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The Safety and Efficacy of Optical Urethrotomy Using a Spongiosum Block With Sedation: A Comparative Nonrandomized Study
The Safety and Efficacy of Optical Urethrotomy Using a Spongiosum Block With Sedation: A Comparative Nonrandomized Study M. Hammad Ather,* Ali Akbar Zehri, Kashifuddin Soomro and Irfan Nazir From the Section of Urology, Aga Khan University, Karachi, Pakistan
Abbreviations and Acronyms ASA ⫽ American Society of Anesthesiologists OU ⫽ optical internal urethrotomy VAS ⫽ visual analogue scale Submitted for publication August 12, 2008. * Correspondence and requests for reprints: Section of Urology, Department of Surgery, P. O. Box 3500, Stadium Rd, Karachi 74800, Pakistan (telephone: ⫹92 21 486 4778; FAX: ⫹92 21 493 4294; e-mail: [email protected]).
Purpose: Optical urethrotomy is generally performed with the patient under general or major regional anesthesia. We determined the safety and efficacy of optical urethrotomy using a spongiosum block with sedation for anterior urethral stricture in a comparative, nonrandomized study. Materials and Methods: In 32 patients with anterior urethral stricture optical urethrotomy was performed under general/major regional anesthesia in 16 patients (group 1) or a spongiosum block and sedation in 16 (group 2). In group 2 a total of 2 to 3 ml 1% lidocaine were slowly injected into the glans penis. Standard optical urethrotomy was performed immediately with a cold cut knife. Results: The 2 groups were matching in terms of patient age, and stricture cause and length. Optical urethrotomy was successfully completed in all patients in group 1 and in 15 of 16 in group 2. In group 2, 15 patients (94%) had no pain or discomfort. One patient reported moderate discomfort and the procedure was abandoned. In group 2 none of the patients required parental analgesia post procedure. The first year recurrence was not significantly different in the 2 groups (p ⫽ 0.192). The anesthetic effect lasted for about an hour and was satisfactory without any complications. Pain score on the visual analogue scale was not different in the 2 groups. Conclusions: Optical urethrotomy using a spongiosum block with sedation is as safe and effective as using regional or general anesthesia, particularly in patients who are more ill. The shorter operative time in the local anesthesia group could also make it cost-effective. Key Words: penis; urethra; anesthesia, local; urethral stricture; pain
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MALE urethral stricture disease is still a common and challenging problem in urological practice and its management continues to evolve. External trauma is now generally assumed to be the cause of most anterior urethral strictures.1,2 Excellent success rates have been reported for surgical reconstruction but an interest in minimally invasive techniques forces investigators to attempt endourological approaches.3,4
OU is a widely accepted procedure and the treatment is done in approximately 80% of patients with urethral stricture.5 Following recurrence patients are treated with repeat OU, dilation or open urethroplasty.6,7 OU is performed using general or spinal anesthesia.5 Avoidance of anesthesia is desirable for a short procedure that may need to be done many times during a lifetime. OU using local anesthesia is not a standard procedure. Ye
0022-5347/09/1815-2134/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 181, 2134-2138, May 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.01.017
OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
et al described the spongiosum block for OU and other minor urethral procedures.8,9 OU is generally considered ideal for urethral strictures less than 2 cm.10 However, others believe that length is not a limiting factor for OU for anterior urethral strictures using local anesthesia.4 In reported contemporary series various techniques of OU using local anesthesia, including topical analgesia, perineal block and spongiosum block, have been described. However, to our knowledge there is no comparative study of general/major regional anesthesia. We have compared the outcome and safety of OU for anterior urethral stricture with the patient under local and general/regional anesthesia.
