Urethrotomy
Encyclopedia
A urethrotomy is an operation which involves incision of the urethra
, especially for relief of a stricture
. It is most often performed in the outpatient setting, with the patient (usually) being discharged from the hospital or surgery center within six hours from the procedure's inception.
Urethrotomy (often referred to as DVIU, or Direct Visual Internal Urethrotomy) is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success is less than 9% for the first or subsequent urethrotomies. Most patients will be expected to experience failure with longer followup and the expected long-term success rate from any urethrotomy approach is 0%. Beginning in 2003, several urology residency programs in the northeastern section of the United States began advocating the use of urethrotomy as initial treatment in the young stricture patient, versus urethral dilitation. It is theorized that the one-to-two years of relief from stricture disease will allow the practitioner and the patient to plan the most effective treatment regimen without having the concern that undergoing multiple dilitations cloud the judgment of the patient. Furthermore, should urethroplasty
be selected by the patient, minimal scar tissue will have developed at the site of the stricture in the urethrotomy patient, as opposed to the patient who had undergone the more conventional (dilitation) route.
or a prior urethrography, the patient is placed in the lithotomy position
, and the urinary meatus
is cleansed with an appropriate surgical cleansing agent (scrub), usually containing Povidone-iodine, then surgically draped. An IV
antibiotic
or other anti-infective medication is administered in conjunction with intravenous normal saline, and allowed to run until administration of the prescribed dose is completed. Most often, procedural sedation
will be the chosen adjunct to patient comfort, and the patient will have received intravenous anxiolytic
medication at sometime prior to, or during the surgical preparation. This medication is usually a benzodiazepine
, often, diazepam
or midazolam
is employed. The urological surgeon or anesthesia
practitioner may also choose to administer a narcotic
analgesic
such as fentanyl citrate, depending on the level of discomfort anticipated by the surgeon. In some cases, usually where longer strictures are present, a rapidly metabolized hypnotic
agent such as propofol
may be selected, as this allows for the immediate induction of short-term general anesthesia (note:endotracheal intubation will also be necessary if general anesthesia is administered). Constant monitoring of vital signs
including pulse oximetry
, cardiac monitoring
(ECG), body temperature and blood pressure
are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit.
A topical anesthetic, usually viscous lidocaine
is instilled into the urethra
, and a penile (crown) clamp is applied for at least five minutes, then removed immediately prior to the insertion of a cystoscope equipped with a transurethral injection system containing a local anesthetic (most often 2% (plain) lidocaine
, or 0.5% (plain) bupivicaine). The urological surgeon will inject the anesthetic at the twelve o'clock, four o'clock, and eight o'clock positions at the face of the stricture using infiltrative technique, and ensuring that the entire length of the stricture has been medicated. The cystoscope (and injection system) will be withdrawn, and sufficient time will be allowed for the local anesthetic to take effect (usually five-to-ten minutes).
At this time a rigid urethrotome or a flexible cystoscope/urethrotome combination will be inserted and guided to the face of the stricture and a small blade towards the tip of the instrument will be deployed using a trigger mechanism to cut the stricture at locations determined by the surgeon. Upon completion of the internal incision(s), the instrument is withdrawn and an appropriately sized Foley catheter
will be inserted through the repair and into the urinary bladder
, and locked into place by filling its balloon (positioned inside of the bladder near the urethral junction) with sterile water. The Foley catheter serves two purposes, first, it provides drainage of the urine produced by/in the kidneys, and secondly, it secures/holds open the incised areas for three to seven days to permit thorough healing of the urethra. The catheter is then attached to a urinary catheter drainage system (large bag or leg bag) via clear polypropylene tubing.
or urinary analgesic/anti spasmodic combination containing methanamine, methylene blue
, and hyoscyamine sulfate. will be offered. Palliative medications may sometimes be prescribed, but are often not necessary because there is usually minimal discomfort post-procedure.
It has become common practice for urologists to prescribe self-catheterization at weekly intervals for the post-urethrotomy patient. After voiding, and using sterile technique, a lubricated Foley catheter is passed into the urethra, through the surgically modified area, into the bladder and allowed to remain in place for up to ten minutes. The catheter is then carefully withdrawn and discarded, and the patient is then instructed to void as soon as possible (this helps to cleanse the urethra of any blood or water-based lubricant and lessen the possibility of infection). Although no formal studies have been conducted, there does appear to be an improvement in intervals between subsequent urethrotomies and an improvement in uroflowmetric data for most patients who have undergone this regimen.
disease, and advocate excision of the damaged area followed by either a surgical anastomosis
of the (now) patent urethral ends, or a grafting of similar tissue harvested from elsewhere on the patients body.
The cost-effectiveness of the procedure has come into question. In the May, 2006 issue of "Urology", a study undertaken by the Urology Department of the University of Washington
essentially concluded that there is a statistical correlation between the length of the stricture and the cost versus benefit ratio of subsequent urethrotomies performed prior to the performance of urethroplasty
in males suffering from bulbar srictures.
