Treatment Of Urethral Strictures Biology Essay

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The study determines the feasibility of routinely performing internal urethrotomy for urethral stricture under local anesthesia in an outpatient setting with out the need of general anesthesia.

Patients and Methods:-

This was a prospective study in Queen Rania Urology Center in King Hussein Medical Center. Between the period of Sep 2002 and Sep 2003, a total of 180 patients presented to our department with known case of urethral strictures, age range from 18 to 70 (median age of 44), all were males.

Results:-

All patients underwent cystoscopy and treatment of stricture under local anesthesia using 20 ml of 2% Xylocaine hydrochloride gel, in an out patient basic. From 180 patients 126 underwent sachsea urethrotomy (70%), 18 underwent meatal dilatation (10%), 27 patients underwent Otis urethrotomy (15%), and nine patients required urethroplasty (5%) which required special preparation as in patient under general anesthesia.

Conclusion:-

We conclude that urethral dilatation and optical internal urethrotomy under local anaesthesia are effective in the treatment of urethral urethrotomy using lidocaine anesthesia and it is a safe and cost effective procedure, as initial outpatient treatment.

Key words: - Urethra, Xylocaine gel, Urethrotomy.

Introduction:-

A urethral stricture occurs when scar tissue forms in the urethra (tube that drains the bladder). The stricture blocks the urethra and may cause the urinary stream to slow to the point where the patient cannot urinate. Causes for urethral stricture formation include trauma (sharp blow to the base of the penis), gonorrhea, or previous instrumentation of the urinary tract.

As the urethral strictures arise from various causes the patient can be asymptomatic or present with severe discomfort secondary to urinary retention. Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential. A urologic consultation should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease.

Treatment of urethral stricture varies; it can be treated by Urethral dilation which includes stretching open the urethra by passing sequentially larger tubes through the penis. Most likely to be successful on smaller strictures. May be performed under local anesthesia in the office. Another way of treatment include the Visualized internal urethrotomy (VIU) - making an incision through the stricture by passing a small knife through the cystoscope. Most likely to be successful on small strictures. This is performed under anesthesia in the OR on an outpatient basis.

Urethroplasty - an operation in which the narrowed portion of the urethra is removed and a new segment of urethra is created using penile or scrotal skin. Usually reserved for severe strictures or patients who failed dilation and VIU.

Urolume Stent - a wire mesh tube is used to hold open the narrowed portion of the urethra. Most successful on smaller strictures.

Material and Methods:-

This was a prospective study in Queen Rania Urology Center in King Hussein Medical Center. Between the period of Sep 2002 and Sep 2003, a total of 180 patients presented to our department with known case of urethral strictures, age range from 18 to 70 (median age of 44), all were males.

The cause of urethral strictures varies fro trauma to chronic infection, or previous instrumentation and surgery to idiopathic causes.

The patients were investigated routinely by kidney function test and urin analysis and culture, renal ultrasound and IVU also were requested according to each case, Elderly patients were investigated to role out other causes for poor stream unless they are known to have urethral strictures and followed accordingly.

Urine flow meter was mandatory in all cases and it was used for both diagnostic and follow up patients post operatively.

Urethrogram was done in selected cased mainly who required urethroplasty or those who are having long strictures.

During surgery the patient was placed in lithotomy position in operating room and 20 ml of 2% Xylocaine hydrochloride gel will be instilled to the urethra over 10 seconds and very gently so as to avoid urethral mucosal injury.

After five minutes diagnostic cystoscopy will be performed so as to determine to actual anatomy of the entire urethras and to identify the site, the severity the location and the nature of the strictures so as to determine the proper was of treatment.

Results:-

In cases of small stricture dilatation can be done under the same local anaesthesia by utilizing a series of increasingly large tubes or dilators that are passed from the urethral opening into the bladder, another way of treatment in cases of small strictures by making an incision through the stricture by passing a small knife through the cystoscope (sachsea urethrotomy). Otis urethrotomy was performed by passing the Otis knife along the whole urethra which was helpful in cases of longer strictures of previously diseased urethra.

Urethroplasty was preserved in cases of completely unhealthy strictures of complete obliteration of urethra in which by passing the urethra has impossible.

A urethral catheter (18 or 20F Foley) was left indwelling for 5 days post-operatively. Then it will be removed and the patient will be examined by urine flow meter to compare the results prior to surgery.

Discussion:-

From 180 patients underwent cystoscopy under local anesthesia for treatment of urethral strictures, 126 underwent sachsea urethrotomy (70%), 18 underwent meatal dilatation (10%), 27 patients underwent Otis urethrotomy (15%), and nine patients required urethroplasty (5%) which required special preparation as in patient under general anesthesia.

There was minimal transient bleeding per urethra which subsided within two hours spontaneously.

In 70% of patients the strictures were controlled by local anaesthetic urethrotomy alone; 61% felt either no pain or mild pain during the procedure; 72% expressed a preference for local anaesthesia should the procedure have to be repeated and 82% were happy with the result of their treatment. Some patients were given some sedation because of irritability especially younger age group, but the procedure was performed successfully.

This technique did not interfere with visual acuity by using the Xylocaine gel.

We conclude that urethral dilatation and optical internal urethrotomy under local anaesthesia are equally successful as initial outpatient treatment.(1,4) With regard to successful performance of the procedure itself, multiple, longer (> 2 cm), post-traumatic, and previously untreated strictures are better managed with dilatation, whereas patients with complications or retention are better managed with internal urethrotomy (2,3,5). It is a safe and cost effective procedure, as initial outpatient treatment. With local anesthesia, internal urethrotomy is an effective, simple, and inexpensive procedure for treatment of anterior urethral stricture.(6)

The ability to perform a variety of urologic procedures (urethrotomy, prostate surgery,(3) penile prosthesis insertion, and bladder neck suspension) under local anesthesia in an outpatient setting is a significant advance in patient care which we hope to achieve soon.(6).

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