British Journol of Urology (1978), 50, 257-261
Endourethral Urethroplasty: A Simple Method for Treatment of Urethral Strictures by Internal Urethrotomy and Primary Split Skin Grafting SILAS PETTERSSON, BJORN ASKLIN and CLAES-CORAN BRATT Department of Urology, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden
Summary- Primary endourethral split skin grafting was performed in 4 patients operated upon for stricture of the bulbous urethra by internal urethrotomy. Post-operatively, all grafts were found to have taken. Follow-up has ranged from 4 to 1 2 months. The results were considered good in all patiepts and after release from the hospital they had no subjective symptoms. Further urethral dilation has not been necessary in any of the patients.
Internal urethrotomy has been used for a long time. A lancellated catheter was used by AmbroBe Part (1510-1590) and through the years the technique has been modified. The ingenious urethrotome described by Otis (1 878) is still in use in many centres 100 years after its introduction. This blind technique was later replaced by internal urethrotomy under direct vision (Helmstein, 1964; Sachse, 1974). Although many authors have had good results with the procedure (Wise et al., 1972; Carlton et al., 1974; Sachse, 1974; Matouschek and Michaelis, 1975) others give the method a limited place as it seldom, if ever, leads to a permanent cure of a stricture (Blandy et al., 1976). At internal urethrotomy, the incision is left to heal by “second intention”. This involves formation of new scar tissue which in time may contract, resulting in recurrence of the stricture. One method of diminishing scar tissue formation after an incision is primary skin grafting. This paper presents a method for treatment of urethral strictures by internal urethrotomy in combination with primary endourethral split skin grafting. Preliminary results of the method have been reported previously (Pettersson and Lundstam, 1977).
Table 1 Patients Treated by Endourethral UrethroPlaty Patient Age Symptoms No. (verrrs)
Duration Treatment of symp- before toms EUPP* hears)
1
24
2
29
3
I1
Acute retention
12
4
51
Acute retention
1
Acute retention Urinary infection Epididymitis Prostatic calculi Poor stream Urinary infection Epididymitis
I
Bouginage
5
Bouginage Internal urethrotomy Bouginage
EUPP =endourethral urethroplasty.
Patients and Methods Clinical During a 12 month period, 4 men were treated by endourethral urethroplasty (EUUP) for strictures
of the bulbous urethra (Table 1). Three patients presented with acute urinary obstruction (Nos. 1, 3 and 4) and 1 complained of poor stream (No. 2). Two had suffered from recurrent epididymitis (Nos. 1 and 2). The duration of symptoms ranged from 1 to 12 years. One patient (No. 3) had had intermittent bouginage every 6 to 8 weeks for 12 years. Ordinary internal urethrotomy was tried first but the stricture recurred within 3 months. Endourethral urethroplasty was performed 9 months later. Prior to treatment, a quantitative urine culture and a retrograde urethrogram were obtained.
Received 7 November 1977. Accepted for publication 8 December 1977.
Operative Procedure The operation was performed under general or 257
258
BRITISH JOURNAL OF UROLOGY
Site of uret hrotomy
+
1
Distance between stricture Balloon
and bladder neck
Skin graft
Fig. 1 Schematic drawing of a silastic Foley catheter. The split skin graft is glued with the epithelial surface towards the catheter. The position of the graft was calculated from the pre-operative urethrogram and transferred to the catheter, measured from the lower edge of the balloon. Note the graft surplus as compared to the length of the incision.
spinal anaesthesia. The urethrotomy was performed with a Winter-Ibe urethrotome under direct vision. The incision was made at 12 o'clock and was carried down until all fibrous tissue was incised and until the urethrotome (20 F) passed easily. A split skin graft (thickness 0.45 mm) was cut with an electric dermatome from the thigh. The graft was made about 2 cm longer than the length of the urethral incision. The breadth was 20 mm, i.e. equal to the circumference of a 20 F catheter. The distance between the bladder neck and the centre of the stricture was measured on the urethrogram (lateral projection) and corrected for enlargement. The calculated distance was marked out on a silastic Foley catheter (20 F), as measured from the lower edge of the balloon (Fig. 1). The graft was centred to the obtained mark and, with the epithelial surface towards the catheter, glued (Arasol, R6hm Pharma, Darmstadt) around the catheter, which was to serve as a splint. As soon as the glue had set, the catheter was inserted into the urethra, the balloon inflated, and the catheter withdrawn until the lower edge of the balloon reached the bladder neck. A firm, well-padded compression dressing of voluminous gauze and elastic adhesive was applied to the perineum and the urethra (Johanson, 1953). The bladder was drained by a suprapubic cystostomy.