MATERIALS AND METHODS A total of 32 patients with anterior urethral stricture that had not been treated previously underwent internal OU, including 16 who received general or major regional anesthesia and 16 who were treated with a spongiosum block with sedation. Following informed consent the patients of 1 (MHA) of the 7 consultant urologists were nonrandomly selected for the spongiosum block. Patients in the control group underwent OU performed during the same period under general/major regional anesthesia, and they met study inclusion and exclusion criteria. Collected data included anatomical location, estimated stricture length on urethrogram, the most probable cause of stricture disease, comorbidities, the duration of recurrence and the type of anesthesia. The diagnosis of urethral stricture was based on symptom scores, clinical history, uroflowmetry and urethrogram. All patients had at least 4 months of followup. Stricture length was considered as 2 cm or greater and 2 cm or less. Procedure time was calculated from cystoscope/ urethrotome introduction to catheterization. Operative time was calculated from the time that the patient was wheeled into the operating room to the time that he was wheeled out. We classified anterior stricture location into 3 anatomical categories, including pendulous, penobulbar and bulbar. The cause of stricture was determined to be inflammatory (lichen sclerosis and sexually transmitted disease), iatrogenic (after transurethral prostate resection or instrumentation, or prolonged catheterization), traumatic or idiopathic. Data were analyzed using SPSS®, version 16. Before the procedure all efforts were made to render patients infection-free. Urine cultures were performed in all patients and confirmatory cultures were obtained after treatment. All patients in group 2 received a spongiosum block to desensitize the anterior urethra and the external urethral sphincter, in addition to 10 ml neutral gel to lubricate the urethra. Supplemental intravenous sedation with 2 to 5 mg midazolam or 20 to 40 mg meperidine were given in patients who were anxious. Patients were placed in the dorsolithotomy position with pulse, blood pressure and electrocardiogram monitored continuously. The genitalia were cleaned with 10% povidone-iodine solution. A rubber penile clamp was applied over the base of the penis and 1% lidocaine solution was injected in the glans penis (see figure). A 27 gauge
2135
Rubber band Spongiosum block technique. Note single layer of gauze applied over base of penis, over which rubber band is applied to achieve venous blockade.
hypodermic needle was used and a dose of 2.5 to 3 ml 1% lidocaine was slowly injected into the glans during 1 minute. To avoid bleeding the glans was squeezed with the swab. The penile clamp was removed after 10 minutes if it interfered with advancement of the urethrotome. Under direct retrograde vision we incised the stricture at the 12 o’clock position. After complete incision of the stricture area while sparing healthy mucosa and confirming free passage of the cystoscope into the bladder, an indwelling 16Fr to 18Fr silicone urethral catheter was left in place for 5 to 7 days. A VAS was used to evaluate pain. The VAS in each group was completed in the recovery room within 30 minutes after surgery. Least and worst pain status were graded as 1 and 10, respectively, and the pain experienced by the patient was graded accordingly. For practical purposes VAS scores were grouped into 4 categories, including 0 —no pain, 1 to 3—mild pain, 4 to 7—moderate pain and 8 to 10 —severe pain.
RESULTS A total of 32 anterior urethral strictures were treated during the study period. Patient age was between 17 and 83 years (median ⫾ SD 59.6 ⫾ 17.30) in the 2 groups. Median age in groups 1 and 2 was 51 ⫾ 17 and 70 ⫾ 8.4 years, respectively. Mean stricture length in groups 1 and 2 was 2.2 ⫾ 1 and 3.1 ⫾ 1 cm, respectively (p ⫽ 0.14). The etiology and anatomical location of the stricture was not different in the 2 groups (table 1). However, ASA status indicated that group 2 had a higher proportion of ASA III-IV patients (p ⫽ 0.04). In addition to higher ASA status, patients in group 2 were older than the patients in group 1. Using the spongiosum block with lidocaine internal urethrotomy under direct vision was successfully completed in 15 of 16 patients (94%). Mean procedure time was 17 minutes in group 1 and 11 minutes in group 2. Mean operative time in group 1
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OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
Table 1. Stricture site, length and etiology, and ASA status in 16 patients per group
Mean ⫾ SD stricture length (cm) No. site: Penile Penobulbar Bulbar No. etiology: Idiopathic Iatrogenic Inflammatory Traumatic No. ASA status: I II III IV
Group 1
Group 2
p Value
2⫾1
3⫾1
0.14
4 9 3
6 6 4
0.56
7 7 1 1
2 8 3 3
0.5
5 10 1 —
4
0.05 —
5 7
was 42.5 vs 21 minutes, which was significantly greater (p ⫽ 0.003). Table 2 shows the pain experienced by patients and reported on the VAS. All patients were premedicated with 2.5 mg midazolam orally. One patient in group 2 required additional meperidine during the procedure. He had moderate but tolerable discomfort when the most proximal part of the bulbar stricture was incised and the optical urethrotome was advanced into posterior urethra. However, due to pain and a dense stricture the procedure was abandoned. Mean stricture length was 2.66 cm (range 1.1 to 4). Bulbar strictures were more prevalent than strictures at the pendulous urethra or penobulbar junction (15 patients or 47% vs 10 or 31% and 7 or 22%, respectively). In three-quarters of the patients stricture etiology was idiopathic (9 or 28%) or iatrogenic (15 or 47%), whereas in a quarter the etiology was secondary to an inflammatory pathological condition. Distal strictures were more often related to inflammatory conditions than bulbar strictures, for which trauma was a more prevalent cause (table 1). Traumatic strictures tended to be much shorter than inflammatory strictures (mean 2.1 vs 3.4 cm, p ⫽ 0.05). Cystoscopy accounted for most iatrogenic strictures (table 2). However, transurethral surgery and traumatic or prolonged catheterization after a severe medical illness or other comorbidities were also frequently related to stricture formation. Hemodynamic monitoring during the procedure indicated no significant changes in parameters. Mean systolic and diastolic arterial pressures at baseline was 128 and 82.4 mm Hg, respectively, and the mean pulse rate was 88 beats per minute. Mean systolic and diastolic arterial pressure at the end of the procedure was 134 and 78.4 mm Hg, respectively, and the mean pulse rate was 76 beats
per minute. None of the patients had transient or new changes from baseline on electrocardiogram. At a mean followup of 10.94 months (range 4 to 65) single OU was successful in 22 patients (69%). Recurrence was noted in 10 of the 32 patients (31%), including 3 of the 16 (19%) in group 2 and 7 of the 16 (44%) in group 1 (p ⫽ 0.126).
