11-Year Outcome Analysis of Endourethral Prosthesis for the Treatment of Recurrent Bulbar Urethral Stricture

Comparison of Diagnostic Value of Sonourethrography with Retrograde Urethrography in Diagnosis of Anterior Urethral Stricture

BACKGROUND

In spite of the advanced imaging methods, MRI and CT-Scan, the role of ultrasonography is still unique in some fields of genitourinary tract diseases.

AIM

This study was aimed at assessing this role in the evaluation of male urinary stricture, and comparison with standard retrograde urethrography (SUG).

METHODS

This was a cross-sectional study. The patients include those who were suspected of anterior urethral stricture and were introduced assessed with imaging techniques (RUG). The patient underwent ultrasonography too. The results of both methods were compared. RUG was considered as the gold standard for this comparison.

RESULT

Ninety-seven patients were studied. The mean age was 46.9 ± 11.7 years (range 21-88 years), in RUG, 22 patients (22.8%) and SUG 23 patients (23.7%) had a stricture, 3 cases with a stricture in RUG had not evidenced of stenosis in SUG. The mean length of urethral stricture in RUG was 12.9 ± 8.1 mm and in SUG was 8.1 ± 7.3 mm. The estimated length in RUG way was significantly higher than SUG way (P=0.025). The sensitivity and specificity in using of SUG were 86.6% and 94.6%, respectively.

CONCLUSION

The result of this study showed stricture length measured by ultrasound is shorter than the length measured by RUG and the sensitivity and specificity in using of SUG was 86.6% and 94.6% respectively that due to the advantages it is an acceptable way.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

[Rational and selective management of patients with anterior urethral stricture disease]

INTRODUCTION

the management of anterior urethral stricture is controversial. A review article was written, which updates the current situation of the surgical treatment of anterior urethral stricture.

MATERIALS AND METHODS

the experience of the Hospital del Trabajador in Santiago de Chile regarding its different surgical approaches, as well as scientific literature on the topic, were reviewed.

RESULTS

traditionally, anterior urethral stricture has been treated using minimally invasive techniques (dilatation and internal urethrotomy), which are unable to cure more than 30-35% of patients. On the other hand, urethral reconstruction surgery (urethroplasty) is more complex and requires training, however it can cure a wide majority of patients in a single surgical procedure. Due to a lack of experience and training in reconstructive surgery, non-invasive methods are overused and abused, to the detriment of the patients' quality of life. There is substantial evidence that internal urethrotomy is an excellent method for treating stricture of up to 1cm in length, however its efficacy decreases drastically above 1.5cm. Notwithstanding, urethroplasty is directly indicated for larger strictures, especially if prior urethrotomy failed.

CONCLUSION

this procedure must be managed selectively, applying the appropriate treatment aimed at curing and not only palliating the disease. Urologists must be better trained in urethroplasty and/or centres of excellence must be established to be able to offer the best treatment in each case.

Impacted calculus within a urethral stent: A rare cause of urinary retention

An elderly male presented to the emergency department with acute urinary retention. He had poor flow of urine associated with serosanguinous discharge per urethra for 3 days duration. Earlier he underwent permanent metallic urethral stenting for post TURP bulbar urethral stricture. Plain X-ray of Pelvis showed an impacted calculus within the urethral stent in bulbar urethra. Urethrolitholapaxy was done with semirigid ureteroscope. Urethral stent was patent and well covered. Subsequently he had an uneventful recovery. We describe a unique case of acute urinary retention due to calculus impaction within a urethral stent.

Management of urethral stent failure for recurrent anterior urethral strictures

BACKGROUND

Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications.

OBJECTIVE

To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures.

DESIGN, SETTING, AND PARTICIPANTS

We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures.

SURGICAL PROCEDURE

The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section.

MEASUREMENTS

Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications.

RESULTS AND LIMITATIONS

Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases.

CONCLUSIONS

The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion.

Management of restenosis after urethral stent placement

PURPOSE

We describe our experience with the management of restricture after urethral stent placement, including endoscopic and open surgical treatment.

