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Routine Internal Dorsal Urethrotomy
THE JOURNAL OF UROLOGY
Vol. 84, No. 5, November 1960 Printed in U.S.A.
ROUTINE INTERNAL DORSAL URETHROTOMY MIMS G. OCHSNER
AND
HUGH WARREN
Fi·oin the Department of Urology, University of Virginia Hospital, Charlottesville, Va.
Stricture of the urethra just within the meatus or in the region of the fossa navicularis has long been recognized as a frequent and troublesome complication in urology. 1- 4 It most commonly follows catheter drainage after some type of prostatic surgery but it may follow catheter drainage alone. Once the stricture develops, if not treated, it may persist for years. This is well demonstrated by a patient in whom a size 16F meatal stricture was noted 1 month following transurethral prostatic resection. No further treatment was prescribed and the stricture was still present 11 years later. Various preventives have been tried from the application of hydrocortisone ointment, 5 to the use of indwelling catheters impregnated with silver nitrate. We believe that the results in these various measures have been unsatisfactory. The etiology of this type of stricture has been attributed to trauma and infection, and both undoubtedly play a part. The intriguing thing is the formation of stricture in this definite position and in most instances without a stricture in a proximal area. That infection plays a part is evident by the observation of reddened, inflamed tissue around the meatus for days after removal of the catheter. The reason that stricture develops in this particular area can possibly be attributed to an anatomical narrowing in the fossa navicularis that permits secretions to gather arounrl the catheter, thus producing an inflammatory reaction in this local area. The incidence of meatal stricture as reported Read at annual meeting of Mid-Atlantic Section of American Urological Association, Inc., White Sulphur Springs, W. Va., November 11-14, 1959. 1 Johnston, J. H.: Postmeatal urethral stricture following prostatectomy. Brit. J. Urol., 25: 155, 1958.
2 Landes, R. R.: Painless dilatation of urethral meatal strictures following transurethral resection of prostate. J. Urol., 70: 626, 1953. 3 Mimpress, T. W. and Pheils, M. T. P.: Urethral stricture following prostatectomy. Brit. J. Urol.,
23: 153, 1951.
4 Nesbit, R. M.: The advantage of perinea! urethrotomy on prostatic resection. South. Surg.,
7: 501, 1938.
5 Warres, H. L.: Urethral stricture following transurethral resection of prostate. J. Urol., 79:
989, 1958.
in the literature is usually around 20 per cent. 2 • 5 To determine the incidence in our own cases we selected a group of 103 consecutive cases of prostatic surgery. These patients had all been treated in a uniform manner relative to catheter drainage and technical procedure. The incidence of meatal stricture was 28.1 per cent (table 1). When we learned of the work reported from the Mayo Clinic by Drs. Emmett, Kirchheim and Greene 6 on routine urethral calibration and dorsal internal urethrotomy we embarked on a simple procedure of our own. A dorsal internal urethrotomy was made with a hook knife blade on each patient subjected to prostatic surgery or transurethral procedures in an effort to reduce the frequency of meatal stricture with which we were most concerned. The procedure is simple (fig. 1). After routine dilatation of the urethra with a size 30F sound, a Kelly clamp is placed in the urethra by an assistant. A hook knife is then introduced until the point approximates the dorsum of the glans just distal to the coronal sulcus. A moderate cut is then made along the urethra to the meatus. Bleeding is brisk but it is immediately stopped by pressure from the thumb and index finger until the resectoscope sheath or an indwelling catheter can be introduced. This tamponades the bleeding so that no further difficulty has been encountered. The results in this series of cases have been tabulated in table 2 and have led to the following observations. Meatal stricture usually appears soon after withdrawal of the catheter, in our series 70 per cent within 1 month. When a stricture is developing immediate and frequent dilatation does not prevent its formation. In most instances there is no stricture of the urethra proximal to the meatal stricture. Where a dorsal urethrotomy has been performed the stricture was of large caliber and admitted a size 24F sound initially in nine of the 10 cases. This is in sharp contrast to strictures without a ure6 Emmett, J. L., Kirchheim, D. and Greene, L. F.: Prevention of postoperative stricture from transurethral resection by preliminary internal urethrotomy. Report of experience with 447 cases. J. Urol., 78: 456-465, 1957.
