Internal urethrotomy with hydraulic urethral dilatations

Treatment of Urethral Stricture Disease by Internal Urethrotomy followed by Intermittent ‘Low-Friction’ Self-Catheterization: Preliminary Communication

The aim of this study was to determine whether the natural course of urethral stricture disease could be modified following urethrotomy by teaching patients intermittent self-catheterization. Preliminary results in 42 patients show that postoperative urine flow rates can be maintained if this method of ‘low-friction’ catheterization is adopted. The technique has been well received by an elderly group of patients and can be recommended for wider use.

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.

What is the place of internal urethrotomy in the treatment of urethral stricture disease?

As a treatment for male urethral stricture, internal urethrotomy (IU) has the advantages of ease, simplicity, speed and short convalescence. Various modifications of the single cold-knife incision in the 12 o'clock position have been proposed, but there are no prospective, randomized studies to prove their claims of greater efficacy. IU can be performed as an outpatient procedure using local anesthesia, with an indwelling silicone catheter for 3 days after the procedure. Complications of IU are usually minor, including infection and hemorrhage. The reported success rate of IU varies, mainly because of differences in the definition of success and the duration of follow-up. Strictures can recur, usually within 3-12 months of IU. There are several known risk factors for recurrence: a previous IU, penile and membranous strictures, long (>2 cm) and multiple strictures, untreated perioperative urinary infection and extensive periurethral spongiofibrosis. Repeated IU might be useful in patients who have a stricture recurrence more than 6 months after the initial procedure, but repeat IU offers no long-term cure after a third IU, or if a stricture recurs within 3 months of the first IU. Such patients should be offered urethroplasty. Repeated IU followed by long-term self-dilation is an alternative option for men with severe comorbidity and limited life expectancy, or those who have failed previous urethroplasty. Overall, IU has a lower success rate (+/-60%) than urethroplasty (+/-80-90%), but if used for selected strictures, the success rate of IU could approach that of urethroplasty.

Iatrogenic prostatic urethral strictures: classification and endoscopic treatment

OBJECTIVES

The treatment of posterior urethral strictures is a controversial subject. For proper treatment, it is important to differentiate between iatrogenic prostatic urethral strictures and post-traumatic membranous urethral strictures.

METHODS

Iatrogenic strictures of the prostatic urethra have been classified according to location and etiology into three categories: type I, located exclusively at the bladder neck; type II, located in the midportion of the prostatic fossa; and type III, when the whole prostatic fossa is replaced by stricture. From 1970 to 1996, 163 patients with postoperative strictures of the prostatic urethra were treated endoscopically.

RESULTS

The results obtained in 122 patients are reported; 41 patients are not evaluable. The median follow-up was 63 months (range 12 to 239). Seven patients required a second endoscopic procedure to attain cure. Good results were achieved in 54 (91%) of 59 patients with type I strictures, in 45 (98%) of 46 patients with type II strictures, and in 13 (76%) of 17 patients with type III strictures. The overall success rate was 92% (112 of 122). Complications occurred in 21 patients (17%), including postoperative urinary tract infection (11%), incontinence (4%), stress incontinence (1%), and severe bleeding (1%).

CONCLUSIONS

Postoperative strictures of the prostatic urethra must be recognized and can be easily treated with endoscopic therapy.

Endoscopic management of urethrovesical anastomotic obliteration following radical retropubic prostatectomy

Urethrovesical anastomotic obliterative strictures are uncommonly reported sequelae of radical retropubic prostatectomy. We report a method to re-establish endoscopically continuity between the bladder and urethra after this complication.

Perforation-reconstitution of proximal urethral obliteration

Post-traumatic or failed postoperative proximal urethral obliteration commonly is managed by technically demanding transpubic procedures. Five cases are reported, which were treated successfully by forceful retrograde perforation with a urethral sound guided by a finger inserted into the prostatic urethra. Temporary urethral catheterization followed by a program of daily self-dilation by catheter during maturation of the tract, with visual urethrotomy as required, facilitated healing.

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.

Postoperative care following internal urethrotomy

A randomized prospective study was set up to assess the role of postoperative catheter drainage and the value of hydraulic self-dilatation of the urethra after internal urethrotomy. Sixty-two patients were admitted into the study and followed-up for two years. The results support the use of a no-catheter posturethrotomy management and advocate the encouragement of postoperative hydraulic self-urethral dilatation.

Visual internal urethrotomy in management or urethral strictures

Visual internal urethrotomy was used in the treatment of urethral strictures in 103 patients. The procedure was performed mostly under local anesthesia. Urethral catheter for forty-eight hours or urethral splinting for two weeks was used as complementary treatment in some cases. We obtained an overall success rate of 95.1 per cent.

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.

Endoscopic management of urethral stricture

Experience with transurethral management of urethral stricture using conventional urethroscope and resectroscope of both infant and adult size is reported and the surgical procedure described. Because incision, dilation, and resection of the stricture are done under direct visual control, it is safe and applicable even in severe strictures hitherto untreatable with other refined closed methods.

Transurethral urethrotomy under vision

Transurethral urethrotomy under vision with the Sachse urethrotome is a new surgical procedure for the treatment of urethral strictures. The chief advantage of the urethrotome is the fact that the surgeon can cut strictures selectively and accurately under clear vision. The procedure is less painful than blind internal urethrotomy and less extensive cases can be done in the office with the patient under local anesthesia. We report on 36 cases with at least 6 months of followup. In 20 cases the strictures were distal to the prostate and the results were considered good in 16, improved in 3 and a failure in 1. The other 16 cases involved vesical neck contractures and all patients had good results. The technique for urethral strictures distal to the prostate and for vesical neck contractures is described and postoperative treatment is emphasized and discussed.

Urethral strictures: treatment with intralesional steroids

A review of steroid management of urethral strictures is presented. The 96 patients were followed for a year or more after urethral injection with triamcinolone. Intralesional steroid may be used in many types of strictures but it is especially useful in those cases with strictures in the distal urethra or the meatus, those occurring after radical prostatectomy and in some cases when 1 or more urethroplasties have been done. Every practicing urologist can benefit from using stricture injection in selected cases.

Congenital proximal bulbar stricture in adults

Congenital proximal bulbar stricture in adults is a definite clinical entity and should be looked for in adults with obscure urinary symptoms. The stricture is usually short and can be demonstrated with a voiding cystogram, urethrogram, and urethroscopy. The condition is thought to be due to incomplete rupture of the cloacal membrane at its junction with the urogenital sinus. The stricture can be treated easily by internal urethrotomy and/or urethral dilatation.