|
RECONSTRUCTIVE
UROLOGY
doi: 10.1590/S1677-553820100003000022
Urethrotomy
has a much lower success rate than previously reported
Santucci R, Eisenberg L
Detroit Medical Center and Michigan State College of Osteopathic Medicine,
Detroit, Michigan, USA
J Urol. 2010 May;183(5):1859-62. Epub 2010 Mar 29.
- Purpose:
We evaluated the success rate of direct vision internal urethrotomy
as a treatment for simple male urethral strictures.
Materials and Methods: A retrospective chart review was performed on
136 patients who underwent urethrotomy from January 1994 through March
2009. The Kaplan-Meier method was used to analyze stricture-free probability
after the first, second, third, fourth and fifth urethrotomy. Patients
with complex strictures (36) were excluded from the study for reasons
including previous urethroplasty, neophallus or previous radiation,
and 24 patients were lost to followup.
Results: Data were available for 76 patients. The stricture-free rate
after the first urethrotomy was 8% with a median time to recurrence
of 7 months. For the second urethrotomy stricture-free rate was 6% with
a median time to recurrence of 9 months. For the third urethrotomy stricture-free
rate was 9% with a median time to recurrence of 3 months. For procedures
4 and 5 stricture-free rate was 0% with a median time to recurrence
of 20 and 8 months, respectively.
Conclusions: 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.
- Editorial
Comment
Our understanding of the success rate of optical internal urethrotomy
for urethral stricture disease has been primarily based on 2 studies
both published in 1996. Pansadoro et al. (1) and Albers et al. (2) were
both large retrospective series of optical internal urethrotomy performed
with modern techniques. Both showed success rates to be 32-40% with
follow-up longer than 24 months. Both demonstrated success to be highest
for short segment strictures in the bulbar urethra: 42%1 and 66% (2).
Cost effectiveness analysis based on these data has suggested that a
single urethrotomy should be attempted before urethroplasty (3). However,
primary urethroplasty was preferred if the success rate of urethrotomy
was to drop below 35%. Now, the current article by Santucci and Eisenberg
demonstrates a much lower success rate for urethrotomy. In fact, the
success rate is so low that it begs us to consider whether urethrotomy
should be abandoned except in those unable to undergo urethroplasty.
How can these data differ so dramatically and which study presents the
most accurate assessment of the true success rate for urethrotomy? Several
elements of the studies by Pansadoro1 and Albers (2) may have led to
an overestimate of the success rate: (1) Several patients in the Albers
series were on self-obduration postoperatively (2). Pansadoro et al
only included those patients with at least 5 years of follow-up, thus
excluding many who may have failed early and then lost to follow-up
(3). The follow-up was not well-recorded in the Albers series. So, the
article by Santucci and Eisenberg may indeed represent the true success
rate of urethrotomy and should serve as a call to others to closely
examine the efficacy of an often-performed but poorly-studied procedure.
References
- Pansadoro
V, Emiliozzi P: Internal urethrotomy in the management of anterior urethral
strictures: long-term followup. J Urol 1996; 156: 73-5.
- Albers
P, Fichtner J, Bruhl P, Muller SC: Long-term results of internal urethrotomy.
J Urol 1996; 156: 1611-4.
- Wright
JL, Wessells H, Nathens AB, Hollingworth W: What is the most cost-effective
treatment for 1 to 2-cm bulbar urethral strictures: societal approach
using decision analysis. Urology 2006, 67: 889-93.
Dr.
Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.edu
|