630
rnTEltNAL DORSAL CTHETHHOTOMY
throtomy 1Yherc a size I 6F souncl has frcquentlr been fonncl m·c·pssary to break through the· strictme. Treatment lias usually been rq1catcd dilatations at intervals of a Yrnek to a month, often extended over a JJc:riocl of months before the stricture shO\rn no c·vidence of recurrence. Providing tlw patirnt witli dilating applianc:c"s for sdf use at home has not been succcssfnl in TABLJ, 1
Per Cent
Procedure
31. (i
Trnnsurei hrnl prosktti c resection
No. 2-1
Retroµubic pros-
\:o. 24 Foley No. 24 Folc;y
3 0
()
.'\o. 21 Fok:v
0
()
Lt1tcetomy
Transnrethrn.l re-
section of bladd()l' tumor Perinea] prostatc,dom)·, rnclical Perimml µrosta1cet-omy Total
Foley
2--1 Folc,v
); 0.
our c>xperience. Fm these: n·a~ons 11·e bdien· tl1c: treatment of preference. is lornl iufiltrntion' and a second intPrnal urcthrotomy with a hook k11ifr. Pressure for a short time and a11 inchrnlling Foley TABLI•}
I
Procedure
prost.atic resection Retropnbic prostatcct-omy Trnnsnret hral l'Osection of bindder tumor
--
28.1
-----------
Post-op. Drainage
t
!
Foley
"'0Folec· . 24
No. 2--1 Folc.,·
I;-, 0
0
0 20.0
11
Total
1:i. (j
0
2
-
Corrected to mo. or morn fol!01ntp Seven of these lO st ric(.ure, (711''."/'1
Frn. l
632
M. G. OCHSNER A)ID H. WARREN
catheter for 48 hours suffice to control bleeding. In our experience this form of treatment shortens the necessary period of dilatation. In conclusion, we believe that routine dorsal internal urethrotomy is effective in reducing the incidence of and, when it occurs, diminishes the density of postoperative meatal stricture.
Martha J e.ffer son Hospital, Charlottesville, 11a. (H.lF.)
REFERENCES MIDDLETON, R. P.: Henry Jacob Bigelow and his operation: A major contribution to urology finally comes into its own. J. Urol., 49: 883,
1943. S £RATTE, J . .T. AND STRAT'l'E, J.: Strictures following transurethral resection. Am. J. Surg., 73: 503-509, 1947. WHITE, E. P. AND BERRY, N. E.: Stricture formation following transurethral resection: Its prevention and treatment. Urol. & Cutan. Rev., 50: 662, 1946. 0
Vol. 84, No. 5, November 1960 Printed in U.S.A.
ROUTINE INTERNAL DORSAL URETHROTOMY MIMS G. OCHSNER
AND
HUGH WARREN
Fi·oin the Department of Urology, University of Virginia Hospital, Charlottesville, Va.
Stricture of the urethra just within the meatus or in the region of the fossa navicularis has long been recognized as a frequent and troublesome complication in urology. 1- 4 It most commonly follows catheter drainage after some type of prostatic surgery but it may follow catheter drainage alone. Once the stricture develops, if not treated, it may persist for years. This is well demonstrated by a patient in whom a size 16F meatal stricture was noted 1 month following transurethral prostatic resection. No further treatment was prescribed and the stricture was still present 11 years later. Various preventives have been tried from the application of hydrocortisone ointment, 5 to the use of indwelling catheters impregnated with silver nitrate. We believe that the results in these various measures have been unsatisfactory. The etiology of this type of stricture has been attributed to trauma and infection, and both undoubtedly play a part. The intriguing thing is the formation of stricture in this definite position and in most instances without a stricture in a proximal area. That infection plays a part is evident by the observation of reddened, inflamed tissue around the meatus for days after removal of the catheter. The reason that stricture develops in this particular area can possibly be attributed to an anatomical narrowing in the fossa navicularis that permits secretions to gather arounrl the catheter, thus producing an inflammatory reaction in this local area. The incidence of meatal stricture as reported Read at annual meeting of Mid-Atlantic Section of American Urological Association, Inc., White Sulphur Springs, W. Va., November 11-14, 1959. 1 Johnston, J. H.: Postmeatal urethral stricture following prostatectomy. Brit. J. Urol., 25: 155, 1958.
2 Landes, R. R.: Painless dilatation of urethral meatal strictures following transurethral resection of prostate. J. Urol., 70: 626, 1953. 3 Mimpress, T. W. and Pheils, M. T. P.: Urethral stricture following prostatectomy. Brit. J. Urol.,
23: 153, 1951.
4 Nesbit, R. M.: The advantage of perinea! urethrotomy on prostatic resection. South. Surg.,
7: 501, 1938.
