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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 406-409

Is minimal invasive technique harmful in treatment of urethral stricture?


Department of Urology, Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey

Date of Acceptance13-Dec-2018
Date of Web Publication6-Mar-2019

Correspondence Address:
Dr. M Akyuz
Department of Urology, Haydarpaşa Numune Training and Research Hospital, Tıbbıye Cad. No: 23 Uskudar/Istanbul 34668
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_145_18

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   Abstract 


Objective: Our goal was to evaluate the effect of previous history of direct vision internal urethrotomy (DVIU) on success rate of open urethroplasty in patients with bulbar urethral stricture. Patients and Methods: We analyzed 133 patients who underwent open urethroplasty for bulbar urethral stricture between January 2008 and May 2017. Patients with penile and fossa navicularis stricture were excluded. We evaluated the effect of previous history of DVIU on success rate of open urethroplasty in patients with urethral stricture. Success of open urethroplasty was defined as disappear of voiding symptoms with maximum flow rate above 15 ml/s. The patients were followed for complications and outcome. Results: Mean age was 54.05 ± 16.5 years. Mean length of stricture was 23.74 ± 10.23 mm. Mean follow-up was 39.77 ± 28.0 months. A total of 76 patients (57.1%) had no history of DVIU. On the contrary, 15.8% had history of DVIU once, 12% had twice, and 15.2% had more than twice. Success rate of open urethroplasty in patients who had no history of DVIU was 84%. However, this success rate was 71.4% in patients who had history of DVIU (P = 0.001). Conclusion: DVIU is easy, simple, and noninvasive technique in treatment of urethral stricture, so it is frequently used among urologists. However, it could not be an alternative technique to open urethroplasty. Internal urethrotomy can be used in some certain indications. Success rate of open urethroplasty can be affected by previous history of any endoscopic procedures.

Keywords: Direct vision internal urethrotomy, open urethroplasty, success


How to cite this article:
Topaktas R, Akyuz M, Kutluhan M A, Kanberoglu H, Koca O, Ozturk M I, Urkmez A. Is minimal invasive technique harmful in treatment of urethral stricture?. Niger J Clin Pract 2019;22:406-9

How to cite this URL:
Topaktas R, Akyuz M, Kutluhan M A, Kanberoglu H, Koca O, Ozturk M I, Urkmez A. Is minimal invasive technique harmful in treatment of urethral stricture?. Niger J Clin Pract [serial online] 2019 [cited 2019 Mar 25];22:406-9. Available from: http://www.njcponline.com/text.asp?2019/22/3/406/253443




   Introduction Top


With its high prevalence, male urethral stricture is one of the most ancient diseases in urological practice. Urethral stricture prevalence stated between 0.6 and 1.4% by different writers affects 15–20% of adult males at some point of time in their lives.[1],[2],[3] Even though different etiological causes play a role in the formation of this disease, the most common being iatrogenic and idiopathic causes.[2],[4]

The treatment of this disease improves day-by-day. Minimal invasive methods such as dilatation, direct visual internal urethrotomy (DVIU), and open urethroplasty techniques are the treatment methods. But it is unclear that which treatment method should be applied on which patient that still continues today among the urologists around the world.[5],[6] Even though open urethroplasty is stated as the golden standard in urethral stricture treatment in questionnaires made in different areas of the world, it is demonstrated that many urologists prefer minimal invasive methods such as dilatation and endoscopic treatments because of their ease of application, simplicity, affordability, and not being a time-consuming or experience-demanding operation such as urethroplasty.[7],[8],[9],[10] But apart from these advantages, low long-term success and formation of stricture again are the most important disadvantages of minimal invasive methods.[11],[12],[13] Thus in new studies, it is stated that the tendency toward urethroplasty increased recently in urethral stricture treatment.[14]

We compared and evaluated our success in the patients we performed open urethroplasty for urethral stricture depending on the application or nonapplication of DVIU before treatment.


   Patients and Methods Top


Data of a total of 172 cases who were applied open urethroplasty in our clinic between January 2008 and May 2017 because of anterior urethral stricture were retrospectively evaluated. Patients who had penile urethral and fossa navicularis stricture or whose information could not be reached during follow-up were excluded from the study. A total of 133 patients who had bulbar urethra localized stricture were included in the study. Etiological cause, age, stricture dimension, and follow-up duration were recorded for the patients. Patients were separated into two groups as the group not applied DVIU (Group 1) and the group applied DVIU before urethroplasty operation (Group 2) and its effect on the success of urethroplasty was compared. In our study, we defined our selection criteria for DVIU before open urethroplasty, which was included in Group 2, not referenced by other clinics, as short, below 1 cm, and single bulbar stricture. The urination complaints disappearing after the operation and maximal flow rate above 15 ml/s in uroflowmetry were considered as a success.

