Urethotomy -my experience

What a relief! I have just come across this site and it is amazing to read that other people have a restriction like myself.! I am male 50+ and now self dilate, when i can remember.I have been doing this for a 1/2 years a little blue plastic rod - very state of the art! I have had an infection with it as i was careless about the hygiene of the process. On returning to the doc a locom explained how to use the rod with a little soap more efficiently and I now do this in the shower - seems ok - just. i should have asked more questions at the time but it seems both embarrassing and such a primitive solution to discuss. Of course you don't imagine others having the condition - and how would you ever find out? I find it really lowers the spirits just thinking about it also ejaculation of sperm is not as brilliant as it once was, although nothing else is affected. Having had a vasectomy years ago i do wonder if the conditions are related?

anyway I shall just continue I guess because although the blockage is at the tip, and small apparently, it does get worse over the month if I leave it for more that 2 weeks.

cheers

Pertwee - what a strange club to belong to !

"I was told ~50% success for initial procedure with the other 50% requiring self-therapy with a balloon catheter after a second procedure. Urethroplasty only considered in extreme cases."

1. The popularly-quoted 50% success rate with urethrotomy isn't a blanket figure. That's if you carefully select just the best strictures - short, flimsy, previously untreated, single strictures, located in the bulbar urethra. Repeat urethrotomies have extremely low cure rates (typically zero).

2. There's the old 'reconstructive ladder' again - the idea that you should reserve urethroplasty for 'extreme cases' once doing urethrotomies over and over again becomes impossible.

(a) the 'reconstructive ladder' is long discredited in the medical literature, and

(b) urethromy or urethroplasty is the patient's choice.

Urethroplasty is more invasive than endoscopic urethroplasty, but it has far higher long-term success rates. It is is more demanding surgery, best performed by a specialist, rather than a general urologist.

Article:

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How to Pass the FRCS(Urol)

Q. Describe, in general terms, how you would manage an anterior urethral stricture:

Avoid the so-called "reconstructive ladder"™ where several urethral dilatations are followed by several optical Urethrotomies and eventually definitive surgery in the form of an Urethroplasty. This sequential process may extend the length and depth of the stricture increasing the complexity and compromising the outcome of Urethroplasty.

Aims of treatment of urethral stricture disease:€“ firstly define the goal of treatment, which essentially is whether the patient wishes his/her stricture to be _managed_ (periodic dilatations or Urethrotomies) or _cured_ (by Urethroplasty).

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Self-catheterization is a traumatic maneuver that most patients view with considerable disdain as a painful, time-consuming, embarrassing, difficult and unnatural practice they would gladly abandon if given the choice. False passages will develop in most cases over time, further complicating the problem. Today we can and must do better.

Urethral Stricture is Now an Open Surgical Disease

Allen Morey

Department of Urology

University of Texas Southwestern Medical Center

Dallas, Texas

0022-5347/09/1813-0953/0 Vol. 181, 953-955, March 2009

THE JOURNAL OF UROLOGY®

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Repeat Urethrotomy and Dilation for Urethral Stricture Disease is neither Clinically Effective Nor Cost-Effective

http://www.urotoday.com/urologic-trauma-and-reconstruction-1345/repeat-urethrotomy-and-dilation-for-urethral-stricture-disease-is-neither-clinically-effective-nor-costeffective-1277.html

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Urethral Stricture Tips

The literature is relatively uniform in stating that the patient who may enjoy success from an internal urethrotomy or dilation with curative intent will have a short segment stricture (1 to 1 1⁄2 cm.), will have relatively superficial spongiofibrosis, and the stricture will be located in the bulbous urethra.

The success rate for internal urethrotomy and dilation for strictures other than in the bulbous urethra is dismally poor.

There is also ample literature which states that repetitive dilation and internal urethrotomy never proceed to cure, but they certainly proceed to spreading the stricture disease, making reconstruction more difficult, and making the results of subsequent reconstruction less than they would have been should the stricture have been addressed initially.

http://www.medicalnewstoday.com/articles/117793.php

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EDITORIAL COMMENT

... this article also casts doubt on the practice of self-catheterization to try to keep strictures open after urethrotomy.

