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Urethral stricture treated with soft catheter dilatation
URETHRAL STRICTURE TREATED WITH SOFT CATHETER DILATATION Reappraisal of an Old Technique SIVAPBASAD MADHAV JOSEPH
MADDURI,
H. KAMAT, J. SEEBODE,
M.D. M.D. M.D.
From the Department of Surgery, Division of Urology, College Medicine and Dentistry of New Jersey and Affiliated Hospitals, Martland Hospital, Newark, New Jersey
of
ABSTRACT-Treatment of strictures of the urethra by soft dilatation using urethral catheters of gradually increasing size has received very little emphasis in view of the sparse literature available on the subject. In 20 patients severe strictures were gradually dilated using this method. A review of these cases is presented along with the technique of soft dilatation.
Stricture of the urethra has been a major problem for more than 2,500 years of recorded history. In spite of a reduction in the number due to gonorrhea, urethral stricture remains a sufficiently common disease to be a source of major concern. To date, there is no single consistently effective modality of treatment. Despite extensive literature on the ingenious techniques of urethroplasty, time-honored dilatation is still considered the treatment of choice in most cases. The term “dilatation of the stricture” strikes the same vivid note in the minds of most physicians: the surgeon trying to negotiate a hard metallic sound through the fibrous contracted area of the urethra. It is definitely a traumatic procedure if even the slightest force is used. It is often associated with pain, bleeding, and laceration of the tissues, resulting in more fibrosis and a tighter stricture eventually defeating the original purpose. There is one other method of dilatation which was called “gradual dilatation” by Flocks and Gulp.’ We prefer the term “soft dilatation” because most of the procedure is carried out by urethral catheters of gradually increasing size
504
over a period of ten to fifteen days. Although this technique was mentioned as one of the therapeutic modalities for treatment of stricture of the urethra in most of the textbooks, very little emphasis is paid to it as evidenced by the scanty literature. Soft dilatation has been used to treat 20 patients with impassable or difficult to dilate strictures at the Jersey City Medical Center in a two-and-one-half-year period from July, 1971, to December, 1973. A preliminary study of these cases is presented. The follow-up period for these cases ranges from six months to two and one-half years. Technique
of Soft Dilatation
The patients selected for this procedure are those with severe urethral strictures which are difficult to dilate. When the patient is first examined, inability to pass the smallest size urethral catheter, history of stricture disease, and absence of noticeable prostatic disease suggest the diagnosis of stricture of the urethra. In cases in which it is possible, retrograde and antegrade urethrograms are obtained to document the narrowed portion of the urethra.
UROLOGY
/ NOVEMBER1974
/ VOLUMEIV,NUMBER5
FIGURE
Case 1. Retrograde
1.
urethrogram
(A) predilatation
and (B) postdilatation
demonstrating
patent
urethra.
Dilatation is attempted gentlv with filiforms and followers; then medium-sized sounds are used. If this fails and the patient is not in retention, dilatation is reattempted after one or two days of hospitalization and antibiotic therapy. When the stricture can be dilated to a 14 F without undue trauma, an attempt is made to insert a urethral Foley catheter. The catheter is left indwelling for twenty-four to thirty-six hours and then changed to the next larger size. The process is repeated until an acceptable size (24 F) is reached. When the urethral catheter is finally removed, a retrograde urethrogram is obtained to establish the effect of the dilatation. The patient is given a trial of voiding before discharge. If during the original attempt only a filiform or the smallest size follower could be negotiated through the stricture, they are left in the urethra and taped to the penis for at least forty-eight hours before graduated dilatation with catheters is attempted. The patient is kept on appropriate antibiotics in therapeutic doses during these procedures. If the patient is in retention and even a filiform could not be passed, urine is drained by inserting a polyethylene catheter through a trocar suprapubically into the bladder. These patients are given the benefit of another dilatation, but many of them require a suprapubic cystostomy. When the bladder is opened, a small metallic sound is passed through the urethra from inside the bladder, and a Foley of small caliber is attached to the sound and pulled into the bladder.
