A prospective, randomized protocol to examine the efficacy of postinternal urethrotomy dilations for recurrent bulbomembranous urethral strictures

Outcomes of HUD Versus CIC in Patients With Urethral Strictures

Treatment of urethral stricture is a complex reconstructive urology treatment. Previous surgery in the treatment of urethral stricture increases the risk of urinary incontinence. Therefore, this study aimed to assess the outcome of comparing two preservative or nonsurgical methods, clean intermittent catheterization (CIC) or hydraulic urethral dilatation (HUD). Forty-eight patients diagnosed with symptomatic urethral stricture were enrolled in the study. Patients were randomly divided into two groups: Nelaton-based dilatation and HUD treatment. Patients were assessed using patient-reported outcome measure for urethral stricture surgery (USS-PROM) through direct clinical interview and were followed up for 12 months. The rate of urinary infection, the need for surgical intervention, and the patient's quality of life were considered as outcomes of the interventions. SPSS software, version 20.0, was used for statistical analysis. Overall, 23 (47.9%) patients underwent HUD of stricture and Nelaton-based dilatation of stricture was done in 25 (52.1%) patients. We found that surgical intervention was required in four patients in the HUD group, but 15 patients in the CIC group required surgical intervention. Also, the need for surgical intervention and urinary tract infection (UTI) was significantly greater in the CIC group compared with the HUD group. With respect to the patient-reported outcomes, the mean Peeling's voiding picture (Q8) and EQ-VAS score (Q16) in the HUD group (p = .02) were significantly greater than those in the CIC group (p = .02). We obtained excellent results by using an HUD catheter. This safe, simple, well-tolerated, home-based procedure reduced the need for hospital admission to operate for repeat.

Direct visual internal urethrotomy: Is it a durable treatment option?

OBJECTIVE

To evaluate the long-term success rate of direct vision internal urethrotomy as a treatment for anterior urethral strictures.

MATERIALS AND METHODS

We retrospectively analyzed the results for patients who underwent internal urethrotomy from January 2009 to January 2014 for anterior urethral strictures. Patients were followed till January 2016. Patients with complicated urethral strictures with a history of previous urethroplasty, hypospadias repair, or previous radiation were excluded from the study, as anticipated low success rate of direct visual internal urethrotomy (DVIU) in these patients. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, and third urethrotomy.

RESULTS

A total of 186 patients were included in this study. Stricture-free rates after first, second, and third urethrotomy were 29.66%, 22.64%, and 13.33%, respectively.

CONCLUSIONS

Although DVIU may be a management option for anterior urethral stricture disease, it seems that long-term results are disappointing.

Collagenase Clostridium histolyticum (Xiaflex) for the Treatment of Urethral Stricture Disease in a Rat Model of Urethral Fibrosis

OBJECTIVE

To evaluate the treatment effect of collagenase Clostridium histolyticum (CCH) in a rat model of urethral fibrosis.

MATERIALS AND METHODS

Thirty male Sprague-Dawley rats (300-350 g) were divided into 5 groups. The rat urethra was injected with normal saline in the sham group and, in the other 4 groups, the rat urethra was injected with 10 μg of transforming growth factor beta 1 to create fibrosis of the urethra. Two weeks following transforming growth factor beta 1 injection, the rats were injected with varying doses of CCH or vehicles, depending on their group. The rats were then euthanized at 4 weeks after CCH or vehicle injection. Urethral tissue was harvested for histologic and molecular analyses. Type I and III collagen levels were evaluated by Western blot analysis.

RESULTS

There was urethral fibrosis and to significant increase in collagen type I and III expressions in the urethral fibrosis group compared with the sham group (P <.05). Urethral injection of CCH appeared to be safe and significantly reduce urethral fibrosis as well as collagen type I and III expressions in the high-dose CCH treatment groups when compared with the treatment control group (P <.01).

CONCLUSION

This study demonstrated a beneficial effect of CCH injections in a rat model of urethral fibrosis. These findings suggest a potential role for CCH as a therapeutic option in urethral stricture patients and warrant further investigation.

Intermittent self-dilatation for urethral stricture disease in males

BACKGROUND

Intermittent urethral self-dilatation is sometimes recommended to reduce the risk of recurrent urethral stricture. There is no consensus as to whether it is a clinically effective or cost-effective intervention in the management of this disease.

OBJECTIVES

The purpose of this review is to evaluate the clinical effectiveness and cost-effectiveness of intermittent self-dilatation after urethral stricture surgery in males compared to no intervention. We also compared different programmes of, and devices for, intermittent self-dilatation. .

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 7 May 2014), CENTRAL (2014, Issue 4), MEDLINE (1 January 1946 to Week 3 April 2014), PREMEDLINE (covering 29 April 2014), EMBASE (1 January 1947 to Week 17 2014), CINAHL (31 December 1981 to 30 April 2014) OpenGrey (searched 6 May 2014), ClinicalTrials.gov (6 May 2014), WHO International Clinical Trials Registry Platform (6 May 2014), Current Controlled Trials (6 May 2014) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials where one arm was a programme of intermittent self-dilatation for urethral stricture were identified. Studies were excluded if they were not randomised or quasi-randomised trials, or if they pertained to clean intermittent self-catheterisation for bladder emptying.

