The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience.

OBJECTIVE: To assess the efficacy, effect of radiotherapy, and complications of direct visual internal urethrotomy (DVIU) and intralesional mitomycin C (MMC) for recurrent bladder neck contracture/vesicourethral anastomotic stenosis (BNC/VUAS). METHODS: Patients who underwent DVIU with intralesional MMC for recurrent BNC/VUAS between 2007 and 2019 at 2 institutions were included. Cold knife incisions were performed in a reproducible fashion followed by injection of 0.3-0.4 mg/mL MMC at each incision site. Those with evidence of complete urethral obliteration, stenosis of the entire posterior urethra, or <3 months follow-up were excluded. Success was defined as the ability to pass a 17-French cystoscope postoperatively without the need for catheterization or additional procedures. RESULTS: Eighty-six patients were analyzed over a median follow-up of 21.1 months. Around 91% had at least 1 prior DVIU, 56% had at least 1 prior dilation, and 44% presented with an indwelling catheter or performed intermittent catheterization. Success was achieved in 65% after 1 procedure, an additional 18% after 2 procedures, and another 7% after 3 or more procedures (90% overall success rate). Nonradiated patients showed a higher overall success rate compared to radiated patients (94% vs 76%, P = 0.04). Of the 9 cystoscopic failures, 5 were asymptomatic and pursued observation. Only 2 (5%) patients with a history of catheterization required this postoperatively. Two patients underwent subsequent urinary diversion surgery. No long-term complications were seen. CONCLUSION: DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in >90% of nonradiated patients and >75% of radiated patients.

Estenosis de la anastomosis vesicouretral tras prostatectomía radical y radioterapia postoperatoria / Vesicourethral anastomotic stricture following radical prostatectomy with or without postoperative radiotherapy

Objetivo: conocer la incidencia de la estenosis de la anastomosis vesicouretral en pacientes con cáncer de próstata tratados con prostatectomía radical. El objetivo secundario fue analizar si la radioterapia postoperatoria incrementa el riesgo de presentar una estenosis de la anastomosis. Material y métodos: se revisaron retrospectivamente las historias de los pacientes sometidos a prostatectomía radical como tratamiento primario entre enero 2000 y diciembre del 2008, con un seguimiento clínico mínimo de 12 meses. Del total de pacientes 258 cumplían los requisitos anteriores. De ellos 25 (9,6%) recibieron radioterapia postoperatoria, 12 (48%) de forma adyuvante y 13 (52%) de rescate. La edad media de los pacientes irradiados fue 64 (46-77) años. La mediana del PSA pre-radioterapia fue 2,3 (0,04-26,1)ng/ ml. El tiempo medio entre la cirugía y la radioterapia fue 17,4 (3-72) meses. La dosis media administrada fue 68 (58-70) Gy. El seguimiento medio fue 50,5 (15-117) meses. Resultados: de 25 pacientes prostatectomizados que recibieron radioterapia 4 (16%) desarrollaron estenosis de la anastomosis vesicouretral. El tiempo medio desde la finalización de la radioterapia hasta la aparición de la estenosis fue de 4 meses (1-22). Por otro lado, 36 (15,4%) pacientes prostatectomizados que no recibieron radioterapia postoperatoria presentaron esta misma complicación. Comparativamente no se apreciaron diferencias significativas entre ambos grupos (p = 0,599).Conclusiones: en nuestra revisión retrospectiva, la radioterapia postoperatoria no incrementó de forma significativa la incidencia de estenosis de la anastomosis vesicouretral (AU)

