Urethral stricture disease continues to be a common problem for patients and urologists alike. Endoscopic treatment offers a simple, potentially effective treatment of primary, short, urethral strictures. For patients who recur after endoscopic management, urethral or bladder neck reconstruction should be offered with an experienced urologic reconstructionist familiar with the complexity of the situation and subtleties of the surgery. With the advent of adjunctive antifibrotic agents the durability of endoscopic repair seems to improve, but their use requires continued research and longer follow-up to determine their efficacy.
Key points
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Urethral stricture disease continues to be a common problem for patients and urologists alike.
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Endoscopic treatment offers a simple, potentially effective treatment of primary, short, urethral strictures.
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For patients who recur after endoscopic management, urethral or bladder neck reconstruction should be offered with an experienced urologic reconstructionist familiar with the complexity of the situation and subtleties of the surgery.
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With the advent of adjunctive antifibrotic agents the durability of endoscopic repair seems to improve, but their use requires continued research and longer follow-up to determine their efficacy.
Introduction
Urethral stricture disease is a common and challenging problem for general urologists and reconstructive urologists alike. Although strictures commonly present with similar symptoms of difficulty voiding, split urine stream, postvoid dribbling, or even urinary retention, urinary strictures may form in discrete areas along the urethra. As the cause and treatment varies between these subtypes, strictures can be best characterized as anterior urethral strictures, posterior urethral strictures, or bladder neck contractures.
In most instances, urethral strictures or bladder neck contractures (BNCs) are initially treated with an in-office dilation. However, this procedure is uncomfortable for patients, can be challenging for the urologist to perform, and generally is associated with high recurrence rates that require repeat intervention. When dilation fails, the next step is often a repeat urethral dilation (UD) or an internal urethrotomy (IU). IU is the type of procedure in which the stricture is opened by cold-knife incision or thermal energy incision performed transurethrally. The intent is to release/open the scar contracture through incision with the goal that generative healing occurs at a more rapid rate than scar formation.
Endoscopic treatment of stricture disease offers a minimally invasive approach with advantages over open surgery, such as its ability to be done as an outpatient or in the clinic, associated lower cost, and relative simplicity compared with urethroplasty. Despite these advantages, urethroplasty remains the most definitive treatment of stricture disease. Even in stricture types whereby endoscopic management has been shown to be most effective (short bulbar urethral strictures), stricture-free rates after urethroplasty are reported as high as 90% to 95% versus 50% to 70% for endoscopic treatment. In certain locations, such as distal or pendulous urethral strictures, the stricture-free rates of dilation or urethral incision are much lower, 30% or less, and should be viewed primarily as a palliative maneuver that will likely require life-long intervention. Endoscopic management has evolved from the single 12-o’clock IU originally described to numerous variations in technique to create the most effective and durable endoscopic repair.
Introduction
Urethral stricture disease is a common and challenging problem for general urologists and reconstructive urologists alike. Although strictures commonly present with similar symptoms of difficulty voiding, split urine stream, postvoid dribbling, or even urinary retention, urinary strictures may form in discrete areas along the urethra. As the cause and treatment varies between these subtypes, strictures can be best characterized as anterior urethral strictures, posterior urethral strictures, or bladder neck contractures.
In most instances, urethral strictures or bladder neck contractures (BNCs) are initially treated with an in-office dilation. However, this procedure is uncomfortable for patients, can be challenging for the urologist to perform, and generally is associated with high recurrence rates that require repeat intervention. When dilation fails, the next step is often a repeat urethral dilation (UD) or an internal urethrotomy (IU). IU is the type of procedure in which the stricture is opened by cold-knife incision or thermal energy incision performed transurethrally. The intent is to release/open the scar contracture through incision with the goal that generative healing occurs at a more rapid rate than scar formation.
Endoscopic treatment of stricture disease offers a minimally invasive approach with advantages over open surgery, such as its ability to be done as an outpatient or in the clinic, associated lower cost, and relative simplicity compared with urethroplasty. Despite these advantages, urethroplasty remains the most definitive treatment of stricture disease. Even in stricture types whereby endoscopic management has been shown to be most effective (short bulbar urethral strictures), stricture-free rates after urethroplasty are reported as high as 90% to 95% versus 50% to 70% for endoscopic treatment. In certain locations, such as distal or pendulous urethral strictures, the stricture-free rates of dilation or urethral incision are much lower, 30% or less, and should be viewed primarily as a palliative maneuver that will likely require life-long intervention. Endoscopic management has evolved from the single 12-o’clock IU originally described to numerous variations in technique to create the most effective and durable endoscopic repair.
Anterior urethral strictures
The anterior urethra is composed of the meatus to the proximal bulbar urethra. Anterior urethral strictures develop through a process called spongiofibrosis, wherein the urethral epithelial cells are damaged either by external or internal trauma, exposing the underlying corpus spongiosum. This exposure results in a dense collagen scar formed by fibroblasts and a narrowing due to external urethral pressure as the urethra attempts to repair itself. The resultant scar is further irritated by the passage of urine, causing even more spongiofibrosis. The causes include idiopathic, iatrogenic, inflammatory, and traumatic, which often occur in predictable locations.
Direct Vision Internal Urethrotomy
After dilation, the most commonly performed treatment of anterior urethral strictures is direct vision internal IU (DVIU). Sachse first introduced DVIU of anterior urethral stenosis in 1974. Because of its minimally invasive approach and the familiarity of endoscopic procedures in urology, it has quickly become a go-to treatment of stricture disease such that in a survey of American Urologic Association members, 85.6% reported using DVIU for anterior stricture management. A recent study looking at national trends continued to show that urethral stricture disease is largely treated by endoscopic urethrotomy or dilation (90.7%) versus urethroplasty (9.3%).