UHOLOGY
/
NOVEMBER
1974
/
VOLUME
IV, NUMBER
5
A conventional suprapubic tube is left in and soft dilatation is carried out by the method described. When adequate urethral diameter has been attained, the suprapubic tube is clamped, and the patient is given a trial of voiding. When he voids the suprapubic tube is with a good stream, removed. All these patients are followed up frequently, and calibration and dilatation are done when necessary. Case
Reports
Case 1 A twenty-four-year-old black man entered the hospital on October 17, 1973, for treatment of a known stricture of the urethra. He was involved in an automobile accident several years prior to admission and sustained a fractured pelvis with complete rupture of the membranous urethra. At that time he was treated with suprapubic cystostomy and an indwelling urethral catheter that was introduced by the antegrade pullthrough technique. The rupture healed well with good approximation of the severed ends of the urethra. He was lost to follow-up and had no dilatations for two years. At the time of admission he had severe frequency and dysuria. Urine culture was sterile and excretory urogram normal except for a trabeculated bladder. A retrograde urethrogram demonstrated stricture of the bulbous urethra with complete obstruction (Fig. 1A). Dilatation was attempted
505
FIGURE 2. Case 2. (A) Urethrogram before dilatation showing complete obstruction of posterior urethra; bladder is filled with contrast medium from intravenous pyelogram performed immediately prior, (B) postdilatation demonstrating normal-appearing posterior urethra.
under anesthesia, and with some difficulty he was dilated to a 16 F with filiforms and Leforte sounds. A 16 F Foley catheter was left indwelling. He was given antibiotics, and the stricture was gradually dilated with catheters of increasing size to a 24 F over a period of thirteen days. A repeat retrograde urethrogram three weeks later showed no evidence of stricture and a normal-looking urethra (Fig. 1B). The patient voided with a satisfactory stream and good control before discharge. This patient has been followed up for three months and has not required dilatation. Case 2 A sixty-two-year-old white man was admitted on September 24, 1973, for urinary retention. He had been having frequency, nocturia, dysuria, and dribbling for two to three years. Catheterization was attempted in the emergency room and later dilatation with filiforms and followers without success. He was voiding small amounts after these procedures. The next day a retrograde urethrogram was obtained which showed a stricture of the bulbomembranous urethra (Fig. 2A). An intravenous urogram was normal, and chest x-ray film revealed a radiopaque density in the right lung. A repeat attempt at dilatation failed. A suprapubic polyethylene catheter was inserted into the bladder. Two days later under spinal anesthesia suprapubic cystostomy was done and a 16 F Foley catheter negotiated into the urethra by the antegrade pull-through method. A suprapubic
506
Malecot catheter was left in the bladder. One week later the 16 F catheter was replaced with a 18 F, and this time the catheter was inserted with ease. The soft dilatation continued up to 24 F in ten days. Two days later the Foley catheter was discontinued, and a retrograde urethrogram showed a satisfactory urethral lumen (Fig. 2B). The urethra admitted a 26 F sound with ease. The suprapubic tube was clamped, and the patient was given a trial of voiding. He voided with a good stream. He was later transferred to the thoracic unit for the evaluation of the lung lesion which turned out to be inoperable cancer. The patient has been followed up for four months and has not required dilatation. Comment The clinical summary of all the patients is presented in Table I. The ages of these patients ranged between twenty-one and eighty-nine years; 65 per cent were more than fifty years of age. Four patients had diabetes, 4 atherosclerotic heart disease, 2 obstructive lung disease, and another cancer of the lung. These 11 patients were considered poor candidates for extensive reconstructive procedures of the urethra. The majority of the strictures, 10 of 20, were of infective origin. Four were traumatic strictures, and 4 patients had stricture following transurethral resection of the prostate. The only female patient in our series had had urethral stenosis since childhood.
UROLOGY
/ NOVEMBER
1974 /
VOLUME
IV, NUMBER
5
TABLE
I.
Clinical summary of patients Duration
Stricture
1 of Soft
I Case Age Number (Years)
Duration
Cause*
Dilatation (Days)
Location
Satisfactory
4 3
13
Fair
2.5
24
8 11 14
Fair Fair Good
3 1.5 4
30 8 24
10
Fair Soft dilatation failed; patient died of uremia Poor; had urethroPl”tY Good
2
12
Membranous Bulbomembranous urethra Bulbomembranous urethra Anterior urethra Membranous Bulbomembranous urethra Bladder neck Bulbous urethra
21 21
Bulbomembranous urethra Urethral stenosis
7
1 2
24 62
Traumatic Infective
5 years 2 Years
3
21
Traumatic
1 year
‘i
5 6
60 80 55
Infective Infective Infective
8 months 2.5 months 15 years
7 8
68 89
Post-TURP (?) Infective
8 years
9
74
Infective
6 Years
10
51
11
82
(?) Congenital Since childhood Post-TURP Bladder neck 2 years
10
12
46
Traumatic
3.5 years
13
25
Infective
10 years
14 15 16 17
49 51 75 71
9 1 3 3
18 19 20
57 60 22
Infective Post-TURP Post-TURP Diabetes and urethritis Infective Infective Traumatic
Bulbomembranous urethra Bulbomembranous urethra Bulbous urethra Bladder neck Bladder neck Anterior urethra Anterior urethra Bulbous urethra Bulbomembranous urethra
.
