Internal Urethrotomy Under Direct Vision in Men

0022-5347 /82/1281-0037$02.0D/0 128,

T1rs JOURNAL OF UROLOGY

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INTERNAL URETHROTOMY UNDER DIRECT VISION

MEN

HUSEYIN M. BEKIROV, ARNOLD B. TEIN, ROBERTO K REID AND SELWYN Z. FREED From the Department of Urology, Albert Einstein College of Medicine, Bronx, New York

ABSTRACT

During a 3½-year period 128 patients with urethral strictures were treated with internal urethrotomy. The etiology, surgical technique, complications and postoperative management are discussed. Appraisal of the results after a mean followup of 25 months showed an over-all success rate of 85 per cent. Transurethral incision of urethral strictures has been a well known method of treatment since Maisonneuve and Otis invented the urethrotomes that still are used today. 1 These instruments have 2 drawbacks: 1) they are introduced blindly and the stricture is cut without vision and 2) they can only be used if the caliber of the stricture is wide enough for their introduction. With the development of the direct vision internal methrotome by Sachse a new modality was brought into our armamentarium for the treatment of urethral strictures. 2 Sachse treated large series of patients with this instrument and reported a success rate of 80 per cent. 3 Since then, other series have been reported. 4 - 10 MATERIALS AND METHODS

During the last 3½ years 128 patients with urethral strictures have been treated with internal urethrotomy. Patients ranged from 16 to 104 years old, with most strictures occurring in patients in the sixth decade. All urethrotomies were done using the Storz instrument with a 0-degree lens. The etiology and frequency of occurrence were noted (table as were the types of strictures (table 2). Most patients were managed in the hospital and the procedure was performed with the patient under general or regional anesthesia. In 17 patients the procedure was done after the instillation of 2 per cent lidocaine into the urethra. This dosage does not interfere with the visual acuity and will give adequate topical analgesia for patients with small strictures. Seven of the cases were done on ambulatory bases and many had undergone intermittent urethral dilations for years, some of them requiring instrumentation every 4 weeks. In 21 cases internal urethrotomy and in 9 cases urethroplasty had been done previously (table 3). OPERATIVE TECHNIQUES

The preoperative investigation consisted of excretory urograms (IVPs), urethrograms and uroflowmetry (table 4). The actual procedure began with urethroscopy to the of the stricture. A 5F urete:ral catheter then was passed under direct vision beyond the stricture into the bladder through the side arm of a Storz urethrotome. With the catheter as a guide the stricture was cut at the 12 o'clock position. It is important for a successful operation to cut through all fibrous tissue of the strictured methra until the lax periurethral tissue is seen. 2 • 4• 6-B If the stricture is too narrow and it is impossible to pass a ureteral catheter the procedure can be attempted without a catheter but there is always the danger of creating a false passage. In rare instances the urethra was obliterated completely and would not permit the passage of the guiding ureteral catheter. In those cases methylene blue was injected into the bladder

through a suprapubic puncture. 6 Manual pressure was concomitantly exerted by an assistant on the abdomen over the bladder. The dye could then be visualized by the cystoscopist through the miniscule opening in the urethra. With the aid of the dye these strictures also are incised at the 12 o'clock position. We used glycine for irrigation during the urethrotomy to prevent complications of excessive absorption of a hypotonic fluid. Minor extravasation of irrigating fluid is harmless. The use of glycine also permits use of a Bugbee cauterizing electrode when bleeding cannot be controlled solely by catheter placement. In all of our patients a 16F or 18F silicone catheter was inserted after the urethrotomy and left indwelling from 1 to 7 days. The catheter acts as a tamponade. Length of catheter drainage is determined the urethral venous oozing and, therefore, the catheter is removed when bleeding stops. We did not use steroid ointments, urethral suppositories or hydraulic self-dilations postoperatively. An antibacterial agent was given for 24 hours before and for about 7 to 10 days postoperatively. COMPLICATIONS

In 5 patients there was considerable extravasation of the irrigating fluid involving the penis and scrotum but this resolved spontaneously in all cases in 2 or 3 days with elevation of the scrotal sac. Acute tubular necrosis developed and resolved subsequently in 1 patient. Another patient suffered sepsis, which responded to broad-spectrum antibioticso The complication rate was <6 per cent. No serious bleeding, epididymitis, priapism, impotence or fistula 7 was observed (table 5). In comparison with the use of the Otis urethrotome, reported by Konnak and Kogan, 11 we did not encounter incontinence, bladder perforation, ruptured urethra or urethrocutaneous fistulas. RESULTS

The patients now have been followed for >3½ years. Followups are subdivided into 6-month intervals (table 6)0 Uroflowmetry was done in >40 per cent of the patients before and after the operation. A close correlation was seen between amelioration of signs and symptoms of the stricture and the improvement in the voiding cystourethrogram, which also has been shown Lipsky and Hubrner. 10 Uroflow rates of >15 ml. per second were considered successful. Patients with good results became free of symptoms. In general, the pyuria cleared and TABLE

L Cause of stricture and frequency of occurrence Noo (%)

Congenital Trauma After radical perineal prostatectomy After transurethral resection of the prostate After transurethral resection of the bladder After gonorrheal disease After long-term catheterization After radiation therapy After urethroplasty

Accepted for publication October 23, 1981. Read at annual meeting of New York Section, American Urological Association, Madrid, Spain, October 11-19, 1980. 37

4 4 6 60 11 22 5 6 7

(3) (3) (5) (47) (9) (17) (4) (5) (5)

Unknown

_L__@

Total

128 (100)

38

BEKIROV AND ASSOCIATES TABLE

2. Types of strictures No.(%) 76 (59)

Bulbomembranous Pendulous urethra Multiple Bladder neck contracture Total

TABLE

22 (17) 19 (15)

..!.!.......ill 128 (100)

3. Previous treatment No. Cases 36

Dilations Internal uretbrotomy Uretbroplasty None Total

TABLE

21 9 62 128

4. Evaluation before and after operation No. Cases 128

IVP Retrograde uretbrogram and voiding cystouretbrogram Uroflowmetry: Preop., 2-10 cc/sec. Postop., > 15 cc/sec.

