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Super Otis Urethrotomy
Vol. 97, Apr. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
SUPER OTIS URETHROTOMY JOHN A. WOLF I JR. From the Department of Urology, University of Washington, King County Hospital and Veterans Administration Hospital, Seattle, Washington The treatment of urethral strictures by dilation is described as early as 600 B.C. in the Indian medical literature. A urologic adage passed on since the late nineteenth century states "never cut if you can dilate." Fixed urethrotomes were used for cutting dense, small caliber strictures provided the instrument could be inserted. If not, suprapubic punch cystostomy and open perinea! urethrotomy were performed. In 1872 Otis described the "dilating urethrotome" with a compass from 23 to 34 F 1 and the Otis bougies for palpating strictures not palpable by urethral sounds. He further described his operation for large caliber stricture including the advantage of making the stricture tense with his instrument in order to completely cut it, and the importance of calibrating the urethra postoperatively to be sure a proper cut had been made. Keyes in 1880 stated that the stricture "must be cut so as to be considerably larger than the normal urethra at that point, and to insure the best results, a single cut should be made-a cut, if possible, to pass beyond all diseased tissues and into healthy tissue." However, because of hemorrhage, extravasation, chordee, perinea! abscess, infection and failure, internal urethrotomy was virtually abandoned at the turn of the century. In 1948 Davis and Lee reported 45 cases of internal urethrotomy using the Maisonneuve fixed urethrotome in combination with dilation to 26 to 28F and for the first time catheterization for 12 days to maintain separation of the cut surfaces while epithelization took place. 2 Good longterm results were obtained. Emmett and Winterringer discussed the Otis urethrotomy prior to transurethral resection of the prostate and reAccepted for publication June 30, 1966. Read at annual meeting of Western Section, American Urological Association, Inc., Portland, Oregon, April 17-21, 1966. 1 Otis, F. N.: Remarks on strictures of the urethra of extreme calibre, with cases, and a description of new instruments for their treatment. New York Med. J., 15: 152-174, 1872. 2 Davis, E. and Lee, L. W.: Lasting results following internal urethrotomy for urethral strictures. J. Urol., 59: 935-938, 1948.
FIG. 1. Super Otis
urethrotomy in progress
ported 6 cases in which urethrotomy to 36F was performed for treatment of urethral stricture. 3 According to Emmett the procedure is accompanied by minimal danger if the membranous urethra is avoided. He describes special use of the straight Otis urethrotome to avoid injury to the membranous urethra. Studies of urethral regeneration were reported by Weaver and Schulte. 4 The urethra will reform if a small strip of mucosa and the corpus spongiosum remain, and if splinted for an adequate period will be of sufficient luminal size. An open operation with suture 3 Emmett, J. L. and Winterringer, J. R.: Urethral stricture following transurethral resection prevented by internal urethrotomy: Preliminary report of experience with Otis urethrotome. J. Urol., 72: 867-874, 1954. 4 Weaver, R. G. and Schulte, J. W.: Experimental and clinical studies of urethral regeneration. Surg., Gynec. & Obst., 115: 729-736, 1962.
713
714
WOLF
1. Data on 18 patients with intractable strictures treated with super Otis urethrotomy
TABLE
Fm. 2. Urethrograms before (A) and after (B) super Otis urethrotomy. closure of the skin only was presented with good results. Thus it was reasoned that an internal cut through the urethra to the skin and deep cavernous tissues might accomplish the same benefit as an external cut through skin, cavernous tissues and urethra, and offer surgical advantages. The Otis urethrotome is ideally suited for this deep internal cut as the modern version has a compass to 45F (fig. 1) fulfilling the principle of Keyes, and a dull knife which will cut rigid tissues easily, but will not incise the skin or normal soft tissues such as the urogenital diaphragm. The closed urethrotome measures 16F and most urethras can be dilated to this size with filiforms and followers. METHOD
Super Otis urethrotomy is performed by making maximum repeated cuts through the entire strictured urethra, including the membranous urethra, to the skin and deep cavernous tissue, usually in both anterior and posterior positions. The adequacy of the operation is checked by passing an Otis bougie at 32F and a splinting catheter is left in place for about 2 weeks. Marked bleeding and hematoma usually occur, but bleeding is controlled by placing a 22F, 30 cc bag
No. patients No. patients followed History of venereal disease History of perineal abscess Positive culture pre-op. Positive culture post-op. Residual urine pre-op. Residual urine post-op. Complications Death (pneumonia) Bleeding requiring hospital adm1ss1on Temporary incontinence (to 4 mos.) Permanent incontinence (incontinent pre-op.) Scrotal slough (secondary to prolonged cystoscopy and extravasation) Failures Average urethral size pre-op. Range (by bougie) Average urethral size post-op. (followup) Range (by bougie) Average patient age Range Average post-op. hospital days Reoperations
18 16 16 2
16 2
15 1 1 3 5
1 1
2?
