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

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.

[Sachse internal urethrotomy: endoscopic treatment of urethral strictures]

The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy (DVUI) method according to Sachse. It is an effective short-term treatment, but the long-term success rate is low. A number of factors influence the outcome of DVUI including stricture location, spongiofibrosis and previous endoscopic stricture treatment. Multiple urethrotomy has a negative impact on the success rate of subsequent urethroplasty. A thorough preoperative diagnostic work-up including combined retrograde urethrogram/voiding cystourethrogram (RUG/VCUG) and urethrocystoscopy is, therefore, mandatory to allow for patient counselling regarding the risk of stricture recurrence and other treatment options. After a failed primary DVUI, subsequent urethrotomy cannot be expected to be curative.

Randomized clinical trial comparing effectiveness of intracorpus spongiosum block versus topical anesthesia for performing visual internal urethrotomy for urethral stricture disease

OBJECTIVE

To compare the efficacy and safety of intracorpus spongiosum block (ICSB) over topical anesthesia for performing visual internal urethrotomy (VIU) in a randomized clinical trial.

METHODS

VIU for urethral stricture can be performed under various types of anesthesia, including topical anesthesia. Although recent studies have shown that ICSB and general anesthesia have comparable efficacy for performing VIU, no studies have compared ICSB with topical anesthesia. Forty consenting patients with single, short, passable anterior urethral stricture were randomized into two groups. Group 1 patients received topical 2% lignocaine jelly and group 2 patients received 1% lignocaine ICSB for undergoing VIU. Pain perception during and after the procedure was assessed by visual analog scale (VAS). The changes in vital parameters during the procedure and procedure-related complications were recorded. Statistical analysis was done using the Mann-Whitney test or t test.

RESULTS

The mean±standard deviation VAS scores intraoperatively (2.85±1.34) and at 1-hour postoperatively (1.17±0.96) were significantly lower (P<01) in group 2 patients than the corresponding scores in group 1 (4.9±1.9 and 2.35±1.34 respectively). The intraoperative rise in pulse rate and in blood pressure were significantly greater (P<.05) in group 1 patients (13±5.1/min and 11.3±6.44 mm Hg) than in group 2 (8.05±5.54/min and 6.35±5.86 mm Hg).

CONCLUSION

ICSB is safe and more effective than topical anesthesia for providing pain relief during VIU. This should become the local anesthesia technique of choice for performing VIU.

The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures

Introduction:

Direct visual internal urethrotomy (DVIU) followed by intermittent self-dilatation (ISD) is the most commonly performed intervention for urethral stricture disease. The objective of this paper is to outline the current scientific evidence supporting this approach for its use in the management of anterior urethral strictures.

Materials and Methods:

A Pubmed database search was performed with the words “internal urethrotomy” and “internal urethrotomy” self-catheterization. All papers dealing with this subject were scrutinized. Cross-references from the retrieved articles were also viewed. Only English language articles were included in the analyses. Studies were analyzed to identify predictors for success for DVIU.

Results:

Initial studies showed excellent outcomes with DVIU with success rates ranging from 50% to 85%. However, these studies reported only short-term results. Recent studies with longer followup have shown a poor success rate ranging from 6% to 28%. Stricture length and degree of fibrosis (luminal narrowing) were found to be predictors of response. Repeated urethrotomies were associated with poor results. Studies involving intermittent self-catheterization following DVIU have shown no role in short-term ISD with one study reporting beneficial effects if continued for more than a year. A significant number of studies have shown long-term complications with SC and high dropout rates.

Conclusions:

DVIU is associated with poor long-term cure rates. It remains as a treatment of first choice for bulbar urethral strictures <1 cm with minimal spongiofibrosis. There is no role for repeated urethrotomy as outcomes are uniformly poor. ISD, when used for more than a year on a weekly or biweekly basis may delay the onset of stricture recurrence.

Optical urethrotomy using topical anesthesia

A series of 28 patients with urethral strictures less than 2 cm length underwent 32 visual optical internal urethrotomy under local urethral anesthesia with lidocaine. The procedure was completed successfully in 26 of 28 (92.9%) patients. Among these 25 of 26 (96%) patients reported mild pain. Visual analogue scale (VAS) was used for the evaluation of pain. All the patients were followed up for at least 6 months. Visual optical internal urethrotomy is a minimal invasive and successful procedure for short (<2 cm) strictures. Visual optical internal urethrotomy under local urethral anesthesia with lidocaine is a safe, comfortable and cost-effective procedure.

