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Endoscopic internal urethrotomy for treatment of urethral strictures Midterm survey
ENDOSCOPIC TREATMENT
INTERNAL
URETHROTOMY
OF URETHRAL
FOR
STRICTURES
Midterm Survey
RICHARD
0.
FRANCOIS CHRISTIAN From Paris,
FOURCADE,
MATHIEU,
M.D.
CHATELAIN,
the Clinique France
M.D.
Urologique
ALAIN
JARDIN,
FRANCOIS
M.D.
RENti
KUSS,
M.D.
RICHARD,
M.D.
M.D.
de la Pitie,
ABSTRACT Success in the management of urethral strictures can be claimed only after many years, patients sometimes faring well for ten years or more before suffering a recurrence. We used endoscopic urethrotomy as primary treatment for a variety of urethral strictures in 123 patients. Follow-up is over two years fw 63 patients and more than jiue years for 18. Over-all success rate at fiue years was 76 per cent. Failures are twice as frequent in strictures, regardless of their origin, involving the anterior urethra than in the bulbar or posterior urethra. Two-thirds occurred in the first year of follow-up, but, as in other techniques, recurrence can occur after four years.
Surgery for urethral strictures is difficult and results are disappointing, with a high rate of early and late recurrence. Initiated by Civiale,’ in the first half of the nineteenth century, internal urethrotomy was developed first in France by Maisonneuve’ and then in the United States by Otis. 3 It was one of the many methods used by urologists to treat urethral strictures. The development by Sachse in 19714 of an endoscopic sharp-knifed urethrotome gave new impetus, at least in Europe, to a semiLaser urethrotomy has abandoned technique. not yet gained enough clinical use for comparison. 5 Since endoscopic urethrotomy is easy to perform, is well accepted by patients, and has a minimal or no hospital stay, will this technique relieve urologists of the problems of open (often two-stage) urethral surgery? Only longterm patient follow-up will answer this question. Herein we report “midterm” experience with this technique.
UROLOGY
/ JULY 1981
/
VOLUMEXVIII.NUMBER
1
Material
and Methods
We started performing endoscopic urethrotomy in 1973 and reviewed the charts of 123 patients operated on from that date to January 1, 1979. All but 2 patients were males. Ages ranged between twelve and eighty-nine years; patients between sixty and eighty-nine years represented 52 per cent of the total. Endoscopic urethrostomy was used as the primary procedure for the treatment of urethral strictures, regardless of their origin, length,
TABLE I. Origin of strictures Origin Inflammatory Iatrogenic Traumatic Congenital Other or unknown
Number 64 28 21 5 5
33
‘$ OF SUCCESS TABLE II.
Location of strictures Number
Location
14 71 21 15 2
Anterior Bulbar Posterior Long or multilocular Female
loot
TO \ 80
?? \
?? \
‘1.
’
;
70 and location. Origin of the strictures is summarized in Table I. If inflammation is the main cause for urethral stricture, 22 per cent are iatrogenic. These include stenosis after simple catheterization (14 cases) and after prostatic surgery, either open or transurethral. Location of the strictures is summarized in Table II and is similar to other series.6-8 Proper follow-up of patients is always difficult, and we have documented follow-ups of more than one year for only 76 patients, more than two years for 63, and more than five years for 18. Technique The surgical technique is similar to that and others. 6,g Careful described by Sachse4 evaluation of the stricture is made by preoperative retrograde and antegrade urethrography to determine the location and length of the stricture. Anesthesia is usually spinal; general or topical anesthesia is used only when spinal anesthesia is contraindicated. Urethrotomy is performed with a sharp lancet-shaped blade, the tip of which is inserted into the dark spot indicating the urethral lumen. Cutting is done precisely at the 12-o’clock position by gently moving the whole apparatus en bloc, until smooth structures are reached. If the stricture is longer than the blade length (i.e., 1.5 cm.), the urethrotome is pushed through the already cut urethra and the same procedure is undertaken. In these cases only, a ureteral catheter is useful to avoid false passages. When the urethrotome can be passed through the stricture, careful urethroscopy will be done; sometimes the ditch between corpora cavernosa must be deepened so that the urethrotome moves freely. The “half-moon” blade can now be used if fibrous scar tissue is too difficult to cut. This blade should never be pushed forward, even with a guide, for fear of false passage. Insertion of a 20-F Foley catheter should then be easy without the help of an insertion device. If not, some additional cutting is done. The catheter is left in place for various periods of
34
60
1
FIGURE 1. all results.