years year months years
4 years 2 years 6 months
Results
Period Period Without of Dilatation Follow-up (Months) (Months)
7
GOOd
6 6
.
.
0.5
. 24
5
30
12
Soft dilatation followed, by TURP Satisfactory
1.5
12
Good
3
7 10 5 10
Fair Good Satisfactory Fair
1.5 3 2 1
6 6 6 10
8 20 11
Good Good Fair
3 4 1.5
6 6 6
.
30 4
*TURP = transurethral resection of prostate.
Most of the strictures were chronic with duration ranging from two to ten years. Only 4 patients had the strictures less than two years. Twelve of the strictures were located in the bulbomembranous urethra. Three patients had anterior urethral strictures, and 4 had strictures in the posterior urethra. One of the patients had periurethral abscess and urinary extravasation. All the patients were eventually treated with soft dilatation. The circumstances related to the initial introduction of the catheter varied. Ten patients had successful filiform-follower dilatation to at least 12 F. Van Buren sounds for initial dilatation were used in 4 patients and female sounds in the female patient. In 4 of the patients attempts at dilatation failed and required suprapubic cystostomy and catheter introduction by the antegrade pull-through technique. One patient with periurethral abscess and urinary
UROLOGY
I
NOVEMBER 1974
/ VOLUME IV, NUMBER 5
extravasation had suprapubic cystostomy and drainage of abscess done initially. This was followed with soft dilatation four weeks later. The duration of the entire procedure ranged from seven to twenty-one days, the average being ten days. Of the 20 patients in the present series 18 are successfully dilated to 22 F. The ease with which the bigger catheter is passed compared with the previous size is amazing when the initial di&ulty to introduce a filiform is taken into consideration. In 1 patient the procedure could not be continued, and the other was a failure. An eighty-four-year-old patient who was admitted for azotemia was found to have stricture of the urethra. Soft dilatation was attempted, but he died on the third hospital day. The other patient had acute retention four weeks after successful soft dilatation. Eventually he had a
507
Turner-Warwick urethroplasty. When the SUCcess rate of soft dilatation is considered, it is probable that only occasional urethroplasties or urinary diversions should be necessary. Most of the patients treated did not require dilatations any more frequently than after conventional dilatation. They remained symptom-free for long periods and required dilatations once every four to six months. Although most of these patients were treated in the hospital, soft catheter dilatation could be done as an outpatient. Conclusions There is no single consistently effective method of treatment for stricture of the urethra. The therapy includes dilatation with filiform and followers, sounds, graduated catheters (soft dilatation), internal urethrotomy, urethroplasty, and intubated urethrotomy.’ Although there are many ingenious techniques of urethral reconstruction, dilatation remains the treatment of choice in most cases, The harm and damage that will be done in trying to “break” or “crack” a narrow, scarred, tight stricture with metal dilators cannot be overemphasized. Soft dilatation with graduated catheters, each one of which
508
is left indwelling for twenty-four to forty-eight hours before changing to the next larger size, is an excellent technique in these difficult cases. It is surprising to note how little emphasis is given to this time-honored technique as evidenced by the sparse literature available on this subject. We treated 20 difficult cases of stricture of the urethra with soft dilatation; 18 were successfully dilated. Follow-ups range from three months to two and one-half years. The results are encouraging. Eleven of the 20 patients are more than fifty years of age with poor general condition and systemic diseases and would have had to have permanent suprapubic cystostomies but for this technique. Soft dilatation is especially useful in patients in whom extensive reconstructive procedures are contraindicated. 65 Bergen Street Newark, New Jersey 07107 (DR. SEEBODE) References 1. FLOCKS, R. H., AND CULP, D.: SurgicalUrology,2nd ed., Chicago, Year Book Medical Publishers, Inc., 1963, p. 302. 2. YELDERMAN,J. J.,AND WEAVER, R. C.: The behavior and treatment of urethral strictures, J. Urol. 97: 1040 (1967).