All patients were given antibiotics. To prevent thrombosis 5 0 0 ml dextran 70 (Macrodex(R), Pharmacia) was given during the operation and every second day post-operatively for 6 days.
Post-operative Care The dressing was retained for 6 days, during which time the patient remained supine in bed. The urethral catheter was removed after 10 days, when the glue was considered to have dissolved. After about 2 weeks, urethroscopy was performed to check the graft. The cystostomy was retained for 4 to 6 weeks. Before the cystostomy was removed, a voiding urethrogram was obtained.
3 4
5
Follow-up Studies The patients were observed at 3, 6, 9 and 12 months post-operatively. The evaluation consisted of quantitative urine culture, urine flow rate, retrograde urethrogram and urethroscopy including intraurethral photography. The patients were also questioned with regard to subjective symptoms such as frequency, pain, voiding stream, and sexual function.
Results Adequate follow-up data are available in all 4 patients. The time since operation ranged between 4 and 12 months (Table 2). The results were considered good in all patients and after release from hospital they had no subjective symptoms. Table 2 Results of Endourethral Urethroplasty Observation Timed micturition time (months) (sec 0.100 mi-')
Minimum Urinary diameter infection on urethrogram (mm)
1
12
9
5
2
9
3 6 6
I
Patient
No.
4
8 6
+
-
Further urethral dilatation was not necessary in any patient. At urethroscopy, 2 weeks post-operatively, all 4 grafts were found to have taken. Around the oval centre of the graft necrotic remnants of the
ENDOURETHRAL URETHOPLASTY: A SIMPLE METHOD FOR TREATMENT OF URETHRAL STRICTURES
259
Fig. 2 An intraurethral photo of a graft 3 months Postoperatively (Patient No. 3). The surplus had been shed and the graft had assumed its final oval shape and pale yellow colour.
graft surplus were seen. At the next endoscopic examination, 3 months after the operation, the surplus had been shed (Fig. 2). At this time, the graft had assumed its final oval shape and pale yellow colour which it preserved during the whole of the follow-up period. In 3 patients (Nos. 2, 3 and 4) a 20 F urethroscope passed the graft without difficulty. In 1 patient (No. l ) , the urethral lumen was slightly decreased at the proximal border of the graft. A 17 F urethroscope, however, passed easily. The urine flow rate was within normal limits by the time the suprapubic catheter was removed. Table 2 shows the results of timed micturition obtained at the last post-operative evaluation. The values were within normal limits. The post-operative urethrogram showed a considerably increased urethral diameter at the site of the former stricture as compared with the preoperative examination (Figs. 3 and 4). The minimum diameter, as measured from the last postoperative urethrogram, is given in Table 2. Three patients (Nos. 1, 2 and 3) had had recurrent
Fig. 3 Pre-operative urethrogram of a bulbous urethral stricture (Patient No. 3).
Fig. 4 Post-operative urethrogram obtained 6 months after endourethral urethroplasty (Patient No. 3).
260
urinary tract infection pre-operatively (Table 1). In 1 patient (No. l), the infection recurred postoperatively; the other 2 had negative cultures (Table 2). Few complications were encountered. Patient No. 1 underwent surgery again 3 days postoperatively due to haemorrhage caused by the percutaneously performed cystostomy. A few weeks later, he had egg-shell-like calcifications from the catheter crushed and evacuated transurethrally. No other complications were encountered.
