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Endoscopic Management of Traumatic Posterior Urethral Stricture: Early Results and Followup
~~2-5347/97/1571-0095$03.00/0
T H E JOURNAL
Vol. 157,95-97,January 1997 Printed in U S A
OF U R O L I K Y
Copyright 0 1997 by AMERICANUROLOCICAL ASSOCIATION, INC.
ENDOSCOPIC MANAGEMENT OF TRAUMATIC POSTERIOR URETHRAL STRICTURE: EARLY RESULTS AND FOLLOWUP M E S H C. GOEL, MAYANK KUMAR AND
RAKESH KAPOOR
From the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
ABSTRACT
Purpose: We assessed the outcome of core through internal urethrotomy for traumatic posterior urethral stricture, and reviewed the followup results of these patients. Materials and Methods: During the last 4 years 13 patients with a stricture up to 2 cm. long underwent core through internal urethrotomy with C-arm fluoroscopy guidance and an orientation in 2 planes. Retrograde urethrotomy was performed and an 18F Foley catheter was left indwelling for 4 weeks, after which urethrotomy was repeated. All patients were advised to perform clean intermittent self-catheterization for urethral calibration and dilation. Outcome was defined as class 1 - 3 patients who required 2 or fewer urethrotomies with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3-5 who required 3 or more urethrotomies. Results: Of the 13 patients 8 (61%)did well after a mean followup of 17.7 months. The 3 patients with a class 1 outcome did well, while 2 of 5 with a class 2 outcome required repeat urethrotomy during followup. Of the 5 patients (39%) with a class 3 outcome in whom core through internal urethrotomy failed 3 required open surgery and 2 were lost to followup. Recurrence rate was 69% at 3 months and 25% at 12 months after the initial procedure. No patient was incontinent at last followup. Two patients had significant hematuria postoperatively, which resolved with conservative treatment. Conclusions: Endoscopic treatment should be considered the first line procedure for all posttraumatic posterior urethral strictures. The morbidity of open surgery can be avoided in 61%of patients. Hospital stay, loss of work, morbidity and related complications are also markedly decreased with endoscopic therapy. KEY WORDS:endoscopy, urethra,urethral stricture, wounds and iqjuries
Treatment of posterior urethral stricture is difficult and controversial.1.2 Methods to maintain urethral continuity include transpubic,3 perineal? and combined perineal and suprapubics approaches performed in 1 or 2 stages,6 or free grafts with good success rates. However, these major operations are invariably associated with morbidity, prolonged hospital stay, impotence and a path of no return after failure.s6 Sachse first attempted direct vision internal urethrotomy in patients with impassable strictures.' The slow evolution of endoscopic methods for posterior urethral stricture included cutting to the light,s resecting to the lights or core through internal urethrotomy.10 Anecdotal reports regarding the outcome of endoscopic treatment have appeared in the literature.8-10 However, the most common problem is the need for repeat urethrotomy or prolonged clean intermittent selfcatheterization. Furthermore, the large number of endoscopic methods described indicates the controversy regarding endoscopic treatment of posterior urethral strictures. Endoscopic core through internal urethrotomy achieves moderate results with minimal morbidity but the long-term outcome of these patients is unknown.8-loInternal urethrotomy has been reserved for short diaphanous strictures or those in which a lumen is noted.11 Associated major complications with longer strictures are contraindications to endoscopic treatment. However, endoscopy for complete urethral obliteration remains controversial. We describe the longterm outcome of endoscopic treatment of traumatic complete
posterior urethral stricture, and attempt to establish the current status of endoscopic therapy. PATIENTS AND METHODS
During the last 4 years patients with traumatic posterior urethral stricture and complete obliteration of the urethra underwent endoscopic realignment (see figure). The condition was assessed by retrograde andor voiding urethrography. Patients in whom the bladder neck and prostatic urethra could not be visualized underwent repeat retrograde urethrography with antegrade placement of a sound or cyetoscope via regional anesthesia. Only 13 patients 25 to 45
A, combined radiograph demonstratescomplete posterior urethral obliteration. B , retrograde urethrognun shows complete blochage with no contrast medium entering posterior urethra and bladder.
