameter ratio, obtained by combined retrograde and antegrade urethrography, provided a fairly accurate measure of the functional significance of a stricture.

Internal urethrotomy without a catheter: use of a urethral stent

A method is presented that permits prolonged urethral stenting following an internal urethrotomy without the need of an indwelling Foley catheter. During this technique a 22F silicone catheter is inserted into the distended bladder, the balloon is left deflated and the catheter is advanced until the drainage hole is beyond the sphincter and no fluid drains through the catheter. At this point the catheter is cut flush with and sutured to the urethral meatus using 2 nylon sutures. The patient then is continent, able to void through the catheter lumen and has the advantage of a urethral stent without requiring catheter drainage. Of 21 patients 19 had good to excellent results 1 to 4 years after internal urethrotomy. Patient acceptance uniformly has been excellent and enthusiastic.

Urethral stricture disease in children

We review our experience with urethral stricture disease in 25 children who were seen between 1970 and 1979. Trauma was the most common etiology (48 per cent). Excellent results were obtained by 1-stage repair and multistage skin inlay urethroplasty. An average of 3.8 procedures per patient was required for multistage repairs versus 1.1 procedures per patient for 1-stage repair. Dilation alone averaged 1.7 procedures per patient and was successful in only 20 per cent. Dilation is unacceptable for management of most strictures in children and urethroplasty should be considered early in the treatment plan. One-stage urethroplasty, when applicable, is preferable to multistage repair. Seven children had a fractured pelvis with prostatomembranous urethral disruption, which was complete in 6 cases and partial in 1. Successful anatomical results were achieved ultimately in all of these cases. No patient who had erections preoperatively was impotent afterward. One child has been totally incontinent since the accident and 3 others have stress incontinence, ony 1 of whom requires treatment.