Statistical Package for Social Sciences (SPSS) software for Windows, version 15.0 (Inc., Chicago, IL, USA) program was used for data analysis and Mann–Whitney U-test and Student's t-tests for statistical analysis. P = 0.001 value was accepted as statistically significant.


   Results Top


All patients were operated after being evaluated by the same surgical team between January 2008 and May 2017. Median age of the patients, stricture length, and duration of follow-up were 54.05 ± 16.5 years, 23.74 ± 10.23 mm, and 39.77 ± 28.0 months, respectively [Table 1]. Etiological causes for stricture were detected as previous endoscopic operation in 45 patients (34.0%), catheterization in 43 patients (32.3%), trauma in 27 patients (20.3%), infection in 5 patients (3.2%), idiopathic and other causes in 13 patients (10.2%).
Table 1: Definitive values of the patients included in the study

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Although 76 out of 133 patients received no endoscopic treatment due to urethra stricture before open urethroplasty, endoscopic treatment was applied before urethroplasty operation in 57 (42.9%). Out of patients treated endoscopically before urethroplasty, DVIU was applied once in 21 (36.8%), twice in 16 (28.0%), and three or more times in 20 (35.2%). Surgical method was perioperatively selected considering the characteristics of the stricture. As urethroplasty method, buccal graft in 92/133, end-to-end anastomosis in 34/133 (25.5%), Heineke-Mickulicz in 4/133 (3%), and penile flap were applied in 3/133 (2.5%).

When the patients were evaluated regardless of whether they received endoscopic treatment before urethroplasty or not, 104 out of 133 patients were successful (78.6%). Recurrence was detected in 29 patients (21.4%).

In [Table 2], between Group 1 and Group 2, no statistically significant difference was detected in age, stricture size, and follow-up duration (P > 0.05). But while the success of open urethroplasty was 84.0% in Group 1, the success rate was 71.4% in Group 2 and the difference was statistically significant (P = 0.001).
Table 2: Comparison of the patients in both groups: DVIU (−): The group which did not have direct visual internal urethrotomy, DVIU (+): The group which had direct visual internal urethrotomy

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   Discussion Top


Although many urologists present urethroplasty as the golden standard in urology practice, it is still unclear and debates in application continue. Owing to its advantages such as being simpler, technically easier, easy to apply as an outpatient treatment with local anesthesia, lower morbidity, and shorter recovery period compared to urethroplasty from its beginning until today, DVIU has a widespread application area in the whole world as primary care in urethral stricture.[3],[11],[12],[13],[14],[15],[16],[17],[18],[19] Widespread use of DVIU application was also shown in questionnaires made in different areas of the world, such as USA, Holland, Italy, and Turkey.[7],[8],[9],[10]

Although the success of open urethroplasty regarded as the golden standard in the definitive treatment of urethral stricture is 85–90%, the success of DVIU which is a more widespread and frequently used as minimal invasive method is stated between 20 and 90% in different series.[12],[15],[16],[20],[21],[22] In recent studies, it is stated that the high short-term success of this method decreases in long-term and stricture is formed again. In their study, Santucci and Eisenberg stated stricture free rate (SFR) of DVIU to be only 9% in a 1–3 years follow-up.[13] In the study by Pansadoro and Emiliozzi, it was stated that recurrent DVIU did not increase success and third internal urethrotomy failed in all patients.[12] In a more current study, SFR was stated as 29.6 after first DVIU, as 22.6% after the second, and as 13.3% after the third DVIU in an average of 6 months follow-up.[17] One-third of the patients included in our study had a story of three or more DVIU applications.

Quite a lot of studies were made on many risk factors affecting the success of urethral stricture treatment and causing stricture recurrence such as the age of the patient, etiological cause, past stricture treatments, stricture localization, and length. But it was stated that the treatment success was completely due to suitable patient selection rather than the characteristics of any particular method and technique. So DVIU and urethroplasty were reported to be two separate techniques with different indications and restrictions rather than two competing or alternative techniques. DVIU should only be used in bulbar area in a single stricture shorter than 1 cm and would cause increase in long-term failure and a decrease in SFR rates with inappropriate widespread use.[7],[11],[22],[23] A result supporting this condition was also reached in our study.

On the contrary to the study stating iatrogenic causes as 32% and idiopathic causes as 34% due to the meta-analysis evaluating the etiological causes of anterior urethral stricture, iatrogenic causes formed by endo-urological operation and catheterization had a high ratio of 66.3% and idiopathic causes were 10.2% in our study.[4] This condition was evaluated based on endo-urological operations becoming more widespread, particularly in recent years.