Discussion Four patients were operated upon for stricture of the bulbous urethra by internal urethrotomy in combination with primary endourethral split skin grafting. Post-operatively, all grafts were found to have been successful. No sign of recurrence of the strictures was encountered. The actual procedure is an application on urethral strictures of the original NovC-Josserand (1919) operation for repair of hypospadias. According to his method, a skin graft was coiled round a probe which was introduced through a subcutaneous tunnel on the ventral aspect of the penis. It should be noted, however, that the whole circumference of the urethra was replaced by this method and that the operation was not performed endourethrally. To some extent, conventional internal urethrotomy may be compared with a traumatic urethral lesion. The amount of scar tissue that follows the incision will depend mainly on whether infection supervenes or not. Infection can prevent the normal migration of epithelial cells or even cause their regression. The excess of granulation tissue which ensues in badly infected wounds contributes to excessive scarring. From experimental studies in the rat, Singh and Blandy (1976) concluded that the post-traumatic inflammatory reaction in the urethra was much more severe when extravasation of urine was not prevented. To reduce the inflammatory reaction after internal urethrotomy, a urethral catheter is often left indwelling for 3 weeks (Katz and Waterhouse, 1971) or longer (Engel et al., 1972; Wise et al., 1972). Despite the deviating function of a urethral catheter, it is nevertheless difficult, if not impossible, to avoid secondary urethritis and infection of the urethrotomy when the urethra is left intubated for several weeks. Another proposed
BRITISH JOURNAL OF UROLOGY
method of reducing the inflammatory reaction in connection with treatment of urethral strictures is the use of steroids administered systemically (Roald, 1955) or injected per urethram (Hebert, 1972). The post-operative inflammatory reaction and scarring tendency, however, may be reduced to a minimum by obtaining conditions for primary healing. This may be achieved by primary skin grafting. The actual graft position on the catheter, which corresponds exactly to the urethrotomy, cannot be given with the present technique. It is, therefore, not possible to use a graft which precisely fits the incision. However, as a skin graft will take only on incised tissue and not on intact urethral epithelium, it may be applied in excess, which reduces the need for accuracy in its application. The graft surplus will necrose and later be shed. As this takes place more rapidly with a thin graft as compared with a full thickness graft, a split skin graft was chosen. When split skin grafts are used, on the other hand, there is a risk of secondary contraction of the graft (McCormack, 1954). The tendency to contract, however, has been considered much less pronounced when a thick split skin graft is used (McCormack, 1954). The results of the procedure were evaluated on the basis of a urine flow rate, urethrograms and endoscopic examinations. Urine flow rate is considered a functional evaluation of the results of urethral stricture repair. It is sufficiently accurate and has the advantage that it can be performed by the patient at home using a stopwatch and a graduated glass. As pointed out by Lapides and Stone (1968), a retrograde urethrogram can delineate most small diameter strictures of the anterior urethra, but strictures of a calibre greater than 20 F are not readily identifiable. Urethrography is, therefore, considered suitable to exclude recurrence of a stricture but is less exact in the grading of a good result after urethroplasty. Urethroscopy with photographs of the urethra offers objective evidence of the results. The easy passage of a former stricture with an instrument of a given calibre provides a modified urethral calibration. So far, the results of the procedure have been encouraging, but the observation time of 4 to 12 months is short and the number of patients too small to permit definite evaluation of the results. Nevertheless, the procedure is easy, it may be performed under local anaesthesia, and the
ENWURETHRAL URETHOPLASTY: A SIMPLE METHOD FOR TREATMENT OF URETHRAL STRICTURES
method does not render other reconstructions more difficult if it should fail.
References
261
endoskopischer Kontrolle. Urologia Internationalk, 30, 266-272.
MeCormack, R. M. (1954). Simultaneous chordee repair and urethral reconstruction for hypospadias. Experimental and clinical studies. Plastic and Reconstructive Surgety, 13, 257-274.
Attwater, H. L. (1943). The history of urethral stricture. British Journal of Urology, 15, 39-5 1. BIandy, J. P., Wadhwa, S., Slngh, M. and Trealdder, G. C. (1976). Urethroplasty in context. British Journal of Urology, 48,697-701. Cnrlton, F. E., Seardino, P. L. .ad Quattlebaurn, R. B. (1974). Treatment of urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. Journal of Urology, 111, 191-193. Engel, R. M. E., Wise, H. A. and Whitaker, R. H. (1972). Otis internal urethrotomy with long-term urethral intubation: A comparison of latex and silastic catheters. Southern Medical Journal, 65, 55-60. Hcbert, P. W. (1972). The treatment of urethral stricture: Transurethral injection of triamcinolone. Journal of Urology, 108, 745-747. Helmstein, K. (1964). Internal urethrotomy: modifications in the operative technique. Acta Chirurgica Scandinavica, suppl., 34. Johnmoo, B. (1953). Reconstruction of the male urethra in strictures. Acta Chirurgica Scandinavica, suppl. 176. Katz, A. S. and Waterhouse, K. (1971). Treatment of urethral strictures in men by internal urethrotomy. A study of 61 patients. Journal of Urology, 105, 807-808. Lapldes, J. and Stone, T. E. (1%8). Usefulness of retrograde urethrography in diagnosing strictures of the anterior urethra. Journal of Urology, 100, 747-750. Matowhek, E. and Michael&, W. E. (1975). uber die transurethrale Schlitzung von HarnrOhrenstrikturen unter
.
