Internal urethrotomy with the Sachse urethrotome

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.

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.

Direct vision internal urethrotomy for the treatment of pediatric urethral strictures: analysis of 50 patients

PURPOSE

In an attempt to evaluate our experience with the treatment of pediatric urethral stricture disease we performed a retrospective review of patients undergoing direct vision internal urethrotomy (DVIU).

MATERIALS AND METHODS

The computerized surgical logs at 2 pediatric hospitals were reviewed to identify patients who underwent DVIU between 1992 and 2001. Hospital and clinical charts were then reviewed. Many variables were analyzed, including patient age, etiology of stricture, technique and clinical outcomes. Minimum followup to be included in clinical outcome analysis was 12 months.

RESULTS

A total of 50 patients were identified (mean age 7.7 years, range 6 months to 17 years). The most common etiology for stricture formation was previous hypospadias repair (20 patients [40%]). Forty patients met the 12-month minimum followup requirement for clinical outcome analysis. Of these patients 20 (50%) had no symptoms to suggest recurrent stricture at a median of 2.0 years (mean 2.7 years, range 12 months to 7 years). Seventeen patients (42.5%) had symptoms of recurrent stricture at a median of 8 months (mean 13 months, range 2 months to 5 years). Technical factors did not influence the ultimate success or failure of the procedure.

CONCLUSIONS

DVIU provides a therapeutic option that successfully treats approximately half of the patients with a reasonably low complication rate. Complications following DVIU should not preclude its use as a therapeutic modality for the treatment urethral strictures in children. If the child fails the initial DVIU, repeat attempts at endoscopic correction of urethral stricture should be abandoned in favor of definitive urethroplasty.

Anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients

PURPOSE

We reviewed our experience with anastomotic urethroplasty for anterior urethral stricture.

MATERIALS AND METHODS

A chart review revealed 168 patients 6 to 82 years old (mean age 38) with at least 6 months of followup (mean 70, range 6 to 291) after anastomotic urethroplasty.

RESULTS

Average stricture length was 1.7 cm. Of the 168 patients stricture recurred in 8 (5%) but was managed by direct vision internal urethrotomy or a single dilation in 5, while repeat urethroplasty was required in 3 (2%). In these 3 cases extenuating circumstances included patient dislodgment of the catheter with attempts to replace it that disrupted repair, a history of urethrocutaneous fistula and periurethral abscess, and previous irradiation complicating the stricture in 1 each. Other complications were uncommon, such as transient thigh pain or numbness in 3 patients (2%), small wound dehiscence in 2 (1%), and scrotal hematoma, erectile dysfunction and self-limited pulmonary edema in 1 (less than 1%) each.

CONCLUSIONS

Anastomotic urethroplasty for anterior stricture has a high success rate of 95%. It is technically straightforward and complications are uncommon. Cure by anastomotic urethroplasty should be strongly favored over long-term management by direct vision internal urethrotomy or dilation.

Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: a controlled study of a new therapy

A controlled study of the effect of treatment of recurrent urethral stricture by internal urethrotomy followed by clean intermittent self-catheterization for 3 months is reported. There were 28 men (median age 70 years, range 18 to 75) allocated to internal urethrotomy and clean intermittent self-catheterization for 3 months (treatment group) and 33 (median age 76 years, range 36 to 87) were randomized to undergo internal urethrotomy only (observation group). The groups were comparable in terms of patient age, etiology of the primary stricture, number of recurrences, length and site of the actual stricture, and preoperative maximum flow rate (p less than 0.01). After termination of the treatment all patients from both groups were evaluated by uroflowmetry 2, 4, 6 and 12 months later, and a new recurrence was defined as a maximum flow rate of less than 10 ml. per second (micturition volume greater than 100 ml.) and a characteristic flow curve. From the treatment group 23 patients could be assessed: 2 had discontinued clean intermittent self-catheterization due to urethral hemorrhage, 2 died during the observation period and 1 was lost to followup. From the observation group 28 patients were assessable: 3 died during the observation period and 1 was lost to followup. Treatment results were not significantly different (p less than 0.01). Of the patients in the treatment and observation groups 78% and 82%, respectively, had a new stricture. The median interval for this to occur was 4 months for both groups. Since no patient had clinical signs of stricture during clean intermittent self-catheterization, we conclude that for the treatment of recurrent urethral stricture clean intermittent self-catheterization following internal urethrotomy should be continued for a long duration, possibly permanently.

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.

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.

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.

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.

Strictures of the male urethra treated by the Otis method

During a 5-year interval 72 consecutive patients with urethral strictures were treated by internal urethrotomy according to the method of Otis. The etiology, surgical technique, complications and postoperative management are discussed. The results after a mean followup of 29 months showed an over-all success rate of 82 per cent (95 per cent confidence limits 71 to 90 per cent). It is concluded that internal urethrotomy should be considered for primary treatment of urethral strictures, since the procedure is easy and complications are few.