15F 10-lSF 27F 14-30F 69 58-84 4 0
2. Preoperative and postoperative urethral calibration by bougienage in 18 patients treated with wper Otis urethrotomy. Only patient E. F. has required dilation
TABLE
Patient
J.M. J. v.
F. D. E.F. C. E. B. W. f.f.* M.G.
S. A. f.f. F. B. H. L. f.f. C. R. f.f. T. S. f.f. N.E. A. C. C.B. D.P.
C. C. f.f. F.P. f.f. * Filiform and follower
t Not measured
Pre-op.
Post-op.
18F 16F 16F 12F 18F 6F 16F 6F lOF 6F 6F 6F lOF 14F 18F 16F 6F 6F
28F 30F 26F 14F 30F 30F 30F 30F 30F 26F 28F 30F xt X X X X
X
SUPER OTIS URETHROTOMY
catheter. The catheter must be placed over a curved and guided through the incised urethra by palpation. The bladder is irrigated free of clots and the catheter is taped securely to the abdomen during the healing period to prevent penoscrotal angle fistula and chordee. Strict daily meafal cleansing allows free drainage of exudate. Warm sitz baths reduce inflammation and help resolve hematoma. Revascularization of avascular tissue and elimination of obstruction both eontribute to alleviation of the symptoms of stricture (fig. Data on 18 patients with intractable strictures to dilation treated with super Otis urethrotomy and followed from 4 months to 2 years are presented in tables l and 2. The operation is indicated for intractable strictures of the entire
urethra, including the membranous where previous perinea! abscess or incisions decrease the chanee of healing. Correction of stric-tures will resolve infection. The advantages over other operations for stricture include short hospitalization, immediate ambulation, ease anC: speed of performance, no skin incision and thus no fistula, and based on urethral regeneration studies, good opportunity for success. SUMMARY
The history of internal urethrotomy is discussed. A new radical operation using modern Otis urcthrotome and based on urethral regeneration studies is presented, with indicn tions, operative procedure and data on patients.
THE JOURNAL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
SUPER OTIS URETHROTOMY JOHN A. WOLF I JR. From the Department of Urology, University of Washington, King County Hospital and Veterans Administration Hospital, Seattle, Washington The treatment of urethral strictures by dilation is described as early as 600 B.C. in the Indian medical literature. A urologic adage passed on since the late nineteenth century states "never cut if you can dilate." Fixed urethrotomes were used for cutting dense, small caliber strictures provided the instrument could be inserted. If not, suprapubic punch cystostomy and open perinea! urethrotomy were performed. In 1872 Otis described the "dilating urethrotome" with a compass from 23 to 34 F 1 and the Otis bougies for palpating strictures not palpable by urethral sounds. He further described his operation for large caliber stricture including the advantage of making the stricture tense with his instrument in order to completely cut it, and the importance of calibrating the urethra postoperatively to be sure a proper cut had been made. Keyes in 1880 stated that the stricture "must be cut so as to be considerably larger than the normal urethra at that point, and to insure the best results, a single cut should be made-a cut, if possible, to pass beyond all diseased tissues and into healthy tissue." However, because of hemorrhage, extravasation, chordee, perinea! abscess, infection and failure, internal urethrotomy was virtually abandoned at the turn of the century. In 1948 Davis and Lee reported 45 cases of internal urethrotomy using the Maisonneuve fixed urethrotome in combination with dilation to 26 to 28F and for the first time catheterization for 12 days to maintain separation of the cut surfaces while epithelization took place. 2 Good longterm results were obtained. Emmett and Winterringer discussed the Otis urethrotomy prior to transurethral resection of the prostate and reAccepted for publication June 30, 1966. Read at annual meeting of Western Section, American Urological Association, Inc., Portland, Oregon, April 17-21, 1966. 1 Otis, F. N.: Remarks on strictures of the urethra of extreme calibre, with cases, and a description of new instruments for their treatment. New York Med. J., 15: 152-174, 1872. 2 Davis, E. and Lee, L. W.: Lasting results following internal urethrotomy for urethral strictures. J. Urol., 59: 935-938, 1948.
