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Results of surgical treatment on short-length bulbous urethral strictures

https://doi.org/10.21886/2308-6424-2021-9-1-32-38

Abstract

Introduction. Urethral stricture disease is one of the most actual problems of modern urology, and the number of this pathology in the population increases year to year. To date, a large number of surgical methods for treating urethral strictures have been proposed. This study represents our experience in the surgical treatment of short-length bulbous urethral strictures.

Purpose of the study. To analyze the results of surgical treatment of patients with short-length bulbous urethral strictures.

Materials and methods. A retrospective analysis of the surgical treatment results in 75 patients with short-length bulbous urethral strictures was carried out. Treatment was carried out using various techniques: internal optical urethrotomy (IOUT), anastomotic urethral plasty, urethral plasty without crossing the spongy body. The effectiveness of the applied methods is assessed.  The standard questionnaire I-PSS (International Prostate Symptom Score) was used to assess the quality of life of patients in all cases, which was filled out before surgery and 6 months after surgery.

Results. The easiest and fastest to perform is the IOUT technique, but it has a high percentage of relapses — up to 76,47% in a follow-up. However, the number of recurrences when performing open surgical techniques, such as urethral plastic surgery without crossing the spongy body, anastomotic urethral plastic surgery, did not exceed 7.14% and 7.4%, respectively. Before surgery average IPSS score in patients who were carried out of IUOT, anastomotic plastic and plastic without crossing a spongy body, respectively 20,65 ± 0,62, 21,52 ± 0,64 and of 23,07 ± 0,76 points, and 6 months after surgical treatment the average score was 8,24 ± 0,63, 4,37 ±  0,33, 5,64 ± 0,37 points.

Conclusions. It was revealed that currently, the most prognostically favourable methods of surgical treatment of urethral stricture disease are anastomotic urethral plasty, urethral plasty without crossing the spongy body.

For citation:


Goncharov N.A., Kuznetsov A.A., Morozov E.A., Kiseleva A.A. Results of surgical treatment on short-length bulbous urethral strictures. Vestnik Urologii. 2021;9(1):32-38. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-1-32-38

Introduction

Urethral stricture is one of the dramatic diseases in men. Unfortunately, there are no statistics on the occurrence rate of this pathology in the Russian Federation. At the same time, the occurrence rate of this disease in the USA is 274 cases per 100,000 applications for medical help. The rate of urethral stricture increases with age and reaches 0.6% at the age of 65 – 69 years and 1.9% at the age of 85 years old and older [1][2].

Urethral strictures can be classified as congenital and acquired. Acquired strictures are divided into inflammatory, traumatic, iatrogenic, resulted from complicated Lichen sclerosus, and idiopathic [3]. They are classified by the localization as prostatic, membranous, bulbous, penile, glandular section of the urethra, scaphoid fossa, external urethral opening. The lengths of the strictures were short (≤ 2 cm), long (> 2 cm), total spongy (more than 75% of the spongiose urethra), and total (damage of the entire urethra) [2][4][5].

According to the published data, one of the most frequently affected urethral sections is the bulbous part of the urinary tract (40 – 55.7% of all patients with stricture disease) [1][6][7]. The main etiological factors of the urethral bulbous section stricture are presently traumatic, iatrogenic, and idiopathic. Iatrogenic causes include transurethral resections, traumatic catheterization of the bladder, cystoscopy, prostatectomy, and brachytherapy (45.5%) [8][9]. In men younger than 45 years old, the main cause was not established and the share of patients with idiopathic strictures was 35.8% [1][8].

The tactics of treatment in patients with urethral stricture disease depend on many factors [10]. They include etiologic factors, length of stricture, and comorbid background. The methods of treatment or short-length urethral bulbous section strictures include endoscopic and palliative: urethral bougienage, cold knife or laser optical internal urethrotomy (OIU), and installation of temporary or permanent stents [2][11].

