Treatment of Urethral Strictures With Internal Urethrotomy and 6 Weeks of Silastic Catheter Drainage

THE JOURNAL OF UROLOGY

Copyright © 1974 by The Williams & Wilkins Co.

TREATMENT OF URETHRAL STRICTURES WITH INTERNAL URETHROTOJV[Y AND 6 WEEKS OF SILASTIC CATHETER DRAINAGE FRANK K CARLTON, PETER L. SCARDINO

AND

ROBERT B. QUATTLEBAUM

Prom the Savannah Urological Clinic, Savannah, Georgia 1 • 2 control of infecThe use of silicone tion 3 and long-term u,,auw~;c 5 have been recognized as separate factors in the treatment of urethral stricture. Simultaneous use of the techniques suggested a µv,oo,,uu,cv of enhancing the previously reported to 70 per cent good results with internal urethrotomy. s-s

METHODS

Forty-eight men and 2 women have been followed for 5 years after internal urethrotomy and 6 Forty-four men weeks of silicone catheter were selected from a clinic treated with intermittent dilatations from 5 to 22 years, averaging 12.5 years and requiring a minimum average of 5 treatments per year. Four men and the 2 women were seen because of acute retention. The patients in age from the third to the eighth decade, with a mean of 64.7 years (table 1). Although the etiology was uncertain in 16 cases, stricture resulted from an inflammatory condition in 28 cases and followed trauma in 6 (table 2). Urethrotomy vvas offered at a time of s.rn,u~ucu symptomatic inwas done. Those volvement. No further patients in retention underwent some type of relief and infection was treated vigorIn addition to routine studies a voiding test was measuring volume per 8 seconds of maximal flow and total voiding capacity. When possible an oblique film was made during Accepted for publication July 20, 1973. Read at annual meeting of Southeastern Section, American Urological Association, Palm Beach, Florida, April 15-18, 1973. 1 Srinivasan, V. and S. S.: Encrustation of catheter materials in vitro. J. 108: 473, 1972. 2 Painter, M. R., Borski, A. A., Trevino, G. S. and Clark, W. E., Jr.: Urethral reaction of foreign objects. J. Urol., 106: 227, 1971. 3 Dunlop, E. M.: Incidence of urethral stricture in the male after urethritis. Brit. J. Vener. Dis., 37: 64, 1961. 'Helmstein, K.: Internal urethrotomy; modifications in the operative technique: urethroscopic control for evaluation of both the primary results of operation and of long term healing. A discussion of 68 cases. Acta Chir. Scand., suppl. 340, 1964. 'Weaver, R. G. and Schulte, J. W.: Experimental and clinical studies of urethral regeneration. Surg., Gynec. & H5: 729, 1962. E. and Lee, L. W.: Lasting results following internal urethrotomy for urethral stricture. J. Urol., 59: 1948. C. P. and Biorn, C. L.: Internal urethrotomy: its use the treatment of urethral strictures of the male patient. J. Urol., 100: 653, 1968. ' 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, 1872.

pyelography. A retrograde urethrogram was done. Endoscopic evaluation of stricture and scar density frequently revealed a worse condition than that suggested or studies. 9 When possible the Otis urethrotome introduced directly but more often a filiform necessary. Initial incision was made at o'clock position with the instrument maximum tension. A second incision under imum tension was made at the 7 o'clock The urethra was then sounded to the caliber it would accept. ensured mucosa! edge If stricture ti.ssu8 continued to into the lumen further dilats tions or incisions were made until the mucosa flat. A 3-way 24F silicone catheter was inserted connected to an irrigation of distilled wateL patient was given antibiotics and ~osa~··~'-h~ the hospital on straight 3 All patients were admonished to drink minimum of 1 gallon of fluid a At the end of week the antibiotics were c u m r , n n was again cautioned to water. The catheter was ~rn~n,non Dilatation was not done and antibiotics were not given. The patient was reviewed vals for the next month and year. RESULTS

Results were categorized as unsatisfactory, the latter determined subjective improvement or if dilatation was Results were considered necessary and the patient had from subjective symptoms and tive examinations. results patient who underwent dilatation nnc'cr,n,wo,h regardless of indication or were satisfactory in 92 per cent patients were considered evaluation was compared to (table 4). Approximately a third of the '.36 categorized as good voided less than 80 ml. seconds." Of 37 patients cultured rrnon,,w,,, 29 were sterile at 6 months and have (table 5). Of 13 0

9 Lapides, J. and Stone, T. E.: Usefulness of urethrography in diagnosing strictures of the urethra. J, Urol., WO: 747, 1968. 10 Weaver, R. G. and Schulte, J. W.: Clinical aspects of urethral regeneration. J. Urol., 93: 247, 1965. 11 Garrelts, B., von: Analysis of micturition. method of recording the voiding of the bladder, Acta Chir. Scand., H2: 326, 1956.

