Predictive value of systemic immune-inflammation index in recurrent urethral strictures

PURPOSE

To investigate the predictive value of systemic immune-inflammation index (SII) in recurrence of urethral stricture in patients undergoing internal urethrotomy.

METHODS

In this two-center, retrospective study, 703 patients who had internal urethrotomy for urethral stricture were included. Demographic, clinical, and laboratory characteristics and operative data were obtained. Two groups were formed from the patients as non-recurrent urethral stricture (n = 490) and recurrent urethral stricture (n = 213).

RESULTS

There was no significant difference in the mean age between the patients with and without recurrence. There was a significant difference in the mean SII values and albumin levels between the recurrence and non-recurrence groups (p = 0.001 and p = 0.006, respectively). Using a cut-off value of 252 for the SII; the sensitivity was 59.62%, the specificity was 70.41%, the positive predictive value was 46.69%, the negative predictive value was 80.05% and the accuracy was 67.14%, respectively. Statistically significant correlation was found between the presence of recurrence and the established cut-off value of the SII (p = 0.001 and p < 0.01, respectively). The risk of recurrence was stated that 3.514 times higher in patients with a SII value of ⩾252.

CONCLUSION

Using the SII the inflammatory state of the urethral tissue can be evaluated. Thus the risk of recurrence after internal urethrotomy operation can be predicted. Open urethroplasty technique instead of DVIU in patients with high SII values may increase the surgical success rates.

Urethral Stricture Disease Guideline Amendment (2023)

PURPOSE

The symptoms of urethral stricture are non-specific and may overlap with other common conditions that can confound diagnosis. Urologists play a key role in the initial evaluation of urethral stricture, currently provide all accepted treatments, and must be familiar with the evaluation, diagnostic tests, and surgical treatments for urethral stricture.

MATERIALS AND METHODS

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates January 1, 1990 to January 12, 2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for the 2023 Amendment was modified to included females and males (search dates December 2015-October 2022 for males; January 1990-October 2022 for females) and a new Key Question on sexual dysfunction was added (search dates: January 1990-10/2022). After inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base.

RESULTS

Once a urethral stricture is diagnosed, clinicians should determine the length and location of the stricture in order to inform treatment. After a period of urethral rest, patients with short (<2cm) bulbar urethral stricture may be treated endoscopically. Urethroplasty may be performed by an experienced surgeon in patients with first time or recurrent anterior and posterior urethral strictures. The best treatment option for urethral stricture in female patients is urethroplasty using oral mucosa grafts or vaginal flaps rather than endoscopic treatment.

CONCLUSION

This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment.

Two brothers with congenital bulbar urethral stricture: case report of a very rare condition

Congenital urethral stricture is rare. It has been reported in only four sets of brothers. We report the fifth set of brothers. Cases of two brothers aged 23 and 18 years old diagnosed with low urinary tract symptoms are presented. We diagnosed an apparently congenital urethral stricture in both brothers. Internal urethrotomy was performed in both cases. Both are asymptomatic after 24 and 20 months of follow-up. Congenital urethral strictures are probably more frequent than we think. We suggest that a congenital origin should be considered if there is no history of infections or trauma.

Reaching Consensus for Comprehensive Outcome Measurement After Urethral Stricture Surgery: Development of Study Protocol for Stricture-Fecta Criteria

Urethral stricture disease is a very heterogeneous condition where different urethral segments can be involved as a result of diverse etiologies which come with variable prognosis. The surgical management of urethral strictures, and in particular urethroplasties can result in very diverse outcomes on many levels and, currently, there is absolutely no consensus about what should and what should not be considered a "success" after urethral surgery. In the wake of well-established quality criteria in urologic oncology, such as tri- or pentafecta outcomes, and given the lack of agreement on meaningful outcomes after urethral surgery, we aim to introduce our study protocol as the first step of a multistep research endeavor to reach consensus on comprehensive urethroplasty outcomes within a novel conceptual framework: the "stricture-fecta criteria". The development of stricture-fecta will be based on a Delphi consensus involving some of worldwide most influencing reconstructive urologists.

The long-term outcome of urethrotomy for primary urethral strictures: a population-based analysis

OBJECTIVE

To determine the long-term outcome of endoscopic urethrotomy for primary urethral strictures based on a population-based approach.

PATIENTS AND METHODS

We analysed a nationwide database of all patients with urethral stricture disease who underwent endoscopic urethrotomy as a primary intervention between January 2006 and December 2007. All patients were followed individually for 7-9 years. Frequencies and types of surgical re-interventions were documented. Repeat surgical interventions were stratified into three treatment types: urethrotomy, urethroplasty, and end-to-end urethral anastomosis.

RESULTS

A total of 1203 men underwent urethrotomy during the index period. The median (SD, range) patient age was 63 (15.7, 20-85) years. A total of 136 patients (11%) died during follow-up. Within the follow-up period, 932 patients (78%) received no further surgical re-intervention for recurrent disease, and 176 patients (14.6%) required one, 53 (4.5%) two, and 41 (3.4%) three or more procedures. The mean number of re-interventions was 1.5/patient and the lowest re-intervention rate was in patients aged ≥80 years (13.9%). In 236 cases (68%) at least one repeat urethrotomy was performed. An open reconstruction was performed in 87 cases (32%), with urethroplasty in 21 patients (24%), and end-to-end anastomosis in 66 patients (76%). The mean interval until re-intervention was 29.5 months.

