SURGICAL MANAGEMENT OF URETHRAL STRICTURES BASED ON ETIOLOGY Where Do Urethral Stents Fit In? JAMES EASTHAM, M.D. TIMOTHY WILSON, M.D. STUART BOYD, M.D.
From the Los Angeles County-University Medical Center, Los Angeles, California
of Southern California
ABSTRACT-Recent studies in the urologic literature indicate a renewed interest in the management of urethral stricture disease. Specifically, urologists are now treating all types of urethral strictures regardless of location, etiology, or extent with methods other than primay urethroplasty or direct vision internal urethrotomy (DVIU), i.e., balloon dilation or urethral stenting. To see which patients might best be managed by these new modalities, we reviewed OUTexverience with urethral strictures at LAC-USC Medical Center
The management of urethral stricture disease remains controversial. The development of new modalities of treatment including urethral stenting’ and balloon dilation2 has only added to this dilemma. We present our results of the surgical management of urethral stricture disease based on etiology in order to ascertain where the various treatment options fit in.
prapubic tube preoperatively had a voiding cystourethrogram. Patients were considered surgical successes if after six months of follow-up there was no evidence of stricture recurrence as evidenced by symptomatology and/or uroflow parameters. Patients requiring a second procedure had recurrent stricture disease verified by ureterography and/or urethroscopy.
Material and Methods
Results
We reviewed the charts of 61 patients who underwent surgical treatment of urethral stricture disease from March 1986 to November 1988 at the Los Angeles County-University of Southern California Medical Center. This included 20 patients whose stricture disease was the result of infection, 16 with stricture secondary to motor vehicle trauma, and 25 patients with non-motor vehicle urethral trauma. Patient records were reviewed for etiology, location, initial surgical management, result of treatment, and further intervention. Preoperative evaluation in all cases included a detailed history and physical examination, routine laboratory screening including urinalysis and urine culture, and a retrograde urethrogram. In addition, those patients who had required a su-
Of the 61 patients with urethral stricture disease, 20 resulted from an infectious etiology. All gave a history of prior gonococcal infection. A minimum of four years elapsed between the development of infection and the onset of obstructive symptoms. All strictures were located in the bulbous or pendulous urethra (Table I). One stricture was less than 1.0 cm, eleven were between 1 and 2.0 cm, two were longer than 2 cm, and the size of six strictures was not reported (Table II). Of these patients, 19 had direct vision internal urethrotomy (DVIU) as the initial treatment and one primary urethroplasty. Of the DVIU patients, only 2 required further treatment, for a reoperation rate of 10 percent (2/19). These occurred in 1 patient
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VOLUME 40. NUMBER 2
TABLE I.
Location Pendulous Bulbous Membranous
Location of urethral strictures in 61 patients
II.
Infectious etiology in 20 patients
Inflammatory
MVA Trauma
Non-MVA Trauma
Initial Procedure
No.
No. Requiring Reoperation
14 6 0
0 4 12
6 19 0
DVIU Urethroplasty
19 1
2 0
TABLE TABLE
III.
TABLE
Length of urethral strictures
11% (2/19) 0% (O/l)
IV. Motor vehicle-related trauma in 16 patients
Size (cm)
Inflammatory
MVA Trauma
Non-MVA Trauma
Initial Procedure
No.
2 Not recorded
1 11 2 6 20
8 2 0 6 Is
8 9 3 5 25
Primary realign. Urethroplasty DVIU
2 7 7
TOTAL
Recperation Rate
No. Requiring Reoperation Reoperation Rate 2 4 3
100% (2/2) 57% (417) 43% (3/7)
Non-motor vehicle-related trauma in 25 patients
TABLE V.
whose stricture was greater than 2 cm, and 1 patient whose stricture length was not reported. Both failures subsequently underwent a second successful DVIU. The patient not undergoing DVIU as the initial treatment, had a successful urethroplasty using a foreskin patch (Table III). Sixteen patients had stricture disease as the result of motor vehicle trauma, with 87 percent (14/16) having an associated pelvic fracture. All strictures were located in the membranous or proximal bulbous urethra (Table I). Eight strictures were less than 1.0 cm, 2 between 1 and 2.0 cm, and six were not reported (Table II). Two of the evaluable patients had initial attempts at primary realignment via interlocking sounds. Post-procedure strictures developed in both of these patients within three months of their injury, for a reoperation rate of 100 percent (2/2). Each required a urethroplasty followed by a DVIU to ultimately resolve their strictures. The remaining patients were initially treated with urinary diversion via suprapubic cystostomy. Seven patients underwent primary urethroplasty as their initial mode of surgical treatment. Four of these required additional surgery, for a reoperation rate of 57 percent (41 7). Seven patients underwent DVIU as the primary procedure. Four of these were successful, but 3 did require additional surgical procedures for a reoperation rate of 43 percent (317) (Table IV). In the remaining 25 patients strictures developed as a result of non-motor vehicle urethral
UROLOGY
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/ VOLUME40,NUMBER2
Initial Procedure
No.
DVIU Urethroplasty Primary realign.
