Efficacy of Mitomycin C Combined with Direct Vision Internal Urethrotomy for Urethral Strictures: A Systematic Review and Meta-Analysis

<b><i>Background:</i></b> The high recurrence of a urethral stricture after direct vision internal urethrotomy (DVIU) has been a problem for years. Mitomycin C (MMC) is an excellent antifibrosis antigen that has been used in many fields, but its effect on a urethral stricture remains controversial. The purpose of this review was to investigate the effectiveness of MMC in reducing the recurrence rate of a urethral stricture after the first urethrotomy. <b><i>Methods:</i></b> Common databases were searched for publications prior to November 30, 2020. Randomized controlled and cohort trials were all included. Recurrence and success rates after the first urethrotomy of the posterior urethra were the main outcomes. Revman 5.3 was used for statistical analysis. Two evaluation systems, the Cochrane risk of bias tool and the Newcastle Ottawa Scale, were used to examine the risk of bias for RCTs and all studies. The quality of evidence was assessed by the Grading of Recommendations, Assessment, Development, and Evaluation standard. <b><i>Results:</i></b> Sixteen trials were included, the reporting quality of which was generally poor, and the evidence level was very low to moderate. The addition of MMC could significantly reduce the recurrence rate of urethral strictures (risk ratio [RR] = 0.42; 95% confidence interval [CI]: 0.26, 0.67; <i>p</i> = 0.0002; 9 trials; 550 participants). The results of the subgroup analysis suggested that the effect of MMC combined with DVIU was significant in short (≤2 cm) anterior urethral strictures (RR = 0.39; 95% CI: 0.20, 0.78; <i>p</i> = 0.008), &#x3e;12-month follow-up (RR = 0.45; 95% CI: 0.26, 0.76; <i>p</i> = 0.003). It also increased the success rate of the first urethrotomy procedure for posterior urethral contracture (RR = 0.74; 95% CI: 0.65, 0.84; <i>p</i> &#x3c; 0.00001; 7 trials; 342 participants). Low-dose local injection of MMC was the most commonly used method. <b><i>Conclusion:</i></b> MMC combined with DVIU is a promising way to reduce the long-term recurrence rate of a short-segment anterior urethral stricture. It also increases the success rate of the first urethrotomy of the posterior urethra. However, more high-quality randomized controlled trials are needed.

Evaluation of Holmium Laser versus Cold Knife in Optical Internal Urethrotomy for the Management of Urethral Stricture

Background : urethral stricture is one of the most difficult urological problems to cure adequately and is know to mankind since ages as it has been documented in ancient literature of Egyptians and Greeks. Aim of the work: the aim of our study is to evaluate and compare the outcomes of Ho:YAG laser urethrotomy with the conventional cold knife technique as regards treatment outcome, efficacy and complications Patients and methods: A total of 20 male patients presented to the urology department at El Maadi military hospital and Ain shams university hospitals diagnosed as urethral stricture requiring optical internal urethrotomy were included in this study. Patients were randomized into two groups : In group A (holmium group): 10 patients underwent internal urethrotomy with Holmium laser. In group B (cold knife group) 10 patients underwent internal urethrotomy with cold knife. Results: based upon uroflowmetry, assessment of treatment effectiveness and complications were made at 3 months follow-up. Post operative fall in the peak flow rate was noted during the follow up in both groups, but was highter fall in the holmium group than the cold knife group at the end of the third month.

Laser epilation of luminal hair following skin graft urethroplasty for hypospadias: the hair snare

A 66-year-old man, who underwent urethral reconstruction using skin grafts for hypospadias five decades earlier as a 13-year-old child, presented with burning micturition and recurrent UTI. A retrograde urethrogram along with micturating cystourethrogram revealed a bulbar urethral stricture and broad neck distal penile urethral diverticulum. On a cystourethroscopic examination, a urethral diverticulum was seen just proximal to the hypospadiac external urethral meatus with 12–15 hair follicles inside the diverticulum and a 1 cm long mid-bulbar stricture. Visual internal urethrotomy for the bulbar stricture, a diverticular neck incision, laser epilation and hair follicle photocoagulation was performed using a 30 W Ho:YAG laser. The depilated hair tufts were extracted. The process was repeated again in 6 months due to recurrent symptoms. A patent urethra with a wide open diverticulum without any residual hair follicles was confirmed. No perioperative complications noted and the patient is doing well on 1 month of follow-up.

Holmium: YAG Versus Cold Knife Internal Urethrotomy in the Management of Short Urethral Strictures: A Randomized Controlled Trial

Introduction: our study aimed to assess the safety and efficacy of Holmium: YAG laser internal urethrotomy compared to the cold knife internal urethrotomy. Methods: Eighty adult male patients presented with a urethral stricture less than 1.5 cm were included in our study; they were randomly allocated into 2 groups representing Holmium and cold knife internal urethrotomy. A careful evaluation with ascending cystourethrogram and uroflowmetry were done on all patients, and they were followed up for 1 year with uroflowmetry. Results: Each group included 40 patients sharing the same demographic data. The most common cause of a urethral stricture in both groups was iatrogenic injury. The mean operative time of the cold knife urethrotomy procedure was 10.98 ± 2.40 minutes compared to 15.43 ± 2.48 minutes in the holmium laser urethrotomy group with a highly significant difference. The results showed success rates of 90% and 80% for the holmium laser and cold knife internal urethrotomy groups respectively. The perioperative complication according to the Clavien-Dindo classification, showed no statistically significant difference in grade 1 and 2 complications. A recurrence rate with the need for redo surgery representing grade 3B complication was seen in 4 cases in the Holmium group compared to 8 cases in the cold knife group with a statistically significant difference. Conclusion: Both Holmium Laser and cold knife internal urethrotomy are an effective surgical option for the treatment of a urethral stricture less than 1.5 cm with a promising outcome after 1-year follow-up with a better success rate using the Holmium laser.