DISCUSSION The spongiosum block technique is based on male urethral anatomy. The anterior urethra is composed of urethral epithelium and underlying corpus spongiosum. At the distal end the corpus spongiosum expands to form the glans penis. When lidocaine is injected subcutaneously into the syncytium of the spongiosum of the glans, it is easy for the anesthesia to spread extensively through the venous sinuses into the corpus spongiosum, rapidly anesthetizing the dermal nerve endings in the whole anterior urethra. Using the spongiosum block minor procedures in the anterior urethra on an outpatient basis have several advantages compared with the same procedure under general or spinal anesthesia in the operating room. Mean operative time is decreased significantly, which translates into significantly lower cost. There was a significant difference in operative time in the current study. The risks of general or spinal anesthesia and the common postoperative nausea or headache are avoided. Various local anesthesia techniques include spongiosum,8,9 topical,11–14 transperineal15 and urethrosphincteric16 blocks. In a randomized clinical trial of hemorrhoidectomy using a mixture of local vs general anesthesia Ho et al noted no differences between the 2 groups in operative time, postoperative pain, nausea or vomiting, the pain-free interval after operation, analgesic requirements or patient satisfaction with the anesthesia method.17 The anxiety and discomfort associated with general anesthetic induction are eliminated. Jerjes et al reported that midazolam has proved to be successful for decreasing anxiety and stress preoperatively, perioperatively and postoperatively with no significant effect on vital signs in a healthy patient.18 In addition, the time requirement for the patient or family is decreased because the urologist can perform anestheTable 2. VAS scores immediately postoperatively in 16 patients per group VAS Score
No. Group 1
No. Group 2
p Value
0—No pain 1–3—Mild pain 4–7—Moderate pain 8–10—Severe pain
10 3 3 0
8 7 1 0
0.30 0.07 0.20 —
OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
sia and surgical manipulation during the initial patient office visit. The patient can return to work or school shortly after undergoing the procedure. Propofol (2,6-diisopropylphenol) is an intravenously administered anesthesia with rapid onset of action and a dose dependent degree of anesthetic activity that dissipates rapidly with the discontinuation of drug administration. Propofol is also an antiemetic and it commonly results in clear headed emergence from anesthesia. However, there are important side effects to propofol anesthesia, including respiratory depression, hypotension and myoclonus. Ben-David et al randomized 100 patients scheduled for outpatient knee arthroscopy to local anesthesia plus a titrated intravenous propofol infusion or mini dose spinal anesthesia.19 The group noted that the 2 techniques provided comparable patient satisfaction and efficiency intraoperatively, and during postoperative recovery and discharge home. In the current study of 16 cases spongiosum block anesthesia with oral sedation was effective. Under this anesthesia all patients were treated well using only 1 dose of 1% lidocaine without any other analgesia. In case the procedure is prolonged, lidocaine can be re-administered. Under direct vision Kamal used a diode laser to treat anterior urethral strictures in 21 patients, of whom 3 successfully tolerated local anesthesia with intraurethral lidocaine jelly.20 Table 3 lists some of the studies of various local anesthesia techniques for anterior urethral procedures. In earlier reports topical lidocaine jelly was used. However, Ye and Zhang popularized the spongiosum block for OU and other procedures in the anterior urethra.8 Recently Al-Hunayan et al reported using a transperineal urethrosphincteric block to perform OU.15 They reported that the mean pain score for OU was 1 (range 0 to 5) and 92% of patients reported that analgesia was satisfactory. Using topical anesthesia Altinova and Turkan reported that 89% of patients only had mild pain on a VAS.11 Kreder et al performed OU using topical anesthesia with 2% lidocaine.10 The
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procedure failed in 3 of 18 patients because of severe pain, while 12 experienced no discomfort or only minimal pain. Using a spongiosum block Ye and Zhang reported no pain in 92% of patients8 and in the current study we noted that 94% of patients had no pain or discomfort. To achieve good functional results with low recurrence the full thickness of the fibrous scar should be incised deeply to reach the healthy spongiosum. In our current experience all anterior urethral strictures could be adequately incised to healthy spongiosum using the spongiosum block. Using this block the recurrence rate in the current study was 19% at a mean followup of 44 weeks and 14% at a mean followup of 12 weeks in the study by Ye and Zhang.8 With topical anesthesia Klufio and Quartey reported a 16% recurrence rate at a followup of 12 to 60 weeks13 and Kirchheim et al reported a 5% recurrence rate at a mean followup of 24 weeks (table 3).14 This indicates that the recurrence rate is similar for various local anesthesia techniques. There were no serious adverse effects in the current spongiosum block series. Rapid anesthetic injection may result in slight tingling, light headedness and rarely fits. For this reason it is recommended that a dose of 3 ml 1% lidocaine be injected slowly into the glans. However, the overall dose of 3 ml 1% lidocaine, even if completely absorbed systemically, would not result in any significant side effects.
