|Year : 2017 | Volume
| Issue : 2 | Page : 367-371
Evaluation of direct visual internal urethrotomy in the management of anterior urethral strictures
Alaa El Deen M El Mahdy, Tarek M Abdelbaky, Mohamed A Selim, Ibrahim M Gomaa
Urology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||16-Apr-2016|
|Date of Acceptance||06-Jun-2016|
|Date of Web Publication||25-Sep-2017|
Ibrahim M Gomaa
Urology Department, Faculty of Medicine, Menoufia University Menoufia 11160
Source of Support: None, Conflict of Interest: None
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.
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.
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.
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 2020 Jan 28];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 .
Male urethral stricture continues to be a common and challenging urologic condition . 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 .
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 . Repeated urethrotomies have not been associated with an improved success rate, and DVIU for longer strictures has usually failed .
Repeated transurethral manipulation of urethral strictures is associated with increased stricture complexity, stricture length, and a marked delay to curative urethroplasty .
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 .
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|| |
This retrospective study 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 103 male patients included in this study.
The present study included patients who had anterior urethral stricture not more than 2 cm 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 2 cm 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. A dorsal 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 in situ for 5, 7 or 10 days.
Patients were followed up 2 weeks after the procedure and every 3 months for the first year and then every 6 months 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 2 weeks after removal of urethral catheter and RUG starting 3 months 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 3 months of follow-up were included.
In the current study, we selected the following criteria for assessment of the success of IU:
- AUA symptom index
- Subjective and objective urine flow rate
- Urethrographic imaging
- Postvoid residual urine volume
- 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.
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|| |
The current study was carried out at the Urology Department of Menoufia University and included 103 patients 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 2 cm, with a mean length of 1.54 ± 0.45 cm for failed the outcome group and 0.85 ± 0.35 cm for the successful outcome group, with a significant P- value (0.0001) [Table 1].
The etiology of urethral stricture was iatrogenic in 14 cases (14.5%), unknown in 40 cases (41.5%), infective in seven cases (7%), balanitis xerotica obliterans and lichen sclerosus in 12 cases (12.5%), traumatic in eight cases (8%), and secondary to failed hypospadias repair in 16 cases (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) [Table 2].
|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 56 cases, bulbopenile in 30 cases, and penile in 11 cases. 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) [Table 3].
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%) [Figure 1] and [Figure 2].
|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 2 cm with a mean of 1.64 ± 0.35 cm for the failed outcome group and 0.9 ± 0.35 cm for the successful outcome group, with a significant P- value (0.0001). Stricture length was less than 1 cm in 51%, whereas it was 1–2 cm in 49% of the successful outcome group, with a significant P- value (0.0017) [Table 4].
Patients were divided into three groups (5, 7, and 10 days) according to the duration of urethral catheterization following the procedure. Percentage of successful outcome was 53% for the 5 days group, whereas it was 50% for the 7 days group and 54% for the 10 days group, with an insignificant P_ value (0.9145) [Table 5].
The mean follow-up period was 12 ± 3 months. The duration of recurrence after IU was 10 ± 3 months with iatrogenic strictures, whereas it was 6 ± 2 months with strictures secondary to failed hypospadias repair. It was earlier (5 ± 2 months) with penile strictures, whereas it was delayed (11 ± 3 months) with bulbar strictures.
Eventually out of the 103 patients, six missed the follow-up. Fifty-one patients (49.5%) had successful outcome, whereas 46 patients (44.5%) had failed outcome [Figure 3].
| Discussion|| |
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 ,,.
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 .
The most common cause of urethral stricture in the current study was unknown (41.5%), which is in agreement with Palminteri et al.  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 . 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  who reported that infective (48%) and iatrogenic strictures (42%) have higher cure rates than do traumatic strictures (16%). In their study, Albers et al.  showed that infective and iatrogenic strictures tend to recur, whereas Boccon and Le Portz  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  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 et al.  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  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 1 cm is a highly suggestive predictor of recurrence after DVIU, as strictures 1–2 cm in length were associated with increased recurrence rates (61%) compared with those of less than 1 cm (21%) in the present study. There is in agreement with the findings of Al-Ali and Al-Shukry  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 10 days) in the duration of urethral catheterization following IU, which is in agreement with the findings of Naudé and Heyns  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 6 weeks  to 10–14 days , 7 days , 4 days , 3 days , 24 h , to no catheterization at all .
