Safety and efficacy of fluoroscopy-guided urethral catheterization in case of failed blind or cystoscopy-assisted urethral catheterization.

This retrospective study evaluated the safety and efficacy of fluoroscopy-guided urethral catheterization in patients who failed blind or cystoscopy-assisted urethral catheterization. We utilized our institutional database between January 2011 and March 2023, and patients with failed blind or cystoscopy-assisted urethral catheterization and subsequent fluoroscopy-guided urethral catheterization were included. A 5-Fr catheter was inserted into the urethral orifice, and the retrograde urethrography (RGU) was acquired. Subsequently, the operator attempted to pass a hydrophilic guidewire to the urethra. If the guidewire and guiding catheter could be successfully passed into the bladder, but the urethral catheter failed pass due to urethral stricture, the operator determined either attempted again with a reduced catheter diameter or performed balloon dilation according to their preference. Finally, an appropriately sized urethral catheter was selected, and an endhole was created using an 18-gauge needle. The catheter was then inserted over the wire to position the tip in the bladder lumen and ballooned to secure it. We reviewed patients' medical histories, the presence of hematuria, and RGU to determine urethral abnormalities. Procedure-related data were assessed. Study enrolled a total of 179 fluoroscopy-guided urethral catheterizations from 149 patients (all males; mean age, 73.3 ± 13.3 years). A total of 225 urethral strictures were confirmed in 141 patients, while eight patients had no strictures. Urethral rupture was confirmed in 62 patients, and hematuria occurred in 34 patients after blind or cystoscopy-assisted urethral catheterization failed. Technical and clinical success rates were 100%, and procedure-related complications were observed in four patients (2.2%). The mean time from request to urethral catheter insertion was 129.7 ± 127.8 min. The mean total fluoroscopy time was 3.5 ± 2.5 min and the mean total DAP was 25.4 ± 25.1 Gy cm2. Balloon dilation was performed in 77 patients. Total procedure time was 9.2 ± 7.6 min, and the mean procedure time without balloon dilation was 7.1 ± 5.7 min. Fluoroscopy-guided urethral catheterization is a safe and efficient alternative in patients where blind or cystoscopy-assisted urethral catheterization has failed or when cystoscopy-urethral catheterization cannot be performed.

Impact of a clinical care pathway developed through the action research method on the psychological well-being and quality of life in male patients with urethral stricture.

BACKGROUND: The objective of this study is to examine the development of a clinical care pathway utilizing an action research methodology for male patients with urethral stricture, and to assess the psychological and quality of life outcomes following the implementation of this pathway. METHODS: Ninety patients diagnosed with urethral stricture, admitted to our hospital between May 2021 and May 2022, were selected as the study cohort. Employing a random number method, these patients were allocated into an observation group and a control group, each comprising 45 individuals. The control cohort employs standard care protocols for individuals with urethral stenosis, while the experimental group employs an action research methodology to develop a clinical care pathway specific to the management of patients with urethral stenosis, with an intervention cycle of 3 months. The investigation evaluated the impact of the intervention by scrutinizing pre- and post-intervention data through the utilization of the WHO Quality of Life Scale (WHOQOL-BREF), in addition to the Anxiety Rating Scale and the Depression Rating Scale. RESULTS: Prior to the intervention, no significant differences were observed in WHOQOL-BREF scores across dimensions, as well as anxiety and depression scores between the 2 groups (P > .05). Subsequent to the intervention, the patients in the observation group exhibited significantly higher scores across all WHOQOL-BREF dimensions and total scores compared to the control group, with statistical significance (P < .05). Moreover, anxiety and depression scores in the observation group were markedly lower than those in the control group, demonstrating statistical significance (P < .05). CONCLUSION: The implementation of a clinical nursing pathway rooted in action research methodology proves to be an effective strategy for enhancing clinical nursing practices, elevating patient quality of life, and diminishing the prevalence of anxiety and depression.

Minimal invasive treatment of urethral strictures: An experimental study of the effect of paclitaxel coated balloons in the wall of strictured rabbit's urethra.

