Holmium laser core through internal urethrotomy with explantation of UroLume stent. An ideal approach for a complicated posterior urethral stricture

The role of lasers in modern urology

INTRODUCTION

The functioning of modern urological departments and the high level of service they provide is possible through, among other things, the use of modern laser techniques.

MATERIAL AND METHODS

Open operations have been replaced by minimally invasive procedures, and classical surgical tools by advanced lasers. The search for new applications with lasers began as technology developed. Among many devices available, holmium, diode and thulium lasers are currently the most popular.

RESULTS

Depending on the wavelength, the absorption by water and hemoglobin and the depth of penetration, lasers can be used for coagulation, vaporization and enucleation. In many centres, after all the possibilities of pharmacological treatment have been exhausted, lasers are used as the primary treatment for patients with benign prostatic hyperplasia, with therapeutic results that are better than those obtained through open or endoscopic operations. The use of lasers in the treatment of urolithiasis, urinary strictures and bladder tumours has made treatment of older patients with multiple comorbidities safe, without further necessity to modify the anticoagulant drug treatment. Laser procedures are additionally less invasive, reduce hospitalization time and enable a shorter bladder catheterization time, sometimes even eliminating the need for bladder catherterization completely. Such procedures are also characterized by more stable outcomes and a lower number of reoperations.

CONCLUSIONS

There are also indications that with the increased competition among laser manufacturers, decreased purchase and maintenance costs, and increased operational safety, laser equipment will become mandatory and indispensable asset in all urology wards.

Comparison of treatment results between holmium laser endourethrotomy and optical internal urethrotomy for urethral stricture

PURPOSE

We comparatively evaluated urethral stricture (US) treatment outcomes, efficacy and complications, using either holmium laser endourethrotomy (HLU) or optical internal urethrotomy (OIU) since studies such as this are scarce in literature.

METHODS

During 2003-2008, 50 men aged 17-78 years were operated on for primary or refractory US, 32 (64%) and 18 (36%) patients, respectively. The average stricture length was 1.86 cm. Strictures were single or multiple, forty-one (82%) and nine (18%) patients, respectively, and were located in the anterior or posterior urethra in 27 (54%) and 32 (64%) patients, respectively. US were iatrogenic in 32 (64%) and idiopathic in 18 (36%). Patients were divided into two groups, grpA and grpB, each containing 25 patients who were treated using either HLU or OIU, respectively. An evaluation scale of 1-3 was adopted and took maximum flow rate (Q(max)), postvoid residual (PVR), and quality of life (QL) into consideration. A score of '1 was very good, '2 was good, and '3 was poor.

RESULTS

Treatment results were evaluated after 3, 6, and 12 months, respectively. Evaluation of grpA was as follows: five (20%), nine (36%), and seven (28%) patients scored a '1; thirteen (52%), nine (20%), and four (16%) patients scored a '2; and seven (28%), eleven (44%), and fourteen (56%) patients scored a '3. Evaluation of grpB: seven (28%), ten (40%), and five (20%) patients scored a '1; eleven (44%), seven (28%), and ten (40%) patients scored a '2; and seven (28%), eight (32%), and ten (40%) patients scored a '3.

CONCLUSIONS

Neither complication rate nor degree of efficacy between HLU and OIU for US revealed a significant difference. We found both laser and conventional urethrotomies to be safe and effective modes of treatment.

Thulium laser urethrotomy for urethral stricture: a preliminary report

BACKGROUND AND OBJECTIVES

The outcome of thulium laser urethrotomy for patients with urethral stricture had not been reported. The purpose of this study was to evaluate outcome of endourethrotomy with the thulium laser as a minimally invasive treatment for urethral stricture.

MATERIALS AND METHODS

Twenty-one consecutive patients with urethral stricture were evaluated by retrograde uroflowmetry, International Prostate Symptom Score (IPSS), and quality of life preoperatively at a single academic center. All patients were treated with thulium laser urethrotomy. All patients were followed up for 12-24 months postoperatively by uroflowmetry and by retrograde with voiding cystourethrogram every 3 months. And all patients were followed up by mailed questionnaire, including IPSS and quality of life.