UROLOGY
/ NOVEMBER1974
/ VOLUMEIV,NUMBERS
MADDURI,
H. KAMAT, J. SEEBODE,
M.D. M.D. M.D.
From the Department of Surgery, Division of Urology, College Medicine and Dentistry of New Jersey and Affiliated Hospitals, Martland Hospital, Newark, New Jersey
of
ABSTRACT-Treatment of strictures of the urethra by soft dilatation using urethral catheters of gradually increasing size has received very little emphasis in view of the sparse literature available on the subject. In 20 patients severe strictures were gradually dilated using this method. A review of these cases is presented along with the technique of soft dilatation.
Stricture of the urethra has been a major problem for more than 2,500 years of recorded history. In spite of a reduction in the number due to gonorrhea, urethral stricture remains a sufficiently common disease to be a source of major concern. To date, there is no single consistently effective modality of treatment. Despite extensive literature on the ingenious techniques of urethroplasty, time-honored dilatation is still considered the treatment of choice in most cases. The term “dilatation of the stricture” strikes the same vivid note in the minds of most physicians: the surgeon trying to negotiate a hard metallic sound through the fibrous contracted area of the urethra. It is definitely a traumatic procedure if even the slightest force is used. It is often associated with pain, bleeding, and laceration of the tissues, resulting in more fibrosis and a tighter stricture eventually defeating the original purpose. There is one other method of dilatation which was called “gradual dilatation” by Flocks and Gulp.’ We prefer the term “soft dilatation” because most of the procedure is carried out by urethral catheters of gradually increasing size
504
over a period of ten to fifteen days. Although this technique was mentioned as one of the therapeutic modalities for treatment of stricture of the urethra in most of the textbooks, very little emphasis is paid to it as evidenced by the scanty literature. Soft dilatation has been used to treat 20 patients with impassable or difficult to dilate strictures at the Jersey City Medical Center in a two-and-one-half-year period from July, 1971, to December, 1973. A preliminary study of these cases is presented. The follow-up period for these cases ranges from six months to two and one-half years. Technique
of Soft Dilatation
The patients selected for this procedure are those with severe urethral strictures which are difficult to dilate. When the patient is first examined, inability to pass the smallest size urethral catheter, history of stricture disease, and absence of noticeable prostatic disease suggest the diagnosis of stricture of the urethra. In cases in which it is possible, retrograde and antegrade urethrograms are obtained to document the narrowed portion of the urethra.
UROLOGY
/ NOVEMBER1974
/ VOLUMEIV,NUMBER5
FIGURE
Case 1. Retrograde
1.
urethrogram
(A) predilatation
and (B) postdilatation
demonstrating
patent
urethra.
Dilatation is attempted gentlv with filiforms and followers; then medium-sized sounds are used. If this fails and the patient is not in retention, dilatation is reattempted after one or two days of hospitalization and antibiotic therapy. When the stricture can be dilated to a 14 F without undue trauma, an attempt is made to insert a urethral Foley catheter. The catheter is left indwelling for twenty-four to thirty-six hours and then changed to the next larger size. The process is repeated until an acceptable size (24 F) is reached. When the urethral catheter is finally removed, a retrograde urethrogram is obtained to establish the effect of the dilatation. The patient is given a trial of voiding before discharge. If during the original attempt only a filiform or the smallest size follower could be negotiated through the stricture, they are left in the urethra and taped to the penis for at least forty-eight hours before graduated dilatation with catheters is attempted. The patient is kept on appropriate antibiotics in therapeutic doses during these procedures. If the patient is in retention and even a filiform could not be passed, urine is drained by inserting a polyethylene catheter through a trocar suprapubically into the bladder. These patients are given the benefit of another dilatation, but many of them require a suprapubic cystostomy. When the bladder is opened, a small metallic sound is passed through the urethra from inside the bladder, and a Foley of small caliber is attached to the sound and pulled into the bladder.