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 ,,. 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 et al. , 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  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 3 cm 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 ± 3 months).
| Conclusion|| |
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 (≤1 cm), bulbar stricture and no extensive spongiofibrosis surrounding the stricture. Patients who are poor candidates for initial or repeated DVIU include those with multiple, long (>1 cm), 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.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhargava S, Chapple CR, Bullock AJ, Layton C, MacNeil S Tissue-engineered buccal mucosa for substitution urethroplasty. BJU Int 2004; 93:807–811.
Zehri AA, Ather MH, Afshan Q. Predictors of recurrence of urethral stricture disease following optical urethrotomy. Int J Surg 2009; 7:361–364.
Mangera A, Chapple C. Management of anterior urethral stricture: an evidence-based approach. Curr Opin Urol 2010; 20:453–458.
Farrell MR, Sherer BA, Levine LA. Visual internal urethrotomy with intralesional mitomycin C and short-term clean intermittent catheterization for the management of recurrent urethral strictures and bladder neck contractures. Urology 2015; 85:1494–1499.
Kumar S, Kapoor A, Ganesamoni R, Nanjappa B, Sharma V, Mete UK Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture. Korean J Urol 2012; 53:614–618.
Al Taweel W, Seyam R. Visual internal urethrotomy for adult male urethral stricture has poor long-term results. Adv Urol 2015; 2015:656459.
Dubey D. The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures. Indian J Urol 2011; 27:392-396.
] [Full text]
Kumar S, Garg N, Singh SK, Mandal AK Efficacy of optical internal urethrotomy and intralesional injection of Vatsala-Santosh PGI tri-inject (triamcinolone, mitomycin C, and hyaluronidase) in the treatment of anterior urethral stricture. Adv Urol 2014; 2014:192710.
Mazdak H, Izadpanahi MH, Ghalamkari A, Kabiri M, Khorrami MH, Nouri-Mahdavi K, et al
. Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. Int Urol Nephrol 2010; 42:565–568.
Kim HM, Kang DI, Shim BS, Min KS Early experience with hyaluronic acid instillation to assist with visual internal urethrotomy for urethral stricture. Korean J Urol 2010; 51:853–857.
Meeks JJ, Erickson BA, Granieri MA, Gonzalez CM Stricture recurrence after urethroplasty: a systematic review. J
Urol 2009; 182:1266–1270.
Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L Contemporary urethral stricture characteristics in the developed world. Urology 2013; 81:191–196.
Han JS, Liu J, Hofer MD, Fuchs A, Chi A, Stein D, et al
. Risk of urethral stricture recurrence increases over time after urethroplasty. Int J Urol 2015; 22:695–699.
Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J
Urol 1996; 156:73–75.
Albers P, Fichtner J, Brühl P, Müller SC Long-term results of internal urethrotomy. J
Urol 1996; 156:1611–1614.
Boccon Gibod L, Le Portz B. Endoscopic urethrotomy: does it live up to its promises? J Urol 1982; 127:433-435.
Naudé AM, Heyns CF. What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nat Clin Pract Urol 2005; 2:538–545.
Al-Ali M, Al-Shukry M. Endoscopic repair in 154 cases of urethral occlusion: the promise of guided optical urethral reconstruction. J
Urol 1997; 157:129–131.
Carlton FE, Scardino PL, Quattlebaum RB. Treatment of urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. J
Urol 1974; 111:191–193.
Sachse H. Treatment of urethral stricture: transurethral slit in view using sharp section. Fortschr Med 1974; 92:12–15.
Lipsky H, Hubmer G. Direct vision urethrotomy in the management of urethral strictures. Br J Urol 1977; 49:725–728.
Hjortrup A, Sørensen C, Sanders S, Moesgaard F, Kirkegaard P
Strictures of the male urethra treated by the Otis method. J
Urol 1983; 130:903–904.
Tian Y, Wazir R, Yue X, Wang KJ, Li H Prevention of stricture recurrence following urethral endoscopic management: what do we have? J Endourol 2014; 28:502–508.
Buckley JC, Heyns C, Gilling P, Carney J SIU/ICUD Consultation on Urethral Strictures: dilation, internal urethrotomy, and stenting of male anterior urethral strictures. Urology 2014; 83(Suppl):
Beckley I, M Garthwaite. Post-operative care following primary optical urethrotomy: towards an evidence based approach. J
Clin Urol 2013; 6:164–170.
Harraz AM, El-Assmy A, Mahmoud O, Elbakry AA, Tharwat M, Omar H, et al
. Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures? Arab J Urol 2015; 13:277–281.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]