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Visual Internal Urethrotomy for Adult Male

Urethral Stricture Has Poor Long-Term Results

Article in Advances in Urology October 2015

DOI: 10.1155/2015/656459

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Hindawi Publishing Corporation
Advances in Urology
Volume 2015, Article ID 656459, 4 pages
http://dx.doi.org/10.1155/2015/656459

Clinical Study
Visual Internal Urethrotomy for Adult Male Urethral Stricture
Has Poor Long-Term Results

Waleed Al Taweel1 and Raouf Seyam1,2

1
Department of Urology, King Faisal Hospital and Research Center, Riyadh 11211, Saudi Arabia
2
Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Correspondence should be addressed to Waleed Al Taweel; [email protected]

Received 6 July 2015; Accepted 12 August 2015

Academic Editor: Miroslav L. Djordjevic

Copyright 2015 W. Al Taweel and R. Seyam. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Objective. To determine the long-term stricture-free rate after visual internal urethrotomy following initial and follow-up
urethrotomies. Methods. The records of all male patients who underwent direct visual internal urethrotomy for urethral stricture
disease in our hospital between July 2004 and May 2012 were reviewed. The Kaplan-Meier method was used to analyze stricture-free
probability after the first, second, third, fourth, and fifth urethrotomies. Results. A total of 301 patients were included. The overall
stricture-free rate at the 36-month follow-up was 8.3% with a median time to recurrence of 10 months (95% CI of 9.5 to 10.5, range:
236). The stricture-free rate after one urethrotomy was 12.1% with a median time to recurrence of eight months (95% CI of 7.1
8.9). After the second urethrotomy, the stricture-free rate was 7.9% with a median time to recurrence of 10 months (95% CI of 9.3
to 10.6). After the third to fifth procedures, the stricture-free rate was 0%. There was no significant difference in the stricture-free
rate between single and multiple procedures. Conclusion. The long-term stricture-free rate of visual internal urethrotomy is modest
even after a single procedure.

1. Introduction curative urethroplasty [14]. Few studies have shown long-

term follow-up of patients after VIU [11].
Male urethral stricture continues to be a common and The purposes of this study are to report the overall
challenging urologic condition. Despite the high failure rate success rate of VIU and to analyze whether repeated VIUs
of visual internal urethrotomy (VIU), it remains the most are associated with a long-term stricture-free rate. This study
commonly performed procedure for the treatment of urethral reflects urologic practice in real-life situations by multiple
strictures [17]. Even when VIU is initially performed selec- urologists in a busy tertiary care hospital.
tively for short bulbar strictures under optimal conditions,
the recurrence rate at 12 months was approximately 40% for 2. Materials and Methods
strictures shorter than 2 cm. VIU and/or urethral dilation
is usually the initial treatment approach offered in most This is a retrospective study of male patients who presented to
cases of male urethral stricture, with no difference in efficacy the Department of Urology and underwent VIU for urethral
between urethral dilation and urethrotomy [810]. Repeated stricture disease between July 2004 and May 2012. We eval-
urethrotomies were not associated with an improved success uated the long-term stricture-free rate after visual internal
rate, and VIU for longer strictures usually failed [11, 12]. urethrotomy following initial and subsequent urethrotomies.
Urethral reconstruction is usually offered only after repeated We extracted data from medical records and our Inte-
failed transurethral stricture treatments, which in some cases grated Clinical Information System on ascending urethro-
span several years [13]. Unfortunately, repeated transurethral gram findings, including the site and length of stricture,
manipulation of bulbar strictures is associated with increased number of previous urethrotomies, and presence of complex
stricture complexity, stricture length, and a marked delay to stricture (after urethroplasty or after radiation). All patients
2 Advances in Urology

with symptoms or signs suggestive of urethral stricture Table 1: Stricture characteristics.

underwent a urethrogram to confirm the diagnosis and
Stricture length Location Number of patients
determine urethral stricture length. All patients underwent
cystourethroscopy before urethrotomy, confirming the diag- Penile 14
Bulbar 75
nosis. <1 cm
Penile and bulbar 0
Four urologists performed the urethrotomies using a Fossa navicularis 2
single incision at the 12 oclock position or using a modified
Penile 16
procedure including multiple radial incisions at the 3, 9, Bulbar 87
and 12 oclock positions; the incisions were made with a 1-2 cm
Penile and bulbar 10
cold knife or laser. Associated fossa navicularis stricture was Fossa navicularis 4
treated with meatotomy prior to urethrotomy. Penile urethral Penile 6
strictures were treated with cold knife urethrotomy. Bulbar 65
Follow-up data included subjective and objective results >2 cm
Penile and bulbar 14
and whether subsequent intervention was needed. Symptoms Fossa navicularis 8
of recurrence included decreased force of the urine stream,
feelings of incomplete bladder emptying, or recurrent uri- Survival functions
nary tract infections. Signs of recurrence were a significant
increase in postvoid residual urine on bladder ultrasound 1.0
or bladder scan, decreased urine flow rate (<15 mL/second),
or stricture as determined by diagnostic cystoscopy or
retrograde urethrogram. Absence of symptoms or signs of 0.8
recurrent stricture in any patient at last follow-up defined
the success of the procedure. The end point of the follow-up
was the last visit that showed failure of treatment or being
Cum survival

0.6
recurrence-free for 36 months. Only data up to the fifth
recurrence after repeated urethrotomy were included.
The Kaplan-Meier method was used to evaluate the 0.4
stricture-free rate (survival function) after the first, second,
third, fourth, and fifth urethrotomies. We used the Statistical
Package of Social Science (SPSS, version 20, IBM Corpo- 0.2
ration, NY, USA). The log-rank test was used to compare
survival differences between procedures.
0.0