Optical urethrotomy for anterior urethral stricture under a new local anesthesia: intracorpus spongiosum anesthesia

OBJECTIVES

To determine the feasibility of routinely performing internal urethrotomy for anterior urethral stricture under intracorpus spongiosum anesthesia in an outpatient setting.

METHODS

In a consecutive series of 23 patients with anterior urethral stricture, a dosage of 3 mL of 1% lidocaine was slowly injected into the glans penis. Next, optical urethrotomy was performed immediately with a cold-cutting knife. The effect of this anesthetic technique was evaluated by questionnaire.

RESULTS

Internal urethrotomy was successfully completed in all the patients. Twenty-two patients (95.7%) had no pain or discomfort. One patient reported minimal but tolerable discomfort while the tissue above the stricture was being cut. The anesthesia lasted for about 1.5 hours and was very satisfactory without any complications.

CONCLUSIONS

Under intracorpus spongiosum anesthesia, optical urethrotomy can be routinely performed in an outpatient setting. With this new local anesthesia, internal urethrotomy is a safe, effective, simple, and inexpensive procedure for treatment of anterior urethral stricture.

Holmium laser ablation of recurrent strictures of urethra and bladder neck: preliminary results

BACKGROUND

The management of patients with recurrent urethral strictures represents a challenge for the practicing urologist.

PATIENTS AND METHODS

We used holmium:yttrium-aluminum-garnet (Ho:YAG) laser in the management of recurrent urethral strictures in 13 patients. The energy level was set at 1.0 at a frequency of 10 pulses/sec. No treatment complications were observed. The mean preoperative maximum flow rate by uroflowmetric analysis was 3.8 mL/sec.

RESULTS

Nine patients (69%) continue to do well with no symptoms at a median follow-up of 27 months with a mean maximum flow rate of 19 mL/sec. Of the four patients in whom treatment failed, three were retreated with the Ho:YAG laser. One of them was managed by insertion of a permanent urethral stent, another continues to do well without any further treatment, and the other is managed with dilation by self-catheterization. One of the four failures underwent open reconstructive urethroplasty after recurrence following his first treatment with the Ho:YAG laser.

CONCLUSION

Our preliminary results suggest that Ho:YAG laser ablation of urethral strictures is safe and might be a reasonable alternative endoscopic treatment for recurrent urethral strictures.

Tratamiento con triamcinolona acetónido (trigon-depot) de las estenosis post-intervención de hipospadias graves

Urethral stenosis is, after the fistula, the most frequent complication in patients undergoing hypospadias repair. Incidence ranges between 6% and 10% depending on the surgical technique. Treatment of this complication with simple dilation of the narrowed segment is enough in most cases. However, dilation of the stricture may be difficult in patients with severe hypospadias that required wide dissection and excision of fibrotic tissue to repair a large deviation and also in patients who had previously multiple operations. We report 3 patients with severe hypospadias (scrotal and perineal) with history of multiple operations for that condition and postoperative urethral stenosis at different sites. All patients had periodical dilations for several months without any improvement. Surgical treatment was indicated to enlarge the stenotic segment. Enlargement was performed using oral mucosa graft in two cases and a local flap in the third one. Urethral stricture recurred in all cases very soon after the plasty and repeated dilations did not improve the symptoms. In the presence of hard scar tissue it was decided to inject triamcinolone DCI acetoide (Trigon depot), a long acting steroid, into the segment where the fibrotic narrowing was more severe, in an effort to obtain the same results reported in the treatment of hypertrophic scars and keloids. All the patients had repeated triamcinolone injections of hypertrophic scars and keloids. All the patients had repeated triamcinolone injections every 2-3 months. Follow-up ranges between 5 and 20 months and all of them are free of symptoms.

Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful?

PURPOSE

We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures.

MATERIALS AND METHODS

Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments.

RESULTS

Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001).

CONCLUSIONS

Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.

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.

Recurrence of urethral stricture after single internal urethrotomy

Recurrence of urethral stricture after single internal urethrotomy was investigated in 66 patients with special reference to some factors which would influence restricturing. In the present study, recurrence rate was 16.7% (11 patients). Recurrences occurred within an average of 11.9 months. Factors that had no influence on restricturing were age, aetiology, site of the stricture and duration of indwelling catheterization. On the other hand, stricture length appeared to influence the outcome (chi 2, p < 0.001). Short stricture (< or = 10 mm) showed only 4.4% recurrence rate, while 42.9% in long stricture (> 10 mm). Internal urethrotomy appeared to be effective particularly when the stricture was short, while it seemed difficult to treat long strictures by single internal urethrotomy.

Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures

OBJECTIVE

To ascertain the duration of intermittent low-friction self-catheterization (ILSC) required to cause stricture stabilization.

PATIENTS AND METHODS

Over a 4 year period, 101 patients with a median age of 62 years (range 16-85) with recurrent urethral strictures were recruited to the trial. All the strictures were treated by internal urethrotomy and the patients were then randomized to perform ILSC twice weekly for either 6 months (group 1) or 36 months (group 2). Out-patient follow-up with urinary flow rate was initially at 1 month and then at 3 monthly intervals. Stricture recurrence rates were compared between the two groups.

RESULTS

Of 101 patients, seven failed to attend after the first out-patient appointment. A further 21 died of unrelated disease whilst on ILSC (although 13 had been followed up for at least 24 months and so were included in the analysis). The median follow-up was 67 months (range 24-78). Ten patients in group 2, who had suffered from recurrent strictures, refused to stop catheterizing at the appointed time and all remain stricture-free on permanent ILSC. Of the remaining 76 patients, 48 catheterized for 6 months and 28 patients performed ILSC for 12 to 36 months (nine stopped earlier than intended). Forty per cent of patients who stopped at 6 months developed a recurrence compared with 14% who catheterized for more than 12 months (P < 0.05) (chi-square test with Yates' correction).

CONCLUSIONS

Our results indicate that ILSC is safe and effective in preventing stricture recurrence in the long term. The recurrence rate of urethral strictures was significantly lower when ILSC was continued for more than 12 months compared with ILSC that was stopped at 6 months. We conclude that catheterization for at least 1 year is required to achieve adequate urethral stabilization.

Prevention of urethral stricture recurrence using clean intermittent self-catheterization

OBJECTIVE

To investigate the effect of clean intermittent catheterization (CIC) on prevention of urethral stricture recurrence after internal urethrotomy.

PATIENTS AND METHODS

Of 55 men who were randomly selected, 43 completed the investigation. Of these, 21 patients performed CIC weekly for 1 year following Sachse's operation for urethral stricture and 22 patients formed the control group after the same operation. All had an objective examination for urethral stricture every 2 months after surgery.

RESULTS

Significantly fewer (P < 0.01) patients developed recurrence of urethral stricture within the first postoperative year in the CIC group (n = 4) compared with the control group (n = 15). No CIC complications were seen, and patients who completed the CIC programme considered the method fully acceptable.

CONCLUSION

Weekly CIC is a simple method of reducing the frequency of urethral stricture recurrence after internal urethrotomy.

Newly diagnosed bulbar urethral strictures: etiology and outcome of various treatments

A retrospective review was performed of 199 consecutive patients who were evaluated at this institution between 1976 and 1990 because of a newly diagnosed bulbar urethral stricture. Mean patient age at diagnosis was 64 years (range 10 to 96) and most patients presented with obstructive symptoms. The stricture etiology was primarily iatrogenic (47%), secondary to a transurethral procedure. The strictures were usually short (less than 2 cm., 96%), single (99%) and located in the proximal bulb (57%). Of the 151 patients receiving treatment at the time of initial diagnosis 101 (67%) underwent urethral dilation, 39 (26%) were managed with direct vision internal urethrotomy and in 11 (7%) a cystotomy tube was placed. With a median followup of 3.5 years (range 0 to 16), there was an estimated retreatment rate of 2.4 treatments per 10 person-years. The probability of not requiring retreatment within 3 years was 65 +/- 5% for urethral dilation and 68 +/- 8% for direct vision internal urethrotomy. When compared to urethral dilation, direct vision internal urethrotomy resulted in a higher incidence of postprocedure cystitis (5% versus 3%), epididymitis (5% versus 3%) and penile hemorrhage (8% versus 2%). These findings indicate that both conservative therapies were equally efficacious as an initial treatment of bulbar urethral stricture. However, direct vision internal urethrotomy did have a slightly higher complication rate. No specific patient or stricture characteristics could be identified that were reliable for predicting therapeutic outcome.

Long-term results of treatment of male urethral strictures using direct vision internal urethrotomy

This study presents long-term results of treatment of urethral strictures in 178 men who underwent direct vision cold urethrotomy between January 1, 1979 and December 31, 1984. Satisfactory urodynamic results were achieved in 69.7% of cases.