CONCLUSIONS

This long-term population-based study suggests that the invasive re-treatment rate in men following initial urethrotomy is 22% within 8 years and lowest in the advanced age cohort.

Management of Recurrent Urethral Strictures: A Therapeutic Challenge

Urethral stricture disease is relatively common, and its management remains a therapeutic challenge for urologists despite recent advancements in endoscopic and reconstructive surgery. The majority of the strictures are acquired from injury or infection. Urethral stent implantation, a minimally invasive procedure, can be safely and effectively used as a primary surgical procedure in treating recurrent urethral stricture. Herein, we present a case of a 43-year-old male patient with complaints of intermittent urination, oliguria, and incomplete voiding with urinary frequency. Further urological investigations, a uroflowmetry, and a urethrogram were carried out. Oliguria, along with a mid-bulbar urethral stricture at the previous excision anastomotic site, was diagnosed. Despite a higher success rate of urethroplasty and temporary stent placement, urethral stricture recurrences are still an occurring entity. No definite therapeutic strategy has been adopted to evaluate and approach the morbidity effectively. Implementation of an effective primary procedure with minimally based complications should be generated to avoid future stricture recurrences. Larger-scale studies involving urethral stricture patients can gather sufficient data to obtain a complete curative treatment option for the future.

Adult urethral stricture: Practice and expertise of urologists in Saudi Arabia

Objective:

The aim of this study is to determine the methods used to evaluate and manage urethral strictures by urologists practicing in Saudi Arabia.

Materials and Methods:

This is a cross-sectional study based on a validated questionnaire directed to all urologists and senior residents practicing in Saudi Arabia. Categorical data reported as frequencies and percentages. A Chi-square test was used for inferential analysis. P < 0.05 was considered statistically significant.

Results:

We received 112 responses, of which 78% were from board-certified urologists. The majority were working in government hospitals. The rate of endoscopic procedures performed exceeded open urethroplasty. Direct Vision Internal Urethrotomy was the most common procedure performed as stated by 85% of the responses. Uroflowmetry with postvoid residual was the most common investigation requested to assess strictures before and after the operation usually in adjunction with retrograde urethrogram and or cystoscopy. Most of the urologists believed in a step-wise approach in the management of strictures and that urethroplasty is indicated only after repeated trials of endoscopic management.

Conclusion:

Our results revealed a preference, and perhaps misuse, of endoscopy which might raise a concern regarding patients' prognosis with repeated endoscopic management. Most of the urologists seem to be reluctant to proceed to a definitive treatment on the time of diagnosis either due to a lack of experience or knowledge. The results showed no difference between practice in government and private hospitals.

Efficacy of oral steroids after optical internal urethrotomy in reducing recurrence of urethral strictures

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.

Double Intracavernous Breakage of Sachse's Knife Blade: Management of a Rare Complication Performing Direct Vision Internal Urethrotomy

Background: Although the breakage of a Sachse's knife blade is already a rare event while performing optical internal urethrotomy, a double failure appears to be at the same time a unique and a challenging complication to manage since no reference has emerged from literature review.

Case Presentation: A male patient, 80 years of age, underwent retreatment of recurrent urethral stricture that occurred after transurethral resection of the prostate. The latter was complicated by severe intraoperative urethrorrhagia; this is the reason he was transferred from another institution where at first a suprapubic cystostomy was carried out, followed by urethral recanalization through internal urethrotomy and finally he underwent intracavernous Sachse's knife blade discharge. Preoperative evaluation included combined retrograde and voiding urethrography and CT to evaluate the complete resolution of the urethral stenosis and to establish the correct location of the blades inside the corpus cavernosum. A transperineal approach to the left corpus cavernosum was carried out with manageable removal of the foreign body and postoperative assessment showed no early considerable complications for the patient.

Conclusion: To our knowledge, this is the first case of double breakage of Sachse's knife blade performing optical internal urethrotomy reported in literature. Although it may appear to be an easy procedure, close attention to its execution must always be paid to prevent major complications. A transperineal approach has proven to be effective and safe without creating any further outcomes to the patient.

Direct visual internal urethrotomy: Is it a durable treatment option?

OBJECTIVE

To evaluate the long-term success rate of direct vision internal urethrotomy as a treatment for anterior urethral strictures.

MATERIALS AND METHODS

We retrospectively analyzed the results for patients who underwent internal urethrotomy from January 2009 to January 2014 for anterior urethral strictures. Patients were followed till January 2016. Patients with complicated urethral strictures with a history of previous urethroplasty, hypospadias repair, or previous radiation were excluded from the study, as anticipated low success rate of direct visual internal urethrotomy (DVIU) in these patients. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, and third urethrotomy.

RESULTS

A total of 186 patients were included in this study. Stricture-free rates after first, second, and third urethrotomy were 29.66%, 22.64%, and 13.33%, respectively.