0 10 20 30 40
3. Results and Discussion
Duration in months
3.1. Results. The mean age was 37 years (range: 1782). A
Factor
total of 446 male patients with urethral stricture disease were 1 1-censored
identified in the computerized records of the Department of 2 2-censored
Urology. Sixty-three patients were lost during follow-up. We 3 3-censored
excluded 82 patients who had complex urethral strictures, 4 4-censored
strictures longer than 5 cm, or dense palpable spongiofibrosis. 5 5-censored
This left 301 eligible patients who continued follow-up until Figure 1: Stricture-free probability after the first, second, third,
the failure of urethrotomy was observed, at which point fourth, and fifth urethrotomies (Kaplan-Meier survival analysis).
an alternative management plan was offered to them. We
reported the duration of follow-up and time to failure of
urethrotomy as the same duration. Further management and
follow-up are excluded from this paper. Most recurrences occurred within the first postoperative
The stricture characteristics are shown in Table 1. The year. Survivors or patients without recurrence were only those
most common location is bulbar urethral stricture in 227 with a stricture length of <1 cm and in the bulbar urethra.
(75%) patients, penile urethral stricture in 36 (11%) patients, There was no significant difference in the survival analysis
combined penile and bulbar urethral stricture in 24 (8%) of duration to recurrence among patients undergoing single
patients, and fossa navicularis stricture in 14 (5%) patients. or multiple procedures ( = 0.181, Figure 1). There was no
The mean stricture length was 13 mm (range: 442). The significant difference in the outcome based on the length of
overall stricture-free rate at the 36-month follow-up was 8.3% the stricture or the type of treatment.
with a median time to recurrence of 10 months (95% CI
9.5 to 10.5, range: 236). The success rate following single 3.2. Discussion. Urethral strictures are often treated with
urethrotomy was modest and dropped significantly after urethrotomy, most commonly direct visual internal urethro-
repeated urethrotomies (Table 2). tomy [15]. With the introduction of lasers, holmium laser
Advances in Urology 3

Table 2: Urethrotomy and stricture-free rate.

Number of Stricture-free rate Median time to failure Number of stricture-free Total number of patients (%)
urethrotomies (months) patients
First 12.1% 8 (95% CI 7.1 to 8.9) 17 140 (46.5%)
Second 7.9% 10 (95% CI 9.4 to 10.6) 8 101 (33.6%)
Third 0% 9 (95% CI 7.3 to 10.7) 0 27 (9%)
Fourth 0% 12 (95% CI 10.4 to 13.6) 0 25 (8.3%)
Fifth 0% 10 (95% CI 6.3 to 13.7) 0 9 (3%)
Overall 8.3% 10 (95% CI 9.5 to 10.5) 25 301 (100%)

urethrotomy was subsequently used in many centers with Repeated VIU was associated with more dismal out-
equal recurrence outcomes as achieved with VIU [16, 17]. comes. This is in accordance with the previously reported
Many urologists prefer VIU over urethral reconstruction data [11, 24, 27]. We found no significant advantage of single
because of its ease to perform, low cost, short hospital stay, versus repeated VIU. We think that the inclusion of long
and perceived low complication rate. They may opt to repeat strictures at different sites masks the claimed advantage of
VIU several times to avoid complex urethral reconstruction, single VIU. Our findings stress that an early attempt at
which requires significant surgical experience. This trend urethroplasty is warranted. This is particularly important
continues despite the moderate success rate reported in because repeated urethrotomies have a negative impact on
the selected patients. To reduce the stricture recurrence the success of subsequent urethroplasty [28].
rate, several investigators evaluated different intralesional Several studies have examined the cost-effectiveness of
adjuvant injections with variable success [1823]. We set out managing anterior urethral strictures. Urethroplasty as the
to report the results of VIU of our patients, including a wider primary therapy was cost-effective only when the expected
inclusion base and strict criteria of success in a long follow- success rate of the first VIU was less than 35% [29], whereas
up period. We felt that these patients constitute a real patient VIU became more favorable when the long-term risk of
group that tempts urologist to repeatedly administer VIU for stricture recurrence was less than 60% [30]. If a repeat
the management of their stricture. urethrotomy is required, open urethroplasty is the treatment
Our stricture-free rate of 8.3% at a median of 10 months of choice for recurrent urethral stricture.
(range: 236) is much lower than that reported by oth-
ers on long-term follow-up [24]. Heyns et al. found that, 4. Conclusions
after a single dilation or urethrotomy in patients who did
not experience restricture within 3 months, the estimated Visual internal urethrotomy is a simple and popular treat-
stricture-free rate was 5060% at 48 months [24]. The higher ment for male urethral stricture; however, the long-term
success rate in that study might be related to the exclusion stricture-free rate is modest even after only a single proce-
of patients who failed the treatment in the first three months dure. Most of the recurrences were found to occur within
from the analysis and the shorter stricture length. Another one year. Thus, definitive curative reconstruction should
study reported a 32% recurrence-free rate after a median be planned as early as possible. Repeated visual internal
follow-up of 98 months following a single internal ure- urethrotomies should be considered only in patients who are
throtomy. The prognostic characteristics of bulbar urethral poor surgical candidates and not because of the convenience
strictures associated with good results included single or of performing a simple procedure.
primary strictures and length shorter than 10 mm [11, 25].
The inclusion of strictures from 1 to 4 cm and the strict Conflict of Interests
success criteria in our study might explain a more realistic
success rate of 12.1% after single VIU. Comparison of studies The authors report no conflict of interests.
that evaluate the outcome of stricture urethra treatment is
greatly affected by the success criteria. This heterogeneity of References
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