PURPOSE: The aim of this study is the evaluation of the distribution of paclitaxel (PTX) released by a coated balloon in the layers of rabbit's urethra. METHODS: 18 rabbits were included. A laser device was used for the stricture formation. After two weeks, dilation of the strictured urethra was performed by using Advance 35LP PTA balloons and Advance 18 PTX PTA balloons. The experimental models were divided into 3 groups. The group Α included two rabbits without any intervention except for the stenosis procedure. Group B compromised six rabbits that underwent dilation with Advance 35LP PTA balloons. Group C consisted of 10 rabbits to which dilation with both Advance 35LP PTA balloons and Advance 18 PTX PTA balloons was applied. Histological evaluation and Immunohistochemistry were performed on all specimens. RESULTS: Inflammation, fibrosis and ruptures were detected in the specimens of the study. In specimens of Group C the decrease of inflammation and fibrosis rate was greater. Anti-PTX antibody was detected in the epithelium, lamina propria and smooth muscle layer of all specimens of urethras that have been harvested immediately and 1 day after the dilation with Advance 18 PTX PTA balloon and it was not observed in any layer of the urethral wall of the rest of the examined specimens of Group C. CONCLUSIONS: PTX's enrichment was detected in the smooth muscle layer of all specimens that have been harvested immediately and 24h after the dilation with Advance 18 PTX PTA balloons. PTX may play an inhibitive role in the recurrence of the stenosis.

Is Allium Ureteral Stent Feasible for the Treatment of Ileal-Ureteral Anastomotic Stenosis? A Case Report

Background: The conventional approach for managing ureteral stenosis involves the placement of a double-J stent. In recent years, the utilisation of Allium ureteral stent (URS) has emerged as a novel treatment alternative for ureteral stenosis. Allium URS has several advantages over traditional stents, including an extended indwelling time and reduced incidence of complications. The number of cases reported worldwide on the use of Allium URS in the treatment of ureteral stenosis is currently limited. In this paper, we present the details of a case involving the use of an Allium URS to treat ileal-ureteral anastomotic stenosis in a 67-year-old patient. We aim to assess the feasibility of using Allium URS in such cases. Case Presentation: A 67-year-old Chinese woman was referred to our hospital for the treatment of left lumbago. Urography showed left ileal-ureteral anastomotic stenosis. Computed tomography (CT) revealed severe hydronephrosis in the left kidney. Subsequently, an Allium URS was implanted via ureteroscopy. We found no instances of haematuria, lumbago or urinary tract irritation during the follow-up period. After 8 months, the patient was readmitted because of left lumbago. CT re-examination revealed that the left hydronephrosis had modestly improved. The Allium URS had detached and showed stone formation on its surface. For further treatment, ureteroscopy was performed and a new Allium URS was implanted. At 3-month follow-up, CT re-examination demonstrated that the stent had dislodged again but that the hydronephrosis in the left kidney had remarkably improved. Cystoscopy revealed that the stent had completely detached and that wall stones had attached on this surface. The stent was removed via cystoscopy. After 1 month, CT scanning showed that the left hydronephrosis of the patient had almost disappeared. Conclusion: Allium URS is effective in the treatment of hydronephrosis caused by ileal-ureteral anastomotic stenosis (AU)

Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease.

Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.

Successful management of pelvic urethral strictures with balloon dilation in 3 cats.

OBJECTIVE: To describe the successful management of pelvic urethral strictures in 3 young cats (1 after perineal urethrostomy, 1 after a third-time urethral obstruction, and 1 with prolonged lower urinary tract signs post-urethral obstruction) using balloon dilation and a short-term, indwelling urethral catheter. CASE SUMMARIES: A 9-month-old neutered male domestic longhair cat with a urethral obstruction and a suspected congenitally narrowed urethra was treated via perineal urethrostomy. The cat later developed acute kidney injury, multidrug-resistant urinary tract infections, and a pelvic urethral stricture. A second case, a 2.3-year-old neutered male domestic shorthair cat, developed a stricture of the pelvic urethra after multiple obstructions and catheterizations. A third case, a 1.2-year-old neutered male domestic shorthair cat, had persistent and prolonged lower urinary tract signs after treatment for a urinary obstruction. The cat also had an abnormally small urethral opening and was ultimately found to have a proximal urethral stricture. The strictures in all 3 cases were successfully treated with a combination of fluoroscopic-guided balloon dilation and short-term indwelling urethral catheterization while managing any present infection. NEW OR UNIQUE INFORMATION PROVIDED: To the authors' knowledge, this is the first published case series of successful balloon dilations paired with the use of a short-term indwelling urethral catheter in cats that developed urethral strictures after catheterization due to urinary obstructions. This procedure appears safe and well tolerated and appears to offer a long-term, cost-effective solution to urethral strictures at the level of the pelvis.

Urethral Stricture/Stenosis as a Complication of High Intensity Focused Ultrasound of the Prostate (HIFU): What is the Overall Patient Experience?