FIG. 1. Super Otis
urethrotomy in progress
ported 6 cases in which urethrotomy to 36F was performed for treatment of urethral stricture. 3 According to Emmett the procedure is accompanied by minimal danger if the membranous urethra is avoided. He describes special use of the straight Otis urethrotome to avoid injury to the membranous urethra. Studies of urethral regeneration were reported by Weaver and Schulte. 4 The urethra will reform if a small strip of mucosa and the corpus spongiosum remain, and if splinted for an adequate period will be of sufficient luminal size. An open operation with suture 3 Emmett, J. L. and Winterringer, J. R.: Urethral stricture following transurethral resection prevented by internal urethrotomy: Preliminary report of experience with Otis urethrotome. J. Urol., 72: 867-874, 1954. 4 Weaver, R. G. and Schulte, J. W.: Experimental and clinical studies of urethral regeneration. Surg., Gynec. & Obst., 115: 729-736, 1962.
713
714
WOLF
1. Data on 18 patients with intractable strictures treated with super Otis urethrotomy
TABLE
Fm. 2. Urethrograms before (A) and after (B) super Otis urethrotomy. closure of the skin only was presented with good results. Thus it was reasoned that an internal cut through the urethra to the skin and deep cavernous tissues might accomplish the same benefit as an external cut through skin, cavernous tissues and urethra, and offer surgical advantages. The Otis urethrotome is ideally suited for this deep internal cut as the modern version has a compass to 45F (fig. 1) fulfilling the principle of Keyes, and a dull knife which will cut rigid tissues easily, but will not incise the skin or normal soft tissues such as the urogenital diaphragm. The closed urethrotome measures 16F and most urethras can be dilated to this size with filiforms and followers. METHOD
Super Otis urethrotomy is performed by making maximum repeated cuts through the entire strictured urethra, including the membranous urethra, to the skin and deep cavernous tissue, usually in both anterior and posterior positions. The adequacy of the operation is checked by passing an Otis bougie at 32F and a splinting catheter is left in place for about 2 weeks. Marked bleeding and hematoma usually occur, but bleeding is controlled by placing a 22F, 30 cc bag
No. patients No. patients followed History of venereal disease History of perineal abscess Positive culture pre-op. Positive culture post-op. Residual urine pre-op. Residual urine post-op. Complications Death (pneumonia) Bleeding requiring hospital adm1ss1on Temporary incontinence (to 4 mos.) Permanent incontinence (incontinent pre-op.) Scrotal slough (secondary to prolonged cystoscopy and extravasation) Failures Average urethral size pre-op. Range (by bougie) Average urethral size post-op. (followup) Range (by bougie) Average patient age Range Average post-op. hospital days Reoperations
18 16 16 2
16 2
15 1 1 3 5
1 1
2?
15F 10-lSF 27F 14-30F 69 58-84 4 0
2. Preoperative and postoperative urethral calibration by bougienage in 18 patients treated with wper Otis urethrotomy. Only patient E. F. has required dilation
TABLE
Patient
J.M. J. v.
F. D. E.F. C. E. B. W. f.f.* M.G.
S. A. f.f. F. B. H. L. f.f. C. R. f.f. T. S. f.f. N.E. A. C. C.B. D.P.
C. C. f.f. F.P. f.f. * Filiform and follower
t Not measured
Pre-op.
Post-op.
18F 16F 16F 12F 18F 6F 16F 6F lOF 6F 6F 6F lOF 14F 18F 16F 6F 6F
28F 30F 26F 14F 30F 30F 30F 30F 30F 26F 28F 30F xt X X X X
X
SUPER OTIS URETHROTOMY
catheter. The catheter must be placed over a curved and guided through the incised urethra by palpation. The bladder is irrigated free of clots and the catheter is taped securely to the abdomen during the healing period to prevent penoscrotal angle fistula and chordee. Strict daily meafal cleansing allows free drainage of exudate. Warm sitz baths reduce inflammation and help resolve hematoma. Revascularization of avascular tissue and elimination of obstruction both eontribute to alleviation of the symptoms of stricture (fig. Data on 18 patients with intractable strictures to dilation treated with super Otis urethrotomy and followed from 4 months to 2 years are presented in tables l and 2. The operation is indicated for intractable strictures of the entire
urethra, including the membranous where previous perinea! abscess or incisions decrease the chanee of healing. Correction of stric-tures will resolve infection. The advantages over other operations for stricture include short hospitalization, immediate ambulation, ease anC: speed of performance, no skin incision and thus no fistula, and based on urethral regeneration studies, good opportunity for success. SUMMARY
The history of internal urethrotomy is discussed. A new radical operation using modern Otis urcthrotome and based on urethral regeneration studies is presented, with indicn tions, operative procedure and data on patients.