CONCLUSIONS

Although DVIU may be a management option for anterior urethral stricture disease, it seems that long-term results are disappointing.

Development of a clinical algorithm for treating urethral strictures based on a large retrospective single-center cohort

Aim: To analyze clinical data from male patients treated with urethrotomy and to develop a clinical decision algorithm.

Materials and methods: Two large cohorts of male patients with urethral strictures were included in this retrospective study, historical (1985-1995, n=491) and modern cohorts (1996-2006, n=470). All patients were treated with repeated internal urethrotomies (up to 9 sessions). Clinical outcomes were analyzed and systemized as a clinical decision algorithm.

Results: The overall recurrence rates after the first urethrotomy were 32.4% and 23% in the historical and modern cohorts, respectively. In many patients, the second procedure was also effective with the third procedure also feasible in selected patients. The strictures with a length ≤ 2 cm should be treated according to the initial length. In patients with strictures ≤ 1 cm, the second session could be recommended in all patients, but not with penile strictures, strictures related to transurethral operations or for patients who were 31-50 years of age. The third session could be effective in selected cases of idiopathic bulbar strictures. For strictures with a length of 1-2 cm, a second operation is possible for the solitary low-grade bulbar strictures, given that the age is > 50 years and the etiology is not post-transurethral resection of the prostate. For penile strictures that are 1-2 cm, urethrotomy could be attempted in solitary but not in high-grade strictures.

Conclusions: We present data on the treatment of urethral strictures with urethrotomy from a single center. Based on the analysis, a clinical decision algorithm was suggested, which could be a reliable basis for everyday clinical practice.

Evaluation and management of anterior urethral stricture disease

Urethral stricture disease affects many men worldwide. Traditionally, the investigation of choice has been urethrography and the management of choice has been urethrotomy/dilatation. In this review, we discuss the evidence behind the use of ultrasonography in stricture assessment. We also discuss the factors a surgeon should consider when deciding the management options with each individual patient. Not all strictures are identical and surgeons should appreciate the poor long-term results of urethrotomy/dilatation for strictures longer than 2 cm, strictures in the penile urethra, recurrent strictures, and strictures secondary to lichen sclerosus. These patients may benefit from primary urethroplasty if they have many adverse features or secondary urethroplasty after the first recurrence.

Clean intermittent self-catheterization does not appear to be effective in the prevention of urethral stricture recurrence

OBJECTIVE

The aim of this study was to assess the effect of clean intermittent self-catheterization (CISC) on stricture recurrence.

MATERIALS AND METHODS

The incidence of stricture recurrence was assessed retrospectively in a group of 126 new patients treated endoscopically for urethral stricture in a general urological setting between 1994 and 2001, of whom 31 performed twice-weekly CISC and 95 did not. Stricture recurrence was defined as recurrent symptomatic stricture requiring further operative intervention following initial intervention. The mean follow-up available was 25 months (range 1-132 months).

RESULTS

Of the 126 patients assessed, 60 (47.6%) developed recurrent stricture and required an average of 3.13 endoscopic retreatments each during the follow-up period. There was no significant difference (chi-squared p = 0.46) between the number of stricture recurrences in those performing CISC (13-41.9%) and those not performing CISC (47-49.5%).

CONCLUSION

CISC does not appear to prevent medium-term stricture recurrence.

Intermittent self-dilatation for urethral stricture disease in males: A systematic review and meta-analysis

BACKGROUND

Intermittent self-dilatation (ISD) may be recommended to reduce the risk of recurrent urethral stricture. Level one evidence to support the use of this intervention is lacking.

OBJECTIVES

Determine the clinical and cost-effectiveness of ISD for the management of urethral stricture disease in males.

SEARCH METHODS

The strategy developed for the Cochrane Incontinence Review Group as a whole (last searched May 7, 2014).

SELECTION CRITERIA

Randomised trials where one arm was a programme of ISD for urethral stricture.

DATA COLLECTION AND ANALYSIS

At least two independent review authors carried out trial assessment, selection, and data abstraction.

RESULTS

Data from six trials that were pooled and collectively rated very low quality per the GRADE approach, indicated that recurrent urethral stricture was less likely in men who performed ISD than those who did not (RR 0.70, 95% CI 0.48-1.00). Two trials compared programmes of ISD but the data were not combined and neither were sufficiently robust to draw firm conclusions. Three trials compared devices for performing ISD, results from one of which were too uncertain to determine the effects of a low friction hydrophilic catheter versus a polyvinyl chloride catheter on risk of recurrent urethral stricture (RR 0.32, 95% CI 0.07 to 1.40); another did not find evidence of a difference between 1% triamcinolone gel for lubricating the ISD catheter versus water-based gel on risk of recurrent urethral stricture (RR 0.68, 95% CI 0.35 to 1.32). No trials gave cost-effectiveness or validated PRO data.

CONCLUSIONS

ISD may decrease the risk of recurrent urethral stricture. A well-designed RCT is required to determine whether that benefit alone is sufficient to make this intervention worthwhile and in whom. Neurourol. Urodynam. 35:759-763, 2016. © 2015 Wiley Periodicals, Inc.