CONCLUSIONS A spongiosum block with sedation is effective and satisfactory for surgical procedures in the anterior urethra. The anesthetic technique is simple, safe, efficacious and cost-effective. It can be routinely used on an outpatient basis for visual internal urethrotomy in patients with anterior urethral stricture and it is particularly helpful in those with multiple comorbid medical conditions. Using local anesthesia also decreases operative time, resulting in cost saving.
Table 3. Reported series of local anesthesia for optical urethrotomy References 9
Ye et al Altinova and Turkan11 Steenkamp et al12 Klufio and Quartey13 Kirchheim et al14 Al-Hunayan et al15 Present series
No. Pts
Anesthetic Technique
Control
% Recurrence
Followup (wks)
% No–Minimal Pain
21 28 104 51 20 26 16
Spongiosum block Topical Topical Topical Topical Transperineal urethrosphincteric block Spongiosum block
No No No No No No Yes (16 pts)
14 16 45 16 5 Not available 19
Mean 12 Mean 24 Mean 60 12–60 Mean 24 Not available Mean 44
98 89 Not available 85 Not available 88 94
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REFERENCES 1. Jordan GH and Schlossberg SM: Surgery of the penis and urethra. In: Campbell’s Urology, 8th ed. Edited by PC Walsh, AB Retik, ED Vaughan Jr and AJ Wein. Philadelphia: WB Saunders Co 2002; pp 3886 –3952. 2. Wessells H and McAninch JW: Use of free grafts in urethral stricture reconstruction. J Urol 1996; 155: 1912. 3. Krishnamurthi V and Spirnak JP: Endoscopic urethroplasty: an alternative to surgical reconstruction for complete urethral obliteration. Semin Urol 1995; 13: 56.
8. Ye G and Zhang YQ: Optical urethrotomy for anterior urethral stricture under a new local anesthesia: intra-corpus spongiosum anesthesia. Urology 2002; 60: 245. 9. Ye G, Xiang-Wei W, Shan-Hong Y, Yong-Gui Z and Wei-Chi L: Outpatient procedures on the glans and anterior urethra under a new local anaesthesia: intracorpus spongiosum anaesthesia. Asian J Surg 2005; 28: 282. 10. Kreder KJ, Stack R, Trasher JB and Donatucci CF: Direct vision internal urethrotomy using topical anesthesia. Urology 1993; 42: 548.
4. Waterhouse K, Laungani G and Patil U: The surgical repair of membranous urethral strictures: experience with 105 consecutive cases. J Urol 1980; 123: 500.
11. Altinova S and Turkan S: Optical urethrotomy using topical anesthesia. Int Urol Nephrol 2007; 39: 511.
5. Matouschek E: Internal urethrotomy of urethral stricture under-vision; a five-year report. Urol Res 1978; 6: 147.
12. Steenkamp JW, Heyns CF and de Kock ML: Internal urethrotomy versus dilation as treatment for male urethral strictures: a prospective, randomized comparison. J Urol; 57: 98.
6. Gaches CGC, Askhen MH and Dunn M: The role of selective internal urethrotomy in the management of urethral stricture: a multi-centre evaluation. Br J Urol 1979; 51: 579.
13. Klufio GO and Quartey JK: Internal optical urethrotomy: a report of fifty-one cases treated under local anaesthesia. West Afr J Med 1990; 9: 242.
