Urétrotomie interne par voie endoscopique

Endoscopic internal urethrotomy

Endoscopic urethrotomy is usually the first line therapy performed to treat the urethra strictures, particularly when it touches the bulbar portion of the channel.

It’s easy production intervention, minimally invasive, requiring only a short hospital stay and also a short interruption of personal and professional activities.

However, it is noted that for short strictures, and the recurrence rate is high.

This raises often secondary or use immediately in urethroplasty, to obtain a more permanent result.

 

Description endoscopic internal urethrotomy

The urethra strictures being defined as a reduction in the caliber of the urethral canal, endoscopic urethrotomy restores normal urethral caliber.

With the patient in the position known size (close to the classic gynecological position) the urologist introduced by the urethral meatus an endoscope into the channel, which follows the progress under visual control to visualize area of ​​the stenosis.

 

endoscope

endoscope

The urologist intubated using a metal guide wire urethral light so as not to lose the way.

Then sectioned under direct vision the stenotic area over the entire thickness and the entire length fibrotic tissue until healthy tissue. This section is usually performed on the roof of the narrowing, or wheel spokes, with particular caution in the area of ​​the urethral sphincter.

It uses this usually effect a cold blade mounted on the surgical endoscope and handled using a trigger.

The use of a fiber laser Holmium is optional.

This procedure is done under general anesthesia or loco-regional-type epidural or spinal anesthesia.

It ended with the laying of a urinary catheter.

 

Pose sonde medicale

 

Possible operating conditions

1) The cold blade

Most commonly used and in particular in cases of stenosis of the bulbar urethra.

Intervention is little or no bleeding and does not require cauterization.

2) The laser

Optional operating mode and no real advantage over the use of the cold blade, particularly in terms of risk of occurrence of relapses.

 

laser

 

Preoperative Evaluation

It is detailed in our page dedicated to the diagnosis of urethral stricture.

The urologist must specify before operating characteristics of stenosis: seat length, tight or not the shrinkage, impact of the stenosis, complications that could lead

Among the useful explorations in this evaluation:

– The urethrovesical endoscopy which allows the diagnosis of stenosis and accurate sound possible tight character and its headquarters;

– Radiological opacification of the urethra, usually by a urethro VCUG and retrograde mictionelle;

– A cytobacteriological urinalysis and a blood balance sheet look a urinary tract infection or kidney failure;

– A pre-anesthetic consultation.

Adjustments to the patient’s personal treatment are eventually made, particularly if treated with anticoagulants or anti-platelet aggrégants.

Operation followup

The bladder catheter is removed on prescription urologist according to their habits. In our practice this catheter is removed the day after surgery.

In the days following the withdrawal, sometimes the patient feels burns during urination and / or traces of blood were found in his urine.

No drug further treatment or any other biological or imaging exploration is required after surgery during hospitalization.

Postoperative consultation in the following quarter the intervention notably allows the surgeon

– Assess the improved strength of the urinary stream by a flow meter, and measure the residual urine by échoscopie;

– To verify the absence of infection with cyto-bacteriological analysis durines.

The patient can usually resume all his personal activities quickly.

 

Risks and complications associated with surgery

Apart from complications related to patient ground (including its comorbidities) or anesthesia, those directly related to the transaction are infrequent.

We can see:

– Urinary tract infection postoperative control requiring the prescription of an antibiotic treatment followed by a new urine culture checking the disappearance of the germ.

– A bladder retention leading to temporary rests a urinary catheter.

– Bleeding from the urethra (or urethral bleeding) which may be accompanied by pelvic pain or urinary tract symptoms related to the presence of clots.

– A urinary incontinence major risk, if applied to the section of a stenosis located in the striated urethral sphincter zone in the membranous portion of the urethra.

 

Advantages and disadvantages of the method

The endoscopic internal urethrotomy reduces hospital stays, to minimize impacts on the personal and professional life of the patient and the operating risks. However, recurrences are common.

 

Rest Period for the patient

The procedure usually lasts less than a quarter of an hour.

The hospitalization lasts mostly within 3 days and in our practice the patient leaves the day after surgery, after removal of the probe and the resumption of spontaneous voiding by natural means.

The recovery of all the personal and professional activities is usually very fast.

The resumption of sexual activity is also fast, but erections can cause bleeding from the urethra or bloody ejaculations at first.

It should be noted that the decrease in noticeable discomfort is sometimes noticeable after a period of a few weeks.

 

Success rate

endoscopic urethrotomy success rates are around 60 to 70% depending on the seat of the stenosis.

The laser provides no measurable benefit over the use of the cold blade.

 

Relapses

The rate of recurrence of urethral stricture after endoscopic urethrotomy is high: 40% of cases in the year following the urétrotomie for a short stenosis of less than 2 cm, and 80% of cases, for superior stenosis 4 cm.

Its indication remains limited ideally for short strictures.

75% of these recurrences occur during the first year after endoscopic urethrotomy, but late recurrences, more than 5 years after surgery can be observed in 5% of cases.

After a maximum of two chess urétrotomies should be considered a urethroplasty because the failure of urétrotomie worsens the characteristics of the stenosis. Surgical repair becomes even more difficult.

The success rate of the second urethrotomy is lower than the first and the second urétrotomie even avoided if the early recurrence occurred within less than a year after the initial urethrotomy. Using the outset urétrotplastie in this situation is lawful as stated BARBAGLI in 2010.

 

Conclusion

Endoscopic urethrotomy is an intervention that was first described in France in the late nineteenth century by OTIS and Maisonneuve.

2/3 of patients undergoing endoscopic urethrotomy are cured, but the failures represent 1/3 of cases.

It should observe the limits of technology.

 

Some bibliographical elements:

 

 

In English

http://www.urethralcenter.it/English_version/pagine/uretrotomia.html

http://www.urology-textbook.com/internal-urethrotomy.html

http://www.medsolution.com/surgery_urogen-internurethro.asp

 

Videos (English)

https://www.youtube.com/watch?v=EN79fdaxEUI

https://www.youtube.com/watch?v=8YijhQEHpbs

https://www.youtube.com/watch?v=MVgUV9FNFg0

 

In French

http://urofrance.org/fileadmin/documents/data/FI/2012/uretrotomie-interne/uretrotomie-interne.pdf

http://www.dematice.org/ressources/DCEM2/urologie/D2_uro_008/co/Module_RU_7.html

http://www.em-consulte.com/article/991333