Direct Vision Internal Urethrotomy Technique
The classic technique described by Sachse in 1974 involves making a single 12-o’clock incision into the urethral scar with a cold knife. Variations on this technique have evolved into making 2 or more incisions to release the scar in more than one location. Care must be taken to not extend the incision through the spongiosum but rather just far enough to release the scar to avoid to damage surrounding tissue.
Laser or hot-knife urethrotomy was initiated as an alternative to cold-knife incision to improve outcomes. The types of lasers used include argon, diode, Nd:YAG, and the more common holmium:YAG or holmium laser. Most published studies evaluating the efficacy of laser versus cold-knife urethrotomy indicate no difference in outcomes. Although frequently found to decrease operative times, laser urethrotomy is still a higher-cost procedure than traditional cold-knife urethrotomy; thus, cold knife persists as the most commonly performed procedure. Another benefit of cold-knife incision over laser incision is the ability to receive tactile feedback. This feedback allows for precise identification of the release of the contracture associated with the scar (the goal of the procedure) and avoiding an overly aggressive and at times destructive maneuver.
Complications
Postprocedure complications from endoscopic IU may include hematuria, dysuria, urinary tract infection, urinary retention, urinary incontinence, or erectile dysfunction. Overall complication rates are similar between hot- and cold-knife urethrotomy, with the exception of hematuria and urinary retention, which is more common with laser urethrotomy. Reports of erectile dysfunction range from 2.2% to 10.6%, and it is associated with long, dense strictures.
Direct Vision Internal Urethrotomy Outcomes
Literature describing DVIU/dilation outcomes largely consist of case series data with variations in patient population, stricture location and/or length, cause, or primary versus recurrent strictures. Additionally, defining outcomes is limited by the diagnostic criteria used before treatment, the definition of treatment success, patient follow-up, or methods used to determine stricture recurrence.
Although distinct procedures, endoscopic IU and endoscopic UD are deemed nearly equivalent in terms of primary treatment of urethral strictures. Steenkamp and colleagues performed a randomized study comparing stricture-free rates between IU and dilation, which found no statistically significant difference in stricture recurrence rates between IU or UD in a well-matched cohort of 104 and 106 patients, respectively.
Several studies have shown varied success rates of endoscopic incision or dilation based on stricture location and length. In a series of 224 patients with a median 98-month follow-up, Pansadoro and Emiliozzi reported a large discordance in treatment success rates for strictures less than or more than 10 mm in length, 71% versus 18%, respectively. Albers and colleagues reported greater success rates for strictures less than 1 cm; Steenkamp and colleagues also highlighted the importance of size criteria for endoscopic stricture repair, as strictures shorter than 2 cm had a 40% recurrence rate at 12 months, whereas strictures longer than 4 cm had an 80% recurrence rate. In terms of location, penile strictures are associated with the highest recurrence rates after endoscopic dilation or incision, with bulbar strictures being the favored location suitable for this type of repair. Pansadoro and Emiliozzi’s series reported similar findings, with recurrence rates after IU of 68% overall, 58% for bulbar, 84% for penile, and 89% for penile bulbar urethral strictures. In addition, treatment success rates of larger-caliber strictures (more than 15 F) are approximately doubled those of narrower lumens, which likely reflects a shallow area of narrowing with minimal spongiofibrosis.
Risks of Repeated Direct Vision Internal Urethrotomy/Dilation
Despite the feasibility of repeated endoscopic treatment of urethral strictures, several studies have reported progressively worse outcomes with each procedure. Although the success of an initial procedure may be 60% to 70%, repeated procedures fail at compounding rates. Heyns and colleagues reported stricture-free rates of 1, 2, or 3 dilations or urethrotomies at 24 months of 60%, 30%, 0%, respectively, and at 48 months rates of 60%, 0%, 0%, respectively. In addition, time to recurrence after a second procedure was dramatically shortened, indicating a limited benefit of a second procedure. There was zero percent success after a third repeat procedure, and this should be viewed as a palliative maneuver. Similarly, Santucci and Eisenberg reported stricture-free rates as low as 6% for a second DVIU and 9%, 0%, 0% for a third, fourth, and fifth. Interestingly, the investigators’ reported stricture-free rate for a single procedure was only 8% at 14 months, significantly lower than previously reported success rates. Risks associated with stricture recurrence after dilation or optical urethrotomy include longer (>2 cm) strictures, penile strictures, those occurring after transurethral resection of the prostate (TURP), and those previously treated.
Further risks of repeated urethrotomy or dilation are lower stricture-free rates at the time of definitive urethroplasty. In a more recent analysis of long-term outcomes of urethroplasty, investigators found that prior DVIU was a statistically significant risk factor for treatment failure.
Optimal Indications for Direct Vision Internal Urethrotomy
Based on the aforementioned studies, the ideal patient characteristics for DVIU take into account stricture size, location, caliber, and prior treatment. Prior endoscopic dilation or DVIU seem to be the strongest predictor of treatment failure. Despite this evidence, endoscopic dilation or urethrotomy is the most commonly performed procedure for anterior stricture management. Therefore, research points to an underutilization of urethroplasty as the definitive repair with a body of literature that demonstrates repeat urethral incision or dilation is not only palliative but can also have a negative effect on stricture-free rates when future urethroplasties are performed ( Table 1 ).
Related posts:
Management of Urethral Strictures
Definition of Successful Treatment and Optimal Follow-up after Urethral Reconstruction for Urethral Stricture Disease
Cost-effective Strategies for the Management and Treatment of Urethral Stricture Disease
Management of Panurethral Stricture
Treatment of Radiation-Induced Urethral Strictures
Effect of Lichen Sclerosis on Success of Urethroplasty
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