2
4
3
Endoscopic
5
internal urethrotmny:
YExs ouer-
time according to the surgeon’s preference, but a previous study lo has shown no difference between patients having the catheter less than five days or more than fifteen. At this time there is general agreement on a three-day catheter period. We have no experience with hydraulic dilatation’ or steroids, either orally or in situ.6 Results The following criteria were used in the evaluation of our patients. Good result is obtained when voiding is easy, with a minimal flow rate of 15 ml./sec., and no further dilatation or surgery is required. Failure is a patient who needs dilatation or surgery. However, cases who have had false passages, mainly in the early years of the series, and multiple urethrotomies are only entered in the series after their urethrotomy is successful. We did not use urethrography as a criterion since there is sometimes a difference between the voiding pattern and the radiologic pattern. Moreover, we could not obtain follow-up x-ray films for all our patients. One of us (FM) checks his results passing a 20-F Benique; his patients have been counted as failures only when difficult passage was stated on the chart or when the procedure was done more than once a year. With these criteria, our over-all results are: 12 of 123 operations failed within the first six months, 1 before the first year of survey, and 6 others between the second and fourth year of follow-up. Adjusting for patients lost to follow-up, our success rate is 76 per cent at five years, and 68 per cent of the failures occurred in the first year (Fig. 1).
UROLOGY / JULY 1981
/
VOLUMEXVIII, NUMBER1
Results compared with location of stricture
TABLE IV.
Results compared with origin of stricture
TABLE III.
(%)
Results Faihres Before 1 Yr.
Failures After 1 Yr.
54 (86) 23 (82) 17 (80) 5 5
7 3 3 0 0
3 2 1 0 0
Success Origin Inflammatory Iatrogenic Traumatic Congenital Unknown
Multilocular Bulbar Posterior Female
Comment Can endoscopic urethrotomy be used as the primary procedure in every case of urethral stricture? If the origin of the stricture does not affect the outcome, it is obvious that the percentage of failures is twice as great for long strictures and for those which are situated in the anterior, penile urethra (Table IV). Moreover, urethrotomy in this location is difficult to perform since there is no “counter resistance” to the blade and enhances false passage and fluid extravasation. We have now abandoned endoscopic urethrotomy for such strictures and prefer one- or two-stage urethroplasty. Can endoscopic urethrotomy be used in the treatment of late traumatic posterior urethral strictures? When traumatic rupture of posterior
JULY 1981 / VOLUME
XVIII, NUMBER
Location
Anterior
Although these results appear to be better than those published in other French series, they are comparable to German series.7’8 Our criteria for success might be less “severe,” but they take into account our patients’ satisfaction with the operation. Failures as compared with origin and location of the stricture are summarized in Tables III and IV. Immediate morbidity appeared to be rare and unimportant. No death occurred in this series. Isotonic saline used as washing fluid caused little discomfort if it happened to infiltrate the scrotum and perineum (9 cases). Hemorrhage (5 cases) was always benign and ceased after a few hours with a mild compressive dressing. Septic complications included epididymitis in 2 cases and postoperative bacteremia in 3. However, a recent study in our institution i1 showed 70-per cent positive intraoperative blood cultures in patients with preoperative infected urine when the blood sample was taken during the “cutting movements” of an uneventful urethrotomy. Transient shock and hypotension were then found in 20 per cent.
