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DILATION, INTERNAL URETHROTOMY, URETHRAL STENTS

 

Urethral Stricture Dilation

This treatment is generally performed in the office and involves stretching of the stricture using progressively larger dilators. Distal strictures towards the tip of the penis are often dilated using progressively larger metal instruments called urethral sounds. Commonly used urethral sounds are Van Buren urethral sounds. Another common dilation method involves the use of filliforms and followers.

Van Buren urethral sounds Filliform and Followers used to dilate urethral strictures.
Van Buren Sounds Filliforms and Followers

The filliform is a long and very narrow instrument that is advanced through the urethra. The filliform is then attached to progressively larger dilating instruments that are guided through the stricture, providing progressive dilation.Alternatively, the stricture can be balloon dilated. Dr. Gelman developed a balloon dilating catheter, now commercially available (Cook Urological), that allows the stricture to be dilated under direct vision.

 

PICTURE OF BALLOON DILATOR, AND CLOSEUP, AND UNOPENED AS SEEN THROUGH A SCOPE, AND OPENED AS SEEN THROUGH A SCOPE

Balloon for urethral stricture dilation when unopened. Balloon for urethral stricture dilation when opened.
Gelman balloon dilator opened and unopened Cook balloon dilator in package.

Dr. Gelman has no commercial interest in this or other devices and has never accepted royalties to avoid any conflict of interest.

 

When this technique is performed, a flexible tip guide wire is gently advanced through the stricture. The balloon dilating catheter is then advanced over the guide wire, and the balloon is guided to the area of narrowing under direct vision. Then, the balloon is slowly inflated. When the balloon is subsequently deflated, the dilating catheter and guidewire can be removed, or a temporary stenting catheter can then be inserted over the guidewire.

 

Although we do not consider this technique to offer considerably improved efficacy compared to other dilation methods, the fact that the procedure is performed under direct vision may be associated with a lower complication rate, as blind dilation methods can be associated with complications such as false passage and urethral perforation. Subsequent to initial dilation, the management may include temporary and/or intermittent placement of a urethral catheter to maintain patency. Self-catheterization is a procedure where a patient inserts a catheter (tube) into his urethra periodically in an attempt to prevent stricture recurrence, using the catheter as a dilating instrument.

 

Internal Urethrotomy (DVIU)

The internal urethrotomy procedure is performed in the operating room using an endoscopic instrument (a telescope that is advanced through the penis). There is a small blade towards the tip of the instrument that can be deployed once the stricture is reached to cut the stricture internally to "open it up" in one or more places.  Since internal urethrotomy is performed using a telescope, it is often called an optical urethrotomy, visual urethrotomy, or DVIU which refers to direct vision internal urethrotomy.

 

PICTURE OF URETHROTOMEPicture of urethrotome used for direct vision internal urethrotomy.

 

Subsequently, an indwelling catheter is placed to stent the urethra open for some period of time (often 3-5 days) as the urethra heals. Some patients are under the false impression that this procedure is a "roto rooter" that "cleans out" and removes scar tissue. The urethra is not like a pipe where there is a build up inside that is scraped out. With urethral stricture disease, the "pipe" itself is narrow. When the urethra is incised, the cut extends though the cells lining the urethra into the surrounding tissues. The urethra is wider at that point, but the incision is simply a cut. After the catheter is placed, the best outcome would be for cells to grow into the "open wound" so that when the catheter is removed, the urethra remains widely patent. This is called epithelialization. However, unfortunately, what more often happens is wound contraction, a response to an injury where the incision heals by forming a contracted scar, leading to a recurrent stricture. When patients are treated with multiple incisions complicated by recurrence, they may feel that they just "tend to form scar tissue". The reality is that this is an expected outcome when this procedure is repeatedly performed.

 

Urethral Stent

This procedure involves placement of an internal metallic stent that has the appearance of a circular chain link fence.

 

PICTURE OF UROLUMEPciture of a Urolume stent.Picture of stent within urethra.

 

The stent is placed into the urethra endoscopically (through the penis) after the stricture is incised, and when deployed, the objective is for the stent to prevent the stented portion of the urethra from contracting as scarring again occurs. The lining of the urethra eventually covers the stent, and the stent remains in place permanently. This procedure is technically simple to perform, but is associated with a high failure and complication rate as strictures often form within or adjacent to the stent.

Proximal bulbous stricure in a patient with a urethral Urolume stent. Stricture in stent seen on a retrograde urethrogram.
Eample of stricture within Urolume stent. PICTURES OF STRICTURE IN STENTS

Although this device was once promoted as an excellent treatment option for the treatment of recurrent bulbar urethral strictures, the urethral stent has been shown to compare very unfavorably to open repair. When patients develop strictures after stent placement, the repair is considerably more challenging than it would have been prior to stent placement. At UC, Irvine, we have successfully reconstructed many patients referred to our institution after stent failures, and Our Results were published in the Journal or Urology. All patients had a technically successful outcome.

 

BEFORE AND AFTER PICTURES

Urethral stricture after stent. Picture after stent removal and urethroplasty.

 

Next Page: Meatotomy and Urethrostomy

 


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