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
, especially for relief of a stricture
Urethral stricture
A urethral stricture is a narrowing of the urethra caused by injury or disease such as urinary tract infections or other forms of urethritis.-Signs and symptoms:...
. It is most often performed in the outpatient setting, with the patient (usually) being discharged from the hospital or surgery center within six hours from the procedure's inception.
Urethrotomy (often referred to as DVIU, or Direct Visual Internal Urethrotomy) is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success is less than 9% for the first or subsequent urethrotomies. Most patients will be expected to experience failure with longer followup and the expected long-term success rate from any urethrotomy approach is 0%. Beginning in 2003, several urology residency programs in the northeastern section of the United States began advocating the use of urethrotomy as initial treatment in the young stricture patient, versus urethral dilitation. It is theorized that the one-to-two years of relief from stricture disease will allow the practitioner and the patient to plan the most effective treatment regimen without having the concern that undergoing multiple dilitations cloud the judgment of the patient. Furthermore, should urethroplasty
Urethroplasty
A urethroplasty is an operation for the repair of an injury or a defect in the walls of the urethra. Commonly, this involves removal and end-to-end anastomosis for shorter strictures or grafting using buccal mucosa for longer ones....
be selected by the patient, minimal scar tissue will have developed at the site of the stricture in the urethrotomy patient, as opposed to the patient who had undergone the more conventional (dilitation) route.
The Procedure
Once the diagnosis has been confirmed by either cystoscopyCystoscopy
Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.Diagnostic cystoscopy is usually carried out with local anaesthesia...
or a prior urethrography, the patient is placed in the lithotomy position
Lithotomy position
The lithotomy position is a medical term referring to a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations...
, and the urinary meatus
Urinary meatus
The urinary meatus is an orifice of the urethra. It is the point at which urine and, in males, semen exits the urethra. The meatus features varying degrees of sensitivity to the touch among males and females....
is cleansed with an appropriate surgical cleansing agent (scrub), usually containing Povidone-iodine, then surgically draped. An IV
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
or other anti-infective medication is administered in conjunction with intravenous normal saline, and allowed to run until administration of the prescribed dose is completed. Most often, procedural sedation
Procedural sedation
Procedural sedation and analgesia previously referred to as conscious sedation is defined as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory...
will be the chosen adjunct to patient comfort, and the patient will have received intravenous anxiolytic
Anxiolytic
An anxiolytic is a drug used for the treatment of anxiety, and its related psychological and physical symptoms...
medication at sometime prior to, or during the surgical preparation. This medication is usually a benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
, often, diazepam
Diazepam
Diazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...
or midazolam
Midazolam
Midazolam is a short-acting drug in the benzodiazepine class developed by Hoffmann-La Roche in the 1970s. The drug is used for treatment of acute seizures, moderate to severe insomnia, and for inducing sedation and amnesia before medical procedures. It possesses profoundly potent anxiolytic,...
is employed. The urological surgeon or anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
practitioner may also choose to administer a narcotic
Narcotic
The term narcotic originally referred medically to any psychoactive compound with any sleep-inducing properties. In the United States of America it has since become associated with opioids, commonly morphine and heroin and their derivatives, such as hydrocodone. The term is, today, imprecisely...
analgesic
Analgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
such as fentanyl citrate, depending on the level of discomfort anticipated by the surgeon. In some cases, usually where longer strictures are present, a rapidly metabolized hypnotic
Hypnotic
Hypnotic drugs are a class of psychoactives whose primary function is to induce sleep and to be used in the treatment of insomnia and in surgical anesthesia...
agent such as propofol
Propofol
Propofol is a short-acting, intravenously administered hypnotic agent. Its uses include the induction and maintenance of general anesthesia, sedation for mechanically ventilated adults, and procedural sedation. Propofol is also commonly used in veterinary medicine...
may be selected, as this allows for the immediate induction of short-term general anesthesia (note:endotracheal intubation will also be necessary if general anesthesia is administered). Constant monitoring of vital signs
Vital signs
Vital signs are measures of various physiological statistics, often taken by health professionals, in order to assess the most basic body functions. Vital signs are an essential part of a case presentation. The act of taking vital signs normally entails recording body temperature, pulse rate ,...
including pulse oximetry
Pulse oximetry
Pulse oximetry is a non-invasive method allowing the monitoring of the oxygenation of a patient's hemoglobin.A sensor is placed on a thin part of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot....
, cardiac monitoring
Cardiac monitoring
The phrase cardiac monitoring generally refers to continuous monitoring with electrocardiography with assessment of the patients condition relative to their cardiac rhythm. It is different from hemodynamic monitoring, which monitors the pressure and flow of blood within the circulatory system. The...
(ECG), body temperature and blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit.
