Iatrogenic Urethral Strictures Following Endoscopic Urethral Procedures: A Disheartening TUPR Outcome (And Pune, India)

Transcription

1 Iatrogenic Urethral Strictures Following Endoscopic Urethral Procedures: A Disheartening TUPR Outcome (And Pune, India) Dr Alex Kavanagh MD FRCSC UBC Urologic Sciences Grand Rounds Oct 4 / 2017 Objectives Anatomy and pathophysiology of urethral stricture Epidemiology Stricture rates with transurethral endoscopy Factors associated with stricture during endoscopy Success rate of dilation / DVIU. When should this be performed? Factors of consideration with urethroplasty in the setting of prior transurethral management of BPH 1

2 Pune India Pune India 2

3 b c Anterior urethra Bulbar Penile (pendulous) Fossa navicularis Posterior urethra Membranous (sphincter) Prostatic a d 3

4 Non-linear urethral segment Fr Practical Endoscopic Classification Normal 30Fr Guidewire 3Fr Flexible Scope 16Fr Obliterative Poor Flow 11Fr 4

5 Bipedal Arterial Supply Proximal urethra antegrade perfusion Distal urethra retrograde perfusion Bipedal Arterial Supply Internal pudendal à common penile Proximal: Bulbar Circumflex Distal: Deep cavernosal à ventral perforators Dorsal artery à glans à retrograde Fig. 3.8 Bipedal arterial blood supply of the urethra ( cp common penile, da dorsal artery of the penis, cc central cavernosal, u urethral, b bulbar artery) 5

6 Epidemiology of Urethral Stricture VA Focused Study (Developed Nation) 0.6% incidence within veteran population Increasing prevalence with age (55Y) More common in black and elderly $200 million per year in USD Roughly $10K / patient year Dilation is primary treatment in 2000 F 1. Age adjusted rate in male dual VA Medicare users with Santucci RA, et al. Male Urethral Stricture Disease. J Urol 2007; 177 Presentation of Urethral Stricture LUTS (~50%) Retention (~20%) UTI / Difficult catheterization / Hematuria (5%) Pain (3%) 23% overall had pain Table 7.1 An analysis of the signs and symptoms of urethral stricture presenting in a first-world cohort of 611 patients Symptom/sign Presenting No. of pts. (%) associated Total LUTS 332 (54.3) 234 (38.6) 566 (92.9) Urinary retention 143 (23.4) 39 (6.4) 182 (29.8) UTI 37 (6.1) 87 (14.2) 124 (20.3) Difficult catheterization 29 (4.8) 54 (8.8) 83 (13.6) Gross hematuria 19 (3.1) 50 (8.2) 69 (11.3) Pain 18 (2.9) 122 (20.0) 140 (22.9) Urethral abscess 14 (2.3) 6 (1.0) 20 (3.3) Renal failure/hydronephrosis 8 (1.3) 17 (2.8) 25 (4.1) Incontinence 6 (1.0) 13 (2.1) 19 (3.1) Sexual dysfunction 5 (0.8) 69 (11.3) 74 (12.1) Rourke KF, Hickle J. The clinical spectrum of the pre- senting signs and symptoms of anterior urethral stric- ture: analysis of a large contemporary cohort. J Urol. 2013;189(5): 6

7 7

8 8

9 9

10 10

11 Pathophysiology - Inflammatory Blandy JP, Fowler C. Urethra and penis inflammation. In: Urology. Oxford: Blackwell Science; p

12 Pathophysiology - Traumatic Blandy JP, Fowler C. Urethra and penis inflammation. In: Urology. Oxford: Blackwell Science; p Pathophysiology Proximal Creep Blandy JP, Fowler C. Urethra and penis inflammation. In: Urology. Oxford: Blackwell Science; p