Accepted for publication July 5, 1996. 95
96
ENDOSCOPIC MANAGEMENT OF TRAUMATIC URETHRAL STRICTURE
years old (mean age plus or minus standard deviation 37.3 -t 8.0 years) with complete obliteration of the posterior urethra were included in the study. Mean interval between injury and the definitive procedure was 4.2 2 2.0 months (range 3 to 6). All strictures were 2 cm. or shorter (mean 1.6 2 0.4). Mean followup was 17.7 t 4.2 months (range 11 to 24). Core through internal urethrotomy was performed with the patient under general or regional anesthesia and in a modified lithotomy position. A 15119F cystoscope with a 30degree telescope was introduced from the suprapubic tract and advanced through the bladder neck to the proximal end of the stricture. Flexible cysto-nephroscopy was performed in case this procedure failed. A Sachse urethrotome (20F) was advanced retrograde through the anterior urethra and the distal end of the block was identified. Endoscopic reconstruction was performed under C-arm fluoroscopic guidance after assessing the exact length and alignment of the obliterated segment. The assistant moved the antegrade cystoscope to and fro while keeping the tip at the blind end of the proximal urethra. If possible a guide wire was advanced directly through an indentation, if noted, and retrieved through the anterior urethra. When no indentation could be visualized auxiliary aids, such as an antegrade light a t the proximal end of the stricture (seen as a red glow) or transrectal ultrasound control, were used to determine the correct passage. This method was possible only in patients with a short diaphanous stricture. However, if the guide wire was not negotiable a long, hollow needle was passed directly into the apex of the prostatic urethra through the scar under C-arm fluoroscopic guidance. The needle was manipulated in 2 planes, considering the direction of the retrograde urethrotome as 1 plane. A guide wire was passed through the needle to establish urethral continuity. Precise and sharp advancing incisions were made at the 12 o'clock position until the bladder neck was reached. The verumontanum acted as a landmark for correct passage. The dorsal incisions were kept precise to minimize injury to the external urethral sphincter. Paraurethral tissue indicated an incorrect pathway. An 18F Foley catheter was placed through the guide wire and remained indwelling for 4 weeks along with a 22F suprapubic catheter. After the Foley catheter was removed urethroscopy was done and elective urethrotomy was repeated to stabilize the stricture. An 18F Foley catheter was left indwelling for 1 more week and then removed after a successful voiding trial. Urine was cultured and appropriate antimicrobials were given for 72 hours preoperatively. Followup included urethral calibration and continence assessment by clinical examination. A urethral caliber smaller than 8F indicated treatment failure. Patients were given prophylactic antibiotics during followup, and were advised to report to the physician immediately if flow decreased or clean intermittent self-catheterization became difficult. If necessary urethrotomy via local anesthesia was repeated. AU patients were advised to perform clean intermittent self-catheterization during followup amrding to a predefined schedule using a 12F Foley catheter daily for the first month and once weekly thereafter. The urethra was calibrated
monthly during the study. Patients with a urethral caliber smaller than 8F underwent repeat u r e h t o m y . Outcome was defined as class 1-3 patients who required 2 or fewer urethrotomies during followup with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3 - 5 who required 3 or more urethrotomies during followup (2 underwent open urethral reconstruction and 3 were lost to followup). RESULTS