A topical anesthetic, usually viscous lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
is instilled into the urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
, and a penile (crown) clamp is applied for at least five minutes, then removed immediately prior to the insertion of a cystoscope equipped with a transurethral injection system containing a local anesthetic (most often 2% (plain) lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
, or 0.5% (plain) bupivicaine). The urological surgeon will inject the anesthetic at the twelve o'clock, four o'clock, and eight o'clock positions at the face of the stricture using infiltrative technique, and ensuring that the entire length of the stricture has been medicated. The cystoscope (and injection system) will be withdrawn, and sufficient time will be allowed for the local anesthetic to take effect (usually five-to-ten minutes).
At this time a rigid urethrotome or a flexible cystoscope/urethrotome combination will be inserted and guided to the face of the stricture and a small blade towards the tip of the instrument will be deployed using a trigger mechanism to cut the stricture at locations determined by the surgeon. Upon completion of the internal incision(s), the instrument is withdrawn and an appropriately sized Foley catheter
Foley catheter
A Foley catheter is a flexible tube that is often passed through the urethra and into the bladder. The tube has two separated channels, or lumens, running down its length. One lumen is open at both ends, and allows urine to drain out into a collection bag...
will be inserted through the repair and into the urinary bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
, and locked into place by filling its balloon (positioned inside of the bladder near the urethral junction) with sterile water. The Foley catheter serves two purposes, first, it provides drainage of the urine produced by/in the kidneys, and secondly, it secures/holds open the incised areas for three to seven days to permit thorough healing of the urethra. The catheter is then attached to a urinary catheter drainage system (large bag or leg bag) via clear polypropylene tubing.
Post Procedural Care
Prior to discharge from the surgical facility, the patient will be instructed on proper care of the urinary drainage system, how to monitor for signs of infection, and the limitations of physical activity necessary for the safety of the patient, and the success of the procedure. A course of oral antibiotics/anti-infective agents will be prescribed. Additionally, a urinary analgesic such as phenazopyridinePhenazopyridine
Phenazopyridine is a chemical which, when excreted into the urine, has a local analgesic effect. It is often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections, surgery, or injury to the urinary tract...
or urinary analgesic/anti spasmodic combination containing methanamine, methylene blue
Methylene blue
Methylene blue is a heterocyclic aromatic chemical compound with the molecular formula C16H18N3SCl. It has many uses in a range of different fields, such as biology and chemistry. At room temperature it appears as a solid, odorless, dark green powder, that yields a blue solution when dissolved in...
, and hyoscyamine sulfate. will be offered. Palliative medications may sometimes be prescribed, but are often not necessary because there is usually minimal discomfort post-procedure.
Post Surgical Evaluation and Care
The surgeon will remove the catheter three to seven days after the surgery is completed. A baseline uroflowmetric study will be performed, and the patient will be instructed to return in thirty days for a follow-up evaluation. This evaluation will include another uroflowmetric study and a complete urinalysis. Follow-up visits are scheduled at six-month intervals, as determined by the practitioner responsible for the treatment plan.It has become common practice for urologists to prescribe self-catheterization at weekly intervals for the post-urethrotomy patient. After voiding, and using sterile technique, a lubricated Foley catheter is passed into the urethra, through the surgically modified area, into the bladder and allowed to remain in place for up to ten minutes. The catheter is then carefully withdrawn and discarded, and the patient is then instructed to void as soon as possible (this helps to cleanse the urethra of any blood or water-based lubricant and lessen the possibility of infection). Although no formal studies have been conducted, there does appear to be an improvement in intervals between subsequent urethrotomies and an improvement in uroflowmetric data for most patients who have undergone this regimen.
Controversy
Many leading urologists in the United States consider urethrotomy to be (almost) totally ineffective at providing long-term resolution of urethral strictureUrethral stricture
A urethral stricture is a narrowing of the urethra caused by injury or disease such as urinary tract infections or other forms of urethritis.-Signs and symptoms:...
disease, and advocate excision of the damaged area followed by either a surgical anastomosis
Surgical anastomosis
In surgical jargon, to create an anastomosis is to join together two hollow organs , usually to restore continuity after resection, or to bypass an unresectable disease process. Historically such procedures were performed with suture material, but increasingly mechanical staplers and biological...
of the (now) patent urethral ends, or a grafting of similar tissue harvested from elsewhere on the patients body.
The cost-effectiveness of the procedure has come into question. In the May, 2006 issue of "Urology", a study undertaken by the Urology Department of the University of Washington
University of Washington
University of Washington is a public research university, founded in 1861 in Seattle, Washington, United States. The UW is the largest university in the Northwest and the oldest public university on the West Coast. The university has three campuses, with its largest campus in the University...
essentially concluded that there is a statistical correlation between the length of the stricture and the cost versus benefit ratio of subsequent urethrotomies performed prior to the performance of urethroplasty
Urethroplasty
A urethroplasty is an operation for the repair of an injury or a defect in the walls of the urethra. Commonly, this involves removal and end-to-end anastomosis for shorter strictures or grafting using buccal mucosa for longer ones....
in males suffering from bulbar srictures.