7. Greenland JE, Lynch TH and Wallace DMA: Optical urethrotomy under local urethral anesthesia. Br J Urol 1988; 67: 385.
14. Kirchheim D, Tremann JA and Ansell JS: Transurethral urethrotomy under vision. J Urol 1978; 119: 496.
15. Al-Hunayan A, Kehinde EO, Shihab-Eldeen A, Abdulhalim H and Al-Saraf A: An assessment of the clinical utility of transperineal urethrosphincteric block (TUSB) in outpatient rigid cystoscopy: a single-blind, randomized study. Int Urol Nephrol 2009; 41: 47. 16. Jordan GH and Devine PC: Management of urethral stricture disease. Clin Plast Surg 1988; 15: 493. 17. Ho KS, Eu KW, Heah SM, Seow-Choen F and Chan YW: Randomized clinical trial of haemorrhoidectomy under a mixture of local anaesthesia versus general anaesthesia. Br J Surg 2000 Apr; 87: 410. 18. Jerjes W, Jerjes WK, Swinson B, Kumar S, Leeson R, Wood PJ et al: Midazolam in the reduction of surgical stress: a randomized clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 564. 19. Ben-David B, DeMeo JP, Lucyk C and Solosko D: A comparison of minidose lidocaine-fentanyl spinal anesthesia and local anesthesia/propofol infusion for outpatient knee arthroscopy. Anesth Analg 2001; 93: 319. 20. Kamal BA: The use of the diode laser for treating urethral strictures. BJU Int 2001; 87: 831.
Abbreviations and Acronyms ASA ⫽ American Society of Anesthesiologists OU ⫽ optical internal urethrotomy VAS ⫽ visual analogue scale Submitted for publication August 12, 2008. * Correspondence and requests for reprints: Section of Urology, Department of Surgery, P. O. Box 3500, Stadium Rd, Karachi 74800, Pakistan (telephone: ⫹92 21 486 4778; FAX: ⫹92 21 493 4294; e-mail: [email protected]).
Purpose: Optical urethrotomy is generally performed with the patient under general or major regional anesthesia. We determined the safety and efficacy of optical urethrotomy using a spongiosum block with sedation for anterior urethral stricture in a comparative, nonrandomized study. Materials and Methods: In 32 patients with anterior urethral stricture optical urethrotomy was performed under general/major regional anesthesia in 16 patients (group 1) or a spongiosum block and sedation in 16 (group 2). In group 2 a total of 2 to 3 ml 1% lidocaine were slowly injected into the glans penis. Standard optical urethrotomy was performed immediately with a cold cut knife. Results: The 2 groups were matching in terms of patient age, and stricture cause and length. Optical urethrotomy was successfully completed in all patients in group 1 and in 15 of 16 in group 2. In group 2, 15 patients (94%) had no pain or discomfort. One patient reported moderate discomfort and the procedure was abandoned. In group 2 none of the patients required parental analgesia post procedure. The first year recurrence was not significantly different in the 2 groups (p ⫽ 0.192). The anesthetic effect lasted for about an hour and was satisfactory without any complications. Pain score on the visual analogue scale was not different in the 2 groups. Conclusions: Optical urethrotomy using a spongiosum block with sedation is as safe and effective as using regional or general anesthesia, particularly in patients who are more ill. The shorter operative time in the local anesthesia group could also make it cost-effective. Key Words: penis; urethra; anesthesia, local; urethral stricture; pain
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MALE urethral stricture disease is still a common and challenging problem in urological practice and its management continues to evolve. External trauma is now generally assumed to be the cause of most anterior urethral strictures.1,2 Excellent success rates have been reported for surgical reconstruction but an interest in minimally invasive techniques forces investigators to attempt endourological approaches.3,4
OU is a widely accepted procedure and the treatment is done in approximately 80% of patients with urethral stricture.5 Following recurrence patients are treated with repeat OU, dilation or open urethroplasty.6,7 OU is performed using general or spinal anesthesia.5 Avoidance of anesthesia is desirable for a short procedure that may need to be done many times during a lifetime. OU using local anesthesia is not a standard procedure. Ye
0022-5347/09/1815-2134/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 181, 2134-2138, May 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.01.017
OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
et al described the spongiosum block for OU and other minor urethral procedures.8,9 OU is generally considered ideal for urethral strictures less than 2 cm.10 However, others believe that length is not a limiting factor for OU for anterior urethral strictures using local anesthesia.4 In reported contemporary series various techniques of OU using local anesthesia, including topical analgesia, perineal block and spongiosum block, have been described. However, to our knowledge there is no comparative study of general/major regional anesthesia. We have compared the outcome and safety of OU for anterior urethral stricture with the patient under local and general/regional anesthesia.