(... continued: )

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EDITORIAL COMMENT

... this article also casts doubt on the practice of self-catheterization to try to keep strictures open after urethrotomy.

Of these patients 73% had recurrence on a self-catheterization regimen and another 18% had so much pain with catheter passage that they had to abandon it. Again, few reconstructive urologists attempt this maneuver since it always seems to fail, not to mention that it unnecessarily condemns the patient to a lifetime of painful self-catheterization, which would not be necessary after surgical cure by open urethroplasty.

An excellent study by Greenwell et al suggests that self-catheterization has no value, at least for anterior strictures,1 and the current authors add doubt about its usefulness for posterior urethral distraction injuries. This suboptimal management scheme remains wildly popular, judging by the referral population seen at our clinic, despite the real doubts as to its efficacy. It is another specter in need of a stake to the heart, in my opinion.

Richard A. Santucci

Department of Urology

Wayne State University School of Medicine

Detroit, Michigan

THE JOURNAL OF UROLOGY

Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 178, 1656-1658, October 2007

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Urethrotomy Has a Much Lower Success Rate Than Previously Reported

Urethrotomy is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success rates were no higher than 9% in this series for first or subsequent urethrotomy during the observation period. Most of the patients in this series will be expected to experience failure with longer followup and the expected long-term success rate from any (1 through 5) urethrotomy approach is 0%. Urethrotomy should be considered a temporizing measure until definitive curative reconstruction can be planned.

http://www.sciencedirect.com/science/article/pii/S0022534710000212

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Pick a urologist at random, and chances are you'll get one who persists with urethrotomies regardless of the cure rate:

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Adult Anterior Urethral Strictures: A National Practice Patterns Survey of Board Certified Urologists in the United States

Travis L. Bullock⁎, Steven B. Brandes, ‡,

Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri

Received 30 March 2006. Available online 10 January 2007.

Most urologists in the United States have little experience with urethroplasty surgery. Most urologists erroneously believe that the literature supports a reconstructive surgical ladder for urethral stricture management. Unfamiliarity with the literature and inexperience with urethroplasty surgery have made the use of endoscopic methods inappropriately common.

http://www.sciencedirect.com/science/article/pii/S002253470602489X

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Management of Adult Anterior Urethral Stricture Disease: Nationwide Survey Among Urologists in The Netherlands

Most Dutch urologists only consider urethroplasty after failed direct vision internal urethrotomy. Endoscopic procedures are widely used, even though the risk of recurrence after two previous failures is virtually 100%.

http://www.europeanurology.com/article/S0302-2838(11)00258-2/fulltext

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Who treats urethral strictures and how?

A.R. MUNDY, D.E. ANDRICH and T.J. GREENWELL

Institute of Urology, UCL, London, UK

Three surgeons perform half the urethroplasties in the UK each year.

http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.91.s2.14.x/pdf

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Review – Reconstructive Urology

What is the Best Technique for Urethroplasty?

... many, if not most, urologists believe that there is a "reconstructive ladder" and that treatment should always start at the bottom with dilatation and urethrotomy and work up the ladder to urethroplasty as a last resort.

This is nonsense.

Unless a patient has a single, previously untreated, short, membrane-like stricture of the bulbar urethra, in which case there is a 50% chance of a cure with dilatation or urethrotomy, the only predictable cure for a urethral stricture at present is a urethroplasty.

EUROPEAN UROLOGY 54 ( 2008 ) 1031–1041

http://cirugiauretra.grupoaulamedica.com/pdf/bloque2/b2_46.pdf

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EDITORIAL: ENDOSCOPY AND DILATION OF URETHRAL DEFECTS AND STRICTURES

The futility and, perhaps, even the jeopardy of repeated dilation and urethrotomy as curative procedures are widely accepted.