UROLOGY i
Success
1
(%) 10 11 62 19 2
Results Failures Before 1 Yr.
Failures After 1 Yr.
3 2 6 1 0
1 2 3 1 0
(71) (73) (87) (W
urethra has not been repaired within the first week there is considerable fibrosis and often a gap between the extremities. Endoscopic urethrotomy has failed in our 2 such cases, and segmental resection is our procedure of choice. ‘* However, we performed 19 endoscopic urethrotomies for secondary strictures in the follow-up of such resections or urethroplasties, with 13 successes. There is always the fear of cutting “a little too high” in the sphincter region, but none of our patients experienced postoperative incontinence. Failures were mainly due to hypertrophic fibrous calluses, and we believe endoscopic resection of the urethral callus can be an alternative to new open surgery, room for the resectoscope being made first by the urethrotome. What is the future of the urethrotomies that failed? Endoscopic urethrotomy can be repeated easily, and 12 of our failure cases have had new urethrotomies: 9 had two, 2 had three more, and I had six more. In this case we consider that urethrotomy, performed as an outpatient procedure, is much like a “visual dilatation.” However, septic complications in such patients are a hazard, and specific antibiotics are used prior to surgery when the urine culture is positive. The remainder of the patients with a “failed” urethrotomy are either operated on or regularly dilated (5 cases). These dilatations are always done on an outpatient basis, and since we started endoscopic urethrotomy, no urethral dilatations are done under anesthesia in the clinic. Conclusion Technically easy to perform after a little training, needing minimal or no hospital stay, with a low immediate morbidity, endoscopic urethrotomy would be the first choice treatment for urethral strictures if it were always successful. This is not quite the case, but its immediate
35
or late results are by no means worse than those of segmental resection or of various urethroplasties. Therefore, we use endoscopic urethrotomy as a primary procedure for the treatment of bulbar or posterior urethral strictures, leaving a fresh perineum to undertake more complicated one- or two-stage operations in our 24-per cent endoscopic failures. Service de Chirurgie Urologique Centre Hospitalier d’Auxerre F 89011, Auxerre, France (DR. FOURCADE) References 1. Attwater HL: The history of urethral stricture, Br. J. Ural. 15: 39 (1943). 2. Maisonneuve J: Derniers perfectionnements apportks B I’urethrotomie interne pour la cure radicale et instantanke des rbtr&issements de l’urkthre, Paris, Delahaye, 1879.
36
3. Otis FN: Remarks on strictures of the urethra of extreme caliber with cases and description of instruments for their treatment, N.Y. Med. J. 15: 152 (1872). 4. Sachse HE: Zur Behandlung der harnorenstrikturdie transurethrale schlitzung unter sicht mit sharfem schnitt, Fortsch. Med. 92: 12 (1974). 5. Rothauge CF: Urethrotomic recanalization of urethral stenosis using argon laser, Urology 16: 2 (19‘30). 6. Gaches CGC, et al: The role of selective internal urethrotomy in the management of urethral stricture, Br. J. Ural. 51: 579 (1979). 7. Matouschek E: Internal urethrotomy under vision, Urol. Res. 6: 147 (1978). 8. Sachse HE: Transurethral cold knife urethrotomy, XVII Congr. Sot. Int. Urol., Paris, 1979, p. 262. 9. Matouschek E, and Michaelis WE: iiber die transurethrale spaltung van ham&en stikturen unter endoscopiche kontrolle, Urol. Int. 30: 266 (1975). 10. Fourcade RO, et al: L’urethrotomie interne sous contrble visuel: renouveau d’une technique ancienne, Nouv. Presse Med. 7: 2960 (1978). 11. Baud F, et al: Bactbriemies per operatoires en Chirurgie urologique endoscopique, Intensive Care (in press). 12. Chatelain C, et al: Segmental urethrectomy and urethrography of fresh and late traumatic urethral lesions, Eur. Ural. 1: 126 (1975).
