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A Systematic Review and Meta-analysis of Adjuncts to Minimally Invasive Treatment of Urethral Stricture in Men. Eur Urol 2021; 80:467-479. [PMID: 34275660 DOI: 10.1016/j.eururo.2021.06.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022]
Abstract
CONTEXT Urethral stricture disease (USD) is initially managed with minimally invasive techniques such as urethrotomy and urethral dilatation. Minimally invasive techniques are associated with a high recurrence rate, especially in recurrent USD. Adjunctive measures, such as local drug injection, have been used in an attempt to reduce recurrence rates. OBJECTIVE To systematically review evidence for the efficacy and safety of adjuncts used alongside minimally invasive treatment of USD. EVIDENCE ACQUISITION A systematic review of the literature published between 1990 and 2020 was conducted in accordance with the PRISMA checklist. EVIDENCE SYNTHESIS A total of 26 studies were included in the systematic review, from which 13 different adjuncts were identified, including intralesional injection (triamcinolone, n = 135; prednisolone, n = 58; mitomycin C, n = 142; steroid-mitomycin C-hyaluronidase, n = 103, triamcinolone-mitomycin C-N-acetyl cysteine, n = 50; platelet-rich plasma, n = 44), intraluminal instillation (mitomycin C, n = 20; hyaluronic acid and carboxymethylcellulose, n = 70; captopril, n = 37; 192-iridium brachytherapy, n = 10), application via a lubricated catheter (triamcinolone, n = 124), application via a coated balloon (paclitaxel, n = 106), and enteral application (tamoxifen, n = 30; deflazacort, n = 36). Overall, 13 randomised controlled trials were included in the meta-analysis. Use of any adjunct was associated with a lower rate of USD recurrence (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.50; p < 0.001) compared to no adjunct use. Of all the adjuncts, mitomycin C was associated with the lowest rate of USD recurrence (intralesional injection: OR 0.23, 95% CI 0.11-0.48; p < 0.001; intraluminal injection: OR 0.11, 95% CI 0.02-0.61; p = 0.01). Urinary tract infection (2.9-14%), bleeding (8.8%), and extravasation (5.8%) were associated with steroid injection; pruritis of the urethra (61%) occurred after instillation of captopril; mild gynaecomastia (6.7%) and gastrointestinal side effects (6.7%) were associated with oral tamoxifen. CONCLUSIONS Adjuncts to minimally invasive treatment of USD appear to lower the recurrence rate and are associated with a low adjunct-specific complication rate. However, the studies included were at high risk of bias. Mitomycin C is the adjunct supported by the highest level of evidence. PATIENT SUMMARY We reviewed studies on additional therapies (called adjuncts) to minimally invasive treatments for narrowing of the urethra in men. Adjuncts such as mitomycin C injection result in a lower recurrence rate compared to no adjunct use. The use of adjuncts appeared to be safe and complications are uncommon; however, the studies were small and of low quality.
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Katims AB, Edelblute BT, Tam AW, Zampini AM, Mehrazin R, Gupta M. Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures. J Endourol 2020; 35:21-24. [PMID: 32689827 DOI: 10.1089/end.2020.0593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Benign ureteroenteric anastomotic stricture (UEAS) is a common postoperative complication after urinary diversion with an incidence of 3%-10%. Our objective is to report long-term follow-up of our technique for endoscopically managing UEAS after cystectomy. Materials and Methods: Patients with endoscopically managed benign UEAS after cystectomy were included. Intervention entailed anetegrade flexible ureteroscopy with biopsy followed by laser incision of the stricture and of periureteral and peri-ileal tissues 1 cm below and 1 cm above the stricture into fat. Triamcinolone injection was then performed, followed by balloon dilation of the incised area to 24F. Parallel Double-J ureteral stents or upside down nephrostomy tubes were placed for 6 weeks. CT scans were obtained at 3 months and 1 year after surgery, and renal ultrasound at 6 and 9 months, and then annually. Results: Twenty-one patients, and a total of 24 UEAS were treated. Urinary diversion included ileal conduit (n = 12), neobladder (n = 7), and Indiana pouch (n = 2). Twenty out of 24 strictures had no recurrence, including three patients who had bilateral disease, yielding an overall success rate of 83.3%. The remaining three patients with recurrence had evidence of stricture within 3 months. Follow-up ranged from 8 to 102 months, with a median of 30 months. Conclusions: Patients treated endoscopically for UEAS have been shown to have acceptable immediate success with less morbidity when compared with ureteral reimplantation. Our technique of laser incision, triamcinolone injection, balloon dilation, and temporary stent placement has a success rate of over 80% and is unique in that long-term data confirms the durability of this endoscopic procedure.
