Triamcinolone injection following internal urethrotomy for treatment of urethral stricture.To investigate the success rate of internal urethrotomy when combined with corticosteroid injection in urethral scar tissue for treatment of urethral stricture. We performed a double-blind, randomized, placebo-controlled study on 70 patients with urethral stricture, urethral stricture steroid injection underwent internal urethrotomy from June to July Patients were randomized into 2 groups; the experimental group 34 patients who received triamcinolone acetonide injection and the control group 36 patients that received an injection of sterile water after internal urethrotomy. Postoperative results were compared between two groups. In the experimental group, 1 2. In the control group, infection, bleeding, and extravasation occurred in 2 5. However, time to monounsaturated fat boost testosterone decreased significantly urethral stricture steroid injection experimental group 8.
Adjunctive maneuvers to treat urethral stricture: a review of the world literature
The development of urethral stricture US or bladder neck contracture is a relatively uncommon but well described condition observed primarily in men. Despite familiarity with US disease, management remains challenging for urologists. Risk factors for the development of USs or bladder neck contracture include primary treatment modality, tobacco smoking, coronary artery disease and poorly controlled diabetes mellitus. Numerous treatment options exist for this condition that vary in procedural complexity, including intermittent self catheterization CIC , serial urethral dilation, endoscopic techniques and open reconstructive repairs.
Repetitive procedures for this condition may carry increased failure rates and morbidities. For the treatment of refractory or recalcitrant bladder neck contracture, newer intralesional anti-proliferative, anti-scar agents have been used in combination with transurethral bladder neck incisions to augment outcome and long-term effect. The primary focus of this systematic review of the published literature is to streamline and summarize various and newer therapeutic modalities available to manage patients with US or bladder neck contracture.
US disease is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition.
It is defined by the constriction of the urethral lumen due to the fibrosis or scarring of the urethral epithelium and its surrounding tissues. Nowadays, US is increasingly encountered by urologists worldwide and its prevalence can occur at a rate as high as 0. It can be caused by a wide spectrum of etiologies ranging from pelvic traumas, repetitive instrumentation, traumatic catheterization CIC , aggressive transurethral resection, localized or diffuse inflammation balanitis xerotica obliterans , infection gonorrhea , adult hypospadias, congenital or idiopathic etiologies 1.
Historically, urethral dilation is considered the oldest and simplest form of management of US, which can be performed with a number of different urologic procedures or devices. In , Saches introduced direst vision internal urethrotomy to treat US by either incision or ablation, which has been considered standard therapy for the anterior US.
Despite its invasiveness, an open urethral reconstruction is the most successful management option for management of US. These therapeutic options can be carefully selected according to the etiology, site and length of the US as well as patient medical conditions, functional and performance status.
A number of clinical reports have examined the role of incision urethrotomy in the management of US over the past years. Adding to this, a considerable proportion of patients will invariably develop recurrences of the strictures in months following their initial treatment and will eventually require surgical repair of higher complexity and morbidity 4.
There is a paucity of published literature regarding adjunctive treatment in the management of non-cancerous induced US. In , a prospective study by Mazdak et al. There have been no advancements of this innovative technique or validation studies to examine its efficacy, safety and reproducibility in the clinical setting, and the only therapeutic options for US were primarily endoscopic or surgical.
Indeed, it is noteworthy to acknowledge that corpora spongiosum is a highly vascular structure that can increase the local diffusion and absorption of the adjunctive agents injected into the US area.
Hence, this potential phenomenon can significantly reduce the local effect of these injectable adjunctive agents in the management of US. Traditionally and in contemporary urologic practice these types of complications are usually treated by urologists in both academic and non-academic settings 7.
With the recent advent of the surgery and refinements in surgical techniques, the prevalence of BNC following RP has continued to decline over the last two decades.
Moreover, the overall prevalence of BNC was lower in the contemporary cohort that underwent robotic assisted laparoscopic prostatectomy RALP in comparison to the historical open RP patient population, owing to the advanced robotic surgical techniques such as enhanced magnification and a running bladder anastomosis 7.
Hence, this group of patients may pose clinical dilemmas and their definitive management can be challenging to reconstructive urologists. In a large retrospective study by Gonzalgo et al. Nevertheless, the management of refractory or recalcitrant disease remains challenging and non-standardized, due in part to a paucity of long-term clinical data.
However, when conservative measures fail, patients with refractory or recalcitrant BNC will likely require additional treatments modalities with increasing procedural complexity. Over the last decade, there have been novel experimental and clinical reports that utilized for the first time injectable agents with anti-proliferative, anti-scar properties steroids and MMC as adjunct to transurethral incision of BNC. In a retrospective analysis by Borboroglu et al.
This study incorporated a multivariable analysis to assess clinical predictors of BNC, and determined that intra-operative blood loss, increased operative time, positive smoking history, diabetes mellitus and coronary artery disease were significant predictors associated with the development of BNC.
This study also highlights that strictures after RP occurred typically within the first 24 months, whereas its onset was delayed after pelvic radiotherapy likely because of progressive radiation-induced fibrosis and tissue necrosis A detailed, comprehensive literature review was performed to identify all published peer-reviewed articles describing injectable agents and US and BNC in the urological literature over a year period to Search results were screened for appropriate studies with particular emphasis placed on clinical and experimental studies as well as review articles.
Articles referenced were screened to maximize review and inclusion of pertinent data. While English language text was not a specific search parameter, only English language publications were considered. Although initial studies regarding the use of the Urolume stents were promising, numerous problems were encountered with urethral stenting, including stent migration, obstruction secondary to tissue in-growth, hematuria, stent encrustation, and the need for repeat surgery 37 , A prospective study by De Vocht et al.