21 3 1
No. Requiring Reoperation Reoperation Rate 5 3 1
24% (5/21) 100% (3/3) 100% (l/l)
trauma: 68 percent (17125) from instrumentation (8 after prolonged catheter drainage, 6 after transurethral resection of prostate, and 3 after self-instrumentation), 24 percent (6/25) from blunt trauma, and 8 percent (2/25) from penetrating injuries. All strictures were located in the pendulous or bulbous urethra (Table I). Eight were less than 1.0 cm, 9 were between 1 and 2.0 cm, and 3 were longer than 2 cm; the size of five strictures were not reported (Table II). Twenty-one of the patients underwent DVIU as the initial surgical management with 5 of these requiring additional procedure(s), for a reoperation rate of 24 percent (5/21). Of the remaining 4 patients, 3 underwent attempts at initial urethroplasty and 1 primary realignment; all of these required further surgical intervention (Table V) . Comment Urethral stricture disease is a complex urologic entity with many patients requiring multiple surgical procedures prior to the resolution of their problems. Prior to the advent of endoscopic procedures, most strictures were treated with either dilatation or open surgery. These both were often unsatisfactory, requiring the
111
need for further intervention. With the development of direct vision internal urethrotomy,3 it was hoped that stricture disease could now be resolved in a single setting. This, however, has not been the case, leading several investigators to search for new modalities to treat urethral strictures, i.e., balloon dilatation or urethral stenting.‘a2 This retrospective study was undertaken to see which patients might best be managed with these new treatments. Based on our results, it would appear that direct vision internal urethrotomy is the treatment of choice for most inflammatory strictures with only 10 percent requiring a subsequent procedure. However, using standard modalities (DVIU or urethroplasty) for the treatment of trauma-related urethral stricture disease we have had a significant reoperation rate in a county hospital, sug-
1. Milroy EJG, Chapple CR, and Wallsten H: A new stent for the treatment of urethral strictures. Preliminary report, Br J Urol 63: 392 (1989). 2. Daughtry JD, Rodan BA, and Bean WJ: Balloon dilatation of urethral strictures, Urology 31: 231 (1988). 3. Sachse H: Zur Behandling der Harnrohren Striktur: de transurethral schlitzurg inter sicht mit scharfen schnitt, Fortschr Med 92: 12 (1974).
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gesting that these new modalities might be most beneficial in trauma-related injuries. We are currently embarking on a clinical trial in the use of urethral stents in this setting as well as in intractable, multiple failure cases. 1200 North State Street Suite 5900 Los Angeles, California 90033 (DR. EASTHAM) References
I
AUGUST
1992
/
VOLUME
40, NUMBER
2
From the Los Angeles County-University Medical Center, Los Angeles, California
of Southern California
ABSTRACT-Recent studies in the urologic literature indicate a renewed interest in the management of urethral stricture disease. Specifically, urologists are now treating all types of urethral strictures regardless of location, etiology, or extent with methods other than primay urethroplasty or direct vision internal urethrotomy (DVIU), i.e., balloon dilation or urethral stenting. To see which patients might best be managed by these new modalities, we reviewed OUTexverience with urethral strictures at LAC-USC Medical Center
The management of urethral stricture disease remains controversial. The development of new modalities of treatment including urethral stenting’ and balloon dilation2 has only added to this dilemma. We present our results of the surgical management of urethral stricture disease based on etiology in order to ascertain where the various treatment options fit in.
prapubic tube preoperatively had a voiding cystourethrogram. Patients were considered surgical successes if after six months of follow-up there was no evidence of stricture recurrence as evidenced by symptomatology and/or uroflow parameters. Patients requiring a second procedure had recurrent stricture disease verified by ureterography and/or urethroscopy.
Material and Methods
Results
We reviewed the charts of 61 patients who underwent surgical treatment of urethral stricture disease from March 1986 to November 1988 at the Los Angeles County-University of Southern California Medical Center. This included 20 patients whose stricture disease was the result of infection, 16 with stricture secondary to motor vehicle trauma, and 25 patients with non-motor vehicle urethral trauma. Patient records were reviewed for etiology, location, initial surgical management, result of treatment, and further intervention. Preoperative evaluation in all cases included a detailed history and physical examination, routine laboratory screening including urinalysis and urine culture, and a retrograde urethrogram. In addition, those patients who had required a su-
Of the 61 patients with urethral stricture disease, 20 resulted from an infectious etiology. All gave a history of prior gonococcal infection. A minimum of four years elapsed between the development of infection and the onset of obstructive symptoms. All strictures were located in the bulbous or pendulous urethra (Table I). One stricture was less than 1.0 cm, eleven were between 1 and 2.0 cm, two were longer than 2 cm, and the size of six strictures was not reported (Table II). Of these patients, 19 had direct vision internal urethrotomy (DVIU) as the initial treatment and one primary urethroplasty. Of the DVIU patients, only 2 required further treatment, for a reoperation rate of 10 percent (2/19). These occurred in 1 patient
110
UROLOGY
/
AUGUST 1992
/
VOLUME 40. NUMBER 2
TABLE I.