Types of urethral stricture and their recurrence rates post urological treatments

Urethral strictures can significantly impact the quality of life for patients because it can be associated with significant complications such as fistulas, bladder calculi, infections and sepsis. Additionally, it might even lead to renal failure. The worldwide prevalence of urethral strictures is high, with an estimated rate of 229-627 patients per 100,000 population. In this literature review, the aim was to discuss the types and etiology of urethral strictures and the recurrence rates following the different management modalities. Studies that were included in this review were published between January 2005 until May 2021. The results support the current evidence that the idiopathic and iatrogenic bulbar strictures are the most common types while penile strictures, the iatrogenic and inflammatory are the most common causes. Recurrence rates are reported after management with almost all of the current management modalities, indicating the need for better interventions to enhance the outcomes and alleviate the quality of care. The recurrence rate of strictures after treatment with internal urethrotomy and direct vision internal urethrotomy by three years is 65%. Other studies reported that the rate of recurrence was estimated to be around 14 after 6 months from internal urethrotomy and up to 27% after 12 months. The rate of complications and recurrence following treatment with anastomotic urethroplasty was estimated to be less than 5%. Detailed information and discussion were provided in the study manuscript.

Direct Visual Internal Urethrotomy in Supine Position in a Patient with Complex Deformities of Both Lower Limbs and Neurogenic Bladder: A Case Report

Direct visual internal urethrotomy (DVIU) is a minimally invasive treatment for urethral stricture and is usually done in lithotomy position. We presented a case of a 35-year-old man with complex deformities of both lower limbs from birth. The lower limbs were severely wasted with ankylosis of the hips, flexion of the knee joints and dorsiflexion at the ankle joints. He had a history of progressively worsening difficult in urination characterized by frequency, urgency, urgency incontinence, nocturia, poor urinary stream (improved by straining), intermittency and feeling of incomplete bladder emptying. He had occasional dysuria and total hematuria. He was not a known hypertensive or diabetic patient. No history of trauma, previous urethral instrumentation, and no history of purulent urethral discharge before the onset of problems. On presentation, his abdomen was full with slight suprapubic distention. The anal sphincter was spastic and the prostate was not enlarged. He had normal non-circumcised male external genitalia. There was no spinal deformity and the upper limbs were normal. White cell count was 14,000 cells/ mm3 with a differential neutrophil of 85.5% and urine culture showed moderate growth of coliforms. Abdominopelvic ultrasound showed a thickened bladder wall with mild hydronephrosis bilaterally and a retrograde urethrography and micturating cystourethrography showed 3 short segment bulbar urethral strictures. There was also a Christmas tree appearance of the bladder. A diagnosis of bladder outlet obstruction secondary to multiple short segment idiopathic bulbar urethral strictures on background neurogenic bladder was made. He had intravenous antibiotics for 48 hours and subsequently a DVIU under spinal anesthesia and in the supine position. Catheter was removed on the 7th day post procedure and he started clean intermittent catheterization (CIC) with 12 French catheters. Seven months post procedure, patient is still satisfied with the outcome of his treatment. We concluded that DVIU can be done safely in the supine position and CIC can help improve post procedure outcome and in managing comorbid neurogenic bladder.

DIRECT VISUAL INTERNAL URETHROTOMY (DVIU) FOR UNTREATED BULBAR URETHRAL STRICTURES. A SOLUTION?

Introduction :Urethral stricture diseases have been treated with numerous approaches. Though open urethroplasty is considered a one-time solution [1], The direct visual internal urethrotomy (DVIU) is still considered an alternative approach in the stepladder of treatment [2,3]. Here we report our experience at a tertiary care hospital with DVIU in a homogeneous series of patients with bulbar urethral stricture who underwent strict follow-up and present a multivariable analysis of the results to identify signicant predictors of treatment failure. We wish to offer new insights into DVIU. Materials and method: We performed a retrospective analysis of patients who underwent internal urethrotomy. Patients who underwent DVIU for untreated bulbar urethral strictures with minimum follow-up of 12 months were included. Patients with traumatic stricture and stricture length >4 cm were excluded.The primary outcome was treatment failure. Multivariable Cox regression analyses by Stata v.12.0 were used to test the association between predictors:- Stricture etiology, stenosis length, preoperative maximum ow [pQmax]) and treatment failure. Results: 215 patients were included. Median follow-up was 35 months. At 5-yr follow-up the failure-free survival rate was 54.4%. On multivariable analysis pQmax was the only signicant predictor of treatment failure. Conclusions: DVIU success rate for untreated bulbar urethral strictures was signicantly associated with preoperative maximum ow rate. The patients with a pre- operative maximum ow lesser than 6 ml/s have a low probability of success and may be considered for alternative treatments such as open urethroplasty, especially when affected by long urethral strictures.