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Urethral strictures after fulguration of posterior urethral valves
Urethral
Strictures
After
Fulguration
of Posterior
Urethral
Valves
By Richa Lal, V. Bhatnagar, and D.K. Mitra New Delhi, India
This report discusses the incidence and predisposing factors for postfulguration urethral strictures in 82 boys with posterior urethral valves treated over 20 years and followed up for a period ranging from 1 to 21 years. A urethral stricture developed in three of the 82 patients (3.6%). All newborns and infants with small urethral caliber at presentation were treated on a temporary tubeless diversion, and fulguration of the valves was deferred until 9 to 12 months of age. A 9F resectoscope with a loop electrode was used to fulgurate at 5, 7, and 12 o’clock positions. A definite technical factor leading to a stricture could be identified in one of these three patients. Comparison of the “stricture” group with the “no stricture”
group suggested that although dry fulguration did not have a definite correlation with stricture formation, it is best avoided. Refulguration and properly managed preoperative catheterization did not predispose to stricture formation. Meticulous surgical technique and avoiding oversized instrumentation were the most important factors for preventing this complication. J Pediatr Surg 33:518-519. Copyright 0 1998 by W.B. Saunders Company.
INCE THE ADVENT of fibreoptic lighting and Hopkins rod lens system in pediatric endoscopes, transurethral fulguration of posterior urethral valves has become the most widely accepted and practiced technique of valve ablation all over the world. Postfulguration stricture formation is its most dreaded complication with its sequelae being severe, prolonged, and more difficult to treat than the valves themselves. The incidence of stricture was reported to be as high as 25% by Myers and Walker1 in 1981. However, with the advent of newer generation of more sophisticated pediatric resectoscopes, improved optics and refinement in surgical technique, series with a 0% stricture rate in newborns and infants have also been reported.z This report describes our method of treatment, the incidence of strictures, and analyzes the possible predisposing factors.
acid base, and electrolyte imbalance and a trral of catheter drainage for 48 hours if the blood urea and serum creatinine were deranged at admission. All newborns and infants whose urethral caliber was too small for a 9F resectoscope were treated on temporary tubeless diversion until the age of 9 to 12 months, whereas older children underwent a primary valve fulguration or a high diversion depending on the response to catheter drainage. Fulguration of the valves was done with a 9F resectoscope using a loop electrode at 5, 7, and 12 o’clock positions with short bursts of coagulating current after the valve leaflets were engaged in the loop under direct vision. The adequacy of fulguration was checked by applying suprapubic pressure on a salinefilled bladder under anesthesia and observing the caliber and force of the stream per urethra. A micturating cystourethrogram was done 6 months after the fulguration to exclude residual valves or postfulguration stricture and to look for the status of postfulguration vesicoureteral reflux. The vesicostomy, if the child had one, was subsequently closed before fulguration.
S
MATERIALS
AND
METHODS
This is a retrospective study done on 82 patients with posterior urethral valves treated over a period ranging from 1 to 21 years. The establislmrem of diagnosis and the evaluation of upper tracts at presentation was performed by a micturating cystourethrogram for demonstration of valves and assessment of vesicoureteral reflux, evaluation of blood urea and serum creatinine, acid-base, and electrolyte status and an ultrasonography for upper tract dilatation, renal cortical thickness, and corticomedullary echogenicity. The treatment at presentation consisted of correction of hydration,
From the Department of Paediutric Surgery, All India Institute of MedIcal Sciences1 New Delhi, India. Address reprint requests to Dr V Bhatnagac MCh, The Department of Paediatric Surgery, All India Institute of Medzcal Sciences, New Delhi, 110029, India. Copyright @ 1998 by WB. Saunders Company 0022-3468/98/3303-0024$03.00/O
518
INDEX WORDS: thral stricture.