George D. Webster

Division of Urology, Duke University Medical Center, Durham, North Carolina

The Journal of Urology, Vol. 157. 102-103, January 1997

http://cirugiauretra.grupoaulamedica.com/pdf/bloque2/b2_2.pdf

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EDITORIAL: TREATMENT OF RECURRENT URETHRAL STRICTURES

... there is no point whatsoever in repeating the procedure in the hope of achieving cure by urethrotomy alone

Euan Milroy, Institute of Urology, The Middlesex Hospital, London

The Journal of Urology Vol. 156, 78-79, July 1996

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EDITORIAL COMMENT

Although this questionnaire was performed in 2002, its findings reflect the unfortunate and paradoxical realities of contemporary urethral stricture care in 2011. Although endoscopic and robotic advancements have clearly transformed all facets of our specialty over the past decade, the only reason that new, minimally invasive treatments have entered the mainstream is that they have been shown to deliver comparable or superior outcomes in terms of safety and efficacy. Nowhere in urology are high failure rates accepted as routinely as they are with endoscopic treatment of urethral strictures.

Many patients presenting in consultation for urethroplasty have an indwelling Foley catheter or use chronic self-catheterization. Many have suffered through repeated, ineffective, painful procedures for a decade or longer. Others are recovering from recent heroic yet futile procedures that serve only to delay and complicate the eventual curative open surgery. These events do little more than deliver a fresh, acute wound over a chronically scarred segment of urethra. Deep urethrotomy cuts produce deep scars that are often counterproductive and associated with increased complexity of repair.

It is time to push the reset button when it comes to urethral stricture care. The Sachse urethrotome is an antiquated instrument from a bygone era. Lasting success is achievable with a single urethroplasty in more than 90% of cases (often a simple excision) and this should now be considered the standard of care for urethral stricture care in our country. Costs are minimal because open urethroplasty involves nothing more than a handful of sutures, a couple of hours of operating room time, and a one-night hospital stay (at most). Expertise in male genital and urethral reconstructive surgery is now readily available in most cities, states, and residency training programs because of a marked expansion in fellowship training programs throughout the US over the past decade. We owe it to our stricture patients to deliver optimal care in the same efficient, effective, and definitive manner that we do for all other urological diseases.

Allen F. Morey, M.D., UT Southwestern Department of

Urology, Dallas, Texas

doi:10.1016/j.urology.2011.02.050

UROLOGY 78: 706, 2011. © 2011 Elsevier Inc

http://www.sciencedirect.com/science/article/pii/S0090429511002500

How is the stricture now after ur 2010 Urethotomy. My doctor suspects stricture as well and i am just wondering if a full surgery is a better option or go with the dialiation and Urethotomy.

I am also in US. I went to a urologist as i was peeing small amounts every 2 hrs my post void vol was 90 cc.He will do a cystoscopy on tuesday just worried ...

Just had my urethotomy yesterday so too soon to tell how things are.

My consultant was adamant that I should go for urethroplasty cut and join as it was a small bulbar stricture.

As this was my first stricture and first ever hospital visit I felt urethroplasty was a big operation for a small problem.

Consultant said recurrence with urethrotomy was 80% and self catheter usage was pointless as it just causes more scarring in the long run.

I noticed he also cut the tip slit wider, he mentioned dilation but I can see its a much wider slit to pass urine through.

I'm based in UK and went to Doctor in 2006 about intermittent blood in my urine. They sent me to local hospital for ultrasound and then told me it was nothing. 7years later things just got worse and painful where blood was present ever time I urinated.

Went to new doctor and was sent for ct scan. Again nothing came up. So went for cystoscopy and this immediately showed a stricture. Cystoscopy was not painful and minor discomfort.

Fed up with NHS and went private.

Spoke with consultant and he referred me for urethrogram X-rays. This was quite uncomfortable a bit of pain as the liquid was entered.

X-ray showed small bulbar stricture at base close to prostate.

So against my consultants advise I went for urethrotomy as my wife and I are trying for kids with fertility treatments and wanted as non evasive procedure as possible.

Stayed overnight in hospital on codeine and paracetamol, the antibiotics used seem to have given me constipation so need to go buy prunes.

Guess I'll be back for urethroplasty in 3yrs. At least I know what to expect.