UROLOGY
/
JULY
1981
/
VOLUME
XVIII,
NUMBER
1
INTERNAL
URETHROTOMY
OF URETHRAL
FOR
STRICTURES
Midterm Survey
RICHARD
0.
FRANCOIS CHRISTIAN From Paris,
FOURCADE,
MATHIEU,
M.D.
CHATELAIN,
the Clinique France
M.D.
Urologique
ALAIN
JARDIN,
FRANCOIS
M.D.
RENti
KUSS,
M.D.
RICHARD,
M.D.
M.D.
de la Pitie,
ABSTRACT Success in the management of urethral strictures can be claimed only after many years, patients sometimes faring well for ten years or more before suffering a recurrence. We used endoscopic urethrotomy as primary treatment for a variety of urethral strictures in 123 patients. Follow-up is over two years fw 63 patients and more than jiue years for 18. Over-all success rate at fiue years was 76 per cent. Failures are twice as frequent in strictures, regardless of their origin, involving the anterior urethra than in the bulbar or posterior urethra. Two-thirds occurred in the first year of follow-up, but, as in other techniques, recurrence can occur after four years.
Surgery for urethral strictures is difficult and results are disappointing, with a high rate of early and late recurrence. Initiated by Civiale,’ in the first half of the nineteenth century, internal urethrotomy was developed first in France by Maisonneuve’ and then in the United States by Otis. 3 It was one of the many methods used by urologists to treat urethral strictures. The development by Sachse in 19714 of an endoscopic sharp-knifed urethrotome gave new impetus, at least in Europe, to a semiLaser urethrotomy has abandoned technique. not yet gained enough clinical use for comparison. 5 Since endoscopic urethrotomy is easy to perform, is well accepted by patients, and has a minimal or no hospital stay, will this technique relieve urologists of the problems of open (often two-stage) urethral surgery? Only longterm patient follow-up will answer this question. Herein we report “midterm” experience with this technique.
UROLOGY
/ JULY 1981
/
VOLUMEXVIII.NUMBER
1
Material
and Methods
We started performing endoscopic urethrotomy in 1973 and reviewed the charts of 123 patients operated on from that date to January 1, 1979. All but 2 patients were males. Ages ranged between twelve and eighty-nine years; patients between sixty and eighty-nine years represented 52 per cent of the total. Endoscopic urethrostomy was used as the primary procedure for the treatment of urethral strictures, regardless of their origin, length,
TABLE I. Origin of strictures Origin Inflammatory Iatrogenic Traumatic Congenital Other or unknown
Number 64 28 21 5 5
33
‘$ OF SUCCESS TABLE II.
Location of strictures Number
Location
14 71 21 15 2
Anterior Bulbar Posterior Long or multilocular Female
loot
TO \ 80
?? \
?? \
‘1.
’
;
70 and location. Origin of the strictures is summarized in Table I. If inflammation is the main cause for urethral stricture, 22 per cent are iatrogenic. These include stenosis after simple catheterization (14 cases) and after prostatic surgery, either open or transurethral. Location of the strictures is summarized in Table II and is similar to other series.6-8 Proper follow-up of patients is always difficult, and we have documented follow-ups of more than one year for only 76 patients, more than two years for 63, and more than five years for 18. Technique The surgical technique is similar to that and others. 6,g Careful described by Sachse4 evaluation of the stricture is made by preoperative retrograde and antegrade urethrography to determine the location and length of the stricture. Anesthesia is usually spinal; general or topical anesthesia is used only when spinal anesthesia is contraindicated. Urethrotomy is performed with a sharp lancet-shaped blade, the tip of which is inserted into the dark spot indicating the urethral lumen. Cutting is done precisely at the 12-o’clock position by gently moving the whole apparatus en bloc, until smooth structures are reached. If the stricture is longer than the blade length (i.e., 1.5 cm.), the urethrotome is pushed through the already cut urethra and the same procedure is undertaken. In these cases only, a ureteral catheter is useful to avoid false passages. When the urethrotome can be passed through the stricture, careful urethroscopy will be done; sometimes the ditch between corpora cavernosa must be deepened so that the urethrotome moves freely. The “half-moon” blade can now be used if fibrous scar tissue is too difficult to cut. This blade should never be pushed forward, even with a guide, for fear of false passage. Insertion of a 20-F Foley catheter should then be easy without the help of an insertion device. If not, some additional cutting is done. The catheter is left in place for various periods of
34
60
1
FIGURE 1. all results.