UHOLOGY
/
NOVEMBER
1974
/
VOLUME
IV, NUMBER
5
A conventional suprapubic tube is left in and soft dilatation is carried out by the method described. When adequate urethral diameter has been attained, the suprapubic tube is clamped, and the patient is given a trial of voiding. When he voids the suprapubic tube is with a good stream, removed. All these patients are followed up frequently, and calibration and dilatation are done when necessary. Case
Reports
Case 1 A twenty-four-year-old black man entered the hospital on October 17, 1973, for treatment of a known stricture of the urethra. He was involved in an automobile accident several years prior to admission and sustained a fractured pelvis with complete rupture of the membranous urethra. At that time he was treated with suprapubic cystostomy and an indwelling urethral catheter that was introduced by the antegrade pullthrough technique. The rupture healed well with good approximation of the severed ends of the urethra. He was lost to follow-up and had no dilatations for two years. At the time of admission he had severe frequency and dysuria. Urine culture was sterile and excretory urogram normal except for a trabeculated bladder. A retrograde urethrogram demonstrated stricture of the bulbous urethra with complete obstruction (Fig. 1A). Dilatation was attempted
505
FIGURE 2. Case 2. (A) Urethrogram before dilatation showing complete obstruction of posterior urethra; bladder is filled with contrast medium from intravenous pyelogram performed immediately prior, (B) postdilatation demonstrating normal-appearing posterior urethra.
under anesthesia, and with some difficulty he was dilated to a 16 F with filiforms and Leforte sounds. A 16 F Foley catheter was left indwelling. He was given antibiotics, and the stricture was gradually dilated with catheters of increasing size to a 24 F over a period of thirteen days. A repeat retrograde urethrogram three weeks later showed no evidence of stricture and a normal-looking urethra (Fig. 1B). The patient voided with a satisfactory stream and good control before discharge. This patient has been followed up for three months and has not required dilatation. Case 2 A sixty-two-year-old white man was admitted on September 24, 1973, for urinary retention. He had been having frequency, nocturia, dysuria, and dribbling for two to three years. Catheterization was attempted in the emergency room and later dilatation with filiforms and followers without success. He was voiding small amounts after these procedures. The next day a retrograde urethrogram was obtained which showed a stricture of the bulbomembranous urethra (Fig. 2A). An intravenous urogram was normal, and chest x-ray film revealed a radiopaque density in the right lung. A repeat attempt at dilatation failed. A suprapubic polyethylene catheter was inserted into the bladder. Two days later under spinal anesthesia suprapubic cystostomy was done and a 16 F Foley catheter negotiated into the urethra by the antegrade pull-through method. A suprapubic
506
Malecot catheter was left in the bladder. One week later the 16 F catheter was replaced with a 18 F, and this time the catheter was inserted with ease. The soft dilatation continued up to 24 F in ten days. Two days later the Foley catheter was discontinued, and a retrograde urethrogram showed a satisfactory urethral lumen (Fig. 2B). The urethra admitted a 26 F sound with ease. The suprapubic tube was clamped, and the patient was given a trial of voiding. He voided with a good stream. He was later transferred to the thoracic unit for the evaluation of the lung lesion which turned out to be inoperable cancer. The patient has been followed up for four months and has not required dilatation. Comment The clinical summary of all the patients is presented in Table I. The ages of these patients ranged between twenty-one and eighty-nine years; 65 per cent were more than fifty years of age. Four patients had diabetes, 4 atherosclerotic heart disease, 2 obstructive lung disease, and another cancer of the lung. These 11 patients were considered poor candidates for extensive reconstructive procedures of the urethra. The majority of the strictures, 10 of 20, were of infective origin. Four were traumatic strictures, and 4 patients had stricture following transurethral resection of the prostate. The only female patient in our series had had urethral stenosis since childhood.
UROLOGY
/ NOVEMBER
1974 /
VOLUME
IV, NUMBER
5
TABLE
I.
Clinical summary of patients Duration
Stricture
1 of Soft
I Case Age Number (Years)
Duration
Cause*
Dilatation (Days)
Location
Satisfactory
4 3
13
Fair
2.5
24
8 11 14
Fair Fair Good
3 1.5 4
30 8 24
10
Fair Soft dilatation failed; patient died of uremia Poor; had urethroPl”tY Good
2
12
Membranous Bulbomembranous urethra Bulbomembranous urethra Anterior urethra Membranous Bulbomembranous urethra Bladder neck Bulbous urethra
21 21
Bulbomembranous urethra Urethral stenosis
7
1 2
24 62
Traumatic Infective
5 years 2 Years
3
21
Traumatic
1 year
‘i
5 6
60 80 55
Infective Infective Infective
8 months 2.5 months 15 years
7 8
68 89
Post-TURP (?) Infective
8 years
9
74
Infective
6 Years
10
51
11
82
(?) Congenital Since childhood Post-TURP Bladder neck 2 years
10
12
46
Traumatic
3.5 years
13
25
Infective
10 years
14 15 16 17
49 51 75 71
9 1 3 3
18 19 20
57 60 22
Infective Post-TURP Post-TURP Diabetes and urethritis Infective Infective Traumatic
Bulbomembranous urethra Bulbomembranous urethra Bulbous urethra Bladder neck Bladder neck Anterior urethra Anterior urethra Bulbous urethra Bulbomembranous urethra
.
years year months years
4 years 2 years 6 months
Results
Period Period Without of Dilatation Follow-up (Months) (Months)
7
GOOd
6 6
.