NovkJossernnd, G . (1919). Nouvelle technique pour la restauration en une seance des hypospadias Ctendus par la tunnellisation avec greffe dermodpidermique. Journal d’Urologie, 8, 449-456. O h , F. N. (1878). “Stricture of the Male Urethra and its Radical Cure”. Pettersson, S. and Lundstnm, S. (1977). Uretroplastie endouretrale. Une mkthode simple de traitement du rCtrCcissement de l’ur6tre. 71st French Congress of Urology, Paris. Rodd, H. (1955). Urethral stricture treated with ACTA and indwelling catheter. Acta Chirurgica Scandinavica, 110, 58. Spchse, H. (1974). Die transurethrale scharfe Schlitzung der HarnrOhrenstriktur unter Sicht . MUnchener medizinische Wochemchr#, 116,2147-2150. Singh, M. and Blandy, J. P. (1976). The pathology of urethral stricture. Journal of Urology, 115, 673-676. Wise, H. A., Engel, R. M. E. and Whitaker, R. H. (1972). Treatment of urethral strictures. Journal of Urology, 107, 269-272.
The Authors Silas Pettersson. MD, Assistant Professor. BjOrn Asklin, MD, Senior Registrar. Claes-GOran Bratt, MD, Senior Urological Registrar. Requests for reprints to: Silas Pettersson, MD, Department of Urology, Sahlgrenska sjukhuset, S-413 45 GOteborg, Sweden.
Endourethral Urethroplasty: A Simple Method for Treatment of Urethral Strictures by Internal Urethrotomy and Primary Split Skin Grafting SILAS PETTERSSON, BJORN ASKLIN and CLAES-CORAN BRATT Department of Urology, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden
Summary- Primary endourethral split skin grafting was performed in 4 patients operated upon for stricture of the bulbous urethra by internal urethrotomy. Post-operatively, all grafts were found to have taken. Follow-up has ranged from 4 to 1 2 months. The results were considered good in all patiepts and after release from the hospital they had no subjective symptoms. Further urethral dilation has not been necessary in any of the patients.
Internal urethrotomy has been used for a long time. A lancellated catheter was used by AmbroBe Part (1510-1590) and through the years the technique has been modified. The ingenious urethrotome described by Otis (1 878) is still in use in many centres 100 years after its introduction. This blind technique was later replaced by internal urethrotomy under direct vision (Helmstein, 1964; Sachse, 1974). Although many authors have had good results with the procedure (Wise et al., 1972; Carlton et al., 1974; Sachse, 1974; Matouschek and Michaelis, 1975) others give the method a limited place as it seldom, if ever, leads to a permanent cure of a stricture (Blandy et al., 1976). At internal urethrotomy, the incision is left to heal by “second intention”. This involves formation of new scar tissue which in time may contract, resulting in recurrence of the stricture. One method of diminishing scar tissue formation after an incision is primary skin grafting. This paper presents a method for treatment of urethral strictures by internal urethrotomy in combination with primary endourethral split skin grafting. Preliminary results of the method have been reported previously (Pettersson and Lundstam, 1977).
Table 1 Patients Treated by Endourethral UrethroPlaty Patient Age Symptoms No. (verrrs)
Duration Treatment of symp- before toms EUPP* hears)
1
24
2
29
3
I1
Acute retention
12
4
51
Acute retention
1
Acute retention Urinary infection Epididymitis Prostatic calculi Poor stream Urinary infection Epididymitis
I
Bouginage
5
Bouginage Internal urethrotomy Bouginage
EUPP =endourethral urethroplasty.