MATERIALS AND METHODS A total of 32 patients with anterior urethral stricture that had not been treated previously underwent internal OU, including 16 who received general or major regional anesthesia and 16 who were treated with a spongiosum block with sedation. Following informed consent the patients of 1 (MHA) of the 7 consultant urologists were nonrandomly selected for the spongiosum block. Patients in the control group underwent OU performed during the same period under general/major regional anesthesia, and they met study inclusion and exclusion criteria. Collected data included anatomical location, estimated stricture length on urethrogram, the most probable cause of stricture disease, comorbidities, the duration of recurrence and the type of anesthesia. The diagnosis of urethral stricture was based on symptom scores, clinical history, uroflowmetry and urethrogram. All patients had at least 4 months of followup. Stricture length was considered as 2 cm or greater and 2 cm or less. Procedure time was calculated from cystoscope/ urethrotome introduction to catheterization. Operative time was calculated from the time that the patient was wheeled into the operating room to the time that he was wheeled out. We classified anterior stricture location into 3 anatomical categories, including pendulous, penobulbar and bulbar. The cause of stricture was determined to be inflammatory (lichen sclerosis and sexually transmitted disease), iatrogenic (after transurethral prostate resection or instrumentation, or prolonged catheterization), traumatic or idiopathic. Data were analyzed using SPSS®, version 16. Before the procedure all efforts were made to render patients infection-free. Urine cultures were performed in all patients and confirmatory cultures were obtained after treatment. All patients in group 2 received a spongiosum block to desensitize the anterior urethra and the external urethral sphincter, in addition to 10 ml neutral gel to lubricate the urethra. Supplemental intravenous sedation with 2 to 5 mg midazolam or 20 to 40 mg meperidine were given in patients who were anxious. Patients were placed in the dorsolithotomy position with pulse, blood pressure and electrocardiogram monitored continuously. The genitalia were cleaned with 10% povidone-iodine solution. A rubber penile clamp was applied over the base of the penis and 1% lidocaine solution was injected in the glans penis (see figure). A 27 gauge
2135
Rubber band Spongiosum block technique. Note single layer of gauze applied over base of penis, over which rubber band is applied to achieve venous blockade.
hypodermic needle was used and a dose of 2.5 to 3 ml 1% lidocaine was slowly injected into the glans during 1 minute. To avoid bleeding the glans was squeezed with the swab. The penile clamp was removed after 10 minutes if it interfered with advancement of the urethrotome. Under direct retrograde vision we incised the stricture at the 12 o’clock position. After complete incision of the stricture area while sparing healthy mucosa and confirming free passage of the cystoscope into the bladder, an indwelling 16Fr to 18Fr silicone urethral catheter was left in place for 5 to 7 days. A VAS was used to evaluate pain. The VAS in each group was completed in the recovery room within 30 minutes after surgery. Least and worst pain status were graded as 1 and 10, respectively, and the pain experienced by the patient was graded accordingly. For practical purposes VAS scores were grouped into 4 categories, including 0 —no pain, 1 to 3—mild pain, 4 to 7—moderate pain and 8 to 10 —severe pain.
RESULTS A total of 32 anterior urethral strictures were treated during the study period. Patient age was between 17 and 83 years (median ⫾ SD 59.6 ⫾ 17.30) in the 2 groups. Median age in groups 1 and 2 was 51 ⫾ 17 and 70 ⫾ 8.4 years, respectively. Mean stricture length in groups 1 and 2 was 2.2 ⫾ 1 and 3.1 ⫾ 1 cm, respectively (p ⫽ 0.14). The etiology and anatomical location of the stricture was not different in the 2 groups (table 1). However, ASA status indicated that group 2 had a higher proportion of ASA III-IV patients (p ⫽ 0.04). In addition to higher ASA status, patients in group 2 were older than the patients in group 1. Using the spongiosum block with lidocaine internal urethrotomy under direct vision was successfully completed in 15 of 16 patients (94%). Mean procedure time was 17 minutes in group 1 and 11 minutes in group 2. Mean operative time in group 1
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OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
Table 1. Stricture site, length and etiology, and ASA status in 16 patients per group
Mean ⫾ SD stricture length (cm) No. site: Penile Penobulbar Bulbar No. etiology: Idiopathic Iatrogenic Inflammatory Traumatic No. ASA status: I II III IV
Group 1
Group 2
p Value
2⫾1
3⫾1
0.14
4 9 3
6 6 4
0.56
7 7 1 1
2 8 3 3
0.5
5 10 1 —
4
0.05 —
5 7
