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Temporary urethral stent with perineal fixation for posterior urethral stenosis (preliminary results)

https://doi.org/10.21886/2308-6424-2021-9-2-80-85

Abstract

Introduction. Urethroplasty is the “gold standard” treatment of urethral stenosis. However, often in connection with old and senile age, as well as due to the presence of concomitant diseases, it is not possible to carry out urethroplasty due to its certain invasiveness. In such cases, one of the methods of treatment is the installation of a urethral stent. But this method has not found practical application due to the frequent migration of stent and the high frequency of its incrustation. The approach developed by us avoids stent migration.

Purpose of the study. To evaluate the immediate results of the placement of a urethral stent with fixation through the perineum.

Materials and methods. A total of 18 patients with urethral stenosis aged 68 to 84 years have been operated on since February 2019. Ten patients had stenosis of the urethrocystoneoanastomosis after radical prostatectomy, 6 patients had iatrogenic stenosis of the prostatic urethra, 1 patient had post-radiation stenosis of the bulbo-membranous urethra. All patients in the preoperative and postoperative periods underwent: IPSS-QoL questioning, uroflowmetry, bladder ultrasound with residual urine volume evaluation, urethroscopy, ascending and micturition urethrocystography. The first stage was an internal optical urethrotomy according to the standard technique. Then, a urethral stent was installed in the area of dissected stenosis. The second stage was an incision in the perineum, the urethra was isolated, and under optical control, through the perineum, the stent was fixed to the urethra with non-absorbable suture material. The stent was removed endoscopically after 6 months.

Results. The median surgery duration averaged 45 minutes. Patients were discharged 2 to 3 days after surgery. The maximum observation period was 20 months. During the observation period, not a single case of stent migration was recorded. All patients showed a persistent increase in Qmax and no residual urine. Six patients had a stress component of urinary incontinence, 4 patients had total urinary incontinence. According to control urethrocystoscopy 6 months after stent removal, clinically insignificant urethral stenosis was noted in all patients. In all cases, moderate signs of stent encrustation were identified. Dysuric phenomena disturbed 5 patients, who were stopped by rectal suppositories with NSAIDs, as well as taking herbal uroseptics. The data from the IPPS-QoL questionnaires confirm the positive effect of the treatment.

Conclusions. Temporary placement of a urethral stent for urethral stenosis is an effective minimally invasive treatment. The technique of fixation through the perineum allows preventing migration in all cases. This approach to treatment significantly improves the quality of life of patients who were contraindicated for urethroplasty for one reason or another. However, the technique requires longer observation and analysis.

For citation:


Kyzlasov P.S., Mustafaev A.T., Ostrovsky D.V., Martov A.G. Temporary urethral stent with perineal fixation for posterior urethral stenosis (preliminary results). Vestnik Urologii. 2021;9(2):80-85. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-2-80-85

Introduction

Urethral stenosis is characterized by pathological narrowing that can be located in any part of the urethra. The clinical picture of urethral stenosis is associated with urination impairments of various degrees: lower urinary tract symptoms, acute or chronic urination retention, recurrent urinary tract infection, and even renal failure [1][2].

According to various authors, urethral stenosis is observed in 0.6–0.9% of the population, and this rate is increasing with the population aging. Besides, it should be noted that long and subtotal stenosis are registered in 15–18% of cases. There were more than 1.5 million visits to the doctor for urethral stenosis in 1992–2000 in the USA [3]. In Great Britain, in the 21st century, more than 16,000 men are admitted for inpatient treatment for urethral stricture annually, 12,000 of them require surgical treatment. The morbidity rate of urethral stricture in the Moscow population varies from 250 to 300 people per 100,000 of the population [4][5].

The gold standard in the treatment for urethral stenosis is urethroplasty. However, because of older age and comorbid diseases, invasive urethroplasty is contraindicated. In such cases, one of the methods of treatment is the installation of a urethral stent. Still, because of frequent migration of the stent and a high rate of incrustations, this method did not become widespread. The proposed method of treatment prevents stent migration and is an effective low-invasive technique of the treatment for urethral stricture regardless of its localization.

Urologists presently have various types of urethral stents. In general, they can be divided into two groups:

  1. Metallic (drawbacks: high rate of dysuria, incrustation, and migration).
  2. Nitinol (drawbacks: frequent migration).

The study aimed to evaluate the results of the treatment for posterior urethral stenosis with a temporary stent fixed through the perineum.

Materials and Methods

Eighteen patients aged 68–84 years were operated on for urethral stenosis in two medical centres. Eleven patients had stenosis of the urethrocystoneoanastomosis after radical prostatectomy, 6 patients had iatrogenic stenosis of the prostatic urethra, and 1 patient had post-radiation stenosis of the bulbo-membranous urethra. All patients in preoperative and postoperative periods underwent IPSS-QoL questioning, uroflowmetry, bladder ultrasound with residual urine volume evaluation, urethroscopy, ascending, and micturition urethrocystography.

The first stage was an internal optical urethrotomy according to the standard technique. Then, a urethral stent (Allium BUS-80, 45 Fr, 80 mm, material: copolymer) was installed in the area of the dissected stenosis (Fig. 1). The second stage was an incision in the perineum, the urethra was isolated. Under optical control, the stent was fixed to the urethra through the perineum with non-absorbable suture material (Figs. 2–3). After the surgery, patients were followed up by a urologist. Total urine retention was observed in the postoperative period. Part of the patients used condom catheters or penile clips. A urethrogram was performed 3 months later to exclude the stent migration (Fig. 4). Endoscopic removal of the urethral stent and ligature was performed 6 months after under local anaesthesia. Control urethrocytoscopy was performed 6 months after the stent removal (Fig. 5).