2
4
3
Endoscopic
5
internal urethrotmny:
YExs ouer-
time according to the surgeon’s preference, but a previous study lo has shown no difference between patients having the catheter less than five days or more than fifteen. At this time there is general agreement on a three-day catheter period. We have no experience with hydraulic dilatation’ or steroids, either orally or in situ.6 Results The following criteria were used in the evaluation of our patients. Good result is obtained when voiding is easy, with a minimal flow rate of 15 ml./sec., and no further dilatation or surgery is required. Failure is a patient who needs dilatation or surgery. However, cases who have had false passages, mainly in the early years of the series, and multiple urethrotomies are only entered in the series after their urethrotomy is successful. We did not use urethrography as a criterion since there is sometimes a difference between the voiding pattern and the radiologic pattern. Moreover, we could not obtain follow-up x-ray films for all our patients. One of us (FM) checks his results passing a 20-F Benique; his patients have been counted as failures only when difficult passage was stated on the chart or when the procedure was done more than once a year. With these criteria, our over-all results are: 12 of 123 operations failed within the first six months, 1 before the first year of survey, and 6 others between the second and fourth year of follow-up. Adjusting for patients lost to follow-up, our success rate is 76 per cent at five years, and 68 per cent of the failures occurred in the first year (Fig. 1).
UROLOGY / JULY 1981
/
VOLUMEXVIII, NUMBER1
Results compared with location of stricture
TABLE IV.
Results compared with origin of stricture
TABLE III.
(%)
Results Faihres Before 1 Yr.
Failures After 1 Yr.
54 (86) 23 (82) 17 (80) 5 5
7 3 3 0 0
3 2 1 0 0
Success Origin Inflammatory Iatrogenic Traumatic Congenital Unknown
Multilocular Bulbar Posterior Female
Comment Can endoscopic urethrotomy be used as the primary procedure in every case of urethral stricture? If the origin of the stricture does not affect the outcome, it is obvious that the percentage of failures is twice as great for long strictures and for those which are situated in the anterior, penile urethra (Table IV). Moreover, urethrotomy in this location is difficult to perform since there is no “counter resistance” to the blade and enhances false passage and fluid extravasation. We have now abandoned endoscopic urethrotomy for such strictures and prefer one- or two-stage urethroplasty. Can endoscopic urethrotomy be used in the treatment of late traumatic posterior urethral strictures? When traumatic rupture of posterior
JULY 1981 / VOLUME
XVIII, NUMBER
Location
Anterior
Although these results appear to be better than those published in other French series, they are comparable to German series.7’8 Our criteria for success might be less “severe,” but they take into account our patients’ satisfaction with the operation. Failures as compared with origin and location of the stricture are summarized in Tables III and IV. Immediate morbidity appeared to be rare and unimportant. No death occurred in this series. Isotonic saline used as washing fluid caused little discomfort if it happened to infiltrate the scrotum and perineum (9 cases). Hemorrhage (5 cases) was always benign and ceased after a few hours with a mild compressive dressing. Septic complications included epididymitis in 2 cases and postoperative bacteremia in 3. However, a recent study in our institution i1 showed 70-per cent positive intraoperative blood cultures in patients with preoperative infected urine when the blood sample was taken during the “cutting movements” of an uneventful urethrotomy. Transient shock and hypotension were then found in 20 per cent.
UROLOGY i
Success
1
(%) 10 11 62 19 2
Results Failures Before 1 Yr.