was 42.5 vs 21 minutes, which was significantly greater (p ⫽ 0.003). Table 2 shows the pain experienced by patients and reported on the VAS. All patients were premedicated with 2.5 mg midazolam orally. One patient in group 2 required additional meperidine during the procedure. He had moderate but tolerable discomfort when the most proximal part of the bulbar stricture was incised and the optical urethrotome was advanced into posterior urethra. However, due to pain and a dense stricture the procedure was abandoned. Mean stricture length was 2.66 cm (range 1.1 to 4). Bulbar strictures were more prevalent than strictures at the pendulous urethra or penobulbar junction (15 patients or 47% vs 10 or 31% and 7 or 22%, respectively). In three-quarters of the patients stricture etiology was idiopathic (9 or 28%) or iatrogenic (15 or 47%), whereas in a quarter the etiology was secondary to an inflammatory pathological condition. Distal strictures were more often related to inflammatory conditions than bulbar strictures, for which trauma was a more prevalent cause (table 1). Traumatic strictures tended to be much shorter than inflammatory strictures (mean 2.1 vs 3.4 cm, p ⫽ 0.05). Cystoscopy accounted for most iatrogenic strictures (table 2). However, transurethral surgery and traumatic or prolonged catheterization after a severe medical illness or other comorbidities were also frequently related to stricture formation. Hemodynamic monitoring during the procedure indicated no significant changes in parameters. Mean systolic and diastolic arterial pressures at baseline was 128 and 82.4 mm Hg, respectively, and the mean pulse rate was 88 beats per minute. Mean systolic and diastolic arterial pressure at the end of the procedure was 134 and 78.4 mm Hg, respectively, and the mean pulse rate was 76 beats
per minute. None of the patients had transient or new changes from baseline on electrocardiogram. At a mean followup of 10.94 months (range 4 to 65) single OU was successful in 22 patients (69%). Recurrence was noted in 10 of the 32 patients (31%), including 3 of the 16 (19%) in group 2 and 7 of the 16 (44%) in group 1 (p ⫽ 0.126).
DISCUSSION The spongiosum block technique is based on male urethral anatomy. The anterior urethra is composed of urethral epithelium and underlying corpus spongiosum. At the distal end the corpus spongiosum expands to form the glans penis. When lidocaine is injected subcutaneously into the syncytium of the spongiosum of the glans, it is easy for the anesthesia to spread extensively through the venous sinuses into the corpus spongiosum, rapidly anesthetizing the dermal nerve endings in the whole anterior urethra. Using the spongiosum block minor procedures in the anterior urethra on an outpatient basis have several advantages compared with the same procedure under general or spinal anesthesia in the operating room. Mean operative time is decreased significantly, which translates into significantly lower cost. There was a significant difference in operative time in the current study. The risks of general or spinal anesthesia and the common postoperative nausea or headache are avoided. Various local anesthesia techniques include spongiosum,8,9 topical,11–14 transperineal15 and urethrosphincteric16 blocks. In a randomized clinical trial of hemorrhoidectomy using a mixture of local vs general anesthesia Ho et al noted no differences between the 2 groups in operative time, postoperative pain, nausea or vomiting, the pain-free interval after operation, analgesic requirements or patient satisfaction with the anesthesia method.17 The anxiety and discomfort associated with general anesthetic induction are eliminated. Jerjes et al reported that midazolam has proved to be successful for decreasing anxiety and stress preoperatively, perioperatively and postoperatively with no significant effect on vital signs in a healthy patient.18 In addition, the time requirement for the patient or family is decreased because the urologist can perform anestheTable 2. VAS scores immediately postoperatively in 16 patients per group VAS Score
No. Group 1
No. Group 2
p Value
0—No pain 1–3—Mild pain 4–7—Moderate pain 8–10—Severe pain
10 3 3 0
8 7 1 0
0.30 0.07 0.20 —
OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
sia and surgical manipulation during the initial patient office visit. The patient can return to work or school shortly after undergoing the procedure. Propofol (2,6-diisopropylphenol) is an intravenously administered anesthesia with rapid onset of action and a dose dependent degree of anesthetic activity that dissipates rapidly with the discontinuation of drug administration. Propofol is also an antiemetic and it commonly results in clear headed emergence from anesthesia. However, there are important side effects to propofol anesthesia, including respiratory depression, hypotension and myoclonus. Ben-David et al randomized 100 patients scheduled for outpatient knee arthroscopy to local anesthesia plus a titrated intravenous propofol infusion or mini dose spinal anesthesia.19 The group noted that the 2 techniques provided comparable