.
0.5
. 24
5
30
12
Soft dilatation followed, by TURP Satisfactory
1.5
12
Good
3
7 10 5 10
Fair Good Satisfactory Fair
1.5 3 2 1
6 6 6 10
8 20 11
Good Good Fair
3 4 1.5
6 6 6
.
30 4
*TURP = transurethral resection of prostate.
Most of the strictures were chronic with duration ranging from two to ten years. Only 4 patients had the strictures less than two years. Twelve of the strictures were located in the bulbomembranous urethra. Three patients had anterior urethral strictures, and 4 had strictures in the posterior urethra. One of the patients had periurethral abscess and urinary extravasation. All the patients were eventually treated with soft dilatation. The circumstances related to the initial introduction of the catheter varied. Ten patients had successful filiform-follower dilatation to at least 12 F. Van Buren sounds for initial dilatation were used in 4 patients and female sounds in the female patient. In 4 of the patients attempts at dilatation failed and required suprapubic cystostomy and catheter introduction by the antegrade pull-through technique. One patient with periurethral abscess and urinary
UROLOGY
I
NOVEMBER 1974
/ VOLUME IV, NUMBER 5
extravasation had suprapubic cystostomy and drainage of abscess done initially. This was followed with soft dilatation four weeks later. The duration of the entire procedure ranged from seven to twenty-one days, the average being ten days. Of the 20 patients in the present series 18 are successfully dilated to 22 F. The ease with which the bigger catheter is passed compared with the previous size is amazing when the initial di&ulty to introduce a filiform is taken into consideration. In 1 patient the procedure could not be continued, and the other was a failure. An eighty-four-year-old patient who was admitted for azotemia was found to have stricture of the urethra. Soft dilatation was attempted, but he died on the third hospital day. The other patient had acute retention four weeks after successful soft dilatation. Eventually he had a
507
Turner-Warwick urethroplasty. When the SUCcess rate of soft dilatation is considered, it is probable that only occasional urethroplasties or urinary diversions should be necessary. Most of the patients treated did not require dilatations any more frequently than after conventional dilatation. They remained symptom-free for long periods and required dilatations once every four to six months. Although most of these patients were treated in the hospital, soft catheter dilatation could be done as an outpatient. Conclusions There is no single consistently effective method of treatment for stricture of the urethra. The therapy includes dilatation with filiform and followers, sounds, graduated catheters (soft dilatation), internal urethrotomy, urethroplasty, and intubated urethrotomy.’ Although there are many ingenious techniques of urethral reconstruction, dilatation remains the treatment of choice in most cases, The harm and damage that will be done in trying to “break” or “crack” a narrow, scarred, tight stricture with metal dilators cannot be overemphasized. Soft dilatation with graduated catheters, each one of which
508
is left indwelling for twenty-four to forty-eight hours before changing to the next larger size, is an excellent technique in these difficult cases. It is surprising to note how little emphasis is given to this time-honored technique as evidenced by the sparse literature available on this subject. We treated 20 difficult cases of stricture of the urethra with soft dilatation; 18 were successfully dilated. Follow-ups range from three months to two and one-half years. The results are encouraging. Eleven of the 20 patients are more than fifty years of age with poor general condition and systemic diseases and would have had to have permanent suprapubic cystostomies but for this technique. Soft dilatation is especially useful in patients in whom extensive reconstructive procedures are contraindicated. 65 Bergen Street Newark, New Jersey 07107 (DR. SEEBODE) References 1. FLOCKS, R. H., AND CULP, D.: SurgicalUrology,2nd ed., Chicago, Year Book Medical Publishers, Inc., 1963, p. 302. 2. YELDERMAN,J. J.,AND WEAVER, R. C.: The behavior and treatment of urethral strictures, J. Urol. 97: 1040 (1967).
UROLOGY
/ NOVEMBER1974
/ VOLUMEIV,NUMBERS