Transurethral urethrotomy under vision

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

BACKGROUND

Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised. The extent and quality of evidence guiding treatment choice for this condition are uncertain.  

OBJECTIVES

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.  

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles.

SELECTION CRITERIA

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5).

MAIN RESULTS

Two randomised trials were identified. One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size.

AUTHORS' CONCLUSIONS

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

BACKGROUND

Strictures of the urethra are the commonest cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Improved choice of graft material and shortened hospital stay suggest urethroplasty may be under used. The extent and quality of evidence guiding treatment choice for this condition is uncertain.

OBJECTIVES

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 26 March 2009), CENTRAL (2009, Issue 1), MEDLINE (January 1950 to March 2009), EMBASE (January 1980 to March 2009), OpenSIGLE (searched 26 March 2009), clinical trials registries and reference lists of relevant articles.

SELECTION CRITERIA

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software; RevMan 5.

MAIN RESULTS

Two randomised trials were identified. One trial compared the outcome of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcome of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. After two years 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There was insufficient data to perform meta-analysis or to reliably determine effect size.

AUTHORS' CONCLUSIONS

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

Application of endoscopic Ho:YAG laser incision technique treating urethral strictures and urethral atresias in pediatric patients

Endoscopic holmium:yttrium-aluminum-garnet (Ho:YAG) laser incision is a new method applied in pediatric urology recent years. To evaluate its therapeutic efficacy on treating the pediatric patients with urethral strictures and urethral atresias, a retrospective study was performed from June 2001 to July 2005 in a total of 28 pediatric patients who underwent endoscopic internal urethrotomy using Ho:YAG laser in our center. In these patients, 25 had urethral strictures and 3 urethral atresias. Follow-up was done ranging from 2 months to 4 years to assess the treatment. Of the 28 patients, 25 (89.3%) have achieved satisfied result without complications following initial incisions. Two patients with urethral atresias and another with long lesion of stricture (> 2 cm) have postoperative stenosis (10.7%). Among the three reoccurred patients, two were successfully reoperated by Ho:YAG laser and open end-to-end anastomosis, respectively. One patient failed to follow-up. With the advantages of safety, efficacy and minimal invasion, endoscopic Ho:YAG laser incision technique could be used as a primary treatment in urethral stricture patients and is worthy to be popularized further in pediatric surgery.

Low-power holmium:YAG laser urethrotomy for treatment of urethral strictures: functional outcome and quality of life

PURPOSE

To evaluate the efficacy of endourethrotomy with the holmium:YAG laser as a minimally invasive treatment for urethral stricture.

PATIENTS AND METHODS

Between January 2002 and January 2004, 32 male patients with symptomatic urethral strictures (8 bulbar, 9 penile, 9 combined) were treated with Ho:YAG-laser urethrotomy in our department. The stricture was iatrogenic in 60% (N = 18), inflammatory in 16.6% (N = 5), traumatic in 13.3% (N = 4), and idiopathic in 7% (N = 3). The stricture was incised under vision at the 12 o'clock location or the site of maximum scar tissue or narrowing in asymmetric strictures. Laser energy was set on 1200 to 1400 mJ with a frequency of 10 to 13 Hz. Postoperatively, drainage of the bladder was performed for 4 days using a 18F silicone catheter. Triamcinolone was instilled intraurethrally after removal of the catheter in all patients. Patients were followed up by mailed questionnaire, including International Prostate Symptom Score and quality of life.

RESULTS

Retrograde endoscopic Ho:YAG laser urethrotomy could be performed in all 32 patients. Most patients (22; 68.7%) did not need any reintervention. Ten patients developed recurrent strictures that were treated by another laser urethrotomy in 4 patients (12.5%), while 6 patients (18.7%) needed open urethroplasty with buccal mucosa. Including 2 patients treated with repeat laser urethrotomy, 24 patients (75%) were considered successful after a mean follow-up of 27 months (range 13-38 months). No intraoperative complications were encountered, although in 5% of patients, a urinary-tract infection was diagnosed postoperatively. No gross hematuria occurred.

CONCLUSIONS

The Ho:YAG laser urethrotomy is a safe and effective minimally invasive therapeutic modality for urethral stricture with results comparable to those of conventional urethrotomy. Further data from long-time follow-up are necessary to compare the success rate with that of conventional urethrotomy and urethroplasty. Nevertheless, the Ho:YAG laser urethrotomy might at least be an alternative to urethroplasty in patients with high comorbidity who are not suitable for open reconstruction.

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.

Evaluation of urethral strictures and associated abnormalities using high-resolution and color Doppler ultrasound

OBJECTIVES

To study the role of urethral sonography and color Doppler imaging in the evaluation of patients with urethral strictures and associated abnormalities.

METHODS

We reviewed our experience with 41 urethral sonographic studies in 35 patients and compared them to 33 retrograde urethrograms. For 6 recent cases, we also used color Doppler imaging to assess spongiosal tissue blood flow and the location of urethral arteries.

RESULTS

Both retrograde urethrography and urethral sonography assessed the caliber and length of the strictures well. Urethral sonography provided additional information about stricture involvement of the spongiosum, location of urethral arteries, and associated abnormalities (that is, periurethral abscess and urethrocutaneous fistula). This information was useful for the clinical stratification of urethral stricture disease and the planning of treatment.

CONCLUSIONS

With the advantages of avoiding radiation to testis, providing real-time evaluation of the distensibility of the urethra, and having the capacity of assessing spongiosum and periurethral tissue involvement and urethral artery location, urethral sonography appears to offer more than retrograde urethrography for the evaluation of anterior urethral stricture.