13 Pathophysiology Inflammatory Sites of inflammatory strictures Distribution of paraurethral glands Blandy JP, Fowler C. Urethra and penis inflammation. In: Urology. Oxford: Blackwell Science; p Pathophysiology Instrumentation Edwards LE, Lock R, Jones P. Post catheterization urethral strictures. A clinical and experimental study. Br J Urol. 1983;55:

14 Etiology Meta Analysis Table 8.1 Meta-analysis of anterior urethral stricture etiology [ 4 ] Cause ( n ) Investigator Stricture ( n ) Idiopathic Iatrogenic Inflammatory Traumatic Wessells and McAninch Wessells et al Andrich and Mundy Santucci et al Elliott et al Andrich et al Fenton et al Total (%); included only bulbar strictures (33) 241 (33) 109 (15) 136 (19) Industrialized countries: Idiopathic 33% Iatrogenic 33% Inflammatory 15% Traumatic 19% Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: etiology and characteristics. J Urol. 2005;65(6): Location All Etiology Bulbar (44 67 %) Penile (12 39 %) Mixed (bulbar and penile) (6 28 % ) Meatal or Submeatal (0 23 %) Membranous ( 0 20 % ) Prostatic ( 0 4 % ) Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: etiology and characteristics. J Urol. 2005;65(6):

15 Etiology - Iatrogenic Strictures Location TUR TABLE II. Etiology of iatrogenic urethral strictures (n 63) Cystoscopy Procedure Prolonged Catheterization Hypospadias Repair Prostatectomy FN 5 (7.9) 0 2 (3.2) 0 1 (1.6) PU 7 (11.1) 2 (3.2) 9 (14.3) 3 (4.8) 0 B 14 (22.2) 3 (4.8) 12 (19) 1 (1.6) 1 (1.6) Total 26 (41) 8 (12.7) 23 (36.5) 4 (6.3) 2 (3.2) KEY: TUR transurethral resection; FN fossa navicularis; PU pendulous urethra; B bulb. Data presented as number of strictures, with percentages in parentheses. Transurethral resection (41 %) Prolonged catheterization (36.5 %) Cystoscopy (12.7 %) Prior hypospadias repair (6.3 %) Radical prostatectomy surgery (3.2 %). Fenton AS, Morey AF, Aviles R, et al. Anterior urethral strictures: etiology and characteristics. J Urol. 2005;65(6): Etiology Transurethral Resection Overall iatrogenic causes (transurethral resection, urethral catheterization, cystoscopy, prostatectomy, brachytherapy and hypospadias surgery) were the etiology in 45.5% In patients older than 45 years the primary modifiable cause was transurethral resection Lumen, N. et al. Etiology of Urethral Stricture Disease in the 21st Century. J. Urol. 2009;182,983-7, 15

16 16

17 17

18 18

19 Transurethral Resection Stricture Lentz et al (1977!) 2,233 consecutive TURP procedures Resectoscope 28Fr, Prior dilation to 30Fr Stricture evaluated if follow-up Flow < 15ml/s or symptomatic, Overall stricture rate 6.3% Lentz Jr HC, Mebust WK, Foret JD, Melchior J. Urethral strictures following transurethral prostatectomy: review of 2,223 resections. J Urol. 1977;117: Transurethral Resection Stricture Stricture Location Bulbar / membranous (32%) Fossa Navicularis (23%) Meatal (17%) Penoscrotal (11%) Multiple (14%) TABLE L Stricture sites after transurethral resections No.(%) lv!eatal 17 (17.53) Post-navicular 23 (23.71) Penoscrotal 11 (11.34) Deep bulb 32 (32.99) Multiple 14 (14.43) Totals 97 (100) Lentz Jr HC, Mebust WK, Foret JD, Melchior J. Urethral strictures following transurethral prostatectomy: review of 2,223 resections. J Urol. 1977;117:

20 Era of Transurethral Resection Stricture No significant incidence change over 40+ years Table 4 Main late complications after TUR-comparison of three periods Authors N Incontinence (%) Re-TUR (%) Impotence (%) Stricture (%) Early Zwergel n.a. n.a. 4.4 Doll a n.a. Intermediate Zwergel n.a. n.a. 3.9 Horninger n.a. n.a. 5.6 Hammadeh Gallucci Gilling Borboroglu n.a Recent Kuntz Muzzonigro n.a. n.a. 3.6 n.a. = not available. a 22% preoperative impotent. Rassweiler, J. Complications of Transurethral Resection of the Prostate (TURP) Incidence, Management, and Prevention. Eur. Urol. 2006;50: Transurethral Resection Stricture Technology Crude Stricture Rate M-TURP % B-TURP 5.4 % TURis 6.8 % HoLep 13.2 % PVP 5.6 % Cornu et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update Eur. Urol. 67:

21 Transurethral Resection Stricture Any bipolar device vs M-TURP R. Study or Subgroup Favors B-TURP Favors M-TURP B-TURP M-TURP Odds Ratio Odds Ratio Events Total Events Total M-H, Fixed, 95% Weight CI M-H, Fixed, 95% CI Akman et al % 1.39 [0.47, 4.12] Autorino et al % 1.00 [0.06, 16.65] Erturhan et al % 1.26 [0.33, 4.81] Fagerström et al % 1.91 [0.17, 21.48] Geavlete et al % 1.07 [0.52, 2.19] Ho et al % 3.40 [0.34, 33.86] Iori et al % 0.96 [0.06, 16.22] Kim et al % 0.48 [0.04, 5.65] Kumar et al % 0.34 [0.01, 8.64] Mamoulakis et al % 1.28 [0.48, 3.42] Nuhoglu et al % 3.45 [0.13, 88.40] Seckiner et al % 2.09 [0.18, 24.73] Singh et al % 1.00 [0.06, 16.76] Yang et al % 0.50 [0.04, 5.67] Total (95% CI) % 1.20 [0.80, 1.80] Total events Heterogeneity: = 3.38, df = 13 (p = 1.00); I² = 0% Test for overall effect: Z = 0.86 (p = 0.39) Favors B-TURP Favors M-TURP Transurethral Resection Stricture TURis vs M-TURP K. Study or Subgroup TURis M-TURP Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Akman et al % 1.39 [0.47, 4.12] Fagerström et al % 1.91 [0.17, 21.48] Geavlete et al % 1.07 [0.52, 2.19] Ho et al % 3.40 [0.34, 33.86] Total (95% CI) % 1.29 [0.74, 2.25] Total events Heterogeneity: = 1.06, df = 3 (p = 0.79); I² = 0% Test for overall effect: Z = 0.88 (p = 0.38) Favors TURis Favors M-TURP 21

22 Transurethral Resection Stricture HoLep vs M-TURP L. Study or Subgroup Ahyai 2007 Eltabey 2010 Gilling 2012 Gupta 2006 Mavuduru 2009 Montorsi 2008 HoLEP M-TURP Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI % 1.00 [0.06, 16.21] % 0.58 [0.21, 1.63] % 3.10 [0.12, 79.23] % 1.00 [0.06, 16.44] % 5.74 [0.25, ] % 1.69 [0.76, 3.77] Total (95% CI) % Total events Heterogeneity: = 3.91, df = 5 (p = 0.56); I² = 0% Test for overall effect: Z = 0.76 (p = 0.45) 1.25 [0.71, 2.19] Favors HoLEP Favors M-TURP Transurethral Resection Stricture PVP vs M-TURP H. Study or Subgroup PVP M-TURP Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI Capitan % 0.48 [0.11, 2.03] Xue % 2.56 [0.48, 13.51] Total (95% CI) % 1.01 [0.37, 2.77] Total events 8 8 Heterogeneity: = 2.22, df = 1 (p = 0.14); I² = 55% Test for overall effect: Z = 0.01 (p = 0.99) Favors PVP Favors M-TURP I. 22