Most authors stated that recurrent urethral manipulation and DVIUs did not increase treatment success and even decreased urethroplasty success. It was even stated that post-urethroplasty failures in long-term results of multivariate analyses were directly related to previous failed DVIUs and similarly, in the study by Roehrborn and McConnell, it was stated that minimal invasive method application before definitive treatment caused the failure to rise from 14 to 28%.[12],[24],[25],[26],[27],[28] On the other hand, Barbagli et al. stated that urethroplasties following failed DVIU can be made as successful primary urethroplasty.[29] In our study, 57.1% (76/133) of the patients were primary patients who did not take any endoscopic treatment before, and the success in this group was statistically higher. This ratio may actually seem quite high when questionnaires made among urologists are considered. We can relate this to our use of DVIU only in bulbar urethra in a quite limited patient group with a single stricture shorter than 1 cm in bulbar urethra only. Most of the group we applied urethroplasty after a failed DVIU application were patients who did not benefit from minimal invasive methods and referred to our clinic for definitive treatment. DVIU operation was applied once in 36.8% (21/57), twice in 28% (16/57), and three or more times in 35.2% (20/57) of these patients.

The first finding we noticed in the results of the study was the surprising similarity in the failure ratios between the studies by Roehrborn and McConnell. Recurrence ratios in the primary urethroplasty-applied group and urethroplasty-applied group after a failed DVIU were 16 and 28.6%, respectively [Table 2]. Our study has restrictions such as being single-centered, retrospective, and having a relatively low number of patients.


   Conclusion Top


As a result, inappropriate overuse of minimal invasive methods that have many advantages in application when compared to urethroplasty generally does not increase success rate and may not be curative. It may be considered that lack of any endoscopic operations applied before urethroplasty on especially complicated patients has a direct effect on the surgeon's success.

Financial support and sponsorship

Nil

Conflict of interest

There are no conflicts of interest.



 
   References Top

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Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol 2007;177:1667-74.  Back to cited text no. 1
    
2.
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Barbagli G, Sansalone S, Djinovic R, Romano G, Lazzeri M. Current controversies in reconstructive surgery of the anterior urethra: A clinical overview. Int Braz J Urol 2012;38:307-16.  Back to cited text no. 6
    
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Palminteri E, Maruccia S, Berdondini E, Di Pierro GB, Sedigh O, Rocco F. Male urethral strictures: A national survey among urologists in Italy. Urology 2014;8:477-84.  Back to cited text no. 9
    
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Akyuz M, Sertkaya Z, Koca O, Caliskan S, Kutluhan MA, Karaman MI. Adult urethral stricture: Practice of Turkish urologists. Int Braz J Urol 2016;42:339-45.  Back to cited text no. 10
    
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Veeratterapillay R, Pickard RS. Long-term effect of urethral dilatation and internal urethrotomy for urethral strictures. Curr Opin Urol 2012;22:467-73.  Back to cited text no. 11
    
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Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: Long-term follow up. J Urol 1996;156:73-5.  Back to cited text no. 12
    
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Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol 2010;183:1859-62.  Back to cited text no. 13
    
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Liu JS, Hofer MD, Oberlin DT, Milose J, Flury SC, Morey AF, et al. Practice patterns in the treatment of urethral stricture among American urologists: A paradigm change? Urology 2015;86:830-4.  Back to cited text no. 14
    
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Wong SS, Aboumarzouk OM, Narahari R, O'Riordan A, Pickard R. Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Rev 2012;12:6934.  Back to cited text no. 16
    
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Pal DK, Kumar S, Ghosh B. Direct visual internal urethrotomy: Is it a durable treatment option? Urol Ann 2017;9:18-22.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Ferguson GG, Bullock TL, Anderson RE, Blalock RE, Brandes SB. Minimally invasive methods for bulbar urethral strictures: A survey of members of the American Urological Association. Urology 2011;78:701-6.  Back to cited text no. 18
    
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Anger JT, Buckley JC, Santucci RA, Elliott SP, Saigal CS. Urologic Diseases in America Project. Trends in stricture management among male Medicare beneficiaries: Underuse of urethroplasty? Urology 2011;77:481-5.  Back to cited text no. 19
    
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Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL, Mundy AR. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004;172:275-7.  Back to cited text no. 20
    
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Naudé AM, Heyns CF. What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nat Clin Pract Urol 2005;2:538-45.  Back to cited text no. 21
    
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Morey A. Urethral stricture is now an open surgical disease. J Urol 2009;181:953-4.  Back to cited text no. 22
    
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Koraitim MM. Post-traumatic posterior urethral strictures: Preoperative decision making. Urology 2004;64:228-31.  Back to cited text no. 23
    
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Albers P, Fichtner J, Brühl P, Müller SC. Long-term results of internal urethrotomy. J Urol 1996;156:1611-4.  Back to cited text no. 25
    
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Culty T, Boccon-Gibod L. Anastomotic urethroplasty for posttraumatic urethral stricture: Previous urethral manipulation has a negative impact on the final outcome. J Urol 2007;177:1374-7.  Back to cited text no. 26
    
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Singh BP, Andankar MG, Swain SK, Das K, Dassi V, Kaswan HK, et al. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology 2010;75:179-82.  Back to cited text no. 27
    
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