Patients and Methods Clinical During a 12 month period, 4 men were treated by endourethral urethroplasty (EUUP) for strictures
of the bulbous urethra (Table 1). Three patients presented with acute urinary obstruction (Nos. 1, 3 and 4) and 1 complained of poor stream (No. 2). Two had suffered from recurrent epididymitis (Nos. 1 and 2). The duration of symptoms ranged from 1 to 12 years. One patient (No. 3) had had intermittent bouginage every 6 to 8 weeks for 12 years. Ordinary internal urethrotomy was tried first but the stricture recurred within 3 months. Endourethral urethroplasty was performed 9 months later. Prior to treatment, a quantitative urine culture and a retrograde urethrogram were obtained.
Received 7 November 1977. Accepted for publication 8 December 1977.
Operative Procedure The operation was performed under general or 257
258
BRITISH JOURNAL OF UROLOGY
Site of uret hrotomy
+
1
Distance between stricture Balloon
and bladder neck
Skin graft
Fig. 1 Schematic drawing of a silastic Foley catheter. The split skin graft is glued with the epithelial surface towards the catheter. The position of the graft was calculated from the pre-operative urethrogram and transferred to the catheter, measured from the lower edge of the balloon. Note the graft surplus as compared to the length of the incision.
spinal anaesthesia. The urethrotomy was performed with a Winter-Ibe urethrotome under direct vision. The incision was made at 12 o'clock and was carried down until all fibrous tissue was incised and until the urethrotome (20 F) passed easily. A split skin graft (thickness 0.45 mm) was cut with an electric dermatome from the thigh. The graft was made about 2 cm longer than the length of the urethral incision. The breadth was 20 mm, i.e. equal to the circumference of a 20 F catheter. The distance between the bladder neck and the centre of the stricture was measured on the urethrogram (lateral projection) and corrected for enlargement. The calculated distance was marked out on a silastic Foley catheter (20 F), as measured from the lower edge of the balloon (Fig. 1). The graft was centred to the obtained mark and, with the epithelial surface towards the catheter, glued (Arasol, R6hm Pharma, Darmstadt) around the catheter, which was to serve as a splint. As soon as the glue had set, the catheter was inserted into the urethra, the balloon inflated, and the catheter withdrawn until the lower edge of the balloon reached the bladder neck. A firm, well-padded compression dressing of voluminous gauze and elastic adhesive was applied to the perineum and the urethra (Johanson, 1953). The bladder was drained by a suprapubic cystostomy.
All patients were given antibiotics. To prevent thrombosis 5 0 0 ml dextran 70 (Macrodex(R), Pharmacia) was given during the operation and every second day post-operatively for 6 days.
Post-operative Care The dressing was retained for 6 days, during which time the patient remained supine in bed. The urethral catheter was removed after 10 days, when the glue was considered to have dissolved. After about 2 weeks, urethroscopy was performed to check the graft. The cystostomy was retained for 4 to 6 weeks. Before the cystostomy was removed, a voiding urethrogram was obtained.
3 4
5
Follow-up Studies The patients were observed at 3, 6, 9 and 12 months post-operatively. The evaluation consisted of quantitative urine culture, urine flow rate, retrograde urethrogram and urethroscopy including intraurethral photography. The patients were also questioned with regard to subjective symptoms such as frequency, pain, voiding stream, and sexual function.
Results Adequate follow-up data are available in all 4 patients. The time since operation ranged between 4 and 12 months (Table 2). The results were considered good in all patients and after release from hospital they had no subjective symptoms. Table 2 Results of Endourethral Urethroplasty Observation Timed micturition time (months) (sec 0.100 mi-')
Minimum Urinary diameter infection on urethrogram (mm)
1
12
9
5
2
9
3 6 6
I
Patient
No.