Location Pendulous Bulbous Membranous
Location of urethral strictures in 61 patients
II.
Infectious etiology in 20 patients
Inflammatory
MVA Trauma
Non-MVA Trauma
Initial Procedure
No.
No. Requiring Reoperation
14 6 0
0 4 12
6 19 0
DVIU Urethroplasty
19 1
2 0
TABLE TABLE
III.
TABLE
Length of urethral strictures
11% (2/19) 0% (O/l)
IV. Motor vehicle-related trauma in 16 patients
Size (cm)
Inflammatory
MVA Trauma
Non-MVA Trauma
Initial Procedure
No.
2 Not recorded
1 11 2 6 20
8 2 0 6 Is
8 9 3 5 25
Primary realign. Urethroplasty DVIU
2 7 7
TOTAL
Recperation Rate
No. Requiring Reoperation Reoperation Rate 2 4 3
100% (2/2) 57% (417) 43% (3/7)
Non-motor vehicle-related trauma in 25 patients
TABLE V.
whose stricture was greater than 2 cm, and 1 patient whose stricture length was not reported. Both failures subsequently underwent a second successful DVIU. The patient not undergoing DVIU as the initial treatment, had a successful urethroplasty using a foreskin patch (Table III). Sixteen patients had stricture disease as the result of motor vehicle trauma, with 87 percent (14/16) having an associated pelvic fracture. All strictures were located in the membranous or proximal bulbous urethra (Table I). Eight strictures were less than 1.0 cm, 2 between 1 and 2.0 cm, and six were not reported (Table II). Two of the evaluable patients had initial attempts at primary realignment via interlocking sounds. Post-procedure strictures developed in both of these patients within three months of their injury, for a reoperation rate of 100 percent (2/2). Each required a urethroplasty followed by a DVIU to ultimately resolve their strictures. The remaining patients were initially treated with urinary diversion via suprapubic cystostomy. Seven patients underwent primary urethroplasty as their initial mode of surgical treatment. Four of these required additional surgery, for a reoperation rate of 57 percent (41 7). Seven patients underwent DVIU as the primary procedure. Four of these were successful, but 3 did require additional surgical procedures for a reoperation rate of 43 percent (317) (Table IV). In the remaining 25 patients strictures developed as a result of non-motor vehicle urethral
UROLOGY
I AUGUST1992
/ VOLUME40,NUMBER2
Initial Procedure
No.
DVIU Urethroplasty Primary realign.
21 3 1
No. Requiring Reoperation Reoperation Rate 5 3 1
24% (5/21) 100% (3/3) 100% (l/l)
trauma: 68 percent (17125) from instrumentation (8 after prolonged catheter drainage, 6 after transurethral resection of prostate, and 3 after self-instrumentation), 24 percent (6/25) from blunt trauma, and 8 percent (2/25) from penetrating injuries. All strictures were located in the pendulous or bulbous urethra (Table I). Eight were less than 1.0 cm, 9 were between 1 and 2.0 cm, and 3 were longer than 2 cm; the size of five strictures were not reported (Table II). Twenty-one of the patients underwent DVIU as the initial surgical management with 5 of these requiring additional procedure(s), for a reoperation rate of 24 percent (5/21). Of the remaining 4 patients, 3 underwent attempts at initial urethroplasty and 1 primary realignment; all of these required further surgical intervention (Table V) . Comment Urethral stricture disease is a complex urologic entity with many patients requiring multiple surgical procedures prior to the resolution of their problems. Prior to the advent of endoscopic procedures, most strictures were treated with either dilatation or open surgery. These both were often unsatisfactory, requiring the
111
need for further intervention. With the development of direct vision internal urethrotomy,3 it was hoped that stricture disease could now be resolved in a single setting. This, however, has not been the case, leading several investigators to search for new modalities to treat urethral strictures, i.e., balloon dilatation or urethral stenting.‘a2 This retrospective study was undertaken to see which patients might best be managed with these new treatments. Based on our results, it would appear that direct vision internal urethrotomy is the treatment of choice for most inflammatory strictures with only 10 percent requiring a subsequent procedure. However, using standard modalities (DVIU or urethroplasty) for the treatment of trauma-related urethral stricture disease we have had a significant reoperation rate in a county hospital, sug-
1. Milroy EJG, Chapple CR, and Wallsten H: A new stent for the treatment of urethral strictures. Preliminary report, Br J Urol 63: 392 (1989). 2. Daughtry JD, Rodan BA, and Bean WJ: Balloon dilatation of urethral strictures, Urology 31: 231 (1988). 3. Sachse H: Zur Behandling der Harnrohren Striktur: de transurethral schlitzurg inter sicht mit scharfen schnitt, Fortschr Med 92: 12 (1974).
112
UROLOGY
gesting that these new modalities might be most beneficial in trauma-related injuries. We are currently embarking on a clinical trial in the use of urethral stents in this setting as well as in intractable, multiple failure cases. 1200 North State Street Suite 5900 Los Angeles, California 90033 (DR. EASTHAM) References
I
AUGUST
1992
/
VOLUME
40, NUMBER
2