Objective: To know the incidence of vesicourethral anastomotic stricture in patients with prostate cancer treated with radical prostatectomy. Our secondary aim was to verify if postoperative radiotherapy increases the risk of presenting anastomotic stricture. Materials and methods: We retrospectively checked the clinical records of patients that had undergone radical prostatectomy as their primary treatment between January 2000 and December2008, with a minimum clinical follow-up of 12 months. Of the total patients, 258 met the foregoing requirements. Of them, 25 (9.6%) received postoperative radiotherapy, 12 (48%) received adjuvant radiotherapy and 13 (52%) received salvage radiotherapy. The mean age of the patients that received radiotherapy was 64 (46-77) years. The mean pre-radiotherapy PSA was 2.3 (0.04-26.1) ng/ ml. The mean time between surgery and radiotherapy was 17.4 (3-72) months. The mean dosage administered was 68 (58-70) Gy. The mean follow-up was 50.5(15-177) months. Results: Of 25 prostatectomized patients that received radiotherapy, four (16%) developed vesicourethral anastomotic stricture. The mean time from the completion of the radiotherapy until the appearance of the stricture was 4 months (1-22). On the other hand, 36 (15.4%) of the prostatectomized patients that did not receive postoperative radiotherapy presented the same complication. Comparatively, we did not note significant differences between both groups (p = 0.599). Conclusions: In our retrospective review, postoperative radiotherapy did not significantly increase the incidence of vesicourethral anastomotic stricture (AU)

Utilidad del láser en el tratamiento de las estenosis uretrales / The usefulness of laser in the treatment of urethral stenosis

Introducción: La uretrotomía óptica fue introducida por Sachse (lj en 1973 y se ha comprobado una tasa de recurrencia de 75-80% a largo plazo. Esto estimuló la búsqueda de nuevas terapias con una menor incidencia de recurrencia. Se intentaron varios tipos de láser: Nd:YAG, KTP, Argón, Ho:YAG, diodo... Desde finales de los 70 diferentes tipos de láser se han venido utilizando en el tratamiento de las estenosis uretrales. Objetivo: Describir la utilidad de la energía láser en las estenosis uretrales, fundamentalmente recurrentes y analizar la experiencia existente con los diferentes tipos de láser (diodo, Nd:Yag, Holmium, KTP, Argon, etc). Métodos: Hemos realizado una revisión sistemática de la bibliografía, basada en una búsqueda en Medline y análisis detallado de los artículos seleccionados. Conclusiones: 1). El uso del láser en el tratamiento de las estenosis uretrales se revela por el momento como una alternativa válida, eficaz y segura, al menos a medio plazo, a la uretrotomía óptica; sin embargo por el momento no se ha demostrado que sea mejor que esta. 2). La elección del tratamiento es cirujano dependiente, y ninguna técnica ha mostrado claramente ser superior a las demás. 3). Se precisan estudios prospectivos a largo plazo, con un mayor número de pacientes y con mayor seguimiento. 4). La tecnología láser es cara y no está disponible en todos los centros (AU)

Introduction: Optical urethrotomy was introduced by Sachse (1) in 1973 and it has a registered long-term recurrence rate of 75-80%. This stimulated the search for new therapies with less recurrences. Several types of láser were tried: Nd:YAG, KTP, Argon, Ho:YAG, diode,... Since the end of the '70s various types of láser are being used for the treatment of ureteral stenosis. Objectives: To describe the usefulness of the láser energy in the treatment of ureteral stenosis, mainly recurrent stenosis and to analyze the current experience with various types of láser (diode, nd:yag, holmium, argon,...) Methods: We performed the systematic review of the bibliography, based on a medline search, and a detailed analysis of the selected articles. Conclusions: 1) the use of láser in the treatment of urethral stenosis is on the a valid, effective, and safe alternative option to optical urethrotomy, at least in the mid term; nevertheless, it has not demonstrated to date being better than that. 2) The election of treatment is surgeon dependent and, and no single technique has demonstrated to be clearly better than the others. 3) Prospective long-term studies with larger numbers of patients and longer follow-up are necessary . 4) láser technology is extensive and it is not available in all centers (AU)

[Low-dose rate brachytherapy with locally integrated beta emitters after internal urethrotomy. A pilot project using an animal model]. / Low-dose-rate-Brachytherapie durch lokal integrierte Betastrahler nach Urethrotomia interna. Ein Pilotprojekt im Tierversuch.