4
8 6
+
-
Further urethral dilatation was not necessary in any patient. At urethroscopy, 2 weeks post-operatively, all 4 grafts were found to have taken. Around the oval centre of the graft necrotic remnants of the
ENDOURETHRAL URETHOPLASTY: A SIMPLE METHOD FOR TREATMENT OF URETHRAL STRICTURES
259
Fig. 2 An intraurethral photo of a graft 3 months Postoperatively (Patient No. 3). The surplus had been shed and the graft had assumed its final oval shape and pale yellow colour.
graft surplus were seen. At the next endoscopic examination, 3 months after the operation, the surplus had been shed (Fig. 2). At this time, the graft had assumed its final oval shape and pale yellow colour which it preserved during the whole of the follow-up period. In 3 patients (Nos. 2, 3 and 4) a 20 F urethroscope passed the graft without difficulty. In 1 patient (No. l ) , the urethral lumen was slightly decreased at the proximal border of the graft. A 17 F urethroscope, however, passed easily. The urine flow rate was within normal limits by the time the suprapubic catheter was removed. Table 2 shows the results of timed micturition obtained at the last post-operative evaluation. The values were within normal limits. The post-operative urethrogram showed a considerably increased urethral diameter at the site of the former stricture as compared with the preoperative examination (Figs. 3 and 4). The minimum diameter, as measured from the last postoperative urethrogram, is given in Table 2. Three patients (Nos. 1, 2 and 3) had had recurrent
Fig. 3 Pre-operative urethrogram of a bulbous urethral stricture (Patient No. 3).
Fig. 4 Post-operative urethrogram obtained 6 months after endourethral urethroplasty (Patient No. 3).
260
urinary tract infection pre-operatively (Table 1). In 1 patient (No. l), the infection recurred postoperatively; the other 2 had negative cultures (Table 2). Few complications were encountered. Patient No. 1 underwent surgery again 3 days postoperatively due to haemorrhage caused by the percutaneously performed cystostomy. A few weeks later, he had egg-shell-like calcifications from the catheter crushed and evacuated transurethrally. No other complications were encountered.
Discussion Four patients were operated upon for stricture of the bulbous urethra by internal urethrotomy in combination with primary endourethral split skin grafting. Post-operatively, all grafts were found to have been successful. No sign of recurrence of the strictures was encountered. The actual procedure is an application on urethral strictures of the original NovC-Josserand (1919) operation for repair of hypospadias. According to his method, a skin graft was coiled round a probe which was introduced through a subcutaneous tunnel on the ventral aspect of the penis. It should be noted, however, that the whole circumference of the urethra was replaced by this method and that the operation was not performed endourethrally. To some extent, conventional internal urethrotomy may be compared with a traumatic urethral lesion. The amount of scar tissue that follows the incision will depend mainly on whether infection supervenes or not. Infection can prevent the normal migration of epithelial cells or even cause their regression. The excess of granulation tissue which ensues in badly infected wounds contributes to excessive scarring. From experimental studies in the rat, Singh and Blandy (1976) concluded that the post-traumatic inflammatory reaction in the urethra was much more severe when extravasation of urine was not prevented. To reduce the inflammatory reaction after internal urethrotomy, a urethral catheter is often left indwelling for 3 weeks (Katz and Waterhouse, 1971) or longer (Engel et al., 1972; Wise et al., 1972). Despite the deviating function of a urethral catheter, it is nevertheless difficult, if not impossible, to avoid secondary urethritis and infection of the urethrotomy when the urethra is left intubated for several weeks. Another proposed
BRITISH JOURNAL OF UROLOGY
method of reducing the inflammatory reaction in connection with treatment of urethral strictures is the use of steroids administered systemically (Roald, 1955) or injected per urethram (Hebert, 1972). The post-operative inflammatory reaction and scarring tendency, however, may be reduced to a minimum by obtaining conditions for primary healing. This may be achieved by primary skin grafting. The actual graft position on the catheter, which corresponds exactly to the urethrotomy, cannot be given with the present technique. It is, therefore, not possible to use a graft which precisely fits the incision. However, as a skin graft will take only on incised tissue and not on intact urethral epithelium, it may be applied in excess, which reduces the need for accuracy in its application. The graft surplus will necrose and later be shed. As this takes place more rapidly with a thin graft as compared with a full thickness graft, a split skin graft was chosen. When split skin grafts are used, on the other hand, there is a risk of secondary contraction of the graft (McCormack, 1954). The tendency to contract, however, has been considered much less pronounced when a thick split skin graft is used (McCormack, 1954). The results of the procedure were evaluated on the basis of a urine flow rate, urethrograms and endoscopic examinations. Urine flow rate is considered a functional evaluation of the results of urethral stricture repair. It is sufficiently accurate and has the advantage that it can be performed by the patient at home using a stopwatch and a graduated glass. As pointed out by Lapides and Stone (1968), a retrograde urethrogram can delineate most small diameter strictures of the anterior urethra, but strictures of a calibre greater than 20 F are not readily identifiable. Urethrography is, therefore, considered suitable to exclude recurrence of a stricture but is less exact in the grading of a good result after urethroplasty. Urethroscopy with photographs of the urethra offers objective evidence of the results. The easy passage of a former stricture with an instrument of a given calibre provides a modified urethral calibration. So far, the results of the procedure have been encouraging, but the observation time of 4 to 12 months is short and the number of patients too small to permit definite evaluation of the results. Nevertheless, the procedure is easy, it may be performed under local anaesthesia, and the
ENWURETHRAL URETHOPLASTY: A SIMPLE METHOD FOR TREATMENT OF URETHRAL STRICTURES
method does not render other reconstructions more difficult if it should fail.
