ENDOSCOPIC
TORIOHIKO I(:HIRO
MANAGEMENT
KOYANAGI,
TSUJI,
OF URETHRAL
STRICTURE
M.D.
M.D.
From the Department School of Medicine,
of Urology, Hokkaido Sapporo, Japan
University
ABSTR4CT - Experience with transurethral management of urethral stricture using conventional urethroscope and resectoscopc of both infant and adult size is reported and the .rurgic~al procedure descrihcd. Because incision, dilation, and resection of the stricture are done under direct kual c,ontrol. it i.s -safeand applicable et;cn in .set:ere strictures hitherto untreatable with other rejined closed rnethod.~.
Transurethral incision of urethral strictures may have been tried by others but has been reported only b! Orandi. ’ This apparently simple and more direct approach to strictures has two drawbacks. First. it is not applicable to an extremely tight strictllre through which a filiform cannot be passed. and second, perineal urethrotomy to Llcilitatcl escape of irrigating fluid is not only a troublesome procedure but also is restricted to those strictures distal to the perineum. iC:e report herein the results of WI- endoscopic method with conventional urethroscope and resectoscope which we believe to be a simpler and more direct approach to this problem. This method was derived from our experirnct~ in the tmlsurethral resection of congenital anterior urethral lesions in children, the rclsults of which have been reported elsewhere.” htfaterial
and
Stricture sites were at the membranous urethra subdiaphragmatic and deep in 2 patients, bulbous in 5, midbulbous in 5, and pendulous in 3. Operative
After saddle anesthesia is administered the patient is placed in the lithotomy position. First the site of stricture is carefully observed with a Storz infant urethroscope (10 F) Sinctb the irrigating fluid flows freel>, around the urcthroscope sheath and out through the external meatus, acuity of the visual field is uo problem. \Vhen the stricture is of an rxtrtmtbly small caliber, an attempt should be n~ade to probe and dilate with a fine ureteral catheter. By rotating the urethroscope in various directions every possible effort is made to pass the scope under direct vision, thus dilating the urethra to 10 F. Although this is dimcult, it can usually be accomplished after several tedious attelnpts. \Vhen this is not feasible, houevc~r. an internal urethrotomy should be tried (also) lmder direct vision) using a Storz infant resectosc*ope (12 F). cannot lxx passed When the knife electrode through the stricture, a gentle anal gradual retrograde incision usually opens the tract large euough to accept the resectoscope sheath. Once this is done, all obstructing tis:sut*s are electrically incised until no hook of knife> electrode is felt in a full circumference of thts llrethra. \Vhen the obstructing tisslle is tc)o voluminous
Methods
Fifteen patients have been treated with this method in the last five years. They had strictllres which were difficult to dilate because of easy formation of false passage or sepsis. Primarily these patients were referred to us for consideration of urethroplasty. Their ages ranged frown f&teen to sixty-three years. Four cases werca coilgenital in origin and 11 were acquired (traumatic urethral rllpture with or without primary realignment and subsequent postinflanimator> in 8 patients, stricture irijury in 1). urethritis in 2, and iatrogenic
1 HOI,O(.l
01
X)HER
Is%
/
\‘oLl:\IE
XII
Ul’XIRl~:H
Technique
I
-123
FIGURE 1. Preoperative urethrogrum (A) demonstrating stricture at suhdiaphragmatic portion of urethra (arrow head), and voiding cystourethrogram (B) revealing urine flow completely obstructed by stricture, and deformity of prostatic fossa resulting from capsular tear. Postoperative urethrogram (C) und voiding cystourethrogram (0); deformity of prostatic fossa remains but is not obstructing, neither is stricture.