Treatment of recurrent urethral strictures using clean intermittent self-catheterisation

The treatment of urethral strictures has been greatly improved by the use of the optical urethrotome. However, there remains a group of patients with recurrent strictures for whom the alternatives remain long-term dilatation/urethrotomy or urethroplasty. Over the last 3 years we have treated 65 such patients using clean intermittent self-catheterisation as a method of self-dilatation. This has resulted in a dramatic decrease in the number of operations performed on these patients, with no significant reduction in urinary flow rate over an average follow-up period of 20 months. The method offers the possibility of long-term cure and should be offered to all all such patients, reducing still further the number of patients who require urethroplasty.

Optical urethrotomy under local urethral anaesthesia

A series of 46 patients underwent 76 optical urethrotomies under local urethral anaesthesia in the out-patient clinic; in 70% of patients the strictures were controlled by local anaesthetic urethrotomy alone; 61% felt either no pain or mild pain during the procedure; 72% expressed a preference for local anaesthesia should the procedure have to be repeated and 82% were happy with the result of their treatment. Optical urethrotomy under local urethral anaesthesia produces results comparable to those reported by others using general anaesthesia. If large numbers of patients are to be treated, possibly repeatedly, then out-patient urethrotomy may result in more efficient use of resources.

Intralesional corticosteroid injections in combination with internal urethrotomy in the treatment of urethral strictures

In the treatment of 38 patients with urethral stricture, 21 received intralesional corticosteroid injections, combined in 17 cases with internal urethrotomy. The aetiology of the lesion is discussed, together with a review of the pertaining literature, and the results of the treatment are evaluated.

Urethral stricture following transurethral prostatectomy

Urethral stricture is the most common late complication of transurethral prostatectomy. Uroflowmetry is recommended as the routine screening procedure for strictures postoperatively. If maximal urinary flow rate (Qmax) is below 10 mL/second the patients should be investigated further. The etiology of urethral stricture is still unclear. Further studies are necessary to evaluate the possible etiologic role of infected urine pre- and/or postoperatively, urethral catheterization pre- and postoperatively, catheter material, and the type and size of the resectoscope. A narrow urethra is probably a predisposing factor for stricture formation, but this is not definitively clarified. Only few randomized studies have been performed to evaluate the different prophylactic methods against development of strictures postresection. Resection via perineal urethrotomy, perhaps preceded by urethral calibration, seems to be a way to avoid anterior urethral strictures. The effects of internal urethrotomy preoperatively on stricture formation are conflicting. Further randomized studies are necessary.

Optical internal urethrotomy as the treatment of choice for primary stricture of the urethra

Seventy-five patients with primary urethral strictures were treated by optical urethrotomy with catheter drainage for 7 days. Good results were obtained in 66% of cases, which were all post-traumatic in nature; 34% had to undergo further procedures such as dilatation or repeat internal urethrotomy.

Direct vision internal urethrotomy. A prospective study of 81 primary strictures treated with a single urethrotomy

The post-operative treatment of urethral strictures as well as the criteria of success have varied considerably. In order to find a solution to this problem, we undertook a prospective evaluation of 81 men treated for their first urethral stricture with a single urethrotomy. Fifty-one patients with a stricture 5 mm or less in length were catheterised post-operatively for 3 days. Patients with strictures longer than 5 mm were catheterised for 3 weeks (14 patients) or 6 weeks (16 patients). All were followed up for a minimum of 24 months. The stricture recurred in 33 patients (41%). We found that 3 days' catheter drainage was sufficient for patients with short strictures. Whether strictures measuring more than 5 mm might be treated similarly needs further investigation.

Complications of treatment of urethral stricture in our practice

Bleeding is the most common early postoperative complication of the treatment of urethral stricture, while recurrent stricture is the most common late postoperative complication irrespective of the method of treatment applied. The different sophisticated methods of urethroplasty make it possible today to treat successfully complicated urethral strictures. The results of such treatment, however, have been associated with a variety of complications (impotence, incontinence and urethrocutaneous fistula), especially when simple methods such as bouginage are used. Although bouginage is associated with a greater recurrence rate of urethral stricture than is urethroplasty, the former should be encouraged in centres where facilities and trained urologists are limited, as it often occurs in the developing countries, since the method is simple and can be used as emergency without prior urethrogram.

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.

Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection

We performed 100 urethroplasties for urethral strictures that fulfilled our criteria for surgical intervention. Strictures were located in the pendulous urethra in 14 cases, bulbar urethra in 33 and membranous urethra in 32, while the entire urethra or multiple adjacent areas were strictured in 21. The etiology of the strictures was traumatic in 47 patients and inflammatory in 22, and no cause was identified in 31. One-stage repairs were performed in 76 cases. Anastomotic repairs were optimal for short traumatic strictures, with 1 failure among 29 cases. Full thickness skin graft repairs were performed for more lengthy inflammatory strictures in 34 cases, with 5 failures. Mitigating against success in these patients were extrapenile skin donor sites, tubed grafts and poor graft beds. Vascularized island flap repairs were performed in 13 patients with 1 failure but there was an associated problem of redundant repairs. Two-stage repairs were reserved primarily for long or multiple strictures, with 2 failures in 24 cases. We conclude that procedure selection should be determined by stricture characteristics, including location, etiology, length and the presence of local adverse factors. An over-all rate free of stricture of 91 per cent was achieved.

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.

Direct vision internal urethrotomy in the treatment of urethral fistulas due to urethral strictures

Five cases of urethral fistula--three with single and two with multiple fistulous tracts--were treated by optical urethrotomy. All of the fistulas healed completely.

Direct Vision Internal Urethrotamy. A Critical Review of 365 Operations

Internal urethrotomy under direct vision for urethral strictures in the male was employed on 369 occasions in 225 patients during a 4-year period. A retrospective review of results showed an overall cure rate of 77% but the cure rate after each individual operation was less than 50%. Operations for recurrence carried a significantly lower cure rate than initial operations but even after several recurrences there were reasonably good results considering the relatively minor procedure. An active post-operative follow-up employing routine urethroscopy showed significantly better results than mictiographic follow-up. The post-operative period of catheterisation and positive urine culture at the time of follow-up had no significant influence on the results.

Optical urethrotomy--a 3-year experience

One hundred and thirty-seven patients underwent optical urethrotomy and have been followed up over a period of 3 years. The overall improvement rate was 66%. The results were unrelated to the length of history, the number of previous dilatations or the site of the lesion. However, traumatic strictures did significantly less well than the others. Although the procedure can be repeated, the chance of failure following the third or subsequent urethrotomy was much greater than after the first or second procedure. Urethrotomy for post-prostatectomy membranous strictures was followed by incontinence in 31% of patients. Otherwise the procedure was safe and should be the first choice of treatment for most patients with urethral strictures.

Long-term results of optical urethrotomy

In a 7-year period 137 men with urethral stricture underwent optical urethrotomy. Over 91% were relieved of their stricture symptoms and required no further treatment, including 41 patients in whom the follow-up period exceeded 4 years. The surgical technique is outlined. Strictures with the best prospect of cure were short and single. Optical urethrotomy is confirmed as the treatment of choice in strictures of the male urethra.

Endourethral urethroplasty--use of a new catheter

Endourethral split skin grafting following visual internal urethrotomy was done successfully in 7 selected patients with stricture of the bulbomembranous urethra. Open substitution or anastomotic urethroplasty might otherwise have been necessary in these patients. The technique involves the use of a specially designed double balloon catheter, in which the second balloon, when distended, keeps the split skin graft in close opposition with the urethral raw area. This function ensures a near 100 per cent graft take, keeps the strictured area wide open and allows early ambulation of the patient, since no perineal compression dressing is required.

Experience with two-stage scrotal flap urethroplasty for stricture

A series of 50 men with variously-caused stricture of the bulbar and/or membranous urethra is presented. The 2-stage scrotal flap urethroplasty described by Blandy was used. As a rule the operation was technically simple. Post-operative incontinence was not a problem. Recurrence or new stricture appeared in 7 cases, but 5 of these strictures were short and could be corrected with internal urethrotomy. Timed micturition showed improved voiding in all of the 18 patients studied before and after urethroplasty. Urodynamic studies in the last 8 cases of the series before and after urethroplasty showed significantly improved urinary flow and voiding post-operatively, with reduction of detrusor pressure and residual urine.

Treatment of urethral stricture by urethroplasty or direct vision urethrotomy. A comparative retrospective study

The outcome of treatment for urethral stricture is evaluated in two groups of patients in a retrospective study: 51 patients were treated with urethroplasty and 41 with direct vision urethrotomy. The groups did not differ greatly as regards primary success. It was 59% in the urethroplasty group and 61% in the urethrotomy group. This favours the view that the primary treatment of a urethral stricture should be direct vision urethrotomy whenever possible.

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.