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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 367-371

Evaluation of direct visual internal urethrotomy in the management of anterior urethral strictures


Urology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission16-Apr-2016
Date of Acceptance06-Jun-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Ibrahim M Gomaa
Urology Department, Faculty of Medicine, Menoufia University Menoufia 11160
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215438

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  Abstract 

Objectives
The aim of the present study was to evaluate the outcome of direct vision internal urethrotomy (DVIU) in the management of patients with anterior urethral stricture.
Background
DVIU is a simple and popular treatment for male urethral stricture; however, the long-term stricture-free rate is modest even after only a single procedure. Therefore, identifying patients at risk for recurrence after DVIU is crucial. There is a paucity of research regarding factors predicting failure after DVIU, notably with no standardized definition of failure.
Patients and methods
We reviewed the charts and retrospectively analyzed the records of 103 male patients who underwent DVIU for anterior urethral stricture disease at Menoufia University Hospital between June 2014 and June 2015. The patients' demographics and stricture characteristics were analyzed. Procedure failure was defined as the need for regular urethral dilatation, redo DVIU, or urethroplasty. In addition, predictors of failure were analyzed.
Results
Successful outcome had occurred in 51 patients. The site of stricture was bulbar in 72.5% of them, whereas it was bulbopenile in 23.5% and penile in 4% of them. Stricture length was less than 1 cm in 51% of them, whereas it was 1–2 cm in 49% of them.
Conclusion
Patients with urethral stricture who are ideal candidates for initial treatment with DVIU tend to have a single, short (≤1 cm) bulbar stricture and no extensive spongiofibrosis surrounding the stricture. Repeated DVIU should be considered only in patients who are poor surgical candidates and not because of the convenience of performing a simple procedure.

Keywords: direct vision internal urethrotomy, failed outcome, recurrence, successful outcome, urethral stricture


How to cite this article:
El Mahdy AM, Abdelbaky TM, Selim MA, Gomaa IM. Evaluation of direct visual internal urethrotomy in the management of anterior urethral strictures. Menoufia Med J 2017;30:367-71

How to cite this URL:
El Mahdy AM, Abdelbaky TM, Selim MA, Gomaa IM. Evaluation of direct visual internal urethrotomy in the management of anterior urethral strictures. Menoufia Med J [serial online] 2017 [cited 2019 Jun 19];30:367-71. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/367/215438

Urethral stricture refers to the anterior urethral disease or a scarring process involving the spongy erectile tissue of the corpus spongiosum with resultant spongiofibrosis and urethral narrowing[1].

Male urethral stricture continues to be a common and challenging urologic condition[2]. Various options for the management of urethral stricture disease are available, ranging from urethral dilatation, internal urethrotomy(IU), urethral stenting, and progressing to anastomotic and substitution urethroplasty[3].

Despite the high failure rate of direct vision internal urethrotomy(DVIU), it remains the most commonly performed procedure for the treatment of urethral strictures, as it is fast, simple to perform, and is associated with a short convalescence[4]. Repeated urethrotomies have not been associated with an improved success rate, and DVIU for longer strictures has usually failed[5].

Repeated transurethral manipulation of urethral strictures is associated with increased stricture complexity, stricture length, and a marked delay to curative urethroplasty[6].

Therefore, identifying patients at risk for recurrence after DVIU is crucial. There is a paucity of research regarding factors predicting failure after DVIU, notably with no standardized definition of failure[7].

The aim of this study was to evaluate the outcome of DVIU in the management of patients with anterior urethral stricture. We investigated stricture characteristics and predictors of failure after DVIU performed for anterior urethral strictures.


  Patients and Methods Top


This retrospectivestudy was conducted on male patients who presented to the Department of Urology, Menoufia University Hospital, and underwent DVIU for anterior urethral stricture disease between June 2014 and June 2015. We extracted data from medical records and reviewed the charts of 103male patients included in this study.

The present study included patients who had anterior urethral stricture not more than 2cm in length on a retrograde urethrogram(RUG) and without severe degree of spongiofibrosis on urethral ultrasonography after signing a written consent of acceptance to be included in our study. Patients with urethral stricture more than 2cm in length on RUG or who had severe degree of spongiofibrosis on urethral ultrasonography were excluded.

Stricture characteristics(cause, site, and length on RUG) and patients' demographics were retrieved and age and history of previous therapeutic interventions for urethral stricture such as previous IU or urethroplasty were recorded.

All patients underwent urethrocystoscopy before urethrotomy to confirm the site of urethral stricture on preoperative RUG and the actual length of urethral stricture was measured by using the cystoscope sheath. Adorsal incision of the fibrous strictured area was performed at the 12 o'clock position until bleeding and visual confirmation of healthy tissue was confirmed. If required, repetition of cuts in the same incision area was performed to allow release of scar contracture and the lumen to heal enlarged around urethral catheter, which was inserted after the procedure. The catheter was left insitu for 5, 7 or 10days.