All 3 patients with a class 1outcome were well after 1 (1) or 2 (2) urethrotomies during a mean followup of 17.7 months. All 5 patients with a class 2 outcome were well but 2 (40%)also required repeat core through internal urethrotomy during followup. Of 5 patients with a class 3 outcome 3 (60%)required open surgery due to failure of multiple urethrotomies (4 times in 1 and 3 times in 2) and 2 were lost to followup. Overall, 9 of 13 patients (69%)required 1 or more core through internal urethrotomies by 3 months after the initial procedure, while 2 of 8 (25%) required 2 or more attempts by 1 year. Mean hospital stay was 4.7 days. Of the 13 patients 8 (61%)were well a t a mean followup of 17.7 months. Of 2 patients with hematuria during the postoperative period 1 responded to conservative therapy (antibiotics and blood transfusion), while 1 required urethroscopy and fulguration of the bleeding points embedded in the fibrous tissue. Secondary hemorrhage occurred in 2 patients, who were treated with perineal compression, broad-spectrum antibiotics and blood transfusion. No patient was incontinent postoperatively. DISCUSSION
Of 13 patients with stricture 8 (61%)were treated entirely by endoscopic reconstruction. Most of these patients otherwise were candidates for open surgery. Only 3 of 13 patients (23%) required open surgery (perineal or transpubic approach) for the stricture. Stricture recurred in 7 of 8 patients (87%)but 5 (62%)had stable results after 1 and 2 (25%) after 2 urethrotomies. Treatment of a traumatic posterior urethral stricture remains a difficult challenge. Conventional therapy for such strictures has involved extensive perineal, transpubic or combined urethroplastie~,3.5~6 which were associated with prolonged hospital stays of 11 to 37 days, operative blood loss of 700 to 5,500 cc and impotence in 20 to 30% of cases, recurrent stenosis in 40 to 55% and need for a repeat procedure in 57 to 66%.12.13 The endoscopic approach to dense posterior urethral stricture was described first relatively recently by S a ~ h s eSince .~ then many endoscopic techniques have been reported with moderate results and acceptable morbidity.8-10 The basic endoscopic technique involves exact preoperative and perioperative assessment of the stricture with fluoroscopy. The defect noted at retrograde andor voiding urethrography is
Outcome of previous studies of endoscopic repair References Leonard et ale Gupta et all0 Fishman et all' Marshall et all' Lieberman et alle Spirnak et alzo El Abdzl Kernohan et alzz
N ~pta, , 6 10 1 4 + 1 4 5 369 6
Mean Length
(cm.) Less than 2.0 1.38
-
2.3 1.6
-
of
posttraumatic posterior urethral stricture Technique
$4 Success
Cut to the light To-and-fro movement of antegrade endoscope Goodwin sound Trocar
83 80 Success
-
Core through Cut to a h u g e Cut to the light and dilation
100
100 60
68.2 71
Mas. Followup Not available 16.2 12 4.1
31
Not available Not available
ENDOSCOPIC MANAGEMENT OF TRAUMATIC URETHRAL STRICTURE
invariably longer. Several techniques have been described for orientation in the correct urethral plane before incision, including cutting t o the light, resecting to the light, cutting to a bougie, cutting for dye (methylene blue) and use of digital rectal or fluoroscopic guidance.R-10.14.15 Most of these procedures are useful for a thin septum-like stricture 0.5to 1.0 cm. long but failure is imminent with longer strictures. Skepticism regarding endoscopic treatment is due to associated complications, such as urethral rupture, bladder or rectal injury, incontinence and a high failure rate.14 Our technique is a definite advancement from the previous methods. The method is basically stereoscopic, since the urethroscope is oriented in 2 planes under C-arm fluoroscopic guidance. Advancement of a hollow needle under such guidance decreases the risk of complications and helps to establish the correct urethral passage. The procedure is more scientific, since no blind manipulation is required. Advantages include treatment of any length stricture and a lower rate of complications. The urethral catheter is left indwelling for 3 to 4 weeks for complete epithelialization. Repeat urethrotomy immediately after catheter removal, regardless of the status of the stricture, enhances urethral healing and stabilizes the dense scarred tissue. This aspect of management is important, since most patients have recurrent stenosis due to residual stricture or