|Year : 2017 | Volume
| Issue : 1 | Page : 35-37
Management of bulbar urethral strictures by direct vision internal urethrotomy: Experience from a Nigerian teaching hospital
AA Salako1, TA Badmus1, RA David1, OJ Isola2, A Laoye1, IA Akinbola1, MC Igbokwe1, RN Babalola1, CI Onyeze1
1 Department of Surgery, Urology Unit, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
2 Department of Surgery, Federal Medical Centre, Owo, Ondo State, Nigeria
|Date of Submission||31-Aug-2016|
|Date of Decision||02-Jun-2017|
|Date of Acceptance||02-Jun-2017|
|Date of Web Publication||26-Nov-2019|
Prof. A A Salako
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun State
Source of Support: None, Conflict of Interest: None
Background: Urethral stricture is a common cause of bladder outflow obstruction, and its management contributes significantly to the workload in urologic practice.
Aim(s): To evaluate the role of direct vision internal urethrotomy (DVIU) in the management of bulbar urethral strictures.
Methods: A retrospective review done at a University Teaching Hospital in Nigeria. Patients who had DVIU for the management of bulbar urethral strictures between July 2008 and June 2015 were studied. Information extracted and analysed were the patients' age, stricture characteristics, DVIU technique, outcome and complications. Statistical Package for Social Sciences version 20 was used for data analysis.
Results: A total of 63 patients had DVIU for bulbar urethral strictures during the period, of which 48 patients (76.2%) were studied. Their ages ranged between 32 and 70 years (mean 49 years). They all had solitary, short-segment, incomplete, bulbar urethral strictures confirmed pre-operatively by retrograde urethrogram. In addition, 36 (75%) also had urethrosonography which confirmed superficial spongiofibrosis. In 28 cases (58%), stricture aetiology was post-inflammatory, while in 12 (25%) and 8 (17%) patients, strictures were due to iatrogenic reasons (post-catheterisation) and straddle injuries, respectively. The DVIU was done by the same group of surgeons. Success rate was 66.7% after first DVIU and increased to 75.0% after a second DVIU was done for those with unsatisfactory outcome after first surgery. Mean follow-up period was 15 months.
Conclusion: In well-selected patients, DVIU is an option for successful treatment of bulbar urethral strictures.
Keywords: Bulbar urethral stricture, direct vision internal urethrotomy, Ile-Ife
|How to cite this article:|
Salako A A, Badmus T A, David R A, Isola O J, Laoye A, Akinbola I A, Igbokwe M C, Babalola R N, Onyeze C I. Management of bulbar urethral strictures by direct vision internal urethrotomy: Experience from a Nigerian teaching hospital. Niger J Health Sci 2017;17:35-7
|How to cite this URL:|
Salako A A, Badmus T A, David R A, Isola O J, Laoye A, Akinbola I A, Igbokwe M C, Babalola R N, Onyeze C I. Management of bulbar urethral strictures by direct vision internal urethrotomy: Experience from a Nigerian teaching hospital. Niger J Health Sci [serial online] 2017 [cited 2021 Sep 19];17:35-7. Available from: https://www.chs-journal.com/text.asp?2017/17/1/35/271622
| Introduction|| |
Urethral stricture is a common urological condition in our environment. Its treatment contributes significantly to the workload for urologists. This treatment could be by urethroplasty, direct vision internal urethrotomy (DVIU) or urethral dilatation (bougienage). Urethroplasty is indicated for complete, long-segment, multiple or complex urethral strictures. Urethrotomy and bougienage are indicated for solitary, incomplete, short-segment urethral strictures. Bougienage is however beginning to lose popularity worldwide because it is a blind procedure that could be discomforting, sometimes traumatic and required to be repeated regularly for life.
Since its introduction by Sachse in 1974, the use of DVIU has increasingly been embraced in urologic practice across many hospitals. It involves cutting the urethral stricture with a urethrotome under direct vision at 12 o'clock position.
We performed this study to evaluate the role of DVIU in the management of bulbar urethral stricture in a Nigerian teaching hospital and hereby present our findings in relation to documented literature on the subject.
| Methods|| |
This is a retrospective review of all patients who had DVIU for the treatment of bulbar urethral strictures in our university teaching hospital over a 7-year period (July 2008–June 2015). After obtaining ethical approval, data regarding the age, stricture characteristics (such as aetiology, location and completeness), DVIU technique, outcome and complications were extracted from hospital records and analysed using the Statistical Package for Social Sciences (SPSS) software for windows; version 21 (Released 2007; IBM Corp., Armonk, New-York, USA.
All the patients had DVIU done in lithotomy position under regional anaesthesia. After administering an intravenous fluoroquinolone antibiotic, the meatus was calibrated and a well-lubricated 18.5Fr urethroscope sheath with zero-degree telescope and urethrotome [Figure 1] was introduced into the urethra. This was advanced to the stricture site under direct endoscopic vision. A guidewire was passed through the urethrotome and threaded into the pin-hole opening in the strictured segment. The cold knife was then advanced under vision into the stricture. The proximal end of the urethrotome was depressed and cut upwards at the 12 o'clock position through the stricture until grossly normal urethra was visualised. This process was repeated until well enough space was created in the urethra to allow passage of an 18Fr silicone-coated Foley's catheter which was used to stent the urethra. Proximal urine diversion with a suprapubic catheter was done for all patients. Postoperatively, patients were observed for haematuria and discharged home once the urine was clear. Average follow-up was for 15 months.