TABLE

71

53

5. Complications No. Cases (%)

Extravasation Acute tubular necrosis Sepsis Total

TABLE

5

1 1 7 (5.5)

6. Followup

Yrs.

No. Cases

3½ 3 2½

22 30 25 14 13 24

2

<½

urinary infection was no longer demonstrated. The final results showed an over-all success rate of 85 per cent. In 19 patients (14.8 per cent) the stricture recurred but a repeat urethrotomy was done and half of the patients had a satisfactory result. The remaining patients require occasional dilations and are being followed closely. In 3 patients a stricture developed at a new site. DISCUSSION

There are several modiJ.lities for the treatment of urethral strictures, ranging from simple dilations to complex multistaged urethroplasties. The success rate of blind urethrotomy as described by Otis is reported to be in the range of 55 to 75 per cent, 11 • 12 with a 12 per cent complication rate. 11 Direct vision internal urethrotomy is a newer technique, with success rates of 85 to 93 per cent4 - 8 and a complication rate of about 9 per cent. 7 In our series of 128 cases we report a success rate of 85 per cent, with a complication rate of <6 per cent. These results compare favorably to those of an open operation. The new direct vision urethrotomy technique can be performed easily and without major risk in all cases. Some strictures have the tendency to restenose and urethrotomy can be repeated in these cases. Finally, a conventional

urethroplasty can be done at a later date. The length of the strictures was not a failure factor in our series. 8 We had 5 patients with urethral strictures, the length of which varied from 4 to 6 cm. However, this method has its limitations and cases of excessive periurethral disease, dense traumatic strictures and strictures developing after radiation therapy are likely to fail. The complication rate of this procedure can be reduced further with experience. One should be certain to incise the stricture at the 12 o'clock position and to avoid getting into the corpora, which will secure minimal bleeding and prevent priapism, impotence and fistula. To minimize the consequences of extravasation of irrigating fluid we recommend the use of glycine, low level of hydrostatic pressure and limiting the time of the procedure. Our series indicates that direct vision urethrotomy is a safe, relatively simple, cost-effective procedure that can be performed on ambulatory patients under local anesthesia. The procedure can be done de novo in patients with strictures in whom a catheter cannot be inserted. REFERENCES

1. Otis, F. N.: Remarks on strictures of the urethra of extreme calibre, with cases, and a description of new instruments for their treatment. N.Y. Med. J., 15: 152, 1872. 2. Sachse, H.: Die transurethrale scharfe Schiltzung der Harnrohrenstriktur mit einem Sichturethrotom. Verh. Dt. Ges. Urol., 25: 143, 1973. 3. Sachse, H.: Zur Behandlung der Harnrohrenstriktur: die transurethrale Schlitzung under Sicht mit scharfem Schnitt. Fortschr. Med., 92: 12, 1974. 4. Matouschek, E. and Michaelis, W. E.: Internal urethrotomy of urethral strictures in men under endoscopic control. Urol. Int., 30: 266, 1975. 5. Matouschek, E.: Internal urethrotomy under vision-a five-year report. Urol. Res., 6: 147, 1978. 6. Renders, G., De Nobel, J., Debruyne, F., Delaere, K. and Moonen, W.: Cold knife optical urethrotomy. Urology, 14: 475, 1979. 7. Sacknoff, E. J. and Kerr, W. S., Jr.: Direct vision cold knife urethrotomy. J. Urol., 123: 492, 1980. 8. Walter, P. C., Parsons, C. L. and Schmidt, J. D.: Direct vision internal urethrotomy in the management of urethral strictures. J. Urol., 123: 497, 1980. 9. Youssef, A. M. R., Cockett, A. T. K. and Mee, A. D.: Internal urethrotomy using Sachse's knife for managing urethral strictures. Urology, 15: 562, 1980. 10. Lipsky, H. and Hubmer, G.: Direct vision urethrotomy in the management of urethral strictures. Brit. J. Urol., 49: 725, 1977. 11. Konnak, J. W. and Kogan, B. A.: Otis internal urethrotomy in the treatment of urethral stricture disease. J. Urol., 124: 356, 1980. 12. Davis, E. and Lee, L. W.: Lasting results following internal urethrotomy for urethral strictures. J. Urol., 59: 935, 1948. EDITORIAL COMMENT The authors further document that direct vision internal urethrotomy is a well established method to treat patients with urethral strictures and results in a high percentage of success. The complication rate was low. Included in the study were 5 patients with extravasation, 1 with tubular necrosis and 1 with sepsis, and all of these patients responded. No impotence was experienced. Since impotence has been noted in 4 of 179 patients treated at the Massachusetts General Hospital I believe that it is a complication that should be discussed with all patients considering the procedure. It is important to perform a moderate urethrotomy as a first procedure, with the understanding that a second stage urethrotomy may be done. Complications of any kind have been few if these rules are followed. Walter S. Kerr, Jr. Department of Surgery Massachusetts General Hospital Boston, Massachusetts