inadequate incision during initial surgery. The recurrent stenosis rate is high, particularly in the early postoperative weeks. The Foley catheter should not be placed on traction to avoid damage to the continence mechanism of the bladder neck, which is important because only the bladder neck constitutes the residual sphincter mechanism after incising the distal sphincter. This may be the reason for our low rate of incontinence. Many surgeons have used corticosteroids to soften the scar and prevent recurrence16.17 but we have not used any such agent. Of our patients with obliterated urethral strictures 61% could be treated by endoscopic realignment. The results of prior studies of endoscopic treatment are shown in the table.8. lo. 14.18-22 The immediate results varied from 83 to 100% but followup data were not available.8-1°.14. 16. 18-20.22.23 We performed open urethroplasty in 3 patients after endoscopic treatment. However, there was no increased surgical difficulty in these patients. Convalescence was similar to that of patients undergoing an initial open operation. Skepticism regarding endourological treatment is due to the fact that epithelialization is jeopardized resulting in a lumen with fibrotic encasement and stricture. Open urethroplasty also is not the panacea, since stenosis can recur even after open surgery. Roehrborn and McConnell reported poor results after open surgery in patients with a posttraumatic urethral stricture (success rate 4596, recurrence rate 57 to 66%) requiring other procedures after perineal or transpubic surgery.17 Recurrence in 7 of 8 patients (87%) in the early and 2 of 8 (25%) in the late postoperative period emphasizes the role of continuous self-dilation and strict vigilance. The outcome can be assessed at a mean followup of 1 year, since few stricture repairs fail after that time. CONCLUSIONS
Although the number of patients in our study is small and long-term followup is awaited, we believe that the endoscopic technique can be useful and should be considered initially in all patfients with a traumatic posterior urethral stricture,
97
particularly those with a stricture 2 cm. or shorter. The high recurrence rate requires monitoring and further treatment, including clean intermittent self-catheterization for early diagnosis and continuous self-dilation. REFERENCES
1. Morehouse, D. D., Belitsky, P. and MacKinnon, K.: Rupture of the posterior urethra. J . Urol., 107: 255, 1972. 2. De Weerd, J . H.: Immediate realignment of posterior urethral injury. Urol. Clin. N. Amer., 4 75, 1977. 3. Waterhouse, K., Laungani, G. and Patil, U.: The surgical repair of membranous urethral strictures: experience with 105 consecutive cases. J . Urol., 1 2 3 500, 1980. 4. Pierce, J. M.. Jr.: Posterior urethral stricture reDair. J . Urol.. 121:' 739, 1979. 5. Badenoch, A. W.: Pull-throuch oDeration for imDassable traumatic stricture of urethra. Brit.- J. Urol., 2 2 404, 1950. 6. Morehouse, D. D. and MacKinnon, K. J.: Management of prostatomembranous urethral disruption: 13-year experience. J . Urol., 123: 173, 1980. 7. Sachse, H.: Die Sichturethrotomie mit scharfem Schitt: Indikation, Technik, Ergebnisse. Urologe A, 17: 177, 1978. 8. Leonard, M. P., Emtage, J., Perez, R. and Morales, A.: Endoscopic management of urethral strictures: "cut to the light" procedure. Urology, 36: 117, 1990. 9. Gonzalez, R., Chiou, R. K., Hekmat, K. and Fraley, E. E.: Endoscopic re-establishment of urethral continuity after traumatic disruption of the membranous urethra. J. Urol., 1 3 0 785, 1983. 10. Gupta, N. P. and Gill, I. S.: Core-through optical internal urethrotomy in the management of impassable traumatic posterior urethral strictures. J. Urol., 1 3 6 1018, 1986. 11. Blandy, J. P.: Urethral stricture. Postgrad. Med. J., 56: 383, 1980. 12. Pierce, J. M., Jr.: Urethroplasty. J. Urol., 125: 508, 1981. 13. Johanson, B.: Reconstruction of male urethra in strictures: application of the buried intact epithelium technique. Acta Chir. Scand., suppl., 1 7 6 304, 1953. 14. Fishman, I. J., Hirsch, I. H. and Toombs, B. D.: Endourological reconstruction of posterior urethral disruption. J. Urol., 137: 283, 1987. 