|Year : 2020 | Volume
| Issue : 5 | Page : 211-215
Is repeated direct vision internal urethrotomy feasible in the management of recurrent anterior urethral strictures?
Cho-Hsing Chung, Wen Ling Wu, Yin-Ting Liu, Kai-Yi Tzou, Su-Wei Hu, Yi-Te Chiang, Chen-Hsun Ho, Chia-Hung Liu, Chia-Chang Wu, Kuan-Chou Chen, Wei-Tang Kao
Department of Urology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
|Date of Submission||01-May-2018|
|Date of Decision||02-Nov-2018|
|Date of Acceptance||06-Nov-2018|
|Date of Web Publication||27-Oct-2020|
Department of Urology, Shuang Ho Hospital, Taipei Medical University No. 291, Zhongzheng Road, Zhonghe District, New Taipei City 235
Source of Support: None, Conflict of Interest: None
Purpose: Direct vision internal urethrotomy (DVIU) is the most common surgical intervention for anterior urethral strictures. We evaluated the long-term outcome and success rate of optic urethrotomy in patients treated in our hospital who had recurrent anterior urethral strictures, according to different predisposing causes and stricture sites. The aim is to find the success rate of optic urethrotomy in patients treated who had recurrent anterior urethral strictures. Materials and Methods: This study is a retrospective chart review. From January 2000 to August 2017, 232 patients received internal optic urethrotomy for anterior urethral strictures in our hospital. A retrospective chart review of all patients involved in the study was performed. Median follow-up period after receiving the first urethrotomy procedure was 91 months (range: 8–204 months). The Kaplan–Meier method was used to analyze the success rate of the first, second, third, fourth, and fifth urethrotomy procedures. Results: Of the 232 patients who underwent at least two procedures of urethrotomy, 150 (64.65%) were included in the study. The success rate of the first urethrotomy procedure was 0%, with a mean time to recurrence of 20 months. For the second urethrotomy, the success rate was 53%, with a mean time to recurrence of 22.5 months. For the third urethrotomy, the success rate was 40%, with a mean time to recurrence of 16.1 months. For the fourth and fifth urethrotomy procedures, the success rate was 39% and 18%, with a mean time to recurrence of 17.9 and 10.2 months, respectively. Patients who had anterior urethral stricture related to previous surgery (surgery-related) had a better outcome (success rate, 87.3%) than patients with strictures stemming from other causes (P = 0.003). No association was found between preoperative infection, the age of the patient, and the site of the strictures and the success rate of the procedure. Conclusion: The patient population was older and had a longer-term follow-up, compared with previous studies, but even with repeated DVIU, the surgery-related stricture group had a higher success rate of urethrotomy than the groups with different etiology. In patients with pelvic fracture or infection, repeated urethrotomy may not be recommended as first-line treatment for recurrent anterior urethral stricture.
Keywords: Anterior urethral stricture direct vision internal urethrotomy, chart review, recurrent urethral stricture, repeated urethrotomy, retrospective, urethrotomy
|How to cite this article:|
Chung CH, Wu WL, Liu YT, Tzou KY, Hu SW, Chiang YT, Ho CH, Liu CH, Wu CC, Chen KC, Kao WT. Is repeated direct vision internal urethrotomy feasible in the management of recurrent anterior urethral strictures?. Urol Sci 2020;31:211-5
|How to cite this URL:|
Chung CH, Wu WL, Liu YT, Tzou KY, Hu SW, Chiang YT, Ho CH, Liu CH, Wu CC, Chen KC, Kao WT. Is repeated direct vision internal urethrotomy feasible in the management of recurrent anterior urethral strictures?. Urol Sci [serial online] 2020 [cited 2020 Nov 28];31:211-5. Available from: https://www.e-urol-sci.com/text.asp?2020/31/5/211/299264
| Introduction|| |
Anterior urethral stricture is an annoying disease for urologists due to the lack of an effective management strategy. In general, the anterior urethra was composed of the divisions of the fossa navicularis, pendulous urethra, and bulbous urethra, and the posterior urethra was composed of the divisions of the membranous urethra, prostatic urethra, and bladder neck. In general, the term “anterior urethral stricture” is anterior urethral disease, which refers to a scarring process involving spongy erectile tissue of the corpus spongiosum or the urethral epithelium. In contrast, the term posterior urethral stricture is not included in the general definition of urethral stricture.