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Affiliation(s)
- Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Beth T Edelblute
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew W Tam
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna M Zampini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mantu Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Mann RA, Virasoro R, DeLong JM, Estrella RE, Pichardo M, Lay RR, Espino G, Roth JD, Elliott SP. A drug-coated balloon treatment for urethral stricture disease: Two-year results from the ROBUST I study. Can Urol Assoc J 2020; 15:20-25. [PMID: 32744999 DOI: 10.5489/cuaj.6661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Mechanical balloon dilation and direct visualization internal urethrotomy (DVIU) are the most widely used treatments for urethral stricture disease in the U.S., but recurrence rates are high, especially after re-treatment. This study investigates the safety and efficacy of the Optilume™ paclitaxel-coated balloon for the treatment of recurrent strictures. METHODS Men with recurrent bulbar strictures ≤2 cm with 1-4 prior endoscopic treatments were treated with the Optilume™ drug-coated balloon. Patients were evaluated within 14 days, three, six, 12, and 24 months post-treatment. The primary safety endpoint was serious urinary adverse events. The primary efficacy endpoint was ≥50% improvement in International Prostate Symptom Score (IPSS) at 24 months. Secondary outcomes included quality of life, erectile function, flow rate, and post-void residual urine volume. RESULTS A total of 53 subjects were enrolled and treated; 46 completed the 24-month followup. Forty-three percent of men had undergone >1 previous dilations, with a mean of 1.7 prior dilations. There were no serious adverse events related to treatment at two years. Success was achieved in 32/46 (70%), and baseline IPSS improved from a mean of 25.2 to 6.9 at 24 months (p<0.0001). Quality of life, flow rate, and post-void residual urine volumes improved significantly from baseline. There was no impact on erectile function. CONCLUSIONS Two-year data indicates the Optilume™ paclitaxel-coated balloon is safe for the treatment of recurrent bulbar urethral strictures. Early efficacy results are encouraging and support further followup of these men through five years, as well as further investigation with a randomized trial.
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Affiliation(s)
- Rachel A Mann
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Ramón Virasoro
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Jessica M DeLong
- Department of Urology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Rafael E Estrella
- Clinica Union Medica, Santiago de los Caballeros, Dominican Republic
| | | | | | | | - Joshua D Roth
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, United States
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Scott KA, Li G, Manwaring J, Nikolavsky DA, Fudym Y, Caza T, Badar Z, Taylor N, Bratslavsky G, Kotula L, Nikolavsky D. Liquid buccal mucosa graft endoscopic urethroplasty: a validation animal study. World J Urol 2019; 38:2139-2145. [PMID: 31175459 DOI: 10.1007/s00345-019-02840-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/03/2019] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To validate a novel method of urethral stricture treatment using liquid buccal mucosal grafts (LBMG) to augment direct vision internal urethrotomy (DVIU) in an animal model. MATERIALS AND METHODS A rabbit stricture model was used to test this method. Strictures were induced in 26 rabbits using electroresection of urethral epithelium. The animals were randomized into two groups: Group-1, treated with DVIU and LBMG in fibrin glue, and Group-2, DVIU with fibrin glue only. LBMG was prepared by suspension of mechanically minced buccal mucosa micrografts in fibrin glue. This LBMG-fibrin glue mixture was later injected into the urethrotomies of Group-1 animals. All animals were killed at 24 weeks after repeat retrograde urethrogram (RUG) and urethroscopy by surgeon blinded to the treatment arm. Radiographic images and histological specimens were reviewed by a radiologist and a pathologist, respectively, blinded to the treatment arm. Stricture treatment was considered a success if a diameter measured on RUG increased by ≥ 50% compared to pre-treatment RUG diameter. Histological specimens were assessed for the presence of BMG engraftment. RESULTS In Group-1, 8/12(67%) animals demonstrated engraftment of LBMG, compared to none in Group-2 (p = 0.0005). 7/12(58%) in Group-1 showed radiographic resolution/improvement of strictures compared to 5/13 Group-2 rabbits (38%, p = 0.145). The median percent change for the Group-1 was 59%, compared to 41.6% for Group-2 (p = 0.29). CONCLUSION This proof-of-concept study demonstrates feasibility of LBMG for endoscopic urethral stricture repairs. Further studies are needed to establish the role of this novel concept in treatment of urethral strictures.