15. de Vries, C. R. and Anderson, R. U.: Endoscopic urethroplasty: an improved technique. J. Urol., 143: 1225. 1990. 16. Chiou, R.-K., Gonzalez, R., Ortlip, S. and Fraley, E. E.: Endoscopic treatment of posterior urethral obliterations: long-term followup and comparison with transpubic urethroplasty. J. Urol., 1 4 0 508, 1988. 17. Roehrborn, C. G. and McConnell, J . D.: Analysis of factors contributing to success or failure of 1-stage urethroplasty for urethral stricture disease. J . Urol., 151: 869, 1994. 18. Marshall, F. F., Chang, R. and Gearhart, J . P.: Endoscopic reconstruction of traumatic membranous urethral transection. J. Urol., 138: 306, 1987. 19. Lieberman, S. F. and Barry, J. M.: Retreat from transpubic urethroplasty for obliterated membranous urethral strictures. J . Urol., 128: 379, 1982. 20. Spimak, J. P., Smith, E. M. and Elder, J. S.: Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilatation. J . Urol., 1 4 9 766, 1993. 21. El Abd, S. A.: Endoscopic treatment of posttraumatic urethral obliteration: experience in 396 patients. J. Urol., 153: 67,1995. 22. Kernohan, R. M., Anwar, K K. and Johnston, S. R.: Complete urethral stricture of the membranous urethra: a different perspective. Brit. J . Urol., 65:54, 1990. 23. McRoberts, J. W. and Ragde, H.: The severed canine posterior urethra: a study of two distinct methods of reuair. J. Urol.. 104: 724, 1970.
T H E JOURNAL
Vol. 157,95-97,January 1997 Printed in U S A
OF U R O L I K Y
Copyright 0 1997 by AMERICANUROLOCICAL ASSOCIATION, INC.
ENDOSCOPIC MANAGEMENT OF TRAUMATIC POSTERIOR URETHRAL STRICTURE: EARLY RESULTS AND FOLLOWUP M E S H C. GOEL, MAYANK KUMAR AND
RAKESH KAPOOR
From the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
ABSTRACT
Purpose: We assessed the outcome of core through internal urethrotomy for traumatic posterior urethral stricture, and reviewed the followup results of these patients. Materials and Methods: During the last 4 years 13 patients with a stricture up to 2 cm. long underwent core through internal urethrotomy with C-arm fluoroscopy guidance and an orientation in 2 planes. Retrograde urethrotomy was performed and an 18F Foley catheter was left indwelling for 4 weeks, after which urethrotomy was repeated. All patients were advised to perform clean intermittent self-catheterization for urethral calibration and dilation. Outcome was defined as class 1 - 3 patients who required 2 or fewer urethrotomies with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3-5 who required 3 or more urethrotomies. Results: Of the 13 patients 8 (61%)did well after a mean followup of 17.7 months. The 3 patients with a class 1 outcome did well, while 2 of 5 with a class 2 outcome required repeat urethrotomy during followup. Of the 5 patients (39%) with a class 3 outcome in whom core through internal urethrotomy failed 3 required open surgery and 2 were lost to followup. Recurrence rate was 69% at 3 months and 25% at 12 months after the initial procedure. No patient was incontinent at last followup. Two patients had significant hematuria postoperatively, which resolved with conservative treatment. Conclusions: Endoscopic treatment should be considered the first line procedure for all posttraumatic posterior urethral strictures. The morbidity of open surgery can be avoided in 61%of patients. Hospital stay, loss of work, morbidity and related complications are also markedly decreased with endoscopic therapy. KEY WORDS:endoscopy, urethra,urethral stricture, wounds and iqjuries