A historical review of anterior urethral stricture disease shows that the management of the disease had changed significantly in the past four decades. Dilatation and optic urethrotomy are procedures widely used for the management of anterior urethral stricture. Except these, there are some other treatments: dilation, lasers, excision primary anastomosis (EPA), graft reconstruction, and flap reconstruction. Since the procedure of optic internal urethrotomy has become the first-line treatment because it is easy to perform and safe for the patients. Due to the uncertainty of urethrotomy, the recurrence rate of this procedure was found to vary from 60% to 90%., Thus, urethrotomy appeared to have a lower success rate than we expected. Reconstructive urethroplasty plays an increasingly important role in the management of anterior urethral stricture. A successful management strategy for this disease is a safe, effective, and feasible treatment option with minimal or no side effects. Although most patients with anterior urethral stricture disease initially complain of mild discomforts, such as lower urinary tract symptoms (LUTS) and urinary tract infection (UTI), few patients experience severe symptoms such as renal failure, acute urinary retention, and severe systemic infection due to UTI. Because the symptoms caused by anterior urethral stricture are mild in intensity, patients tend to receive conservative treatment in the first-line setting such as urethral dilation or endoscopic procedure, rather than invasive reconstructive procedures. However, some patients with anterior urethral stricture disease and recurrent strictures have had repeated urethrotomy procedures. As urethroplasty is a complex and difficult procedure to perform, many urologists in Taiwan opt not to do it and resort to performing repeated urethrotomy as the only treatment for this disease. The study aims to evaluate the success rate after repeated urethrotomy procedures, according to the etiology and site of anterior urethral strictures in patients treated in our hospital.
The urethra is often divided further at the junction of the membranous and penile urethra, and it is termed the bulbomembranous urethra. This region consists of a 2-cm length of urethra within the urogenital diaphragm as well as being within the striated urethral sphincter and the first few proximal centimeters of the bulbous urethra, just distal to the sphincter within the penile bulb. The bulbospongy urethra begins a few centimeters distal to the membranous urethra.
| Subjects and Methods|| |
All patients undergoing direct vision internal urethrotomy (DVIU) for anterior urethral stricture disease between January 2000 and August 2017 were identified from the Taipei Medical Hospital and Shuang Ho Hospital, Taipei University computerized database using the International Classification of Disease-9 codes for urethrotomy. In total, 232 patients underwent repeated (at least two) DVIU for symptomatic anterior urethral strictures in our hospital, and patient with only one time DVIU wound not be included. Of these 232 patients, 24 patients were excluded from the study because of concurrent bladder neck contracture with anterior urethral stricture and 58 patients were excluded due to the lack of long-term follow-up. Therefore, in total, 150 patients were included in this study. Preoperative assessment included cystoscopy, urine analysis, and urine culture. Patients with preoperative infections were treated with antibiotics. The DVIU was performed under the direct vision with a cold-knife incision of the stricture at the 12 o'clock position, and other technical procedures such as cold knife, balloon dilatation, and laser were not included in our study. DVIU was performed by >10 urologists in our hospitals, and because our study was retrospective we did not have standard protocol for urethrotomy with sounding or not. In this article, the only treatment of the anterior urethral stricture in the record is optic internal urethrotomy. In all patients, an 18–20F Foley catheter was left in place and removed within 2 weeks of the procedure. The patients' medical charts were retrospectively reviewed and analyzed for the etiology of anterior urethral stricture, patient's age, stricture site, repeated sessions of DVIU, outcome, and side effects. Treatment failure was defined as recurrent symptomatic stricture requiring further operative intervention. Follow-up was scheduled after each urethrotomy procedure. Others signs of recurrence included the decreased force of stream, incomplete emptying, recurrent UTI, increased postvoid residual urine, the obstructive pattern on the uroflow study, or definitive radiographic or cystoscopic evidence of recurrent stricture. If recurrence of the stricture was found by cystoscopy, the DVIU procedure was repeated. The data were analyzed by SPSS statistical software (IBM, Version 18.0, SPSS Corp., Armonk, NY, USA). The Kaplan–Meier method was used to evaluate the absence of a stricture (i.e., the stricture-free rate) after the first, second, third, fourth, fifth, and subsequent urethrotomy procedures.