23 23

24 24

25 Transurethral Resection Factors: Resectoscope Size Retrospective review 71 patients w/ TURP. Resectoscope circumference 24 F in group 1 (n=35) or 26 F in group 2 (n=36). No difference in age, prostate volume, resection time / weight of resected prostate tissue, catheter type / duration, energy level Higher incidence of bulbar stricture was detected in 26Fr scope compared to 24Fr (p=0.018). No difference was detected between the groups for meatal / penile stricture (p=0.386). Gu nes, M. et al. Does resectoscope size play a role in formation of urethral stricture following transurethral prostate resection? IBJU. 2015;41(4):

26 Transurethral Resection Factors: Electrical Current Leak In vitro experiment. Evaluated current leakage with M-TURP Proposed mechanism of electrical burn as risk factor for TURP associated urethral stricture 20% of the total current output was shunted to the metal sheath when an intact loop/rollerball was used. 100% of the current was short-circuited to the sheath when a loop/rollerball with faulty insulation Concluded electrical burn hypothesis unlikely with intact loop, but high likelihood with faulty insulation. Particularly when conductive gel is utilized. Zheng W et al. Electrical burn of urethra as cause of stricture after transurethral resection. J Endourol 2000;14: Faulty Electrode Flash 26

27 Transurethral Resection Factors: Electrical Current Leak In vitro experiment. Evaluated current leakage with M-TURP and determined power density to cause burn to porcine liver Cutting Mode: Mean stray current of 70 ma with an intact loop and 144 ma with a loop having faulty insulation. Coagulation mode: Mean stray current of 35 ma and, with a loop with faulty insulation, 40 ma. Determined that a power density 7.5W/cm2 was actually more likely to be reached with non-conductive gel Concluded electrical burn hypothesis likely with a damaged electrode. Suggest conductive gel may reduce risk. Sofer M et al. Stray radiofrequency current as a cause of urethral strictures after transurethral resection of the prostate. J Endourol Mar;15(2): Factors in TURP that contribute 27

28 Transurethral Resection Factors: Local Anesthetic Gel 261 TURP patients randomized to receive lubricating jelly containing either 3% tetracaine hydrochloride, 1% lidocaine hydrochloride, or no local anaesthetic. No patient had a history of urethral instrumentation or urethral stricture. After 6 months' follow-up, 32% treated with tetracaine jelly developed urethral strictures, 4% with lidocaine and (2%) who received jelly without anaesthetic. 3% tetracaine jelly associated with a high incidence of post-turp urethral strictures. No statistically significant difference between 1% lido and plain jelly Pansadoro, V. et al. Urethral Stricture following Transurethral Resection of the Prostate. The Role of Local Anaesthetics. 1993;72: Transurethral Resection Factors: Post-operative Urethral Foley 205 TURP patients Divided into 2 groups: urethral silicon catheter / suprapubic silicon catheter. Follow-up: 6-24 months Urethral foley (22Fr 3-way x 24hrs): 17% stricture SP foley: 4% stricture *stricture evaluated if Flow < 15ml/s, defined stricture as < 19Fr urethra Hammarsten, J. et al. Urethral Stricture following Transurethral Resection of the Prostate. The Role of the Catheter. BJU. 1989;63:

29 Transurethral Resection Factors: Post-operative Urethral Foley 2,233 consecutive TURP procedures Significant effect of Catheter size 22Fr (5%) developed stricture; 24Fr (6%), 26Fr (14%) Urethral dilation / calibration Pre-existing urethral stricture: 3X risk of new post-turp stricture No significant effect of Catheter duration (median 3 days, range 1-8) Pre-operative / post-operative urinary tract infection Length of resection time / volume of resected tissue Lentz Jr HC, Mebust WK, Foret JD, Melchior J. Urethral strictures following transurethral prostatectomy: review of 2,223 resections. J Urol. 1977;117: Transurethral Resection Factors: Experience Experience No significant difference resident to staff (overall rate) Higher rate of meatal and FN stricture in resident group TABLE 3. Stricture type (total) Meatal Post- Peno- Deep Navicular Scrotal Bulb Multiple Teaching staff Residents Lentz Jr HC, Mebust WK, Foret JD, Melchior J. Urethral strictures following transurethral prostatectomy: review of 2,223 resections. J Urol. 1977;117:

30 Transurethral Resection Factors: Irrigation Temperature Retrospective study of 167 TURP patients Group 1 (n 75), TURP with room temp irrigation. Group 2 (n 78), TURP with warm irrigation solution (39-40 C) and a device to maintain the temperature of the ventral penile skin at about 36 C The rate of urethral stricture was 21.3% in group 1 and 6.3% in group 2 at the end of 6 months of follow-up (P.002). Park, J.K. et al. Is Warm Temperature Necessary to Prevent Urethral Stricture in Combined Transurethral Resection and Vaporization of Prostate? J. Urol. 2009;74(1) 30

31 31

32 32

33 Treatment DVIU vs Dilation Heyns et al 1998 Randomized 210 patients to filiform dilation vs DVIU Follow-up every 3 months for mean 2 years (3 63mo) with catheterization and RUG Repeated with 2 nd or 3 rd treatment for recurrence Results No significant difference in success between dilation or DVIU Longer stricture (>2cm) have higher failure rates Overall 30% stricture free rate at 48 months 2 nd dilation has minimal sustained value (~15%) 3 rd dilation has zero sustained value Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J Urol. 1998;160:

34 DVIU Success Survivors 8/76 (8%) Median recurrence 7 months Median follow-up 18 months May be biased estimate based on referral patterns Santucci, R. Urethrotomy Has a Much Lower Success Rate Than Previously Reported. J Urol. 2010;183, Dilation Experience 34

35 I don t know, the guy said your urethra is closing up and we need to operate on it, and they did, he said. And they said, Yeah, we didn t really get it. It didn t quite work. We have to do it again. And they did it again. Urethroplasty Anastomotic Buccal mucosal graft Dorsal Ventral 35

36 Anastomotic Urethroplasty Anastomotic Urethroplasty Outcome: > 93% sustained durable success rate 1 Complications (Total complication rate ~6% 2 ) Bleeding / infection (2%) Urinary tract infection (5%) Chordee / penile shortening (2%) Penile pain (2%) ED (3%) * transient in 40% Morey AF, et al. SIU/ ICUD Consultation n Urethral Strictures: Anterior urethra-primary anastomosis. J. Urol. 2014;83:S23 6 Blaschko SD. et al. Trends, utilization, and immediate perioperative complications of urethroplasty in the United States: data from the national inpatient sample J. Urol. 2015;85:

37 When to avoid Anastomotic Urethroplasty Impaired distal (retrograde perfusion) Hypospadias Prior distal stricture repair When to avoid Anastomotic Urethroplasty Incompetence of Bladder neck Prior TURP 37

38 Buccal Mucosal Graft Urethroplasty Outcome: ~75-85% success 1,2 Commonly reserved for bulbar segment stricture >= 2cm Complications Donor site morbidity (bleeding, infection, numbness, Stenson s duct obstruction) 1 year 15% numbness, 30% tightness Graft failure / anastomosis contraction (5-15%, 95% in first 5Y) Barbagli G. et al. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol 1996;78: Barbagli G. et al. Long-Term Followup and Deterioration Rate of Anterior Substitution Urethroplasty. J. Urol. 2014;192:3:

39 39

40 Case Presentation Membranous Stricture 57M Presents with obstructive voiding symptoms 18 months following TURP Cystoscopy demonstrates 8Fr membranous urethral stricture Ventral Onlay Urethroplasty Completed 40

41 41

42 42

43 43

44 Questions 44