Patients were followed up 2weeks after the procedure and every 3months for the first year and then every 6months thereafter. Patients were instructed to come for the follow-up if new urological symptoms appear between the follow-up periods. The follow-up of these patients included American Urological Association(AUA) symptoms score, uroflowmetry to determine urine flow rate, Pelviabdominal ultrasonography to estimate the postvoiding residual urine volume starting 2weeks after removal of urethral catheter and RUG starting 3months after the procedure. If there was stricture recurrence on RUG, recurrence of obstructive symptoms or obstructive uroflowmetry pattern cystourethroscopy and DVIU was done. Only patients who completed at least 3months of follow-up were included.

In the current study, we selected the following criteria for assessment of the success of IU:

  1. AUA symptom index
  2. Subjective and objective urine flow rate
  3. Urethrographic imaging
  4. Postvoid residual urine volume
  5. Requirement for a subsequent procedure


Failure of DVIU was defined as the need for further instrumentation–that is, if patients required maintenance regular urethral dilatation, redo DVIU or urethroplasty.

Statistical analyses

For association between categorical variables, the c 2-test was used, whereas Student's t-test was used for comparing means between groups. Logistic regression analysis was used to determine independent predictors of failure after DVIU. All statistical analyses were performed using SPSS(SPSS Inc., Chicago, Illinois, USA), with a P- value less than 0.05 considered to indicate statistical significance.


  Results Top


The current study was carried out at the Urology Department of Menoufia University and included 103patients who underwent DVIU for anterior urethral stricture between June 2014 and June 2015. Six patients missed follow-up and were excluded from our statistics. Patients were divided into two groups according to outcome of the procedure(successful and failed).

The length of stricture measured by a RUG varied from 0.5 to 2cm, with a mean length of 1.54±0.45cm for failed the outcome group and 0.85±0.35cm for the successful outcome group, with a significant P- value(0.0001)[Table1].
Table 1: Preoperative parameters

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The etiology of urethral stricture was iatrogenic in 14cases(14.5%), unknown in 40cases(41.5%), infective in seven cases(7%), balanitis xerotica obliterans and lichen sclerosus in 12cases(12.5%), traumatic in eight cases(8%), and secondary to failed hypospadias repair in 16cases(16.5%). Failed outcome occurred in 83% of the strictures because of balanitis xerotica obliterans and lichen sclerosus, and in 75% of the strictures secondary to failed hypospadias repair with significant P- value(0.0276)[Table2].
Table 2: Percentage of success in relation with the etiology of urethral stricture

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The site of urethral stricture was bulbar in 56cases, bulbopenile in 30cases, and penile in 11cases. It was bulbar in 72.5%, whereas it was bulbopenile in 23.5% and penile in 4% of the successful outcome group, with a significant P- value(0.0011)[Table3].
Table 3: Site of urethral stricture across outcome groups

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Percentage of successful outcome was high(82%) with bulbar urethral stricture in fresh cases and low(31%) in recurrent cases; on the other hand, with penile urethral stricture it was low in both fresh(20%) and recurrent cases(17%)[Figure1] and [Figure2].
Figure 1: Percentage of success in fresh cases in relation with the site of stricture.

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Figure 2: Percentage of success in recurrent cases in relation with the site of stricture.

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The stricture length as measured by the cystoscope sheath ranged from 0.5 to 2cm with a mean of 1.64±0.35cm for the failed outcome group and 0.9±0.35cm for the successful outcome group, with a significant P- value(0.0001). Stricture length was less than 1cm in 51%, whereas it was 1–2cm in 49% of the successful outcome group, with a significant P- value(0.0017)[Table4].
Table 4: The length of stricture across outcome groups

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Patients were divided into three groups(5, 7, and 10days) according to the duration of urethral catheterization following the procedure. Percentage of successful outcome was 53% for the 5days group, whereas it was 50% for the 7days group and 54% for the 10days group, with an insignificant P_ value(0.9145)[Table5].
Table 5: The duration of urethral catheterization across outcome groups

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The mean follow-up period was 12±3months. The duration of recurrence after IU was 10±3months with iatrogenic strictures, whereas it was 6±2months with strictures secondary to failed hypospadias repair. It was earlier(5±2months) with penile strictures, whereas it was delayed(11±3months) with bulbar strictures.

Eventually out of the 103patients, six missed the follow-up. Fifty-one patients(49.5%) had successful outcome, whereas 46patients(44.5%) had failed outcome[Figure3].
Figure 3: Percentage of final outcome results.

