The treatment of urethral strictures

Analysis of the results of many-year treatment of 788 patients with traumatic urethral strictures indicated that it was advisable to perform Khol'tsov's operation without leaving a catheter in the urethra in short strictures of the anterior urethral segment, Solovov's operation was indicated for occlusive strictures of the posterior urethral portion, whereas endourethral interventions (urethrotomy, resection) were beneficial in short patent strictures. Vesicourethral strictures required transurethral electroresection. Stenotic urethral changes were seen at different levels in 3.7% of postoperative patients. Some recommendations were proposed by the authors for prevention of the changes. A classification of urethral strictures was also presented.     

The surgical treatment of urethral strictures

The authors reviewed the results of surgical management of 233 patients aged 8-76 years who had suffered urethral strictures. A total of 266 operations were made in the period of 1970-1989. Urethral tunneling which had been widely used in clinical practice for strictures of the urethra until 1980 yielded 91.2% recurrences of the disease, which made surgeons modify the surgical policy. During the past decade 127 patients with urethral strictures and obliterations have undergone 138 surgical interventions: 91 (65.9%) urethral resections, 34 (24.6%) internal optical urethrotomies and transurethral resections of scarring tissue, 7 (5.1%) cutaneous urethral plastic surgeries and only 6 (4.4%) urethral tunnelings. The number of relapses was reduced to 13.4%. The authors consider that urethral resection should be the operation of choice in urethral strictures and obliterations. Endoscopic treatment techniques (urethrotomy and transurethral resection) are indicated in short strictures and scarring deformity of the posterior urethra after prostate operation. It is advisable to apply cutaneous urethral plastic surgery in case of extended strictures.     

The treatment of postoperative anal sphincter insufficiency

Postoperative anal sphincter insufficiency was revealed in 94 patients, ageing 14-64 yrs. Surgical treatment was conducted in 80 of them: sphincteroplasty--in 29, sphincterolevatoroplasty--in 37, sphincterogluteoplasty--in 8, plasty, using the m. gluteus maximus flap--in 6. Results of the patients treatment, followed up 1-4 yrs, were: good--in 54 (76.1%), fair--in 11 (15.5%) and poor--in 6 (8.4%) of them.     

Endoscopic treatment of urethral strictures

The present article reviews the literature regarding the endoscopic treatment of urethral strictures. Only few prospective randomised clinical trials with sufficient power have been performed and most of the literature provides evidence of only level 3 and 4. Since length, location, extent and calibre of the urethral stricture have an important impact on prognosis, diagnosis and the role of ultrasonography are discussed. Pathophysiology of wound healing is discussed in relation to urethrotomy, as it explains the outcomes of the procedure. Operative techniques using cold knife and laser, use of endoprostheses, indications, complications, results and postoperative management are described. The possible role of urethral catheters, hydraulic dilatations and corticosteroid applications are discussed.     

腔道技术治疗尿道狭窄的现状

各种腔道技术治疗尿道狭窄简单、安全,有效.并发症少,容易掌握.结合各种预防狭窄复发的措施,进一步提高了手术的疗效.     

New treatment for urethral strictures

A new operative technique using synthetic, absorbable mesh for grafting a urethral defect was applied in 7 mongrel male dogs. The ventral half of the urethral circumference with its surrounding corpus spongiosum was excised for a length of 3 to 4 cm. A Dexon mesh of the same dimensions, woven in our laboratory from polyglycolic acid fibers, was sutured to the defective area. A perineal urethrotomy was established, and no splints were left behind. Dogs were studied between two and six months. Retrograde urethrography showed that the operative area healed without strictures or irregularities. Intravenous urography showed no back pressure effects, and cultured urine was always sterile. Histologic examination two months after surgery showed that the urothelium was completely healed, without inflammatory changes or disruption. Suburothelial tissues were replaced by dense collagenous connective tissue. The excised corpus spongiosum did not regenerate. After six months, the area of dense collagen described was diminished in size so that the operative area could be hardly identified except by the absence of corpus spongiosum.     