5 Warres, H. L.: Urethral stricture following transurethral resection of prostate. J. Urol., 79:
989, 1958.
in the literature is usually around 20 per cent. 2 • 5 To determine the incidence in our own cases we selected a group of 103 consecutive cases of prostatic surgery. These patients had all been treated in a uniform manner relative to catheter drainage and technical procedure. The incidence of meatal stricture was 28.1 per cent (table 1). When we learned of the work reported from the Mayo Clinic by Drs. Emmett, Kirchheim and Greene 6 on routine urethral calibration and dorsal internal urethrotomy we embarked on a simple procedure of our own. A dorsal internal urethrotomy was made with a hook knife blade on each patient subjected to prostatic surgery or transurethral procedures in an effort to reduce the frequency of meatal stricture with which we were most concerned. The procedure is simple (fig. 1). After routine dilatation of the urethra with a size 30F sound, a Kelly clamp is placed in the urethra by an assistant. A hook knife is then introduced until the point approximates the dorsum of the glans just distal to the coronal sulcus. A moderate cut is then made along the urethra to the meatus. Bleeding is brisk but it is immediately stopped by pressure from the thumb and index finger until the resectoscope sheath or an indwelling catheter can be introduced. This tamponades the bleeding so that no further difficulty has been encountered. The results in this series of cases have been tabulated in table 2 and have led to the following observations. Meatal stricture usually appears soon after withdrawal of the catheter, in our series 70 per cent within 1 month. When a stricture is developing immediate and frequent dilatation does not prevent its formation. In most instances there is no stricture of the urethra proximal to the meatal stricture. Where a dorsal urethrotomy has been performed the stricture was of large caliber and admitted a size 24F sound initially in nine of the 10 cases. This is in sharp contrast to strictures without a ure6 Emmett, J. L., Kirchheim, D. and Greene, L. F.: Prevention of postoperative stricture from transurethral resection by preliminary internal urethrotomy. Report of experience with 447 cases. J. Urol., 78: 456-465, 1957.
630
rnTEltNAL DORSAL CTHETHHOTOMY
throtomy 1Yherc a size I 6F souncl has frcquentlr been fonncl m·c·pssary to break through the· strictme. Treatment lias usually been rq1catcd dilatations at intervals of a Yrnek to a month, often extended over a JJc:riocl of months before the stricture shO\rn no c·vidence of recurrence. Providing tlw patirnt witli dilating applianc:c"s for sdf use at home has not been succcssfnl in TABLJ, 1
Per Cent
Procedure
31. (i
Trnnsurei hrnl prosktti c resection
No. 2-1
Retroµubic pros-
\:o. 24 Foley No. 24 Folc;y
3 0
()
.'\o. 21 Fok:v
0
()
Lt1tcetomy
Transnrethrn.l re-
section of bladd()l' tumor Perinea] prostatc,dom)·, rnclical Perimml µrosta1cet-omy Total
Foley
2--1 Folc,v
); 0.
our c>xperience. Fm these: n·a~ons 11·e bdien· tl1c: treatment of preference. is lornl iufiltrntion' and a second intPrnal urcthrotomy with a hook k11ifr. Pressure for a short time and a11 inchrnlling Foley TABLI•}
I
Procedure
prost.atic resection Retropnbic prostatcct-omy Trnnsnret hral l'Osection of bindder tumor
--
28.1
-----------
Post-op. Drainage
t
!
Foley
"'0Folec· . 24
No. 2--1 Folc.,·
I;-, 0
0
0 20.0
11
Total
1:i. (j
0
2
-
Corrected to mo. or morn fol!01ntp Seven of these lO st ric(.ure, (711''."/'1
Frn. l
632
M. G. OCHSNER A)ID H. WARREN
catheter for 48 hours suffice to control bleeding. In our experience this form of treatment shortens the necessary period of dilatation. In conclusion, we believe that routine dorsal internal urethrotomy is effective in reducing the incidence of and, when it occurs, diminishes the density of postoperative meatal stricture.
Martha J e.ffer son Hospital, Charlottesville, 11a. (H.lF.)
REFERENCES MIDDLETON, R. P.: Henry Jacob Bigelow and his operation: A major contribution to urology finally comes into its own. J. Urol., 49: 883,
1943. S £RATTE, J . .T. AND STRAT'l'E, J.: Strictures following transurethral resection. Am. J. Surg., 73: 503-509, 1947. WHITE, E. P. AND BERRY, N. E.: Stricture formation following transurethral resection: Its prevention and treatment. Urol. & Cutan. Rev., 50: 662, 1946. 0