| Results|| |
A total of 63 male patients had DVIU for bulbar urethral strictures during the period, of which 48 patients (76.2%) were studied. The remaining 15 patients (23.8%) had incomplete records and were excluded from analysis. The age of the patients studied ranged between 32 and 70 years, with a mean age of 49 years. They all had solitary, short-segment, incomplete, bulbar urethral strictures confirmed pre-operatively by retrograde urethrogram (RUG). In addition, 36 (75%) also had urethrosonography which confirmed minimal (superficial) spongiofibrosis. Post-inflammatory strictures predominated among the patients studied [Figure 2]. The DVIU was done by the same group of surgeons. Duration of hospital stay was between 3 and 8 days while period of post-operative urethral stenting ranged from 14 to 21 days. Eight patients (16.7%) had mild haematuria which resolved spontaneously while four patients (8.3%) had clot retention managed by bladder irrigation. One patient (2.1%) experienced post-operative acute epididymo-orchitis while there was no penile oedema (from urine extravasation) or mortality experienced in any patient.
Surgical outcome was objectively assessed with uroflowmetry and post-void residual urine volume done 3-monthly after the procedure. Success rate was 66.7% (32) after first DVIU and increased to 75.0% (36) after a second DVIU was done for those with unsatisfactory outcome after first surgery.
Further evaluation of the 12 patients with failed outcome from DVIU revealed that 3 (25%) had urethrosonography while 9 (75%) did not before the DVIU was done. All 12 patients with unsatisfactory outcome after the second DVIU however had urethroplasty, with good outcome [Table 1].
| Discussion|| |
In this study, the mean age of our patients was 49 years, which is similar to the mean age of urethral stricture disease reported from other studies in our environment., Post-inflammatory aetiology predominated in our findings, comparable with reports from other centres in Nigeria., Although post-inflammatory strictures are generally soft and supposedly more amenable to DVIU compared with traumatic strictures, the stricture aetiology did not influence the outcome of DVIU in our study, consistent with findings by other researchers.,
The outcome of DVIU in our patients was comparable with results from other series published in literature. Seventy-five per cent of our patients had satisfactory urinary flow rates and acceptably low post-void residual urine volumes over an average follow-up duration of 15 months. This is comparable to findings of Shittu, Holm-Nielsen et al. and Ahmed and Kalayi, who reported cure rates between 75% and 77% after DVIU. Ramyil et al. also found satisfactory outcome in 80% of their patients after one or more sessions of DVIU, with a recurrence rate of 32.9%. However, there are contrasting reports from other parts of the world. A report published by Santucci and Eisenberg showed a curative success rate of DVIU to be only 9% while Pansadoro and Emiliozzi reported a curative success rate of 32%. A possible explanation for the differing results is that the follow-up period in their studies was much longer, compared to follow-up periods in our environment. Many of the patients in our study were lost to follow-up early and our 15-month mean follow-up duration is relatively low.
Our patients were assessed postoperatively using uroflowmetry and post-void residual urine volume, which are objective surgical outcome measures. This is an improvement on similar work in Nigeria by Ramyil et al. and Shittu, who followed up the patients in their study mainly by clinical evaluation.
All our patients had pre-operative RUG that showed solitary, short-segment, incomplete, bulbar urethral strictures, which has been associated with good outcome from DVIU. However, the degree of spongiofibrosis could not be fully assessed pre-operatively in 12 (25%) patients who did not have urethrosonography. Considering the fact that majority (75%) of patients who had unsatisfactory outcome after two sessions of DVIU were the ones who did not have urethrosonography done to ascertain extent of spongiofibrosis before surgery, there is a possibility that true stricture length and degree of spongiofibrosis are not accurately ascertained by RUG alone.
The patients with unsatisfactory outcome after the second DVIU however had urethroplasty done with satisfactory outcome. The DVIU that had earlier been done for them did not adversely affect the procedure or outcome from urethroplasty, consistent with experience from other centres.,
| Conclusion|| |
DVIU is an option for the treatment of solitary, incomplete, short-segment, bulbar urethral strictures. With strict patient selection including urethrosonography to confirm minimal spongiofibrosis, good outcome is relatively guaranteed. There is however need for more studies on a prospective basis with larger patient cohort to assess the long-term outcomes in our environment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ramyil V, Dakum N, Liman U, Udeh E. Visual internal urethrotomy in the management of anterior urethral stricture. Afr J Urol 2008;13:267-72.
Olajide AO, Salako AA, Aremu AA, Eziyi AK, Olajide FO, Banjo OO. Complications of transverse distal penile island flap: Urethroplasty of complex anterior urethral stricture. Urol J 2010;7:178-82.
Shittu O. Internal optical urethrotomy in the management of urethral strictures in Nigerians: Technique and outcome. Afr J Urol 2001;7:62-5.
Sachse H. Treatment of urethral stricture: Transurethral slit in view using sharp section. Fortschr Med 1974;92:12-5.
Bullock TL, Brandes SB. Adult anterior urethral strictures: A national practice patterns survey of board certified urologists in the United States. J Urol 2007;177:685-90.
Salako AA, Olajide AO, Aremu AA, Afolayan MO, Adejare IE, Oseni OG. Pendulous urethral stricture: Peculiarities and relevance of longitudinal penile fascio-cutaneous flap reconstruction in poor resource community. Urol J 2014;10:1088-94.
Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: Long-term followup. J Urol 1996;156:73-5.
Holm-Nielsen A, Schultz A, Møller-Pedersen V. Direct vision internal urethrotomy. A critical review of 365 operations. Br J Urol 1984;56:308-12.
Ahmed A, Kalayi GD. Urethral stricture at Ahmadu Bello University Teaching Hospital, Zaria. East Afr Med J 1998;75:582-5.
Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol 2010;183:1859-62.
[Figure 1], [Figure 2]