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  Discussion Top


Many urologists prefer DVIU over urethral reconstruction because of its ease to perform, low cost, short hospital stay, and perceived low complication rate. They may prefer to repeat DVIU several times to avoid complex urethral reconstruction, which requires significant surgical experience[8],[9],[10].

In the current study, we set out to report the results of DVIU of our patients, including a wider inclusion base and strict criteria of success.

Comparison of studies that evaluate the outcome of urethral stricture treatment is greatly affected by the success criteria. This heterogeneity of the definition of success has been clearly shown in a meta-analysis of urethroplasty outcome involving more than 300 articles[11].

The most common cause of urethral stricture in the current study was unknown(41.5%), which is in agreement with Palminteri etal. [12] who reported that unknown strictures were the most common, occurring in 35.8% of patients.

There is contradictory evidence as to whether etiology affects the risk of stricture recurrence[13]. Infective(71%) and iatrogenic strictures(64%) have higher success rates than do traumatic strictures(50%), which is in agreement with the findings of Pansadoro and Emiliozzi [14] who reported that infective(48%) and iatrogenic strictures(42%) have higher cure rates than do traumatic strictures(16%). In their study, Albers etal. [15] showed that infective and iatrogenic strictures tend to recur, whereas Boccon and Le Portz [16] demonstrated that infective strictures do worse than either iatrogenic or traumatic strictures. From these contradictory results, it is clear that stricture etiology cannot be considered a predictive factor for the recurrence of stricture after IU.

Our results showed that patients who underwent DVIU for the first time had higher success rate compared with those who had positive history of previous DVIU or urethroplasty. So that, the first IU has the best chance of successful outcome and repeated DVIU is associated with more dismal outcomes, which is in agreement with the findings of Naudé and Heyns [17] who reported that the success rate of IU decreases with each procedure performed.

The bulbar urethra was the most common site(58%) of urethral stricture in our present study, which is in line with the findings of Palminteri etal. [12] who reported that the bulbar urethra was the most common site, while panurethral and multiple sites were the least common. However, panurethral strictures were not included in our present study as the focus was on strictures treated by DVIU.

Bulbar strictures are associated with lower recurrence rates, whereas penile site of the stricture is a highly suggestive predictor of recurrence after DVIU, as success rate was higher in bulbar strictures(66%) than in penile strictures(18%) in the present study. This is in agreement with the findings of Pansadoro and Emiliozzi [14] who reported that 58% of bulbar strictures recurred after one IU, whereas 84% of penile strictures recurred. However, our study showed lower recurrence rate(34%) with bulbar urethral strictures. This may be attributed to the small sample size and the short period of follow-up in our study.

Stricture length more than 1cm is a highly suggestive predictor of recurrence after DVIU, as strictures 1–2cm in length were associated with increased recurrence rates(61%) compared with those of less than 1cm(21%) in the present study. There is in agreement with the findings of Al-Ali and Al-Shukry [18] who reported that there is clear evidence that stricture length determines the success rate of IU.

Our results showed that there was no statistical significant difference between the success rates in three different groups(5, 7, and 10days) in the duration of urethral catheterization following IU, which is in agreement with the findings of Naudé and Heyns [17] who reported that whether post-IU catheterization should be employed, and if so, the optimal duration is a matter of debate.

The recommended periods of post-IU catheterization differ widely between authors, from 6weeks [19] to 10–14days[20], 7days[21], 4days[21], 3days[17], 24h[22], to no catheterization at all[14].

In the current study, the need for regular urethral dilatation after IU was considered as a failure based on previous reports suggesting that regular post-IU self-dilation of the urethra might delay recurrence but that it did not prevent it, and even that it might be associated with more complex corrective urethroplasty[23],[24],[25]. After defining regular post-IU self-dilation of the urethra as a failure, the failure rate in the present study was 44.5%, which was relatively higher than the failure rate reported by Harraz etal.[26], which was 41.8%. This may be due to inclusion in our study of bulbopenile and penile strictures in addition to bulbar strictures, which alone was included in their study.

The success rate was 49.5% in the present study, which is much higher than that reported by Al Taweel and Seyam [6] who published that the overall stricture-free rate at the 36-month follow-up was 8.3%. This may be due to inclusion of strictures till 3cm and the strict success criteria in their study in addition to the small sample size and the short period of follow-up in our study(mean follow-up period was 12±3months).


  Conclusion Top


Selection of the most appropriate procedure is the cornerstone in management of urethral stricture disease. Patients with urethral stricture who are ideal candidates for initial treatment with DVIU tend to have a single, short(≤1cm), bulbar stricture and no extensive spongiofibrosis surrounding the stricture. Patients who are poor candidates for initial or repeated DVIU include those with multiple, long(>1cm), penile strictures, or extensive spongiofibrosis. Repeated DVIU should be considered only in patients who are poor surgical candidates, with severe comorbidities or limited life expectancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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