MATERIALS AND METHODS

We surveyed our prospectively collected database for patients with restenosis after urethral stent insertion. We reviewed patient age, comorbidities, indications for stent placement, restricture length, management of restricture, postoperative complications and the further restenosis rate.

RESULTS

Overall we have treated 22 patients with failed urethral stents with a median followup of 30 months (range 1 to 96). All stents were initially placed for urethral stricture management. Stricture etiology included prostate cancer therapy in 9 cases, idiopathic causes in 6, urethral instrumentation in 2, trauma in 2, simple prostatectomy in 2 and gender reassignment/phalloplasty in 1. Ten patients had anterior urethral stricture, 11 had posterior stricture and 1 patient had each type. Of the 22 patients with stenosis after stent placement 13 underwent urethroplasty. Of the 18 patients with indwelling stents at treatment the stent was removed in 8 intraoperatively and in 10 the stent was left in situ. Ten of the 11 anterior strictures were treated with urethroplasty. Only 4 of the 12 posterior strictures were treated with urethroplasty, while 8 were managed endoscopically. Our overall success rate for treatment after stent failure was 67% (8 of 12 cases) for posterior urethral strictures and 82% (9 of 11) for anterior strictures.

CONCLUSIONS

Urethral stent failure requires complex intervention. A failed posterior urethral stent can often be managed endoscopically. Conversely we have managed failed anterior urethral stents by urethroplasty.

Preservation of lower urinary tract function in posterior urethral stenosis: selection of appropriate patients for urethral stents

PURPOSE

We describe our experience with urethral stents to manage iatrogenic posterior urethral stenosis.

MATERIALS AND METHODS

We surveyed our retrospective database for patients in whom we placed a urethral stent for posterior urethral stricture disease. We reviewed patient age, comorbidities, indications for stent placement, stricture length, postoperative complications and the repeat stenosis rate.

RESULTS

Overall we placed urethral stents in 13 patients, of whom 12 presented with posterior urethral stenosis and 1 presented with anterior and posterior stricture. The etiology of urethral stricture was prostate cancer therapy in 11 of 13 cases and simple prostatectomy in 2. Urethral stenting was chosen instead of urethral reconstruction largely due to prior radiation for prostate cancer and avoidance of the morbidity of surgery. Overall 6 of 13 patients required additional procedures for stricture recurrence, including 5 in previously irradiated patients. Two patients had stents removed due to migration or pain. Genitourinary infections developed in 5 of 13 patients. Eight of 13 patients with a posterior urethral stricture were incontinent, as expected after stent placement. Incontinence was managed by an artificial urinary sphincter in willing patients with 9 of 13 continent.

CONCLUSIONS

Urethral stents provide reasonable treatment for patients with posterior urethral stenosis when attempting to preserve lower urinary tract function caused by stricture disease after prostate cancer therapy. Prior radiation seems to increase the failure rate. Continence can be maintained after posterior urethral stenting in select patients.

One-stage urethral reconstruction for stricture recurrence after urethral stent placement

PURPOSE

We report our 8-year experience with 1-stage open urethral reconstruction in 10 patients with recurrent bulbar and/or membranous strictures after UroLume urethral stent placement.

MATERIALS AND METHODS

Ten consecutive referral patients underwent preoperative contrast imaging and urethroscopy followed by primary anastomotic repair or substitution urethroplasty, with concomitant open UroLume removal (when the stent was still present). Postoperative evaluation included contrast imaging 3 weeks after surgery, urethroscopy 4 months after surgery, uroflowmetry, and American Urological Association symptom score assessment.

RESULTS

At a medium followup of 51.2 months all patients remain free of bulbar or membranous stricture recurrence. No patient has required dilation or any other intervention.

CONCLUSIONS

One-stage open reconstruction with stent extraction offers a definitive treatment option with a high success rate for patients with recurrent bulbar and/or membranous strictures following urethral stent placement.