Failures After 1 Yr.
3 2 6 1 0
1 2 3 1 0
(71) (73) (87) (W
urethra has not been repaired within the first week there is considerable fibrosis and often a gap between the extremities. Endoscopic urethrotomy has failed in our 2 such cases, and segmental resection is our procedure of choice. ‘* However, we performed 19 endoscopic urethrotomies for secondary strictures in the follow-up of such resections or urethroplasties, with 13 successes. There is always the fear of cutting “a little too high” in the sphincter region, but none of our patients experienced postoperative incontinence. Failures were mainly due to hypertrophic fibrous calluses, and we believe endoscopic resection of the urethral callus can be an alternative to new open surgery, room for the resectoscope being made first by the urethrotome. What is the future of the urethrotomies that failed? Endoscopic urethrotomy can be repeated easily, and 12 of our failure cases have had new urethrotomies: 9 had two, 2 had three more, and I had six more. In this case we consider that urethrotomy, performed as an outpatient procedure, is much like a “visual dilatation.” However, septic complications in such patients are a hazard, and specific antibiotics are used prior to surgery when the urine culture is positive. The remainder of the patients with a “failed” urethrotomy are either operated on or regularly dilated (5 cases). These dilatations are always done on an outpatient basis, and since we started endoscopic urethrotomy, no urethral dilatations are done under anesthesia in the clinic. Conclusion Technically easy to perform after a little training, needing minimal or no hospital stay, with a low immediate morbidity, endoscopic urethrotomy would be the first choice treatment for urethral strictures if it were always successful. This is not quite the case, but its immediate
35
or late results are by no means worse than those of segmental resection or of various urethroplasties. Therefore, we use endoscopic urethrotomy as a primary procedure for the treatment of bulbar or posterior urethral strictures, leaving a fresh perineum to undertake more complicated one- or two-stage operations in our 24-per cent endoscopic failures. Service de Chirurgie Urologique Centre Hospitalier d’Auxerre F 89011, Auxerre, France (DR. FOURCADE) References 1. Attwater HL: The history of urethral stricture, Br. J. Ural. 15: 39 (1943). 2. Maisonneuve J: Derniers perfectionnements apportks B I’urethrotomie interne pour la cure radicale et instantanke des rbtr&issements de l’urkthre, Paris, Delahaye, 1879.
36
3. Otis FN: Remarks on strictures of the urethra of extreme caliber with cases and description of instruments for their treatment, N.Y. Med. J. 15: 152 (1872). 4. Sachse HE: Zur Behandlung der harnorenstrikturdie transurethrale schlitzung unter sicht mit sharfem schnitt, Fortsch. Med. 92: 12 (1974). 5. Rothauge CF: Urethrotomic recanalization of urethral stenosis using argon laser, Urology 16: 2 (19‘30). 6. Gaches CGC, et al: The role of selective internal urethrotomy in the management of urethral stricture, Br. J. Ural. 51: 579 (1979). 7. Matouschek E: Internal urethrotomy under vision, Urol. Res. 6: 147 (1978). 8. Sachse HE: Transurethral cold knife urethrotomy, XVII Congr. Sot. Int. Urol., Paris, 1979, p. 262. 9. Matouschek E, and Michaelis WE: iiber die transurethrale spaltung van ham&en stikturen unter endoscopiche kontrolle, Urol. Int. 30: 266 (1975). 10. Fourcade RO, et al: L’urethrotomie interne sous contrble visuel: renouveau d’une technique ancienne, Nouv. Presse Med. 7: 2960 (1978). 11. Baud F, et al: Bactbriemies per operatoires en Chirurgie urologique endoscopique, Intensive Care (in press). 12. Chatelain C, et al: Segmental urethrectomy and urethrography of fresh and late traumatic urethral lesions, Eur. Ural. 1: 126 (1975).
UROLOGY
/
JULY
1981
/
VOLUME
XVIII,
NUMBER
1