Treatment of posterior urethral stricture is difficult and controversial.1.2 Methods to maintain urethral continuity include transpubic,3 perineal? and combined perineal and suprapubics approaches performed in 1 or 2 stages,6 or free grafts with good success rates. However, these major operations are invariably associated with morbidity, prolonged hospital stay, impotence and a path of no return after failure.s6 Sachse first attempted direct vision internal urethrotomy in patients with impassable strictures.' The slow evolution of endoscopic methods for posterior urethral stricture included cutting to the light,s resecting to the lights or core through internal urethrotomy.10 Anecdotal reports regarding the outcome of endoscopic treatment have appeared in the literature.8-10 However, the most common problem is the need for repeat urethrotomy or prolonged clean intermittent selfcatheterization. Furthermore, the large number of endoscopic methods described indicates the controversy regarding endoscopic treatment of posterior urethral strictures. Endoscopic core through internal urethrotomy achieves moderate results with minimal morbidity but the long-term outcome of these patients is unknown.8-loInternal urethrotomy has been reserved for short diaphanous strictures or those in which a lumen is noted.11 Associated major complications with longer strictures are contraindications to endoscopic treatment. However, endoscopy for complete urethral obliteration remains controversial. We describe the longterm outcome of endoscopic treatment of traumatic complete
posterior urethral stricture, and attempt to establish the current status of endoscopic therapy. PATIENTS AND METHODS
During the last 4 years patients with traumatic posterior urethral stricture and complete obliteration of the urethra underwent endoscopic realignment (see figure). The condition was assessed by retrograde andor voiding urethrography. Patients in whom the bladder neck and prostatic urethra could not be visualized underwent repeat retrograde urethrography with antegrade placement of a sound or cyetoscope via regional anesthesia. Only 13 patients 25 to 45
A, combined radiograph demonstratescomplete posterior urethral obliteration. B , retrograde urethrognun shows complete blochage with no contrast medium entering posterior urethra and bladder.
Accepted for publication July 5, 1996. 95
96
ENDOSCOPIC MANAGEMENT OF TRAUMATIC URETHRAL STRICTURE
years old (mean age plus or minus standard deviation 37.3 -t 8.0 years) with complete obliteration of the posterior urethra were included in the study. Mean interval between injury and the definitive procedure was 4.2 2 2.0 months (range 3 to 6). All strictures were 2 cm. or shorter (mean 1.6 2 0.4). Mean followup was 17.7 t 4.2 months (range 11 to 24). Core through internal urethrotomy was performed with the patient under general or regional anesthesia and in a modified lithotomy position. A 15119F cystoscope with a 30degree telescope was introduced from the suprapubic tract and advanced through the bladder neck to the proximal end of the stricture. Flexible cysto-nephroscopy was performed in case this procedure failed. A Sachse urethrotome (20F) was advanced retrograde through the anterior urethra and the distal end of the block was identified. Endoscopic reconstruction was performed under C-arm fluoroscopic guidance after assessing the exact length and alignment of the obliterated segment. The assistant moved the antegrade cystoscope to and fro while keeping the tip at the blind end of the proximal urethra. If possible a guide wire was advanced directly through an indentation, if noted, and retrieved through the anterior urethra. When no indentation could be visualized auxiliary aids, such as an antegrade light a t the proximal end of the stricture (seen as a red glow) or transrectal ultrasound control, were used to determine the correct passage. This method was possible only in patients with a short diaphanous stricture. However, if the guide wire was not negotiable a long, hollow needle was passed directly into the apex of the prostatic urethra through the scar under C-arm fluoroscopic guidance. The needle was manipulated in 2 planes, considering the direction of the retrograde urethrotome as 1 plane. A guide wire was passed through the needle to establish urethral continuity. Precise and sharp advancing incisions were made at the 12 o'clock position until the bladder neck was reached. The verumontanum acted as a landmark for correct passage. The dorsal incisions were kept precise to minimize injury to the external urethral sphincter. Paraurethral tissue indicated an incorrect pathway. An 18F Foley catheter was placed through the guide wire and