Posterior
urethral
valves,
cystoscopy,
ure-
RESULTS
The age at presentation, and hence, treatment, ranged from the newborn period to 15 years and was classified into four groups (Table 1). All newborns and infants were treated initially on a temporary tubeless diversion and subsequently fulgurated around the age of 9 to 12 months. The duration of follow-up ranged from 1 to 21 years and was greater than 10 years in 29 patients (Table 2). Incidence of PostjZguration
Strictures
A postfulguration urethral stricture developed in three of the 82 patients (3.6%). The stricture occurred in the membranous urethra or at the site of valve fulguration. Predisoposing Factors The incidence of strictures in this study has been correlated with dry fulguration, ie, fulguration in the Jouma/
ofpediarric
Surgery,
Vol33,
No 3 (March),
1998: pp 518-519
STRICTURES
IN POSTERIOR
URETHRAL
519
VALVES
Table I. Age at Presentation No of Patents bl = 82)
Age Group
Table 3. Postfulguration Percentdge
Predisposing
Newborn
12
14.6
Preoperative
1 mo-1 yr
2.6
31.7
Dry fulguration
I yr-5 yr >5 yr
27 17
32.9 20.8
Refulguration
presence of a urinary diversion, refulguration, and preoperative catheterization (Table 3). Of the three patients in whom a stricture developed a definite cause could be identified in one of them as tearing of valves and creation of a false passage accompanied by profuse bleeding. This patient had been catheterized for 9 days preoperatively before being referred to this hospital and had also been refulgurated for residual valves. The other two patients had a vesicostomy and hence, a dry urethra at the time of valve fulguration. However, Table 3 shows that in the “no stricture” group, dry fulguration was done in 36 patients, 15 after a bilateral high loop ureterostomy and 21 after a vesicostomy. The duration of preoperative catheterization in the no stricture group ranged from 1 to 21 days (mean, 6.25 days). Prolonged periods of catheterization were usually done at primary care centers before referral. DISCUSSION
The incidence of postfulguration strictures was reported to be 25% by Myers and Walker1 in 1981, 8% by Crooks3 in 1982, and 12% by Churchill et al4 in 1983. Nijman et al2 in 1991 reported a 0% incidence in his series of 85 boys including newborns and infants. The incidence of postfulguration strictures in the present study was 3.670. The predisposing factors implicated in the series reported by Crooks? were the use of a loop electrode, presence of large valves, and dry fulguration. This author believed that the loop electrode could produce greater current injury extending deep into the surrounding corpus spongiosum and that urethral strictures after dry fulguration were analogous to the stenosis seen after a dry ureteral implant. However, in the present series. a loop electrode was used in all the patients, and it did not seem to predispose to stricture formation if care was taken to avoid a deep, circumferential and prolonged fulguration. Myers and Walker’ and Churchill et al4 found an unacceptably high incidence of strictures in children undergoing fulguration under I year of age with a 9F or Table 2. Length
of Follow-Up
No. of Patwmts tn = 82)
Percentage
l-5
31
37.8
5-10 >I0
22 29
268 35.4
Duration Follow-Up
of (yr)
Factor
catheterization
Strictures:
Predisposing
Factors
(n = 821
Stnciure Group hl = 3)
No Stricture Group fn = 79)
I
23
2 1
36 10
1OF resectoscope sheath. The other factors that were found to be associated with increased stricture rate were fulguration through a perineal urethrostomy and bladder neck incision with valve ablation. Dry fulguration did not predispose to increased stricture rate. We therefore advocated temporary tubeless diversion in newborns and small infants and delayed fulguration to 1 year of age. Nijman and Scholtmeijer2 found no strictures in his series of 85 boys including newborns and infants undergoing fulguration with an 8F resectoscope sheath. Hence, the measures that one could advocate for preventing postfulguration strictures are gentleness in surgical technique, avoidance of oversized instrumentation in a small caliber urethra especially since valve patients are usually small for age, minimizing fulguration time, avoiding excessive and deep fulguration, fulguration under direct vision, and shortening the duration of preoperative catheterization and use of nonreactive small sized catheters. There was no evidence in this study to suggest that use of a loop electrode or refulguration, if done meticulously, led to stricture formation. Data in this study show that although two of the three patients in the stricture group did have a dry fulguration, 36 of the 79 patients in the no stricture group did not acquire a stricture despite dry fulguration (Table 3). Because of the wide disparity in the number of patients in the two groups, the percentages have not been compared. Hence, the figures in this clinical study do not suggest a direct correlation between dry fulguration and stricture formation. However, one could speculate that perhaps, two of the three strictures in this series could have been prevented by not doing a dry fulguration. With the advent of more sophisticated pediatric resectoscopes and improved optics, neonatal fulguration would become equally safe by avoiding urinary diversion and hence, dry fulguration as a risk factor for stricture formation would be eliminated. REFERENCES 1. Myers DA, Walker RD: Prevention of urethral strxtures m the management of posterior urethral valves. .l Ural 126:655-657,198l 2. Nijman RJM, Scholtmeijer RJ: Complications of tram-urethral electroincision of posterior urethral valves. Br .I Urol67:324-326, 1991 3, Crooks KK: Urethral strictures following transurethral resection of posterior urethral valves. J Urol 127:1153-1154, 1982 4. Churchill BM, Krueger RP, Fleicher MH: Complications of posterior urethral valve surgery, Urol Clm North Am 10:519-530. 1983
Strictures
After
Fulguration
of Posterior
Urethral
Valves
By Richa Lal, V. Bhatnagar, and D.K. Mitra New Delhi, India
This report discusses the incidence and predisposing factors for postfulguration urethral strictures in 82 boys with posterior urethral valves treated over 20 years and followed up for a period ranging from 1 to 21 years. A urethral stricture developed in three of the 82 patients (3.6%). All newborns and infants with small urethral caliber at presentation were treated on a temporary tubeless diversion, and fulguration of the valves was deferred until 9 to 12 months of age. A 9F resectoscope with a loop electrode was used to fulgurate at 5, 7, and 12 o’clock positions. A definite technical factor leading to a stricture could be identified in one of these three patients. Comparison of the “stricture” group with the “no stricture”
group suggested that although dry fulguration did not have a definite correlation with stricture formation, it is best avoided. Refulguration and properly managed preoperative catheterization did not predispose to stricture formation. Meticulous surgical technique and avoiding oversized instrumentation were the most important factors for preventing this complication. J Pediatr Surg 33:518-519. Copyright 0 1998 by W.B. Saunders Company.