References
261
endoskopischer Kontrolle. Urologia Internationalk, 30, 266-272.
MeCormack, R. M. (1954). Simultaneous chordee repair and urethral reconstruction for hypospadias. Experimental and clinical studies. Plastic and Reconstructive Surgety, 13, 257-274.
Attwater, H. L. (1943). The history of urethral stricture. British Journal of Urology, 15, 39-5 1. BIandy, J. P., Wadhwa, S., Slngh, M. and Trealdder, G. C. (1976). Urethroplasty in context. British Journal of Urology, 48,697-701. Cnrlton, F. E., Seardino, P. L. .ad Quattlebaurn, R. B. (1974). Treatment of urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. Journal of Urology, 111, 191-193. Engel, R. M. E., Wise, H. A. and Whitaker, R. H. (1972). Otis internal urethrotomy with long-term urethral intubation: A comparison of latex and silastic catheters. Southern Medical Journal, 65, 55-60. Hcbert, P. W. (1972). The treatment of urethral stricture: Transurethral injection of triamcinolone. Journal of Urology, 108, 745-747. Helmstein, K. (1964). Internal urethrotomy: modifications in the operative technique. Acta Chirurgica Scandinavica, suppl., 34. Johnmoo, B. (1953). Reconstruction of the male urethra in strictures. Acta Chirurgica Scandinavica, suppl. 176. Katz, A. S. and Waterhouse, K. (1971). Treatment of urethral strictures in men by internal urethrotomy. A study of 61 patients. Journal of Urology, 105, 807-808. Lapldes, J. and Stone, T. E. (1%8). Usefulness of retrograde urethrography in diagnosing strictures of the anterior urethra. Journal of Urology, 100, 747-750. Matowhek, E. and Michael&, W. E. (1975). uber die transurethrale Schlitzung von HarnrOhrenstrikturen unter
.
NovkJossernnd, G . (1919). Nouvelle technique pour la restauration en une seance des hypospadias Ctendus par la tunnellisation avec greffe dermodpidermique. Journal d’Urologie, 8, 449-456. O h , F. N. (1878). “Stricture of the Male Urethra and its Radical Cure”. Pettersson, S. and Lundstnm, S. (1977). Uretroplastie endouretrale. Une mkthode simple de traitement du rCtrCcissement de l’ur6tre. 71st French Congress of Urology, Paris. Rodd, H. (1955). Urethral stricture treated with ACTA and indwelling catheter. Acta Chirurgica Scandinavica, 110, 58. Spchse, H. (1974). Die transurethrale scharfe Schlitzung der HarnrOhrenstriktur unter Sicht . MUnchener medizinische Wochemchr#, 116,2147-2150. Singh, M. and Blandy, J. P. (1976). The pathology of urethral stricture. Journal of Urology, 115, 673-676. Wise, H. A., Engel, R. M. E. and Whitaker, R. H. (1972). Treatment of urethral strictures. Journal of Urology, 107, 269-272.
The Authors Silas Pettersson. MD, Assistant Professor. BjOrn Asklin, MD, Senior Registrar. Claes-GOran Bratt, MD, Senior Urological Registrar. Requests for reprints to: Silas Pettersson, MD, Department of Urology, Sahlgrenska sjukhuset, S-413 45 GOteborg, Sweden.