patient satisfaction and efficiency intraoperatively, and during postoperative recovery and discharge home. In the current study of 16 cases spongiosum block anesthesia with oral sedation was effective. Under this anesthesia all patients were treated well using only 1 dose of 1% lidocaine without any other analgesia. In case the procedure is prolonged, lidocaine can be re-administered. Under direct vision Kamal used a diode laser to treat anterior urethral strictures in 21 patients, of whom 3 successfully tolerated local anesthesia with intraurethral lidocaine jelly.20 Table 3 lists some of the studies of various local anesthesia techniques for anterior urethral procedures. In earlier reports topical lidocaine jelly was used. However, Ye and Zhang popularized the spongiosum block for OU and other procedures in the anterior urethra.8 Recently Al-Hunayan et al reported using a transperineal urethrosphincteric block to perform OU.15 They reported that the mean pain score for OU was 1 (range 0 to 5) and 92% of patients reported that analgesia was satisfactory. Using topical anesthesia Altinova and Turkan reported that 89% of patients only had mild pain on a VAS.11 Kreder et al performed OU using topical anesthesia with 2% lidocaine.10 The
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procedure failed in 3 of 18 patients because of severe pain, while 12 experienced no discomfort or only minimal pain. Using a spongiosum block Ye and Zhang reported no pain in 92% of patients8 and in the current study we noted that 94% of patients had no pain or discomfort. To achieve good functional results with low recurrence the full thickness of the fibrous scar should be incised deeply to reach the healthy spongiosum. In our current experience all anterior urethral strictures could be adequately incised to healthy spongiosum using the spongiosum block. Using this block the recurrence rate in the current study was 19% at a mean followup of 44 weeks and 14% at a mean followup of 12 weeks in the study by Ye and Zhang.8 With topical anesthesia Klufio and Quartey reported a 16% recurrence rate at a followup of 12 to 60 weeks13 and Kirchheim et al reported a 5% recurrence rate at a mean followup of 24 weeks (table 3).14 This indicates that the recurrence rate is similar for various local anesthesia techniques. There were no serious adverse effects in the current spongiosum block series. Rapid anesthetic injection may result in slight tingling, light headedness and rarely fits. For this reason it is recommended that a dose of 3 ml 1% lidocaine be injected slowly into the glans. However, the overall dose of 3 ml 1% lidocaine, even if completely absorbed systemically, would not result in any significant side effects.
CONCLUSIONS A spongiosum block with sedation is effective and satisfactory for surgical procedures in the anterior urethra. The anesthetic technique is simple, safe, efficacious and cost-effective. It can be routinely used on an outpatient basis for visual internal urethrotomy in patients with anterior urethral stricture and it is particularly helpful in those with multiple comorbid medical conditions. Using local anesthesia also decreases operative time, resulting in cost saving.
Table 3. Reported series of local anesthesia for optical urethrotomy References 9
Ye et al Altinova and Turkan11 Steenkamp et al12 Klufio and Quartey13 Kirchheim et al14 Al-Hunayan et al15 Present series
No. Pts
Anesthetic Technique
Control
% Recurrence
Followup (wks)
% No–Minimal Pain
21 28 104 51 20 26 16
Spongiosum block Topical Topical Topical Topical Transperineal urethrosphincteric block Spongiosum block
No No No No No No Yes (16 pts)
14 16 45 16 5 Not available 19
Mean 12 Mean 24 Mean 60 12–60 Mean 24 Not available Mean 44
98 89 Not available 85 Not available 88 94
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OPTICAL URETHROTOMY USING SPONGIOSUM BLOCK WITH SEDATION
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15. Al-Hunayan A, Kehinde EO, Shihab-Eldeen A, Abdulhalim H and Al-Saraf A: An assessment of the clinical utility of transperineal urethrosphincteric block (TUSB) in outpatient rigid cystoscopy: a single-blind, randomized study. Int Urol Nephrol 2009; 41: 47. 16. Jordan GH and Devine PC: Management of urethral stricture disease. Clin Plast Surg 1988; 15: 493. 17. Ho KS, Eu KW, Heah SM, Seow-Choen F and Chan YW: Randomized clinical trial of haemorrhoidectomy under a mixture of local anaesthesia versus general anaesthesia. Br J Surg 2000 Apr; 87: 410. 18. Jerjes W, Jerjes WK, Swinson B, Kumar S, Leeson R, Wood PJ et al: Midazolam in the reduction of surgical stress: a randomized clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 564. 19. Ben-David B, DeMeo JP, Lucyk C and Solosko D: A comparison of minidose lidocaine-fentanyl spinal anesthesia and local anesthesia/propofol infusion for outpatient knee arthroscopy. Anesth Analg 2001; 93: 319. 20. Kamal BA: The use of the diode laser for treating urethral strictures. BJU Int 2001; 87: 831.