Bougienage is a palliative method of treatment that provides the dilation of the urinary tract and is indicated to patients with severe comorbid pathology [2][12][13][14]. Another alternative method of the treatment of urethral strictures is OIU with any applied energy. Urethral bougienage and OIU are nearly identical and very controversial by their effectiveness (10 – 90%) [15][14][15][16][17][18]. The most effective method of treatment for urethral bulbous section strictures shorter than 2 cm is a dissection of the urethral affected area and the formation of a direct anastomosis. This method proved to be effective in a long-term perspective [19][20]. One of the oldest Russian schools of treatment for the urethral stricture is the Rostov school that provides the rate of successful outcomes 98.7% [21][22][23]. Prof. Barbagli et al. reported positive results in 90.8% of cases after anastomosis plasty in 153 patients with strictures of different etiology and length [24]. Urethral resection plasty with anastomosis “edge-to-edge” is included in clinical recommendations for patients with urethral stricture [2]. However, this method also has disadvantages. After spongious body incision, the urethral artery gets damaged, which impairs the hemodynamics in the distal parts of the spongious body and can negatively affect the processes of regeneration [25, 26]. Apart from the incision of arterial and venous vessels, nervous stems get damaged, which may result in different sexual impairments registered in 14.3% of cases [27][28]. The search for alternative methods with high effectiveness and a lower rate of complications is going on. One of such methods is urethra plasty without spongious body incision. Based on the analysis of modern available data, the authors found different methods of urethra plasty without spongious body incision. They include the method of Heineke-Mikulicz that is based on a longitudinal incision of the stricture and its cross suturing without cicatricle tissue excision. First, this method was described in 2010 by Lumen et al. [29]. Jordan’s method is vessel-sparing anastomotic plasty. This technique provides circulatory excision of the affected mucosa with the formation of circulatory anastomosis of the urethral mucosa and sparing of the spongious body ventral part [30][31]. Mundy urethroplasty includes a longitudinal incision of the stricture along the dorsal surface, incision of the cicatricle mucosa with a spearing of the spongious layer, and formation of an anastomosis between the edges of the normal mucosa. The formed urethral defect is fixed by the method of Heineke-Mikulicz [32]. Chapman et al. compared the results of urethra plasty with the incision and without the incision of the spongious body in 352 patients: 258 patients had standard anastomosis formed and 94 patients underwent urethral plasty without spongious body incision. Successful outcomes were achieved in 93.8% and 97.9% of cases, respectively. Post-operative complications were observed in 8.1% versus 4.3% (p = 0.25) of cases. Patients that underwent anastomotic plasty more often reported the development of sexual dysfunction (14.3% versus 4.3%, p = 0.008) [27]. The study aimed to perform a comparative retrospective analysis of surgical treatment for short-length bulbous urethral strictures.

Materials and Methods

A comparison of a consistent group of patients with the bulbous urethral stricture not more than 2 cm treated in 2017 – 2019 (75 patients) was performed. The mean age of patients was 51.2 ± 4.1 years old. By the etiological factor, the strictures were divided into 12 traumatic (16%), 24 inflammatory (32%), and 32 iatrogenic (42.7%) cases. Idiopathic urethral strictures were observed primarily in young patients (7 cases, 9.3%). The primarily revealed urethral stricture was found in 64 (85.3%) cases. The recurrence of stricture was registered in 11 (14.7%) patients. It was registered in the urethral bulbous section (75 cases, 100%) by the localization.

Patients underwent the following surgeries: OIU, anastomotic urethra plasty (these methods were recommended as the methods of choice), and urethra plasty without spongious body dissection, which is a relatively new method of treatment.

Results

OIU was performed on 34 patients. In 27 cases, urethral anastomotic plasty “edge-to-edge” was performed. In 14 cases, urethra plasty without spongious body dissection was made. It should be noted that all patients who underwent urethra plasty without spongious body dissection were primary. Post-operative hospitalization of patients after OIU was 4.03 ± 0.24 days, anastomotic plasty ― 5.85 ± 0.32 days, plasty without spongious body dissection ― 4.14 ± 0.18 days. The mean period of catheterization after OIU was 6.32 ± 0.22 days, anastomotic plasty ― 13.30 ± 0.37 days, and urethra plasty without dissection ― 12.07 ± 0.71 days. The simplest method of surgical intervention was OIU and it was characterized by the highest rate of recurrence (76.47%). The recurrence after urethra plasty without spongious body dissection was observed in one patient (7.14%). The recurrence after standard anastomotic plasty was registered in two patients (7.41%).

The average surgery duration in patients who underwent anastomotic plasty was ≈ 110 minutes, urethra plasty without spongious body dissection ― ≈ 90 minutes, and OIU ― ≈ 30 minutes.

Before surgery, the mean I-PSS score (International Prostate Symptom Score) in groups that underwent OIU, anastomotic plasty, and plasty without spongious body dissection was 20.65 ± 0.62, 21.52 ± 0.64, and 23.07 ± 0.76 points. In six months, the average I-PSS score was 8.24 ± 0.63 after OIU, 4.37 ± 0.33 after anastomotic plasty, and 5.64 ± 0.37 points after plasty without spongious body dissection. The data on the results of surgical treatment of patients with urethral stricture disease are presented in Table 1.