remained indwelling for 4 weeks along with a 22F suprapubic catheter. After the Foley catheter was removed urethroscopy was done and elective urethrotomy was repeated to stabilize the stricture. An 18F Foley catheter was left indwelling for 1 more week and then removed after a successful voiding trial. Urine was cultured and appropriate antimicrobials were given for 72 hours preoperatively. Followup included urethral calibration and continence assessment by clinical examination. A urethral caliber smaller than 8F indicated treatment failure. Patients were given prophylactic antibiotics during followup, and were advised to report to the physician immediately if flow decreased or clean intermittent self-catheterization became difficult. If necessary urethrotomy via local anesthesia was repeated. AU patients were advised to perform clean intermittent self-catheterization during followup amrding to a predefined schedule using a 12F Foley catheter daily for the first month and once weekly thereafter. The urethra was calibrated
monthly during the study. Patients with a urethral caliber smaller than 8F underwent repeat u r e h t o m y . Outcome was defined as class 1-3 patients who required 2 or fewer urethrotomies during followup with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3 - 5 who required 3 or more urethrotomies during followup (2 underwent open urethral reconstruction and 3 were lost to followup). RESULTS
All 3 patients with a class 1outcome were well after 1 (1) or 2 (2) urethrotomies during a mean followup of 17.7 months. All 5 patients with a class 2 outcome were well but 2 (40%)also required repeat core through internal urethrotomy during followup. Of 5 patients with a class 3 outcome 3 (60%)required open surgery due to failure of multiple urethrotomies (4 times in 1 and 3 times in 2) and 2 were lost to followup. Overall, 9 of 13 patients (69%)required 1 or more core through internal urethrotomies by 3 months after the initial procedure, while 2 of 8 (25%) required 2 or more attempts by 1 year. Mean hospital stay was 4.7 days. Of the 13 patients 8 (61%)were well a t a mean followup of 17.7 months. Of 2 patients with hematuria during the postoperative period 1 responded to conservative therapy (antibiotics and blood transfusion), while 1 required urethroscopy and fulguration of the bleeding points embedded in the fibrous tissue. Secondary hemorrhage occurred in 2 patients, who were treated with perineal compression, broad-spectrum antibiotics and blood transfusion. No patient was incontinent postoperatively. DISCUSSION
Of 13 patients with stricture 8 (61%)were treated entirely by endoscopic reconstruction. Most of these patients otherwise were candidates for open surgery. Only 3 of 13 patients (23%) required open surgery (perineal or transpubic approach) for the stricture. Stricture recurred in 7 of 8 patients (87%)but 5 (62%)had stable results after 1 and 2 (25%) after 2 urethrotomies. Treatment of a traumatic posterior urethral stricture remains a difficult challenge. Conventional therapy for such strictures has involved extensive perineal, transpubic or combined urethroplastie~,3.5~6 which were associated with prolonged hospital stays of 11 to 37 days, operative blood loss of 700 to 5,500 cc and impotence in 20 to 30% of cases, recurrent stenosis in 40 to 55% and need for a repeat procedure in 57 to 66%.12.13 The endoscopic approach to dense posterior urethral stricture was described first relatively recently by S a ~ h s eSince .~ then many endoscopic techniques have been reported with moderate results and acceptable morbidity.8-10 The basic endoscopic technique involves exact preoperative and perioperative assessment of the stricture with fluoroscopy. The defect noted at retrograde andor voiding urethrography is
Outcome of previous studies of endoscopic repair References Leonard et ale Gupta et all0 Fishman et all' Marshall et all' Lieberman et alle Spirnak et alzo El Abdzl Kernohan et alzz
N ~pta, , 6 10 1 4 + 1 4 5 369 6
Mean Length
(cm.) Less than 2.0 1.38
-
2.3 1.6
-
of
posttraumatic posterior urethral stricture Technique
$4 Success