to be incised, resection with a loop electrode is used. The depth of incision or resection should be just above the spongiosum since profuse bleeding may hinder the visual field if the is penetrated. Subsequently spongiosum urethral dilation is done simply by serial passage of a 15, 17, and 21 F urethroscope under direct vision. If any obstructing tissue remains, it is incised with an adult resectoscope (24 F) until the sheath is accepted easily. Finally, the urethra is dilated up to 30 F with Van Buren sounds. A Foley catheter (22 F) is left indwelling for one week. After removal of the catheter the patient is instructed in hydraulic urethral dilation. 3 Postoperatively, urethrogram and voiding cystourethrogram are taken. Urethral bougienage for the purpose of calibration is done before hospital discharge. Subsequent calibration is done one month later, every three months thereafter for the first year, and then every six months. Urethroscopy is routinely performed
421
one month postoperatively to assess the status of repair. To date the longest follow-up has been five years and the shortest six months, with an average of two years. Results To be considered cured the patient must have no dysuria objectively, must show roentgenographic evidence of improvement by urethrogram and voiding cystourethrogram, calibration and must have an easy urethral with 22 F sound during the subsequent followup. Those patients who have no dysuria but who require an occasional urethral dilation are considered improved, and those who had to resort to urethroplasty were considered failures. Twelve patients were cured, 1 was improved, and 2 were failures. In the successful cases complete regeneration of urethral epithelium and satisfactory repair of the incised area were confirmed urethroscopically. Two cases of
UROLOCY
/ OCTOBEH
1878
/
VOLVhlE XII
NI’hlBER
4
Glilure had stricture involving ;l relatively long segment of iirethra: post-traumatic and post0peratix.e deep l~ulbous (3-cm. length) stricture in a fourtec-ir-fear-old boy and pendulous (6-cm. secondary to primary urethral Icugth) stricture amyloidosis. ’ The onI>, complication was intraoperative bleeding from thca spongiosum in 1 case. With ;m increasrb in our experience this problem has not recllrrecl since Eve now avoid cutting too deepl>. into the spongiosum. There was no postoperative sepsis, abscess formation, or fistula. Notc\vorth) is a total lack of incontinence or ilnpotence in those patients with strictrlrcs of meml~ranous or subc~iaphr”Rmati~ portion. ( :asc Reports
IIuring sllprapul)ic prostatectom!in this sixty-)-ear-old man the posterior capsule was p~~rforated itt full thickness. Since primal-!,
closure of this tear was not tec*hlliwll) feasible, a urethral catheter M’S left indw~~lling and the patknt \~.as placed in tractiotl in the hope ot occluding this perforation. \\‘h patient could not void becauw of thta strictlw in the subdiaphragmatic portion of t 11~5uwthra (Fig. 1X). Urethroscopy. c~onfir1tl(~(l a total occlusion of urethral lunitvi with an c~utrc~mel>~ fibrous tisslle at this portion. Sew-1x1 attempts to advance a filiform under clirrxc,t Csion c,ither \,ia a transurethral route or ;t ;uprapul)ic cs>-stostom>, tract \vere rlnsrlc,ces?tul. Then ;t ( 10 F’I \V;IS pushd Storz inf:,lnt urethroscope carefull\. through this fihrollal\. )l)liter-ated portioli i;,r about 1 cm. untler dirbct1 \isrlal control. This broke ope11 thca stricttire. anti the scope \\‘its s1Iccessfu11\’ ad\w~cYYl tc b 1lw 111~‘111hr3nous ilrc~thra and prostatic ti)\sx. Si~l>s+ 3 1 dilation \\(xrc’ ~lotrc~ r,usil\clllent incsision c ii
TORIOHIKO I(:HIRO
MANAGEMENT
KOYANAGI,
TSUJI,
OF URETHRAL
STRICTURE
M.D.
M.D.
From the Department School of Medicine,
of Urology, Hokkaido Sapporo, Japan
University
ABSTR4CT - Experience with transurethral management of urethral stricture using conventional urethroscope and resectoscopc of both infant and adult size is reported and the .rurgic~al procedure descrihcd. Because incision, dilation, and resection of the stricture are done under direct kual c,ontrol. it i.s -safeand applicable et;cn in .set:ere strictures hitherto untreatable with other rejined closed rnethod.~.
Transurethral incision of urethral strictures may have been tried by others but has been reported only b! Orandi. ’ This apparently simple and more direct approach to strictures has two drawbacks. First. it is not applicable to an extremely tight strictllre through which a filiform cannot be passed. and second, perineal urethrotomy to Llcilitatcl escape of irrigating fluid is not only a troublesome procedure but also is restricted to those strictures distal to the perineum. iC:e report herein the results of WI- endoscopic method with conventional urethroscope and resectoscope which we believe to be a simpler and more direct approach to this problem. This method was derived from our experirnct~ in the tmlsurethral resection of congenital anterior urethral lesions in children, the rclsults of which have been reported elsewhere.” htfaterial
and
Stricture sites were at the membranous urethra subdiaphragmatic and deep in 2 patients, bulbous in 5, midbulbous in 5, and pendulous in 3. Operative
After saddle anesthesia is administered the patient is placed in the lithotomy position. First the site of stricture is carefully observed with a Storz infant urethroscope (10 F) Sinctb the irrigating fluid flows freel>, around the urcthroscope sheath and out through the external meatus, acuity of the visual field is uo problem. \Vhen the stricture is of an rxtrtmtbly small caliber, an attempt should be n~ade to probe and dilate with a fine ureteral catheter. By rotating the urethroscope in various directions every possible effort is made to pass the scope under direct vision, thus dilating the urethra to 10 F. Although this is dimcult, it can usually be accomplished after several tedious attelnpts. \Vhen this is not feasible, houevc~r. an internal urethrotomy should be tried (also) lmder direct vision) using a Storz infant resectosc*ope (12 F). cannot lxx passed When the knife electrode through the stricture, a gentle anal gradual retrograde incision usually opens the tract large euough to accept the resectoscope sheath. Once this is done, all obstructing tis:sut*s are electrically incised until no hook of knife> electrode is felt in a full circumference of thts llrethra. \Vhen the obstructing tisslle is tc)o voluminous
Methods
Fifteen patients have been treated with this method in the last five years. They had strictllres which were difficult to dilate because of easy formation of false passage or sepsis. Primarily these patients were referred to us for consideration of urethroplasty. Their ages ranged frown f&teen to sixty-three years. Four cases werca coilgenital in origin and 11 were acquired (traumatic urethral rllpture with or without primary realignment and subsequent postinflanimator> in 8 patients, stricture irijury in 1). urethritis in 2, and iatrogenic
1 HOI,O(.l
01
X)HER
Is%
/
\‘oLl:\IE
XII
Ul’XIRl~:H
Technique
I
-123
FIGURE 1. Preoperative urethrogrum (A) demonstrating stricture at suhdiaphragmatic portion of urethra (arrow head), and voiding cystourethrogram (B) revealing urine flow completely obstructed by stricture, and deformity of prostatic fossa resulting from capsular tear. Postoperative urethrogram (C) und voiding cystourethrogram (0); deformity of prostatic fossa remains but is not obstructing, neither is stricture.