Fig. 1. Installed urethral stent

Fig. 2. The moment of the urethral stent fixation to the urethra

Fig. 3. Fixed urethral stent

Fig. 4. Urethrogram 3 months after stent placement

Fig. 5. Location of the stent 6 months after

Statistical analysis. There are methods of calculation of descriptive statistics (the rate of qualitative parameters, mean, standard deviation, minimal and maximal values for quantitative parameters). The calculations were made in the software STATISTICA 10 (StatSoft Inc., Tucla, USA).

Results

The maximum follow-up period was 20 months. There were no cases of stent migration registered during the follow-up period. All patients had a stable increase in Qmax (Fig. 6) and no residual urine. During the follow-up period, not a single case of stent migration was recorded. All patients showed a stable increase in Qmax and no residual urine. Six patients had a stress component of urinary incontinence, 4 patients had total urinary incontinence. According to the control urethrocytoscopy, 6 months after the stent removal, significant clinical signs of urethral stenosis resolved in all patients (Fig. 5). In all the cases, moderate signs of stent incrustation were observed. Dysuric phenomena disturbed 5 patients, which was resolved by rectal suppositories with non-steroidal anti-inflammatory drugs and oral herbal uroseptics. The data from the IPPS-QoL questionnaires confirmed the positive effect of the treatment (Fig. 7).

Fig. 6. Uroflowgram: A – before the urethral stent installation; B – 12 months after the urethral stent installation and 6 months after its removal

Fig. 7. IPPS and QoL before and after urethral stent placement

Discussion

The issue of posterior urethral stenosis in patients with contraindications to urethroplasty remains unsolved. The installation of a temporary urethral stent fixed through the perineum provides effective treatment for patients with complicated comorbidity. Remote postoperative treatment results suggest that this technique can be applied as a low-invasive method of treatment for posterior urethral stenosis.

Conclusion

The installation of a temporary urethral stent for urethral stenosis is an effective and low-invasive method of treatment. The methods of fixation through the perineum prevent stent migration. The treatment of posterior urethral stenosis with the temporary installation of a urethral stent is feasible in certain cases. The proposed approach improves the quality of life of patients who have contraindications to urethroplasty. However, this method requires longer observation and analysis.

References

1. Vorobiev V.A., Beloborodov V.A., Popov S.L., Shumara M.A., Antipina I.V., Sedykh E.A., Mamedov E.G., Bardonov T.V. Diagnostics of the urethral stricture disease. Sib. Med. J. (Irkutsk). 2017;151(4):34-36. (In Russ.). eLIBRARY ID: 32706617

2. Kogan M.I., Krasulin V.V., Gluhov V.P., Mitusov V.V., Dombrovskij V.I., Il'yash A.V. Vizualizaciya obstrukcij mocheispuskatel'nogo kanala u muzhchin. Rostov-na-Donu: Izd-vo RostGMU; 2017. (In Russ.). ISBN 978-5-74530527-6

3. Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol. 2007;177(5):1667-74. DOI: 10.1016/j.juro.2007.01.041

4. Sinelnikov L.M., Protoshchak V.V., Shestaev A.Yu., Karpushchenko E.G., Yartsev A.A. Urethral stricture: current state of the problem (literature review). Journal EKU. 2016;(2):80-87. (In Russ.). eLIBRARY ID: 32706617

5. Kotov S.V. Urethral strictures in men - current state of the art. J. Medicinsky vestnik Bashkortastana. 2015;10(3):266-270. (In Russ.). eLIBRARY ID: 24245674


About the Authors

P. S. Kyzlasov
State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Centre
Russian Federation

Pavel S. Kyzlasov — M.D., Dr.Sc.(M); Prof., Dept. of Urology and Andrology, Medical and Biological University of Innovation and Continuing Education, State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Center.

123098, Moscow, 23 Marshal Novikov st.

Tel.: +7 (965)356-18-82


Competing Interests:

The authors declare no conflicts of interest.



A. T. Mustafaev
State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Centre
Russian Federation

Ali T. Mustafayev — M.D.; Postgraduate Student, Dept. of Urology and Andrology, Medical and Biological University of Innovation and Continuing Education, State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Center.

123098, Moscow, 23 Marshal Novikov st.


Competing Interests:

The authors declare no conflicts of interest.



D. V. Ostrovsky
G.Ya. Remishevskaya Khakassian Republican Clinical Hospital
Russian Federation

Dmitriy V. Ostrovsky — M.D.; Head, Urology Division, G.Ya. Remishevskaya Khakassian Republican Clinical Hospital.

655012, The Republic of Khakassia, Abakan, 23 Lenin ave.


Competing Interests:

The authors declare no conflicts of interest.



A. G. Martov
State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Centre
Russian Federation

Alexey G. Martov — M.D., Dr.Sc.(M), Full Prof.; Dept. of Urology and Andrology, Medical and Biological University of Innovation and Continuing Education, State Scientific Center of the Russian Federation - A.I. Burnazyan Federal Medical Biophysical Center.

123098, Moscow, 23 Marshal Novikov st.


Competing Interests:

The authors declare no conflicts of interest.



For citation:


Kyzlasov P.S., Mustafaev A.T., Ostrovsky D.V., Martov A.G. Temporary urethral stent with perineal fixation for posterior urethral stenosis (preliminary results). Vestnik Urologii. 2021;9(2):80-85. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-2-80-85

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