Cut to the light To-and-fro movement of antegrade endoscope Goodwin sound Trocar
83 80 Success
-
Core through Cut to a h u g e Cut to the light and dilation
100
100 60
68.2 71
Mas. Followup Not available 16.2 12 4.1
31
Not available Not available
ENDOSCOPIC MANAGEMENT OF TRAUMATIC URETHRAL STRICTURE
invariably longer. Several techniques have been described for orientation in the correct urethral plane before incision, including cutting t o the light, resecting to the light, cutting to a bougie, cutting for dye (methylene blue) and use of digital rectal or fluoroscopic guidance.R-10.14.15 Most of these procedures are useful for a thin septum-like stricture 0.5to 1.0 cm. long but failure is imminent with longer strictures. Skepticism regarding endoscopic treatment is due to associated complications, such as urethral rupture, bladder or rectal injury, incontinence and a high failure rate.14 Our technique is a definite advancement from the previous methods. The method is basically stereoscopic, since the urethroscope is oriented in 2 planes under C-arm fluoroscopic guidance. Advancement of a hollow needle under such guidance decreases the risk of complications and helps to establish the correct urethral passage. The procedure is more scientific, since no blind manipulation is required. Advantages include treatment of any length stricture and a lower rate of complications. The urethral catheter is left indwelling for 3 to 4 weeks for complete epithelialization. Repeat urethrotomy immediately after catheter removal, regardless of the status of the stricture, enhances urethral healing and stabilizes the dense scarred tissue. This aspect of management is important, since most patients have recurrent stenosis due to residual stricture or inadequate incision during initial surgery. The recurrent stenosis rate is high, particularly in the early postoperative weeks. The Foley catheter should not be placed on traction to avoid damage to the continence mechanism of the bladder neck, which is important because only the bladder neck constitutes the residual sphincter mechanism after incising the distal sphincter. This may be the reason for our low rate of incontinence. Many surgeons have used corticosteroids to soften the scar and prevent recurrence16.17 but we have not used any such agent. Of our patients with obliterated urethral strictures 61% could be treated by endoscopic realignment. The results of prior studies of endoscopic treatment are shown in the table.8. lo. 14.18-22 The immediate results varied from 83 to 100% but followup data were not available.8-1°.14. 16. 18-20.22.23 We performed open urethroplasty in 3 patients after endoscopic treatment. However, there was no increased surgical difficulty in these patients. Convalescence was similar to that of patients undergoing an initial open operation. Skepticism regarding endourological treatment is due to the fact that epithelialization is jeopardized resulting in a lumen with fibrotic encasement and stricture. Open urethroplasty also is not the panacea, since stenosis can recur even after open surgery. Roehrborn and McConnell reported poor results after open surgery in patients with a posttraumatic urethral stricture (success rate 4596, recurrence rate 57 to 66%) requiring other procedures after perineal or transpubic surgery.17 Recurrence in 7 of 8 patients (87%) in the early and 2 of 8 (25%) in the late postoperative period emphasizes the role of continuous self-dilation and strict vigilance. The outcome can be assessed at a mean followup of 1 year, since few stricture repairs fail after that time. CONCLUSIONS
Although the number of patients in our study is small and long-term followup is awaited, we believe that the endoscopic technique can be useful and should be considered initially in all patfients with a traumatic posterior urethral stricture,
97
particularly those with a stricture 2 cm. or shorter. The high recurrence rate requires monitoring and further treatment, including clean intermittent self-catheterization for early diagnosis and continuous self-dilation. REFERENCES
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