|
|
ORIGINAL ARTICLE |
|
|
|
| Year : 2000 | Volume
: 17
| Issue : 1 | Page : 28-30 |
| |
Optical internal urethrotomy under local anaesthesia
Nayan K Mohanty, Mukund Khetan, Alok K Jha, Rajender P Arora
Department of Urology, Safdarjang Hospital, New Delhi, India
Correspondence Address:
Nayan K Mohanty
D-II/87, West Kidwai Nagar, New Delhi - 110 023
India
 Source of Support: None, Conflict of Interest: None  | Check |
 Abstract | | |
Objective: Recurrence of urethral stricture after single internal urethrotomy is quite high, resulting in repeated urethrotomies. This results in a long waiting period for the patient to undergo urethrotomy under anaesthesia. Our aim was to perform urethrotomy under local anaesthesia so that hospital-stay-waiting-period is reduced to the minimum.
Method: We analysed our patients between Jan '93 to Jan '98, who underwent repeated optical internal urethrotomy (0.1. U.) under local anaesthesia. A total number of 220 patients of stricture urethra underwent internal urethrotomy under local anaesthesia as a day care procedure using 2% Lignocaine jelly and intravenous Diazepam 10mg.
Results: Our results revealed 35% (78 patients) had recurrence who underwent repeated urethrotomies (189) under local anaesthesia, number of urethrotomies depending on the etiology and length of the stricture. None of these patients were admitted in the hospital.
Conclusion: We conclude that 0.1. U. can safely be performed under local anaesthesia as a day-care procedure and the procedure is well tolerated by the patient without any hospitalisation and anaesthesia risk.
Keywords: Stricture; Urethrotomies; Internal; Anaesthesia
How to cite this article:
Mohanty NK, Khetan M, Jha AK, Arora RP. Optical internal urethrotomy under local anaesthesia. Indian J Urol 2000;17:28-30 |
| Introduction | |  |
Management of stricture urethra depends on the site, size, etiology and nature of stricture. Short strictures of less than 10mm long situated in bulbar, bulbomembranous or prostatic urethra resulting from trauma, instrumentation, inflammation and without any history of any earlier surgical procedure are best suited for optical internal urethrotomy (O.I.U.).
Introduction of O.I.U. by Sachse [1] has simplified the management of urethral stricture. The result of O.I.U. had been generally optimistic [2],[3],[4],[5] ; however, some studies have shown lower cure rate. [6] Recurrence rate after a single O.I.U. varies from 5 to 50% thereby requiring repeated O.I.U. There are several factors influencing recurrence rate of stricture after O.I.U. like preoperative infection, [13] catheters used, [14] patient's age, site of lesion, [15] stricture length and periurethral scarring. [16]
In a country like ours where road traffic accident is high resulting in fractured pelvis, the incidence of stricture urethra is quite enormous and is a burden for the urologist and the hospitals. Patients have to wait for a long time for admission for the procedure to be done under general or regional anaesthesia.
We undertook to treat such stricture urethra as an outpatient procedure under local anaesthesia as a day-care procedure thereby reducing the risk of anaesthesia hazards and no hospitalisation.
| Material and Methods | | |
Between Jan '93 to Jan '98 all primary urethral strictures (excluding meatus stenosis and bladder neck obstruction) were included in our study. Diagnosis of these patients were done from clinical history, retrograde urethrogram, micturating cystourethrogram and uroflowmetry. None of these patients had any previous history of treatment for stricutre excepting suprapubic cystostomy on whom required. After fulfilling the inclusion criteria, they were subjected to O.I.U. under local anaesthesia. Inj. Gentamycin 80mg IM was given before surgery as a prophylactic measure and an intravenous 5% Dextrose drip was started into which 10mg of Diazepam was pushed. The local parts after being adequately cleaned and draped, lOml of 2% Lignocaine jelly was pushed into the urethra and kept for 7-10 minutes. O.I.U. was then performed using 21F Storz-Sachse's urethrotomy sheath and straightblade knife and 0° telescope. The technique used was similar to that described by Smith. Postoperative indwelling catheterisation using 16F Teflon-coated latex catheter was used. Patients were kept for observation for 6 hours and then sent home with the advice to come to OPD for catheter removal after five days with coverage of Norfloxacin (400mg) twice a day orally for seven days. All the patients were followed up for atleast 24 months. On follow-up recurrences, RGU, UFR, Urine c/s and MCU were repeated when symptoms suggested recurrences since both correlated with symptomatology. [17]
| Results | | |
A total number of 286 patients of stricture urethra were initially registered during the period Jan '93 to Jan '98, out of which only 220 patients could be followed up for 24 months and 66 patients were lost to follow-up. The average age of our patients was 24 years, ranging from 17 to 40 years. Out of the 220 patients, 60% (132 patients) had stricture located in bulbar and bulbomembranous urethra, 30% (66 patients) had their stricture located in prostatic urethra, while rest 10% (22 patients) had penile stricture [Table 1].
Subjective pain by visual analogue was carefully noted in our series. Most of our patients (202) did not show any visual analogue for pain during O.I.U. in our series, may be because:
- All our patients were given Inj. Diazepam 10mg intravenously during the procedure.
- Again most of our patients had history of traumatic etiology with extensive scarring and pelvic nerve injury resulting in partial sensory denervation of the urethra.
These two factors may have played a major role for the procedure to the less painful in our series. However, a few patients (18 patients) did express subjective pain by visual analogue during the procedure, particularly those who had some element of urethral inflammation or infection and stricture in penile urethra. Intensity of pain threshold decreased with subsequent urethrotomies.
In our series, all our patients had O.I.U. performed at 12 o'clock position only.