INCE THE ADVENT of fibreoptic lighting and Hopkins rod lens system in pediatric endoscopes, transurethral fulguration of posterior urethral valves has become the most widely accepted and practiced technique of valve ablation all over the world. Postfulguration stricture formation is its most dreaded complication with its sequelae being severe, prolonged, and more difficult to treat than the valves themselves. The incidence of stricture was reported to be as high as 25% by Myers and Walker1 in 1981. However, with the advent of newer generation of more sophisticated pediatric resectoscopes, improved optics and refinement in surgical technique, series with a 0% stricture rate in newborns and infants have also been reported.z This report describes our method of treatment, the incidence of strictures, and analyzes the possible predisposing factors.
acid base, and electrolyte imbalance and a trral of catheter drainage for 48 hours if the blood urea and serum creatinine were deranged at admission. All newborns and infants whose urethral caliber was too small for a 9F resectoscope were treated on temporary tubeless diversion until the age of 9 to 12 months, whereas older children underwent a primary valve fulguration or a high diversion depending on the response to catheter drainage. Fulguration of the valves was done with a 9F resectoscope using a loop electrode at 5, 7, and 12 o’clock positions with short bursts of coagulating current after the valve leaflets were engaged in the loop under direct vision. The adequacy of fulguration was checked by applying suprapubic pressure on a salinefilled bladder under anesthesia and observing the caliber and force of the stream per urethra. A micturating cystourethrogram was done 6 months after the fulguration to exclude residual valves or postfulguration stricture and to look for the status of postfulguration vesicoureteral reflux. The vesicostomy, if the child had one, was subsequently closed before fulguration.
S
MATERIALS
AND
METHODS
This is a retrospective study done on 82 patients with posterior urethral valves treated over a period ranging from 1 to 21 years. The establislmrem of diagnosis and the evaluation of upper tracts at presentation was performed by a micturating cystourethrogram for demonstration of valves and assessment of vesicoureteral reflux, evaluation of blood urea and serum creatinine, acid-base, and electrolyte status and an ultrasonography for upper tract dilatation, renal cortical thickness, and corticomedullary echogenicity. The treatment at presentation consisted of correction of hydration,
From the Department of Paediutric Surgery, All India Institute of MedIcal Sciences1 New Delhi, India. Address reprint requests to Dr V Bhatnagac MCh, The Department of Paediatric Surgery, All India Institute of Medzcal Sciences, New Delhi, 110029, India. Copyright @ 1998 by WB. Saunders Company 0022-3468/98/3303-0024$03.00/O
518
INDEX WORDS: thral stricture.