| Results|| |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] show the stricture-free survival rates as determined by the Kaplan–Meier method. Comparison of the etiology and the stricture-free success rate depicted that surgery-related strictures had the best prognosis. The mean age of the patients in this study was 74.3 years (range: 33–92 years). Of the 150 patients, the urethra patency rate for the first urethrotomy procedure was 0%, with a mean time to stricture of 20 months. For the second urethrotomy procedure, the urethral patency rate was 53%, with a mean time to stricture of 22.5 months. For the third urethrotomy, the urethral patency rate was 40%, with a mean time to stricture of 16.1 months. For the fourth and fifth procedures, the urethral patency rate was 39% and 18%, with a mean time to stricture of 17.9 and 10.2 months, respectively. The mean follow-up period was 91 months (range: 8–204 months). Most strictures occurred in the bulbar urethra (86/150, 57%) with a few in the penile urethra (28/150, 19%), penile bulbar urethra (20/150, 13%), and fossa navicularis (16/150, 11%). According to the different causes of anterior urethral stricture, the highest success rate was found for the surgery-related group (87.3%), which consisted by two groups in our study: transurethral resection of prostate (TURP) and transurethral resection of bladder tumor (TURBT). The overall success rate of repeated DVIU in our study was found to be 82.7%. Stricture recurrence, defined as LUTS, UTI, and all “anterior urethral stricture,” was confirmed by cystoscopy. The patent urethra was defined as no complaints of LUTS or persistent UTI symptoms.
| Discussion|| |
In 2002, the rate of male anterior urethral stricture disease was reported to be about 0.6% in susceptible patients in North America, with >5000 inpatient hospital annual visits. Since Dr. Sachse's report in 1974, optical internal urethrotomy has become a popular method in the management of anterior urethral strictures. DVIU is generally known as optic urethrotomy. Although DVIU and urethral dilation are simple endoscopic procedures that are widely used in the management of new and recurrent male anterior urethral strictures, recent studies have shown that the success rate after one urethrotomy procedure was only 8% and after multiple urethrotomies it was close to 0%. Treatment for recurrent anterior urethral strictures presents a challenge for urologists. Although the success rate of urethrotomy has been reported to lower than that of urethroplasty by many studies, the ease of performing the former procedure and the safety to the patients make urethrotomy the first-line treatment of male anterior urethral strictures. Many methods of urethroplasty appear to be successful for traumatic strictures but are less successful for strictures caused by catheterization and instrumentation, and for those caused by infection. Moreover, urethroplasty requires more surgical technique and experience.
Urethral ultrasonography is a dynamic imaging study which generates a more accurate length and location of the stricture, the extent of urethral disease and the degree of urethral obstruction. It provides a reliable, accurate tool with no additional radiation exposure to the patient which can help to select operative procedure. According to Nash et al., if the strictured urethral diameter is found to be <2 mm which indicate a severe obstruction, they suggest to remove the diseased urethra by direct excision and primary anastomosis alone or in combination with a graft or flap urethral reconstruction.
In our study, the most common cause of stricture was related to surgery (126/150, 84%). Of these 126 patients, 120 patients (95%) experienced anterior urethral stricture after the TURP and four patients (5%) developed anterior urethral stricture after TURBT and the left two cases were both TURP and TURBT. In this group, the success rate was up to 87.3% after repeated DVIU. However, previous studies have reported posturethrotomy complications of up to 27%. In our study, >265 procedures of urethrotomy were performed, with no severe complications recorded. No patient reported erectile or ejaculatory dysfunction. In our study, the median time to recurrence was 20 months after urethrotomy, but strictures can recur for up to 5-10 years posttreatment. Therefore, follow-up for 10 years is recommended.
Our study was a retrospective review, and there was no standard follow-up protocol. When patients complained of LUTS or suspicious anterior urethral stricture, cystoscopy was performed.
All patients were shown to have stricture recurrence by cystoscopy. Another limitation is that the urethrotomy procedures were performed by >10 urologists, and thus the surgical procedure was not standardized. Although different surgeons had different techniques, cold-knife urethrotomy was performed in every patient, and no patient received laser urethrotomy. In this study, in all patients, the Foley catheter was removed within 2 weeks of the procedure, but no standard protocol was followed. The patent urethra was defined as no complaints of LUTS or persistent UTI symptoms. Because of this definition, the success rate of urethrotomy for anterior urethral stricture may have been overestimated.
According to Mundy, iatrogenic strictures happen at any age and are generally found at the junction of the bulbar and penile urethra after catheterization, which commonly involves the membranous urethra and urethral sphincter after TURP which was so-called “sphincter strictures.” According to Pansadoro and Emiliozzi, the recurrence rates also differ according to stricture location; 58% of bulbar strictures will recur after urethrotomy, compared with 84% for penile strictures and 89% for membranous strictures.