On the transurethral treatment of urethrostenosis in males

The paper deals with the authors' own experience in endoscopic treatment of urethrostenosis in males. Since 1980, 86 patients have been treated in this manner. Good results were obtained in 60 (70%) after one surgical procedure and in 18 (21%) after two operations. Two patients were operated upon by routine methods. We are of the opinion that transurethral treatment of urethrostenosis in males is an easy and simple method which may yield -- if properly performed -- very good therapeutic results, but requires appropriate equipment and high surgical skills.

Long-term followup of endoscopic management of urethral strictures in children

The long-term followup of 31 children with urethral strictures managed by an endoscopic technique was reviewed. Four children could not be managed endoscopically and required urethroplasty, yielding an over-all success rate of 87 per cent. Repeat endoscopic procedures were needed in approximately a third of the patients and intralesional steroids enhanced the change of success. The initial favorable short-term results with endoscopic management of urethral strictures in children are confirmed in this expanded series.

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.

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.

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.

Balloon dilatation of urethral strictures

Postinflammatory and posttraumatic urethral strictures present a significant clinical problem. Conventional dilatation techniques are usually associated with recurrence and aggravation of the strictures. This is attributed to the mucosal and periurethral trauma associated with conventional dilatation methods. The initial results in seven patients undergoing balloon dilatation for urethral strictures are presented. The method is relatively atraumatic and painless, and better long-term results are anticipated.

Surgical management of urethral stricture in the male

Urethral dilatation has long been the standard treatment for patients with urethral stricture. However, in many patients such dilatations may be difficult, painful, or have to be done at frequent intervals. The alternative techniques of direct vision urethrotomy or urethroplasty have been considered in 101 patients over a twelve-year period. Skin inlay urethroplasty in this series showed a significant level of complications and an absolute failure rate of 15 per cent. A prospective study of 39 patients undergoing urethrotomy using the Sachse optical urethrotome has shown that 82 per cent of patients are symptom-free and 13 per cent symptomatically improved at a follow-up ranging from sixteen months to three and one-half years (mean twenty-five months). We believe that urethrotomy using the Sachse optical urethrotome should now be the initial treatment of choice in the management of urethral stricture. Urethral dilatations or urethroplasty should be reserved for those patients who have persisting stricture despite such urethrotomy.

Endoscopic management of urethral strictures in children

The management of urethral strictures in children prior to urethroplasty has involved dilation and internal urethrotomy. Low success rates with these modalities led to the evaluation of visual urethrotomy and intralesional steroid injection. Of 12 patients so managed 10 achieved an excellent result, with 2 classified as having good results initially. These 2 cases were ultimately converted into the excellent category following repeat procedures. Non-invasive urinary flow rates proved invaluable in the management and assessment of these patients, and the success of their treatment.

Internal urethrotomy with the Sachse urethrotome

30 patients with urethral strictures treated with internal urethrotomy with the Sachse urethrotome were followed from 2-25 months postoperatively. Reexamination included retrograde urethrography and flow studies. One half of the patients were fully satisfied, one fourth reasonably so, whereas the remaining patients were dissatisfied. Urethrography and flow study revealed a considerably higher rate of recurrence than the clinical results.

Urethral stricture

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Internal urethrotomy using Sachse knife for managing urethral strictures

Urethral strictures secondary to trauma have been a frequent cause of obstruction in the male population residing in Saudi Arabia. This study of 59 patients presenting with urethral strictures covers a two-year period. Patients were asked to return for the initial follow-up one month after treatment and were asked about the force of their urine stream. They returned again after six months for a urethrogram; finally yearly follow-ups were commenced.

Direct vision internal urethrotomy in the management of urethral strictures

Direct vision internal urethrotomy is a safe, effective means to treat urethral strictures and vesical neck contractures. Its success rate approaches 90 per cent with 6 months of followup, although a longer interval may be necessary for a more accurate record. It often can be performed in an outpatient setting, under topical anesthesia and with only 1 day of catheter drainage, which provides considerable savings in hospital costs.

Direct vision cold knife urethrotomy

During a 3-year period urethral strictures in 75 patients were treated by cold knife urethrotomy. Analysis of the etiology, diagnosis, surgical technique, complications and postoperative management is described. Satisfactory results were achieved in 71 per cent of the cases. The over-all morbidity rate was 9 per cent. Patients with strictures more than 2 cm. long had unsatisfactory results, while those managed with a silicone catheter postoperative for less than 7 days had better results. Direct vision cold knife urethrotomy is a safe technique that should be exercised as a therapeutic trial before a final decision is made to perform definitive urethroplasty.

The role of selective internal urethrotomy in the management of urethral stricture: a multi-centre evaluation

The advent of selective internal urethrotomy under direct vision has enabled precision endoscopic surgery to be undertaken on a wide range of urethral strictures. A multi-centre survey of 197 cases involving 322 urethrotomy procedures from 5 urological departments in England is reported. The overall results after a follow-up of up to 4 years suggest that there is no indication for further procedures currently existing in 160 (81%) of those cases subjected to selective internal urethrotomy. The additional injection of triamcinalone acetate into the strictured area prior to urethrotomy is recommended in resistant cases. The procedure of selective internal urethrotomy is, in our opinion; the best primary method for the treatment of urethral stricture, and it is hoped this will reduce the indications for anastomotic or substitution urethroplasty.

Cold knife optical urethrotomy

Cold knife optical urethrotomy with the Sachse urethrotome was used in 44 patients with urethral strictures. Appraisal if the results, after a mean follow-up of fourteen months, showed 77.3 per cent success rate regarding urine flow rates and 81.8 per cent regarding subjective response of the patient.