Posterior
urethral
valves,
cystoscopy,
ure-
RESULTS
The age at presentation, and hence, treatment, ranged from the newborn period to 15 years and was classified into four groups (Table 1). All newborns and infants were treated initially on a temporary tubeless diversion and subsequently fulgurated around the age of 9 to 12 months. The duration of follow-up ranged from 1 to 21 years and was greater than 10 years in 29 patients (Table 2). Incidence of PostjZguration
Strictures
A postfulguration urethral stricture developed in three of the 82 patients (3.6%). The stricture occurred in the membranous urethra or at the site of valve fulguration. Predisoposing Factors The incidence of strictures in this study has been correlated with dry fulguration, ie, fulguration in the Jouma/
ofpediarric
Surgery,
Vol33,
No 3 (March),
1998: pp 518-519
STRICTURES
IN POSTERIOR
URETHRAL
519
VALVES
Table I. Age at Presentation No of Patents bl = 82)
Age Group
Table 3. Postfulguration Percentdge
Predisposing
Newborn
12
14.6
Preoperative
1 mo-1 yr
2.6
31.7
Dry fulguration
I yr-5 yr >5 yr
27 17
32.9 20.8
Refulguration
presence of a urinary diversion, refulguration, and preoperative catheterization (Table 3). Of the three patients in whom a stricture developed a definite cause could be identified in one of them as tearing of valves and creation of a false passage accompanied by profuse bleeding. This patient had been catheterized for 9 days preoperatively before being referred to this hospital and had also been refulgurated for residual valves. The other two patients had a vesicostomy and hence, a dry urethra at the time of valve fulguration. However, Table 3 shows that in the “no stricture” group, dry fulguration was done in 36 patients, 15 after a bilateral high loop ureterostomy and 21 after a vesicostomy. The duration of preoperative catheterization in the no stricture group ranged from 1 to 21 days (mean, 6.25 days). Prolonged periods of catheterization were usually done at primary care centers before referral. DISCUSSION
The incidence of postfulguration strictures was reported to be 25% by Myers and Walker1 in 1981, 8% by Crooks3 in 1982, and 12% by Churchill et al4 in 1983. Nijman et al2 in 1991 reported a 0% incidence in his series of 85 boys including newborns and infants. The incidence of postfulguration strictures in the present study was 3.670. The predisposing factors implicated in the series reported by Crooks? were the use of a loop electrode, presence of large valves, and dry fulguration. This author believed that the loop electrode could produce greater current injury extending deep into the surrounding corpus spongiosum and that urethral strictures after dry fulguration were analogous to the stenosis seen after a dry ureteral implant. However, in the present series. a loop electrode was used in all the patients, and it did not seem to predispose to stricture formation if care was taken to avoid a deep, circumferential and prolonged fulguration. Myers and Walker’ and Churchill et al4 found an unacceptably high incidence of strictures in children undergoing fulguration under I year of age with a 9F or Table 2. Length
of Follow-Up
No. of Patwmts tn = 82)
Percentage
l-5
31
37.8
5-10 >I0
22 29
268 35.4
Duration Follow-Up
of (yr)
Factor
catheterization
Strictures:
Predisposing
Factors
(n = 821
Stnciure Group hl = 3)
No Stricture Group fn = 79)
I
23
2 1
36 10
1OF resectoscope sheath. The other factors that were found to be associated with increased stricture rate were fulguration through a perineal urethrostomy and bladder neck incision with valve ablation. Dry fulguration did not predispose to increased stricture rate. We therefore advocated temporary tubeless diversion in newborns and small infants and delayed fulguration to 1 year of age. Nijman and Scholtmeijer2 found no strictures in his series of 85 boys including newborns and infants undergoing fulguration with an 8F resectoscope sheath. Hence, the measures that one could advocate for preventing postfulguration strictures are gentleness in surgical technique, avoidance of oversized instrumentation in a small caliber urethra especially since valve patients are usually small for age, minimizing fulguration time, avoiding excessive and deep fulguration, fulguration under direct vision, and shortening the duration of preoperative catheterization and use of nonreactive small sized catheters. There was no evidence in this study to suggest that use of a loop electrode or refulguration, if done meticulously, led to stricture formation. Data in this study show that although two of the three patients in the stricture group did have a dry fulguration, 36 of the 79 patients in the no stricture group did not acquire a stricture despite dry fulguration (Table 3). Because of the wide disparity in the number of patients in the two groups, the percentages have not been compared. Hence, the figures in this clinical study do not suggest a direct correlation between dry fulguration and stricture formation. However, one could speculate that perhaps, two of the three strictures in this series could have been prevented by not doing a dry fulguration. With the advent of more sophisticated pediatric resectoscopes and improved optics, neonatal fulguration would become equally safe by avoiding urinary diversion and hence, dry fulguration as a risk factor for stricture formation would be eliminated. REFERENCES 1. Myers DA, Walker RD: Prevention of urethral strxtures m the management of posterior urethral valves. .l Ural 126:655-657,198l 2. Nijman RJM, Scholtmeijer RJ: Complications of tram-urethral electroincision of posterior urethral valves. Br .I Urol67:324-326, 1991 3, Crooks KK: Urethral strictures following transurethral resection of posterior urethral valves. J Urol 127:1153-1154, 1982 4. Churchill BM, Krueger RP, Fleicher MH: Complications of posterior urethral valve surgery, Urol Clm North Am 10:519-530. 1983