DATA COLLECTION AND ANALYSIS

Two authors screened the records for relevance and methodological quality. Data extraction was performed according to predetermined criteria using data extraction forms. Analyses were carried out in Cochrane Review Manager (RevMan 5). The primary outcomes were patient-reported symptoms and health-related quality of life, and risk of recurrence; secondary outcomes were adverse events, acceptability of the intervention to patients and cost-effectiveness. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Eleven trials were selected for inclusion in the review, including a total of 776 men. They were generally small; all were of poor quality and all were deemed to have high risk of bias. Performing intermittent self-dilatation versus not performing intermittent self-dilatation The data from six trials were heterogeneous, imprecise and had a high risk of bias, but indicated that recurrent urethral stricture was less likely in men who performed intermittent self-dilatation than men who did not perform intermittent self-dilatation (RR 0.70, 95% CI 0.48 to 1.00; very low quality evidence). Adverse events were generally poorly reported: two trials did not report adverse events and two trials reported adverse events only for the intervention group. Meta-analysis of the remaining two trials found no evidence of a difference between performing intermittent self-dilatation and not performing it (RR 0.60, 95% CI 0.11 to 3.26). No trials formally assessed acceptability, and no trials reported on patient-reported lower urinary tract symptoms, patient-reported health-related quality of life, or cost-effectiveness. One programme of intermittent self-dilatation versus another We identified two trials that compared different durations of intermittent self-dilatation, but data were not combined. One study could not draw robust conclusions owing to cross-over, protocol deviation, administrative error, post-hoc analysis and incomplete outcome reporting. The other study found no evidence of a difference between intermittent self-dilatation for six months versus for 12 months after optical urethrotomy (RR 0.67, 95% CI 0.12 to 3.64), although again the evidence is limited by the small sample size and risk of bias in the included study. Adverse events were reported narratively and were not stratified by group. No trials formally assessed acceptability, and no trials reported on patient-reported lower urinary tract symptoms, patient-reported health-related quality of life, or cost-effectiveness. One device for performing intermittent self-dilatation versus another Three trials compared one device for performing intermittent self-dilatation with another. Results from one trial at a high risk of bias were too uncertain to determine the effects of a low friction hydrophilic catheter and a standard polyvinyl chloride catheter on the risk of recurrent urethral stricture (RR 0.32, 95% CI 0.07 to 1.40). Similarly one study did not find evidence of a difference between one percent triamcinolone gel for lubricating the intermittent self-dilatation catheter versus water-based gel on risk of recurrent urethral stricture (RR 0.68, 95% CI 0.35 to 1.32). Two trials reported adverse events, but one did not provide sufficient detail for analysis. The other small study reported fewer instances of prostatitis, urethral bleeding or bacteriuria with a low friction hydrophilic catheter compared with a standard polyvinyl chloride catheter (RR 0.13, 95% CI 0.02 to 0.98). 'Happiness with the intervention' was assessed using a non-validated scale in one study, but no trials formally assessed patient-reported health-related quality of life or acceptability. No trials reported on patient-reported lower urinary tract symptoms or cost-effectiveness. GRADE quality assessment The evidence that intermittent self-dilatation reduces the risk of recurrent urethral stricture after surgical intervention was downgraded to 'very low' on the basis that the studies comprising the meta-analysis were deemed to have high risk of bias, and the data was imprecise and inconsistent. Insufficient evidence No trials provided cost-effectiveness data or used a validated patient-reported outcome measure, and adverse events were not reported rigorously. Acceptability of the intervention to patients has not been assessed quantitatively or qualitatively.

AUTHORS' CONCLUSIONS

Performing intermittent self-dilatation may confer a reduced risk of recurrent urethral stricture after endoscopic treatment. We have very little confidence in the estimate of the effect owing to the very low quality of the evidence. Evidence for other comparisons and outcomes is limited. Further research is required to determine whether the apparent benefit is sufficient to make the intervention worthwhile, and in whom.

Male urethral strictures and their management

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

SIU/ICUD Consultation on Urethral Strictures: Dilation, internal urethrotomy, and stenting of male anterior urethral strictures

Male urethral stricture is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition. Our objective was to review all contemporary and historial articles on the topic of dilation, internal urethrotomy, and stenting of male anterior urethral strictures. An extensive review of the scientific literature concerning anterior urethral urethrotomy/dilation/stenting was performed. Articles were included that met the criteria set by the International Consultation on Urological Diseases (ICUD) urethral strictures committee and were classified by level of evidence using the Oxford Centre for Evidence-Based Medicine criteria adapted from the work of the Agency for Health Care Policy and Research as modified for use in previous ICUD projects. Using criteria set forth by the ICUD, a committee of international experts in urethral stricture disease reviewed the literature and created a consensus statement incorporating levels of evidence and expert opinion in regard to dilation, internal urethrotomy, and stenting of male anterior urethral strictures.