191

192

CARLTON, SCARDINO AND QUATTLEBAUM

TABLE

1. Age distribution

Age (yrs.)

TABLE

30-39 40-49 50-59 60-69 70-79 80-

No. Cases Sepsis Septicemia Bleeding Epididymitis Pyuria New stricture Incontinence

2

8 11 15 13 1

TABLE 2.

Etiology

Traumatic: Accidental, 4 Iatrogenic, 2 Inflammatory Uncertain

TABLE

6

28 16

3. Clinical evaluation and period of observation Acceptable No.(%)

Good No.(%)

> 4 yrs. 3-4 yrs. 2-3 yrs. 6 mos.-1 yr.

18 9 3 6

Unsatisfactory No.(%)

5 5

2 2 4 (8)

10 (20)

36 (72)

TABLE

4. Voiding capacity and clinical evaluation Good

A

No. (%)

< 50 ml./8 sec. 50-7 5 ml./8 sec. 80 or more ml./8 sec.

bl Unsatisccepta e factory No. (%) No. (%)

4 5 5

12 24 36 (72)

10 (20)

4 (8)

Postop. Preop. Infection-24 Sterile-12 Not cultured-14

Infected

Sterile

6

18 11

l 5

3 2 1

new strictures developed. The graph shows a comparison of preoperative and postoperative flow studies in 21 patients in relation to total voiding capacity (see figure). A comparison with the normal range as described by von Garrelts is made. 12 The graph demonstrates the direct relation of voiding capacity to maximal flow in the normal and postoperative series and the absence of this relationship in the stricture group. Twenty-one asymptomatic patients had clear and uninfected urine 1 week following catheter removal. All 14 patients depicted within the standard deviation lines on the graph were in this group. There was no correlation between postoperative flow rate and evaluation of good or acceptable. Eight acceptable patients underwent dilatation 1 time only and had no objective stricture. Frequency of dilatation in the other 5 patients had not been established. Three unsatisfactory results were associated with intractable pyuria. One catheter was removed after 4 weeks because of discomfort. Control of urethritis and catheter toleration seemed directly related to enthusiastic hydration.

Nineteen patients had complications (table 7). One patient who bled required transfusion and endoscopic fulguration. Fifteen patients experienced a temperature of more than 102F and 5 had culture proved gram-negative septicemia. One patient remained incontinent for 3 weeks following catheter removal and 2 had new strictures requiring dilatation. CONCLUSIONS

9

6. Results related to etiology Good

Traumatic Inflammatory Uncertain

10 5 3 3

COMPLICATIONS

5. Infection

TABLE

TABLE

7. Postoperative complications

No. Cases

Acceptable

Unsatisfactory

20

6

10

4

2 2

6

remained sterile. Of the total group 11 had infection at some time postoperatively (table 6). The cause of 2 unsatisfactory results was inflammatory. In 2 cases the cause was uncertain; in 1 patient the presenting stricture involved approximately 70 per cent of the penile urethra. In 2 of these patients

Internal urethrotomy and long-term silicone catheter drainage can be definitive methods of treating urethral stricture. Proper patient selection remains a problem. Our patients did not undergo dilatation before urethrotomy. The Otis urethrotome is designed to cut relatively dense scarred tissue under tension and pass over normal mucosa. This characteristic is nullified by decreasing the differential diameter in strictured and normal portions of the urethra. Localization of incisions at 5 and 7 o'clock rather than any dorsal position avoids damaging penetrating vessels before they branch into end arteries. Sounding forces the incised mucosa apart, providing maximal separa12 Garrelts, B., von: Micturition in urethral stricture. Acta Chir. Scand., ll4: 466, 1957.

URETHRAL STRICTURES TREATED WITH INTERNAL URETHROTOMY AND DRAINAGE

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PRE

" POST 200 V

w


ro

a::

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g3:

e.,_

80 /J,

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J, 0

0

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Diagram shows relation between maximal flow per 8 seconds and square root calculated from total volume compared to normal series (unbroken line). Broken lines represent plus or minus 2 standard deviations.

tion between cut edges_ Endoscopic review allows control of incision depth and assures thoroughness of removing folds and Six weeks of catheter drainage allows sufficient time for new epithelium to cover the area between the separated mucosa! edges and fix the new diameter against the surrounding fascia minimizing subsequent retraction! The consumption of large amounts of

water improves catheter toleration and vention of infection. Our results are related to prolonged drainage and minimum tion with silicone catheters - Strict attention endoscopic control is basic to the ultimate come. Because of the natural urethral stricture longer