Table 1. Results of surgical treatment in patients with urethral stricture disease

Parameters

OIU

Anastomotic plasty “edge to edge”

Urethral plasty without spongious body incision

Number of patients

34

27

14

Duration of surgery, min

30 ± 2.14

110 ± 4.42

90 ± 6.44

Duration of catheterization, days

6.32 ± 0.22

13.30 ± 0.37

12.07 ± 0.71

Postoperative bed-day

4.03 ± 0.24

5.85 ± 0.32

4.14 ± 0.18

Recurrence cases

26 (76.5%)

2 (7.4%)

1 (7.1%)

Complications

3 (8.2%)

3 (11.1%)

0 (0%)

Preoperative I-PSS, summary score

20.65 ± 0.62

21.52 ± 0.64

23.07 ± 0.76

Postoperative I-PSS, summary score

8.24 ± 0.63

4.37 ± 0.33

5.64 ± 0.37

Notes: OIU —optical internal urethrotomy; I-PSS — International Prostate Symptom Score

Discussion

The authors evaluated the results of three different methods of surgical treatment for short-length urethral bulbous section strictures. Despite technical simplicity and the shortest time of intervention, OIU is characterized by a high rate of recurrences: up to 76% in the present study and up to 90% according to the published data [14][15][16][17]. For the improvement of the results, it is possible to form a direct anastomosis with spongiofibrosis dissection and spatulation of the urethral ends for an increase in the urethral duct lumen but this will lead to the impairment of the trophic of the tissues distal to the anastomosis. The studied method of circulation-sparing surgery minimized the recurrence rate of strictures. Anastomotic plasty of the urethra and spongious body-sparing urethroplasty had similar results. The mean I-PSS scores were nearly identical (4.37 ± 0.33 and 5.64 ± 0.37) in six months. Positive results in patients with urethra plasty were obtained in 92.6% of cases when the spongious body was not dissected and 92.86% of cases when anastomosis was formed.

Conclusion

Despite a diversity of variants of surgical treatment for short-length strictures, the issue of the choice of the method remains acute. Clinical recommendations on the treatment for urinal duct strictures have lately been implemented in the Russian Federation but the choice of the method depends on the surgeon’s preferences. Urethroplasty with and without spongious body dissection are highly effective methods of treatment that contribute to the restoration of normal urination in patients with stricture disease. However, there are presently no studies on the evaluation of long-term results of urethral plasty without spongious body dissection so that it could be recommended as an effective method of treatment for patients with stricture disease.

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About the Authors

N. A. Goncharov
Volgograd Regional Clinical Hospital № 1; Volgograd State Medical University
Russian Federation

Nikolay А. Goncharov — M.D.; Assist., Dept. of Emergency Medicine, Volgograd State Medical University; Head, Urology Division, Volgograd SRH No. 1.

400081, Volgograd, 13 Angarskaya st.; 400081, Volgograd, 13 Angarskaya st..; tel.: +7 (937) 721-56-84


Competing Interests: no conflicts of interest


A. A. Kuznetsov
Volgograd Regional Clinical Hospital № 1; Volgograd State Medical University
Russian Federation

Alexander A. Kuznetsov — M.D., Cand. Sc.(M); Assoc. Prof. (Docent); Dept. of General Surgery with the Urology Course, Volgograd State Medical University; Urologist, Urology Division, Volgograd SRH No. 1.

400081, Volgograd, 13 Angarskaya st.; 400081, Volgograd, 13 Angarskaya st.


Competing Interests: no conflicts of interest


E. A. Morozov
Volgograd Regional Clinical Hospital № 1
Russian Federation

Egor A. Morozov — M.D.; Assist., Dept. of General Surgery with the Urology Course.

400081, Volgograd, 13 Angarskaya st.;


Competing Interests: no conflicts of interest


A. A. Kiseleva
Volgograd Regional Clinical Hospital № 1; Volgograd State Medical University
Russian Federation

Anna A. Kiseleva — M.D.; Assist., Dept. of Emergency Medicine, Volgograd State Medical University; Urologist, Urology Division, Volgograd SRH No. 1.

400081, Volgograd, 13 Angarskaya st.; 400081, Volgograd, 13 Angarskaya st.


Competing Interests: no conflicts of interest


For citation:


Goncharov N.A., Kuznetsov A.A., Morozov E.A., Kiseleva A.A. Results of surgical treatment on short-length bulbous urethral strictures. Vestnik Urologii. 2021;9(1):32-38. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-1-32-38

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