Extraction of UroLume endoprosthesis with one-stage urethral reconstruction using buccal mucosa

Long-term analyses of the UroLume Endoprosthesis have shown conflicting results with regard to efficacy and restricture rates. The best management of recurrent urethra stricture disease at the site of a previous UroLume stent is unknown. We describe a previously unreported technique for transperineal excision of the UroLume for recurrent bulbar urethral stricture disease with one-stage reconstruction using buccal mucosa. At 9 months of follow-up, the patient was voiding well with no evidence of stricture recurrence.

Recent advances in the field of urology

Advances have been made in every aspect of urology that strengthen the scientific underpinning of current urologic practices and that hopefully will encourage further scientific investigation into the source, mechanisms, and cure of urologic diseases. This article reviews some of the advances that have been detailed in the recent urologic literature.

Imaging of urethral disease: a pictorial review

Retrograde urethrography and voiding cystourethrography are the modalities of choice for imaging the urethra. Cross-sectional imaging modalities, including ultrasonography, magnetic resonance (MR) imaging, and computed tomography, are useful for evaluating periurethral structures. Retrograde urethrography is the primary imaging modality for evaluating traumatic injuries and inflammatory and stricture diseases of the male urethra. Sonourethrography plays an important role in the assessment of the thickness and length of bulbar urethral stricture. Although voiding cystourethrography is frequently used to evaluate urethral diverticula in women, MR imaging is highly sensitive in the demonstration of these entities. MR imaging is also accurate in the local staging of urethral tumors.

Long-term results of a self-expanding wallstent in the treatment of urethral stricture

OBJECTIVE

To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease.

PATIENTS AND METHODS

The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications.

RESULTS

The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%).

CONCLUSIONS

The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.

The 12-year outcome analysis of an endourethral wallstent for treating benign prostatic hyperplasia

OBJECTIVE

To evaluate the long-term results of using the Urolume(TM) endourethral prosthesis (American Medical Systems, Minnetonka, MN, USA) for managing benign prostatic hyperplasia (BPH), an alternative minimally invasive option.

PATIENTS AND METHODS

Sixty-two patients with moderate/severe lower urinary tract symptoms secondary to BPH were treated with the Urolume stent by one surgeon (J.H.P.). They were followed up at 12 weeks, 6 months and then yearly. Data recorded before and after treatment included symptom scoring, peak urinary flow rate (PFR) and postvoid residual volume (PVR). A one-way anova was used to compare baseline and the 5- and 12-year follow-up data.

RESULT

Twenty-two and 11 patients completed the 5- and 12-year follow-up, respectively. Twenty-one (34%) patients died with the stent in situ from causes unrelated to BPH and Urolume insertion. Twenty-nine (47%) stents were removed; 18 in the first 2 years, seven at 3-5 years and four at 9-10 years. Early stent explantation was primarily a result of poor case selection, or stent malposition/migration. Four stents were removed because the patient was dissatisfied. Late stent explantation was for symptom progression. At 5 years, the symptom score and PFR were 6.82 an 11.7 mL/s, respectively, compared with 20.4 and 9 mL/s at basleine (P < 0.05); at 12 years, the symptom score, PFR and PVR were 10.82, 11.5 mL/s and 80 mL, respectively. The mean quality of life score was 2 and no patient opted for any further treatment.

CONCLUSION

The Urolume wallstent is a safe treatment for BPH, in selected patients. Careful case selection and experience is mandatory. This stent can provide the urologist with an alternative along with other minimally invasive treatments for men with BPH at high risk of requiring transurethral resection.

Extraction of UroLume endoprostheses with one-stage urethral reconstruction

We describe a technique for transperineal excision of UroLume endoprostheses with one-stage urethral reconstruction. We have used this technique in 3 patients with occluded urethral stents placed for bulbar stricture disease. All patients experienced acceptable outcomes.

Percutaneous Placement of Permanent Metal Stents for Treatment of Ureteroenteric Anastomotic Strictures

PURPOSE

To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy.

PATIENTS AND METHODS

Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits.

RESULTS

At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients.

CONCLUSIONS

Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.