医源性胆管狭窄的手术治疗

目的 探讨医源性胆管狭窄的手术治疗方法.方法 回顾性总结1989年1月至2006年12月收治的235例医源性胆管损伤及胆管狭窄患者的临床资料.对损伤或狭窄患者采用胆肠通路重建术、保留和利用乳头括约肌的修复术、肝移植术等进行修复.结果 本组182例患者行胆肠Roux-en-Y吻合术,12例行胆总管对端吻合术,34例行自体带蒂组织瓣吻合术,6例行胆总管切开成形T管引流术,1例行肝移植术.随访时间1～10年,189例获随访.手术优良率为94.7%(179/189).狭窄复发率为5.3%(10/189),复发原因主要为合并结石、硬化性胆管炎、胆汁性肝硬化等.1例因严重胆汁性肝硬化、门静脉高压症,术后死于肝功能衰竭.结论 胆肠Roux-en-Y吻合术是可靠的治疗方法.利用自体带蒂组织瓣修复胆管能保留胆管下端Oddi括约肌的功能,效果良好,但远期疗效有待进一步评估.胆管内不需要常规放置支撑管.肝移植是治疗胆管狭窄引起的终末期胆病的有效方法.     

Endoscopic treatment of benign ureteral strictures

BACKGROUND: The traditional choice of procedure for treatment of ureteral stricture is open surgical repair. Advances in endourology have provided the urological surgeon with an alternative to open surgery for the treatment of benign ureteral stricture. METHODS: Twenty-seven benign ureteral strictures in 24 patients were treated by the endourological method. Twelve endoureterotomies were performed using a cold knife via a 9.5Fr Storz ureteroscope and 15 high pressure balloon dilations were performed. The ureters were stented with 7 Fr double-J stents for 6 weeks. RESULTS: The success rate was 9/12 (75%) in the endoureterotomy group and 9/15 (60%) in the balloon dilation group after follow-up for more than 6 months. CONCLUSIONS: Endoscopic treatment of ureteral strictures appeared to be a safe and reasonably effective modality for the treatment of ureteral strictures, especially for the short type that are non-ischaemic in origin and not associated with radiation therapy. Endourological treatment of ureteral strictures is the procedure of choice for initial management of benign ureteral strictures and has high success rates and fewer complications.     

The artificial sphincter in the treatment of congenital incontinence

From 1974 to 1988 the available AMS artificial sphincter models (AS 721, AS 761, AS 742, AS 791, AS 792 and AS 800) were implanted in 40 patients with congenital incontinence using a total of 75 prostheses. Despite mechanical problems with the earliest models 82.5% of all patients obtained a good result. The definitive failure rate due to urethral erosion was 2.5% and due to infection of the prosthesis 7.5%. The remaining failures were due to upper urinary tract deterioration in four patients.     

The treatment of closed injuries and posttraumatic strictures of the urethra

Immediate and long-term results of treatment were evaluated for 211 males who had pelvic and urethral injuries. Most common were the methods: primary epicystostomy followed by urethroplasty, healing on a permanent catheter from the bladder, the primary suture. The material of 12 autopsies was investigated to characterize morphohistological features of pelvic and urethral traumas with consequent pathomorphological substantiation of the ways to recover urethral patency. It is revealed that urethral injuries especially in hip bone fractures should be considered as severe. An individual surgical approach in the condition is to allow for its severity, presence of combined injuries, diagnostic evidence on urethral involvement.     

Long-term results of treatment for ureteroenteric strictures

Objectives. To review the long-term outcome for ureteroenteric stricture treatment.Methods. The ileal conduit diversions that formed ureteroenteric strictures from 1966 to 1999 were reviewed. The strictures were diagnosed radiographically, and malignancy was excluded. The treatment, location, length, diameter, and timing of stricture development after conduit creation was evaluated and compared regarding the time until stricture recurrence (failure). Success was defined as symptomatic improvement and radiologic evidence of patency.Results. Forty patients, after exclusions, returned for ureteroenteric stricture repair, comprising 79 procedures (27 open repairs and 52 balloon dilations). The open repair had a success rate at 1, 2, and 3 years of 92%, 87%, and 76%, respectively. Seven of the open cases were preceded by failed dilations. Balloon dilation had a success rate at 1, 2, and 3 years of 15%, 15%, and 5%, respectively (P = 0.0001 versus open). Similar patency results for open versus balloon (P = 0.0001) were noted with analysis restricted to each patient’s first stricture repair. Strictures greater than 1.0 cm were more likely to recur (P = 0.03). All strictures forming within 6 months of the conduit creation were treated with dilation and failed within 1 year. Of note, 11 of the 40 patients were found to have less than 25% renal function on the strictured side.Conclusions. Open repair for ureteroenteric strictures offers excellent long-term patency (76% at 3 years, P = 0.0001). On review, balloon dilation appeared to have less successful patency rates and was often followed by open repair after failure. Patients with a history of anastomotic strictures should be closely monitored to avoid renal damage and failure.     

Endoscopic treatment of postoperative colorectal anastomotic strictures

Background: The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. Methods: From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. Results: Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition (p < 0.05). Conclusion: High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002