Moreover, four patients had their Urolume stents removed two for intractable pain and two for stent obstruction. Additional study by Hussain et al. The Urolume stent is no longer commercially available. The stent has a 24 Fr outside diameter and is preloaded on a disposable delivery device. The stent was provided in lengths of 30 to 70 mm in 10 mm increments. The Memokath has been previously used to treat prostatic obstruction and detrusor dyssynergy in the posterior urethra and was recently evaluated for use in the anterior urethra.
The primary endpoints were urethral patency, defined as the ability to pass a 16 Fr flexible cystoscopy and reflected in significantly improved uroflowmetry and symptom scores. Urethral patency was 3. Durability effect on the US was not assessed.
Intermittent or gradual dilation of the bladder neck has been used to treat contractures and prevent recurrent disease. In a large study from the United Kingdom of patients who underwent open RP over a 9-year-period, the prevalence of BNC was reported at 9. Although CIC provides a non-surgical approach to BNC management, significant patient tolerance and compliance are necessary for successful results. Adding to this, some patients experience complications of CIC such as recurrent urinary tracts infections, hematuria, false urethral passages and USs.
A more widely practiced approach is cold knife endoscopic incision of BNC. The authors reported that cold knife urethrotomy provides safe and effective response for the initial treatment of patients with anastomotic stricture after RP. However, there is limited long-term data for patients undergoing repeat endoscopic procedure for recurrent, refractory or recalcitrant BNC.
A recent study by Ramirez et al. Short-term success rate were high but longer follow up is needed In patients with long areas of contractures not amenable to endoscopic procedures, devastating BNC from distraction injuries or those failed numerous endoscopic managements merit consideration for open reconstruction of bladder neck.
Open surgical reconstruction may be technically challenging and could cause greater morbidity. Various open surgical approaches have been previously prescribed such as abdomino-perineal, perineal or transpubic. There was a relatively high risk of new onset urinary incontinence after reconstructive surgery but this was successfully treated with artificial urinary sphincter AUS implantation in most patients Additional open surgical reconstructive techniques were previously described in a small case series of four patients with vesicourethral anastomotic stricture following RP treated with various surgical approaches: Although conventional approaches to refractory or recalcitrant BNC include endoscopic therapy through incision or dilation or open surgical excision with re-anastomosis, experimental techniques involving resection with the Holmium laser or injection of medications with anti-proliferative properties at the site of the bladder neck incisions have recently been reported in the published literature.
With two years of follow up, Eltahawy et al. The MMC drug is an anti-proliferative and anti-scar forming agent, well known as an antitumor antibiotic, was discovered in and has been used clinically since , when it was first stemmed from pterygium surgery. In in-vitro and animal models MMC has been shown to inhibit fibroblast proliferation, collagen deposition and scar formation 42 - Ionizing radiation has been shown to prevent hypertrophic scarring and keloid formation.
This prompted Olschewski et al. In this study, ten patients received internal urethrotomy followed by high-dose-rate HDR brachytherapy Gy within 5 hours after internal urethrotomy. They concluded that endourethral HDR brachytherapy proved to be an effective method that can reduce urethral re-stricture.
Similarly, Sun et al. Although initial studies have shown promising results in preventing recurrent US, these results should be interpreted within the limitation of the preliminary results, the small size sample, and the single-arm study design. Whether the endourethral brachytherapy actually helps in the management of recurrent US is yet to be determined, and the actual radiation dose, duration as well as long-term safety and efficacy need to be systematically evaluated as end-points in a large randomized clinical trial.
This suggests that synthesis of collagen and other extracellular matrix proteins are involved in this process. Another animal study by Jaidane et al. In the second phase, electrocoagulation-induced US was treated with visual internal urethrotomy in halofuginone and a normal-diet group, respectively. It should be noted that these studies were performed on animal models with limited study size.
They instilled HA via an gauge tube catheter between the urethral lumen and foley catheter after urethrotomy. The use of HA was further examined by Chung et al. They recently reported combination use of HA with carboxymethyl cellulose CMC in preventing recurrence of US after internal urethrotomy Extended follow-ups are needed to confirm the long-term effects. Other therapeutic agents and techniques, including maintaining the temperature of the urethra during TURP, intraurethral use of captopril gel and cyclooxygenase-2 inhibitor are sporadically reported with varying benefits 52 - However, the safety and efficacy of these agents and techniques will need to be validated in a large randomized study where patient safety, efficacy and outcomes are end-points.
Moreover, Collagenase is currently FDA-approved for debriding chronic dermal ulcers and severely burned tissues Animal studies have evaluated the efficacy and effectiveness of biodegradable stents in vitro with promising results, however, clinical studies are required to validate their safety and efficacy in humans 58 , Numerous treatment options exist for this condition that vary in procedural severity, including intermittent self CIC, serial urethral dilation, endoscopic techniques and open reconstructive repairs.
Long-term clinical data are lacking and double-blinded randomized clinical trials are needed to validate safety and efficacy where patient safety, efficacy and outcome are end-points. The authors have no conflicts of interest to declare. National Center for Biotechnology Information , U. Journal List Transl Androl Urol v. Raheem and Jill C. Received Apr 19; Accepted May 1.
Copyright Translational Andrology and Urology. Abstract The development of urethral stricture US or bladder neck contracture is a relatively uncommon but well described condition observed primarily in men. Evidence synthesis for this systematic review Non-cancerous induced urethral stricture US US disease is one of the oldest known urologic diseases, and continues to be a common and challenging urologic condition.
Open in a separate window. Methods A detailed, comprehensive literature review was performed to identify all published peer-reviewed articles describing injectable agents and US and BNC in the urological literature over a year period to Footnotes Conflicts of Interest: Male urethral stricture disease.