We used undersized Teflon-coated latex Foley's catheter for five days for postoperative drainage as Teflon is known to be more durable than silicon coated as it is able to effect a longer lasting insulation from the the underlying latex catheter.
During the follow-up uroflowmetry was done in all patients periodically to access the success rate. Out of the 220 patients, 78 (35%) patients showed decrease in average and maximum flow rate and these were labelled as failures for which they underwent repeated urethrotomies, while success was achieved in 142 patients (65%).
The complication rate in our series was 11% (29 patients) only, without any major complication [Table 2].
Almost all the patients tolerated the procedure well under local anaesthesia without much discomfort.
| Discussion | | |
O.I.U. was first described two decades ago and remains useful modality for treatment of stricture urethra. Postoperative catheterisation period varies from 3 days to 6 weeks. [19],[20],[21],[22] Holm Nielsen has shown longer catheterisation does not improve the final result while Aagaard reported that 3-days' catheterisation is sufficient for short strictures. We kept the catheter for five days and had fairly good result.
Since recurrence rate following O.I.U. is high needing repeated urethrotomies, performance of the same under local anaesthesia, greatly reduces the risk of anaesthesia, hospital stay and the burden on the urologist.
In our study, we could perform a total number of 409 urethrotomies (220+189) safely under local anaesthesia as a day-care procedure without hospitalisation on 220 patients and the procedure was well tolerated by the patients.
| Conclusion | | |
In a country like ours where incidence of road traffic accident is high resulting in a high incidence of stricture urethra, management of such strictures by O.I.U. under local anaesthesia not only greatly reduces the burden on the hospital and the urologist but also the risk from anaesthesia hazard, financial constraint on the patients, as it is a safe and well-tolerated procedure.
| References | | |
| 1. | Sachse, H. Zur Behandlung der Harnrohrenstriktur: Die transurethrale Schlitzung unter Sicht nit scharfem Schnitt. Fortschr Med 1974;92:12.  |
| 2. | Walther PC, Parsons CL, Schmidt JD: Direct vision internal urethrotomy in the management of urethral strictures. J Urol 1980; 123: 497-499. |
| 3. | Smith PJB, Dunn M, Roberts JBM. Surgical management of urethral stricture in the male. Urology 1981; 18: 582. |
| 4. | Smith PJB, Roberts JBM, Ball AJ, Kaisary AV. Long-term results of optical urethrotomy. Br J Urol 1983; 55: 698-700. |
| 5. | Gibod LB, Le Portz B: Endoscopic urethrotomy: Does it live up to its promises? J Urol 1982; 127: 433-435. |
| 6. | Bekirov HM, Tein AB, Reid RE, Freed SZ. Internal urethrotomy under direct vision in men. J Urol 1982; 128: 37-38. [PUBMED] |
| 7. | Asklin B, Petterson S. Visual internal urethrotomy with postoperative cystostomy or urethral catheter. Scand J Urol Nephrol 19 : 5. |
| 8. | Abdel-Hakim A, Bernstein J, Hassouna M, Elhilali MM. Visual internal urethrotomy in management of urethral strictures. Urology 1983; 22: 43-45. [PUBMED] |
| 9. | Pain JA, Collier DG St J. Factors influencing recurrence of urethral strictures after endoscopic urethrotomy: The role of infection and peri-operative antibiotics. Br J Urol 1984; 56: 217-219. |
| 10. | Holm-Nielsen A, Schultz A, Moller-Pedersen V. Direct vision internal urethrotomy: A critical review of 365 operations. Br J Urol 1984; 56: 308-312. |
| 11. | Aagaard J, Andersen J, Jaszezak P. Direct vision internal urethrotomy: A prospective study of 81 primary strictures treated with a single urethrotomy. Br J Urol 1987; 59: 328-330. |
| 12. | Murdoch DA, Badenoch DR Oral ciprofloxacin as prophylaxis for optical urethrotomy. Br J Urol 1987; 60: 352-354. |
| 13. | Pitamaki KK, Tammela LJ, Kontturi MJ. Recurrence of urethral stricture and late results after optical urethrotomy: Comparison of strictures caused by toxic latex catheters and other causes. Scand J Urol Nephrol 1992; 26: 327. |
| 14. | Merkle W, Wagner W. Risk of recurrent stricture following internal urethrotomy: Prospective ultrasound study of distal male urethra. Br J Urol 1990; 65: 618-620. [PUBMED] |
| 15. | Johnston SR, Bagshaw HA, Flynn JT, Kellnett MJ, Blandy JP. Visual internal urethrotomy. Br J Urul 1980; 52: 542-545. |
| 16. | Talja M, Ruutu M, Andersson LC, Alfthan O. Urinary catheter structure and testing methods in reiation to tissue toxicity. Br J Urol 1986; 58: 443-449. [PUBMED] |
| 17. | Blacklock NK. Catheters and urethral strictures. Br J Urol 1986; 58: 475-478. |
| 18. | Stone AR, Randall JR, Shorrock K et al. Optical urethrotomy - A 3-years' experience. Br J Urol 1983; 55: 701-704. |
| 19. | Gaches CGC, Ashken MH, Dunn M, Hammonds JC, Jenkins IL. The role of selective internal urethrotomy in the management of urethral stricture: A multi-centre evaluation. Br J Urol 1979; 51: 579. |
| 20. | Sacknoff EJ, Kerr WS. Direct vision cold knife urethrotomy. J Urol 1980;123:412. |
| 21. | Kinder PW, Rous SN. The treatment of urethral stricture disease by internal urethrotomy - A clinical review. J Urol 1979; 121: 45-46. [PUBMED] |
| 22. | Koraitim M. Experience with 170 cases of posterior urethral strictures during 7 years. J Urol 1985; 133: 408-410. [PUBMED] |
[Table 1], [Table 2]
|