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Affiliation(s)
- Kathryn A Scott
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Guanqun Li
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jared Manwaring
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Daniela A Nikolavsky
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Yelena Fudym
- Department of Pathology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Tiffany Caza
- Department of Pathology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Zain Badar
- Department of Radiology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Nicole Taylor
- Department of Radiology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Gennady Bratslavsky
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Leszek Kotula
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Dmitriy Nikolavsky
- Department of Urology, State University of New York Upstate Medical University, Syracuse, NY, USA.
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A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9046430. [PMID: 31139658 PMCID: PMC6500724 DOI: 10.1155/2019/9046430] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/31/2019] [Indexed: 12/21/2022]
Abstract
To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.
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Abstract
This study aimed to develop an indwelling catheter that can be used for urethral flushing, urethral secretion drainage, local urethral drug delivery, and urine drainage.We designed a new indwelling catheter type that has a balloon, 4 peripheral grooves, and a C-shaped groove on its surface. In addition, there is a flushing channel, a balloon channel, and a urine drainage channel in the catheter body. However, the most critical characteristic is that the flushing channel and the 4 peripheral grooves are connected with the C-shaped groove, and the flushing liquid can reach the C-shaped groove through the flushing channel and then flow out through the peripheral grooves, while the balloon channel leads to the balloon. Generally, our design is to add 4 peripheral grooves, a C-shaped groove, and a flushing channel to the indwelling catheter that is applied clinically nowadays.We designed a new type of indwelling catheter, which is multifunctional, and we had acquired a national patent in China. In theory, the new catheter type cannot only be used for urine drainage, bladder irrigation, but also for urethral flushing, urethral excretion drainage, and local urethral drug delivery at the same time.This new indwelling catheter can theoretically reduce catheter-associated urinary tract infection and facilitate urethral secretion drainage or flushing out, which is especially suitable for the treatment and nursing of patients who underwent urethral operation. However, the new catheter have not been produced and tested clinically, and this is our next step.
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Affiliation(s)
| | | | - Ning Zhao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Gupta S, Roy S, Pal DK. Efficacy of oral steroids after optical internal urethrotomy in reducing recurrence of urethral strictures. Turk J Urol 2017; 44:42-44. [PMID: 29484226 DOI: 10.5152/tud.2017.66564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/30/2017] [Indexed: 11/22/2022]
Abstract
Objective Optical internal urethrotomy is a feasible modality of treatment for short segment bulbar urethral strictures. Recurrence is an important problem after urethrotomy. This study aimed at evaluating the efficacy of oral steroid (deflazocort) in reducing the recurrence of strictures after urethrotomy. Up to date, no study has evaluated the role of oral steroids after urethrotomy. Material and methods In this case-control study, patients undergoing urethrotomy (bulbar urethral strictures <2 cm) were divided into two groups according to patients receiving (Group 1) or not receiving (Group 2) oral steroid (deflazocort 6 mg tablets) after operation. Both groups were controlled at 1, 3 and 6 months after catheter removal (usually 5-6 days after operation) with uroflowmetry, and the flow rates were statistically compared. Deflazocort was given after catheter removal, at first 6 mg twice daily for two weeks, then 6 mg once daily for another two weeks (self-obturation was not performed). Results A total of 72 patients were selected for the study as per inclusion criteria. They were divided into 2 groups as those receiving (Group 1: deflazocort group; n=36) or not receiving (Group 2; n=36) deflazocort. Median postoperative maximum flow rates in the deflazocort group were 26.2, 22.3 and 18.2 mL/sec, and in the control group was 24.4, 17.1 and 13.7 mL/sec at postoperative 1., 3. and 6. months, respectively. Lesser patients in the deflazocort group had recurrence. The difference was statistically significant only at postoperative 3 (p value=0.03), and 6. months (p value=0.02) (p value=0.15). Conclusion Oral steroids can be used after internal urethrotomy to reduce the recurrence of urethral strictures.
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Affiliation(s)
- Sandeep Gupta
- Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Sayak Roy
- Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Dilip Kumar Pal
- Institute of Post Graduate Medical Education and Research, Kolkata, India
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Novel Concept and Method of Endoscopic Urethral Stricture Treatment Using Liquid Buccal Mucosal Graft. J Urol 2016; 196:1788-1795. [DOI: 10.1016/j.juro.2016.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/18/2022]
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