RESULTS

Retrograde endoscopic thulium laser urethrotomy was performed in all 21 patients. Most patients (N = 16; 76.2%) did not need any reintervention. Five patients developed recurrent strictures, of them two patients were treated by another laser urethrotomy, one patient was treated by open urethroplasty with buccal mucosa and the other two patients' reintervention were treated by urethral dilation. No intraoperative complications were encountered, although in 9.5% (N = 2) of patients, a urinary tract infection was diagnosed postoperatively. No gross hematuria occurred. Including two patients treated with repeat laser urethrotomy, 17(81.0%) showed good flow of urine (Q(ave)>16.0 ml/second) and adequate caliber urethra in retrograde urethrogram (RGU) 12 months after operation. Three (14.3%) patients showed narrow stream of urine (Q(ave)<8.0 ml/second) and urethral dilation was done every month or 2 months. There was one patient whose Q(ave) was between 8.0 and 16.0 ml/second. And this patient was treated by neither urethral dilation nor another laser urethrotomy.

CONCLUSIONS

The thulium laser urethrotomy was a safe and effective minimally invasive therapeutic modality for urethral stricture.

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.

The Surgical Management of Obstructive Stents Used for Urethral Strictures

PURPOSE

We present our referral experience with patients who had extensive urethral obstruction following UroLume insertion and were treated with urethroplasty.

MATERIALS AND METHODS

We retrospectively analyzed the records of 13 men with urethral stricture who experienced recurrent obstruction following placement of a UroLume endoprosthesis. In all patients several attempts at urethral dilation and optical urethrotomy failed to overcome the obstruction. Complete excision of the obstructed urethra containing the stent with the surrounding periurethral fibrosis was done in all patients. In 12 patients a 1-stage bipedicled penile island tubularized flap was used to bridge the urethral defect. In 1 patient 1-stage urethroplasty was performed and he is awaiting stage 2. Followup assessment included urine flow, post-void residual urine measurement, retrograde urethrogram and urethroscopy at different intervals.

RESULTS

Of the 12 patients who underwent complete treatment 1 had a short segment stricture at the site of the distal anastomosis 3 months after catheter removal, which was successfully managed by internal urethrotomy. He was doing well at the 12-month followup. In 11 patients a successful outcome was noted immediately after catheter removal and it was maintained at a mean followup of 1.8 years (range 1 to 4).

CONCLUSIONS

Complete excision of the obstructed urethra containing the UroLume stent with the surrounding periurethral fibrosis is an important first step in reconstruction. Subsequent use of a 1-stage bipedicled penile island tubularized flap resulted in excellent long-term results. In a small subset of cases delayed stage 2 repair after skin inlay is a valuable option.

Endourethral prostheses for urethral stricture

A number of urethral stents made of different materials, with different time of indwelling and different designs, primarily based on the vascular stent concept, have been applied in the clinical practice so far. According to the published studies, urethral stents have justified their clinical application, however with certain limitations. Within an attempt to overcome the limitations, a covered, temporary urethral stent was initially designed by Daniel Yachie and Zeljko Markovic in Allium corporation from Israel. With its triangular shape, the stent is a replica of the obstructive urethral lumen. The follow-up of results was done according to a priori established protocol including the following:UCG, uroflowmetry and interview with patients. Due to stent migration, the stent over stent technique was applied in two case, while reposition by balloon-catheter outward traction was performed in two cases of caudal migration. No irritative discomforts were reported in the first 6 months after stent dwelling. Uroflowmetric controls verified at least four times better results than before the insertion. Given it is the question of covered stent, there is no possibility of proliferative secondary lumen obstruction. On account of soft structure and conic shape of posterior part of stent, no lesions of the external urethral sphincter were manifested. The stent is simply withdrawn after 12 months by outward traction using the forceps at the time when the stent construction turns into soft and straight wire. After 12-16 months in all cases we removel stent and in all patients we find complete rekanalisation without any disuric problem. In 5 cases we find new "contact" stricture on anterior part of stent and treated succeed with balloon recanalisation.

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.