to be incised, resection with a loop electrode is used. The depth of incision or resection should be just above the spongiosum since profuse bleeding may hinder the visual field if the is penetrated. Subsequently spongiosum urethral dilation is done simply by serial passage of a 15, 17, and 21 F urethroscope under direct vision. If any obstructing tissue remains, it is incised with an adult resectoscope (24 F) until the sheath is accepted easily. Finally, the urethra is dilated up to 30 F with Van Buren sounds. A Foley catheter (22 F) is left indwelling for one week. After removal of the catheter the patient is instructed in hydraulic urethral dilation. 3 Postoperatively, urethrogram and voiding cystourethrogram are taken. Urethral bougienage for the purpose of calibration is done before hospital discharge. Subsequent calibration is done one month later, every three months thereafter for the first year, and then every six months. Urethroscopy is routinely performed
421
one month postoperatively to assess the status of repair. To date the longest follow-up has been five years and the shortest six months, with an average of two years. Results To be considered cured the patient must have no dysuria objectively, must show roentgenographic evidence of improvement by urethrogram and voiding cystourethrogram, calibration and must have an easy urethral with 22 F sound during the subsequent followup. Those patients who have no dysuria but who require an occasional urethral dilation are considered improved, and those who had to resort to urethroplasty were considered failures. Twelve patients were cured, 1 was improved, and 2 were failures. In the successful cases complete regeneration of urethral epithelium and satisfactory repair of the incised area were confirmed urethroscopically. Two cases of
UROLOCY
/ OCTOBEH
1878
/
VOLVhlE XII
NI’hlBER
4
Glilure had stricture involving ;l relatively long segment of iirethra: post-traumatic and post0peratix.e deep l~ulbous (3-cm. length) stricture in a fourtec-ir-fear-old boy and pendulous (6-cm. secondary to primary urethral Icugth) stricture amyloidosis. ’ The onI>, complication was intraoperative bleeding from thca spongiosum in 1 case. With ;m increasrb in our experience this problem has not recllrrecl since Eve now avoid cutting too deepl>. into the spongiosum. There was no postoperative sepsis, abscess formation, or fistula. Notc\vorth) is a total lack of incontinence or ilnpotence in those patients with strictrlrcs of meml~ranous or subc~iaphr”Rmati~ portion. ( :asc Reports
IIuring sllprapul)ic prostatectom!in this sixty-)-ear-old man the posterior capsule was p~~rforated itt full thickness. Since primal-!,
closure of this tear was not tec*hlliwll) feasible, a urethral catheter M’S left indw~~lling and the patknt \~.as placed in tractiotl in the hope ot occluding this perforation. \\‘h patient could not void becauw of thta strictlw in the subdiaphragmatic portion of t 11~5uwthra (Fig. 1X). Urethroscopy. c~onfir1tl(~(l a total occlusion of urethral lunitvi with an c~utrc~mel>~ fibrous tisslle at this portion. Sew-1x1 attempts to advance a filiform under clirrxc,t Csion c,ither \,ia a transurethral route or ;t ;uprapul)ic cs>-stostom>, tract \vere rlnsrlc,ces?tul. Then ;t ( 10 F’I \V;IS pushd Storz inf:,lnt urethroscope carefull\. through this fihrollal\. )l)liter-ated portioli i;,r about 1 cm. untler dirbct1 \isrlal control. This broke ope11 thca stricttire. anti the scope \\‘its s1Iccessfu11\’ ad\w~cYYl tc b 1lw 111~‘111hr3nous ilrc~thra and prostatic ti)\sx. Si~l>s+ 3 1 dilation \\(xrc’ ~lotrc~ r,usil\clllent incsision c ii