OBJECTIVE: To analyze the location and management of urethral stricture/stenosis in patients treated with High-intensity focused ultrasound (HIFU) of the prostate as well as to describe patient reported satisfaction in these men. METHODS: Patients with a history of HIFU requesting consultation for stricture were identified from 2010 to 2020. Demographic and prior treatment data were recorded. Patients who presented for evaluation underwent retrograde cystoscopy, retrograde urethrogram, voiding cystourethrogram, and antegrade cystoscopy through a suprapubic tract. Patients who only had virtual consultation and did not present for in-person evaluation, were followed longitudinally to assess long-term outcomes and quality of life. RESULTS: Over the 10-year study period, 17 patients were identified with a mean age of 65.8 years. Prior to initial consultation, a total of 88% of patients had at least 1 failed surgical intervention at a mean of 45 months post-HIFU. The majority of patients (94%) had strictures that included but were not necessarily limited to the prostatic urethra. Patients underwent various treatments postevaluation, favoring endoscopic therapy (38%), and proximal diversion (20%) at a mean follow-up of 68.2 ± 7.5 months. Only 38% reported satisfaction with urinary symptoms. CONCLUSION: Urethral narrowing post-HIFU appears to overwhelmingly involve the prostatic urethra. Patients usually have a significant treatment burden over a prolonged period and are often managed with repeated endoscopic treatment, extirpative prostatic surgery, or urinary diversion as they have obstruction that is not amendable to urethral reconstruction. Most patients with HIFU strictures experience a diminished QOL due to persistent urinary symptoms.

A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment.

Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.

The use of local therapy in preventing urethral strictures: A systematic review.

BACKGROUND: Urethral stricture disease is a common problem amongst men in Western countries often leading to a decreased quality of life. Current endoscopic treatment procedure shows an unsatisfying stricture recurrence rate which could be improved by addition of local therapies. OBJECTIVES: To provide an overview of both preclinical and clinical studies in order to investigate current level of evidence on the addition of local therapy to improve urethral stricture recurrence rates after endoscopic procedures. METHODS: We performed a literature search in December 2020 and August 2021 using Cochrane, Embase, PubMed, Scopus and Web of Science and identified articles through combinations of search terms for 'urethral stricture disease', 'stricture formation' and 'local interventions'. We used the SYRCLE, RoB-2 and ROBINS-I tools to assess risk of bias across included studies. We did not perform a meta-analysis due to methodological differences between studies. RESULTS: We included 32 articles in the qualitative analysis, 20 of which were preclinical studies and 12 clinical studies. Regarding preclinical articles using an animal model, nearly all interventions showed to have a positive effect on either urethral fibrosis, urethral stricture formation and/or fibrotic protein expression levels. Here, immunosuppressants and chemotherapeutics seemed most promising for possible clinical purposes. Regarding clinical studies, mitomycin-C and hyaluronic acid and carboxymethylcellulose showed positive effects on urethral stricture recurrence rates with low to intermediate risk of bias across studies. However, the positive clinical effects of mitomycin-C and steroids seemed to decrease in studies with a longer follow-up time. CONCLUSION: Although local adjuvant use of mitomycin-C or hyaluronic acid and carboxymethylcellulose may carry clinical potential to improve urethral structure recurrence rates after endoscopic procedures, we believe that a large, well-designed RCT with a yearlong follow-up time is necessary to identify the true clinical value.

Conservative Management of Lichen Sclerosus Male Urethral Strictures: A Multi-Institutional Experience.

OBJECTIVE: To assess the outcomes and safety of conservative management of lichen sclerosus urethral stricture disease (LS-USD). METHODS: This multi-institutional study included patients with LS-USD managed with endoscopic procedures or clean intermittent catheterization (CIC) regimens between 2005 and 2019. Those with an obliterative stricture, a history of prior urethral reconstruction, or <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. RESULTS: 112 men were analyzed with a median follow-up of 30.0 months (IQR 12.0-55.5). Median age was 52.5 years (IQR 42.6-61.0) and median body mass index was 34.5 kg/m2 (IQR 29.9-40.7). Median stricture length was 12.0 cm (IQR 2.8-20.0). 89% of patients underwent urethral balloon dilation, with a median of 2 (IQR 1-3) per patient. CIC was performed in 46% of patients, with 31% of this subgroup using intraurethral steroids. 84% of patients avoided invasive surgery or permanent indwelling catheterization, with an improvement in urethral stricture patient-reported outcome measure scores (P = .0013). Those who failed were more likely to have a history of UTI (P = .04), urosepsis (P = .03), AUR (P <.001), and more likely to perform CIC (P = .01). CONCLUSIONS: Over medium-term follow-up, most patients with LS-USD were safely managed with conservative techniques. Caution is warranted in those who develop UTIs, urosepsis, and AUR and the potential long-term consequences of repetitive conservative interventions must be considered.

Diagnosis and treatment of anterior urethral strictures in China: an internet-based survey.