BACKGROUND: The treatment of urethral strictures represents an unsolved urological problem. PATIENTS AND METHODS: The effect of a (32)P-coated urethral catheter in the sense of low-dose rate brachytherapy to modulate wound healing will be analyzed in an animal experiment. RESULTS: Unfortunately it is not possible to present any results because this is being studied for the first time and there are no experiences with low-dose rate brachytherapy and this form of application in the lower urinary tract. Furthermore the animal experiment will only start in the near future. Both decade-long experiences with radiotherapy to treat benign diseases and our own results of previous studies in otolaryngology and ophthalmology let us expect a significantly lower formation of urethral strictures after internal urethrotomy. CONCLUSION: This study will contribute to improving the treatment of urethral strictures as demanded in previous papers.

Effects of irradiation using a radioisotope-filled balloon on tissue hyperplasia caused by stent placement in a canine urethral model.

PURPOSE: To evaluate 20 Gy and 40 Gy of intraluminal beta-irradiation using a 188Re-7mercaptoacetyltriglycine (MAG3)-filled balloon catheter to reduce tissue hyperplasia caused by covered stent placement for 12 weeks of follow-up in a canine urethral model. MATERIAL AND METHODS: Ten dogs underwent 188Re-MAG3-filled balloon dilatation immediately after stent placement; 20 Gy at 1-mm tissue depth in group I (n = 5) and 40 Gy in group II (n = 5), whereas 5 dogs (group III) underwent conventional balloon dilatation only. RESULTS: There were no significant differences among the three groups for percentage diameter of stenosis, although this was highest in group III. There was a tendency toward lower mean thickness of the epithelial layer and the papillary projection for out-stent area, and thickness of the papillary projection and degree of inflammatory cells for instent area in groups I and II compared with group III. Thickness of the papillary projection in out-stent area was significantly different among the three groups (P = 0.031). It was significantly less thick in group I than in group III (P < 0.05), whereas group II was not significantly different from group III. CONCLUSION: 188Re-MAG3-filled balloon dilatation has the potential to reduce tissue hyperplasia after 12 weeks of follow-up in a canine urethral model. The use of 20 Gy compared to 40 Gy did not show significant differences.

[Endourethral brachytherapy for the prevention of recurrent strictures following internal urethrotomy]. / Endoluminale Brachytherapie zur Vorbeugung von rezidivierenden Strikturen nach Urethrotomia interna.

METHODS AND MATERIALS: Between November 2000 and December 2002 endoscopic incision or transurethral scar resection was followed by endourethral brachytherapy (BT) which was performed in patients with recurrent bulbar strictures ( n=9), bladder neck stenosis after transurethral prostatectomy (TUR-P) ( n=3), anastomotic stricture after radical prostatectomy ( n=2) or penile urethral stricture ( n=1). High dose rate (HDR) iridium-192 BT started on the day of the endoscopic incision or resection and continued for the following 3 days. The BT fractionation scheme was 4x3 Gy in the first three patients (until first relapse) and 4x4 Gy in all following patients. The dose was calculated at 3 mm tissue depth using 3-dimensional CT-planning. As of February 2004, the median follow-up of all patients reached 22 months. RESULTS: Seven of 15 patients (46%) are recurrence free. In two patients (13.3%), recurrent strictures developed 12 month later, outside of the region of initial treatment. In six patients (40%) the treatment was considered to be unsuccessful as recurrent strictures were found between 2 and 12 months after the initial or second course of treatment. CONCLUSION: Endourethral brachytherapy after endoscopic incision or resection is a promising treatment for the prevention of recurrent strictures of the urethra, bladder neck or vesicourethral anastomosis. The initial results have been very good, but with longer follow-up recurrence occurred in the irradiated area in 40% of patients. Prospective randomized studies in patients with a strictly defined type of recurrent stricture, or even after the first internal urethrotomy, should be done in the future.

[Experience in treating residual urethritis and its complications with low-intensity laser radiation]. / Opyt lecheniia rezidual'nykh uretritov i ikh oslozhnenii nizkointensivnym lazernym izlucheniem.

The authors analyze the results of laser therapy of residual urethritis and complications of urethral inflammations: cystitis, prostatitis, epididymitis, urethral strictures. Laser therapy was found particularly effective in the treatment of residual urethritis and valuable in multiple-modality treatment of urethrogenic epididymitis, cystitis, and prostatitis. The authors discuss the possibility of palliative therapy of cicatricial strictures of the urethra developing after installations and instrumental invasions for urethritis.