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.

Patterns of management of urethral stricture disease in the Veterans Affairs system

OBJECTIVES

To describe the number of urethral dilations, urethrotomies, and urethroplasties performed on men with a diagnosis of urethral stricture disease seeking care in the Veterans Affairs (VA) health care system in southern California and southern Nevada over a 5-year period. To date, few health services research studies have evaluated patterns of care for urethral stricture disease using national datasets.

METHODS

We analyzed stricture treatment for male veterans with an ICD-9 diagnosis code for urethral stricture in the National Patient Care Database (NPCD). Encounters for urethral stricture procedures performed were identified based on the presence of Physicians Current Procedural Terminology Coding System (4th edition, CPT-4) codes for treatments performed during the fiscal years 2002-2006.

RESULTS

A total of 1457 men carried a diagnosis of urethral stricture disease during the index time period. Of these, 333 men (23%) underwent 431 procedures. Of the 216 men who underwent urethral dilations, 170 (79%) underwent only 1 procedure and 26 (12%) underwent 2 procedures. Of the 79 men who underwent urethrotomy, 76 (96%) underwent 1 procedure. Sixteen men (5%) underwent a urethroplasty, 8 of whom underwent a perineal urethrostomy.

CONCLUSIONS

The vast majority of men treated for stricture disease underwent only 1 such procedure over a 5-year time period. Further research is required to investigate whether this is a quality-of-care issue or patients refusing intervention. It is possible that some patients may be temporized for a significant period with dilation/urethrotomy, whereas those with rapid recurrence require early urethroplasty.

Porcine Small Intestinal Submucosa Augmentation Urethroplasty and Balloon Dilatation of a Urethral Stricture Secondary to Inadvertent Prostatectomy in a Dog

A 10-month-old, male German shepherd dog experienced inadvertent prostatectomy during cryptorchidectomy. Cystourethral anastomosis was performed 1 day later. The dog developed stranguria and incontinence. A proximal urethral stricture was diagnosed with a contrast urethrogram 5 weeks later. Urethral augmentation with an onlay graft of porcine small intestinal submucosa was performed. Urinary diversion was accomplished with a urethral catheter followed by a cystostomy tube. The stricture recurred over the next 6 weeks. Three urethral balloon dilatations were performed 3 days apart, with the third attempt resulting in expansion of the stricture. Twenty-two months postdilatation, the dog intermittently urinated with a steady stream and had mild to moderate urinary incontinence.

Comparison of neodymium-doped yttrium aluminum garnet laser treatment with cold knife endoscopic incision of urethral strictures in male patients

OBJECTIVE

To assess the effectiveness of visual laser ablation treatment with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in male patients with urethral strictures and to compare the effects with those obtained in patients treated with Sachse's optical urethrotomy.

MATERIALS AND METHODS

Fifty patients aged 22 to 83 (mean age 61.8) with primary (n = 26, 52%) and recurrent (n = 24, 48%) urethral strictures 0.3 to 2.4 cm long qualified for the study. The patients were randomized into two groups: 30 men treated using visual laser ablation of urethral strictures (VLASU) with Nd:YAGlaser and 20 men treated by correction of urethral strictures using Sachse's optical urethrotomy.

RESULTS

At 12-month follow-up, seven (35%) patients who underwent optical urethrotomy and 21 (70%) in the VLASU group did not require repetition of the procedure. The choice of VLASU as a method of treatment significantly decreased the probability of therapeutic failure and recurrence of urethral strictures (p = 0.02).

CONCLUSION

VLASU can be used as a method of treatment of this disorder. It is an effective, modern, low-invasive, and repeatable technique and is technically simple and easy to master. It can be used in cases in which introduction of a 22 Char optical urethrotome into the stricture site is impossible, as well as for treatment of multiple strictures during one procedure.

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.

Using stainless steel chopstick for self-performing urethral sounding in preventing recurrence of anterior urethral stricture

Male urethral stricture is prone to recurrence, ranging from 40% to 80% according to the length of stricture no matter what treatment is introduced. Therefore, it has long been a common challenge for urologists to handle the problem. Sounding or self-dilation has proved to be effective in reducing the recurrence rate significantly. However, a standard equipment set of urethral bougie is too expensive for a patient's own use. On the other hand, the performance of regular outpatient sounding is time-consuming and costly. We present an easy way to perform urethral self-dilation using a stainless steel chopstick, which has proved to be cost effective and satisfactory for patients. From February 2001 to February 2003, 6 patients, with a mean age of 64.6 years (range 47-79), were introduced to this maneuver after a urethrotomy and were taught how to perform self-sounding with a stainless steel chopstick (18 Fr equivalent). The distance of advancement was determined individually by calibrating the location of the stricture. The long-term result of this maneuver was later checked with a telephone questionnaire about urination status in April 2005. The urethral strictures were located at penile in 3 patients, bulbar in 1, and navicular fossa with meatus in 2. The mean period for performing self-dilation was 15.3 weeks (range, 2-52). The mean follow-up period was 41.5 months (range, 26-55). No recurrence of stricture was found.

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.