BACKGROUND: To investigate the current diagnostic and therapeutic approaches to anterior urethral strictures of Chinese urologists and to compare with developed countries and the American Urologic Association guidelines. METHODS: Anonymous questionnaires were distributed to members of Official Wechat Account of urology from March 19, 2020 to April 10, 2020. Descriptive and multiple correspondence analysis were used to analyze the data. RESULTS: A total of 1276 online questionnaires were received. The response rate was 21.7% (1276/5878). The most common diagnostic methods for anterior urethral stricture were urethrography (90.7%) and urethrocystoscopy (85.4%), while urethral dilation (92.3%) and internal urethrotomy (60.1%) were the main therapeutic procedures. End-to-end urethroplasty (45.2%) was the most common open surgery, followed by skin flap urethroplasty (14.9%) and free graft urethroplasty (12.4%). 76.2% of urologists used urethroplasty only after the failure of minimally invasive surgery (reconstructive ladder treatment strategy). Furthermore, middle-aged or elderly urologists who had attended trainings, had senior practice roles, and who utilized a reconstructive ladder treatment approach were most likely to perform urethroplasties. CONCLUSIONS: Anterior urethral stricture treatment in China is still dominated by minimally invasive surgery, with most urologists using the reconstructive ladder treatment strategy. In general, the overall diagnostic and therapeutic strategies were similar between China and developed countries, with some deviations from the American Urologic Association guidelines.

[Urethral strictures: a variety of treatments requiring regular practice]. / Sténoses urétrales : une variété de traitements nécessitant une pratique régulière.

Urethral stricture is defined by a decrease in the caliber of the urethral lumen which can cause a decrease or an interruption of the urine flow. This disease is much more common in men than in women, and several causes can be identified. The diagnosis depends on a careful patient history focusing on obstructive and/or irritative lower urinary tract symptoms and is confirmed by a specific work-up. Treatment ranges from conservative management to open surgery and requires specialized surgeons, so as an adequate technical platform. The evolution of surgical techniques has fortunately significantly increased long term success rates. Hence, the classical saying heard about the outcome of urethral stenosis treatment : « once a stricture, always a stricture ¼ is no longer the rule.

La sténose urétrale est définie comme une diminution du calibre de la lumière urétrale qui peut engendrer une diminution du flux urinaire. Cette pathologie est plus fréquente chez l'homme et on l'attribue à de nombreuses causes. Le diagnostic dépend d'une bonne anamnèse, marquée essentiellement par des troubles mictionnels obstructifs et/ou irritatifs, et est confirmé par des examens complémentaires spécifiques. Le traitement peut aller de la prise en charge conservatrice à la chirurgie ouverte, et requiert toujours des chirurgiens spécialisés ainsi qu'un plateau technique adéquat. Ces 25 dernières années, le développement des techniques chirurgicales a permis d'augmenter le taux de succès, ce qui contredit l'adage classique du milieu du siècle dernier : « once a stricture, always a stricture ¼.

How I Do It: The Optilume drug-coated balloon for urethral strictures.

Urethral stricture disease can be difficult to treat and stricture recurrence is common. The management of stricture disease has evolved and urethroplasty can achieve a high rate of lasting urethral patency. Nevertheless, endoscopic treatments still seem to have sub-optimal outcomes with high stricture recurrence rates. The Optilume drug-coated balloon represents a step forward in the endoscopic management of urethral strictures. The drug-coated balloon may offer an intermediate step prior to repeated dilations, urethrostomies, or urethroplasty. This treatment modality is a promising alternative to current endoscopic management and an option for patients that are poor surgical candidates or decline urethroplasty.

Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry.

OBJECTIVE: To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success. MATERIALS AND METHODS: The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census. RESULTS: We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64). CONCLUSIONS: Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.

Endoscopic Dilatation of Meatal Stenosis of Ureterocele in Adult Patients: An Easy and Innovative Technique with Literature Review.

This study presents initial experience in endoscopic meatal dilatation of obstructive ureterocele in adult patients. During cystourethroscopy, we tried to find the orifice of ureterocele, passed a guide wire and introduce an 8 Fr ureteroscope in to the ureterocele orifice, going up to the renal pelvis as under vision dilatation of ureterocele meatus. Two Double-J stent were inserted and remained for six weeks to keep the meatus dilated. Adverse effect of endoscopic management was decreased due to minimal anatomic changes. Patients' symptoms were relieved and no evidence of new onset vesico-ureteral reflux and obstruction were seen after up to one-year follow-up. Endoscopic meatal dilatation of stenotic ureterocele in adult patients is safe and effective thus, trying to find the orifice of ureterocele is suggested.