Therefore, as the typical iatrogenic stricture is the bulbar urethra and the bulbar urethra stricture had the lowest recurrence rates, it is reasonable in our study that surgery-related anterior urethral stricture has a better outcome. The reason may be the most of iatrogenic strictures are less severe, shorter strictures, less infection, but these need more further studies to proof.
There are some other procedures such as urethra dilatation, laser urethrotomy, injectable agents, and urethral stents. For urethra dilatation, this may include different methods: balloon, urethral sounds, or self-dilation with catheters. Studies have shown no difference in recurrence rates following urethral dilation versus internal urethrotomy., About injectable agents, some surgeon use mitomycin C, which showed promising results. Others may use triamcinolone injection, which showed a significant decrease in both time to recurrence and recurrence rate at 12 months without any significant increase in rates of perioperative complications., About laser urethrotomy, a meta-analysis of complications associated with laser urethrotomy reported an overall complication rate of 12%, which is above the 6.5% incidence reported for cold-knife urethrotomy. However, until now, the results of laser urethrotomy are mixed and with the improvement of new lasers and experience with them, future data may show better results. In our method, the inclusion criteria were only cold knife. Therefore, we could not know other technical procedure influence the outcome of the urethrotomy.
According to one review article in 2017, both DVIU and dilation have equivalent outcomes. DVIU could be used for untreated, short (<2 cm) bulbar strictures. In contrast, urethroplasty should be used for long (>2 cm), previously treated or penile strictures. The stricture length, location, and complexity should be considered when surgeon decided which urethroplasty. For short bulbar strictures, EPA has high success rate and the success rate is greater than substitution urethroplasty. For longer strictures (2–4 cm), success rates of EPA are higher in the proximal bulbar urethra. The main limitation of EPA is stricture length, and if bulbar strictures are longer or penile strictures. Among substitution urethroplasty, grafts are preferred over flaps. Among grafts urethroplasty, many studies had reported a high successful rate for buccal mucosal graft urethroplasty. There are many advantages of buccal mucosal graft urethroplasty: (1) the epithelium is elastic and easily managed. (2) it is simple to Harvest buccal mucosa and the wound of harvest site heal rapidly. (3) thinner lamina propria of the buccal mucosa in contrast to the one of skin and bladder mucosa, which make vessels easily provide the blood supply for the graft.
Because our study is retrospective study and during long follow-up time, there was no persistent standard treatment consensus, we focused on the treatment “DVIU” which is used at the past and present.
Many techniques are used to stop the process of wound contraction and to prevent stricture recurrence. One of them is to leave a Foley catheter for 6 weeks after urethrotomy, in the hope that the urethra will mold by the catheter when it heals. However, studies have shown that the failure rate of long-term catheterization after internal urethrotomy is similar to the failure rate with 3–7 days of catheterization, and even 6-week placement is insufficient time to stop the forces of wound contraction. In our retrospective study, 6-week placement was ideal, but the poor compliance may result in shortening of placement.
The definition of postoperative failure is recurrent symptomatic strictures. For no standard follow-up protocol, we did not check cystoscopy postoperatively regularly. Once we decided to performed DVIU, we checked cystoscopy preoperatively. Another is a limitation is: because we did not have standard protocol for urethrotomy in our hospital and the study was retrospective study, therefore, we did not record the subgroup of sounding and nonsounding.
| Conclusion|| |
DVIU provides a safe first-line therapeutic option for elderly patients with anterior urethral strictures. A previous study has reported a stricture-free success rate of only 8% with one urethrotomy procedure and close to 0% with multiple urethrotomies. In this study with long-term follow-up, the stricture-free success rate in the patient population is up to 80%. Compared with previous studies, in this study, the patients had a better prognosis and longer follow-up. In this retrospective review, we found that most cases of the urethral disease had resulted from catheterization or instrumentation. Although repeated urethrotomy appeared to be more effective than we had expected, a 20% failure rate still remains after repeated procedures. It has been suggested that urethroplasty has a higher success rate in patients with recurrent stricture. However, in elderly patients and patients who are poor candidates for surgery or have a limited life expectancy, repeated urethrotomy may be able to achieve the same goal as urethroplasty. Patients with anterior urethral stricture related to previous surgery appeared to have a better outcome compared with patients with strictures of other etiology. In patients with anterior urethral strictures of other etiology and in a certain group of patients, urethrotomy may be considered as a transitional treatment, and curative reconstruction should be scheduled.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]