Michael J. Metro, MD discusses therapeutic and reconstructive surgery options for the treatment of strictures.
Hello. I'm Michael Metro. Um I am the director of reconstructive urology here at Temple University in philadelphia. I'm also the director of the urologic recon and trauma surgery here at Temple. And this is a series that's meant to educate both urologist residents about the importance of urethral reconstruction and the diagnosis that this discussion for therapeutic options and then the subsequent tricks of surgery to make a successful outcome and the treatment of urethral stricture disease. This particular component of the talk talks about what the therapeutic options for the treatment of a structure that you've diagnosed correctly in your office. So what are the factors that affect therapy? Well, we want to make sure we're aligned with the goals of our patients, right? And some patients have certainly different goals and other and sometimes the 20 year old patient with a pelvic fracture and a urethral stricture resulting from that Has certain different goals than, say, a 90 year old that might be in a nursing home and it has an exclusive bulb are stricter. So certainly those are the two ends of the spectrum. But everywhere in between, there's different patients have different goals. So I want to make sure you're having the right goal discussion with your patient. So age is one of them. The location of the structure is important. Also, ball bar versus pendulous versus metal versus posterior stricture. All of those strictures are treated somewhat differently, some more been more complex fashions than other. So that's important. Also, in addition, the length of the structure, because that will determine whether we could do something simple like an ass thematic or an end post, uh, a non transected, an asthmatic repair versus a substitution urethra plastic with buccal mucosa or two stage. Aretha plastic. The Luminal diameter of the structure at diagnosis is important because that tells us a little bit about the urgency of the intervention that we want to offer a patient. If a patient is an impending urethral urinary retention, we would want to know that so that we can offer them a timely procedure or so or allow their bladder to drain in a different way before their reconstructive procedure, degree of spongy of fibrosis is sometimes um, affects our therapy and that sometimes that's noted in the operating room. So those are things to tell a patient about that. Some of our treatment decisions are on the fly in the operating room. And quite honestly, that's why a lot of people like reconstructive surgery because it makes you think on your feet, it's not wrote surgery like cataract that pretty similar in every patient. And then patients that have had prior therapy is important to those that have had no therapy forces those that have had years and years of dilation. Zor prior to a possible. Yes. So if we look at a little bit about strictures, we tried to figure out severity of structures and that's over the years it's been tried to be classified. Um Now Charles divine down in Virginia, came up with this stricture classification of A to F. And they were based on severity uh somewhat of Luminal diameter, in somewhat of sponge. Oh, fibrosis, this really never took off because no one ever heard about. Oh, this is a great D ball bar stricture from um the basically the father reconstructive urology here in the United States. Um This is another one that Doctor Mechanic, my fellowship director came up with using ultrasound and he did a somewhat more simple one that was normal, mild, moderate, and severe based on degree of Luminal occlusion. Again, this seems somewhat elegant, but it was based on ultrasound study, which is was not commonly done and still is not commonly done. So really there hasn't been a great classification system for strictures, although every year at the way you'll see every few years at the way you'll see a an attempt to classify or clarify strictures. So most of us use high grade, moderate cade, mild or normal when we're describing strictures. Now, how do we want to treat patients well. First of all, we want to figure out what are how we, how we define success. So for for reconstructive urologist successes, not requiring dilation is in the future in the office or self dilation. A patient who will have a normal voiding uh not only pattern but method to standing. Hopefully. Uh We want to allow for normal function of the genital urinary system and a Jack Territory canal. And we want to provide good cost mrs to the patients so that they're not thinking about the Eureka reconstruction. They had 20 years down the road. So basically two schools have thought with urethral reconstruction. One of them is endo yuri through options. And these are a dilation which is a simple procedure that can be done in the office uh on the same vein with an endo yuri throw option is an incision or your astronomy and that's done in the operating room. What sedation over the years. Different techniques to do this. Your astronomy were developed. Some of them are incisions, some of them have been lasers. Uh some of them have been incisions with injections of steroids or other medicines to reduce the recurrence of stricture formation. And then there has even been a urethral stent that most of you know developed as patients will often ask can't they put a stent in my urethra like they did in my coronary artery and I'll go over why that's not a great option for patients. And then what is the future of endo yuri throw options? And those might be? I know your etheric oils that around the world are used more commonly than in the States. There's not a I know you're re throw coil option that's been FDA approved in the United States yet. Mhm. Okay. So if these are options under your literally why why do we even do uh why is there a reconstructive urologist at every hospital um uh in every major center? Well that's because they don't have great long term success rates. Okay. So why don't we just do a direct vision internally are a threat to me on everybody. Well, multiple studies and these are the big ones have come up with uh good studies to show that the success rate while very good short term for direct vision internal your throttle me are very poor long term. The first one is the Pans Andorra study in 1996. They looked on 100 and 42 patients for bull bar urethral strictures that were followed for five years. And they showed a 47 to 61% failure rate after the first incision or urethra chris Hines and um South Africa in 1998 published a similar paper with 210 patients. Um It followed for four years with similar poor success rates. And then Tasha and Green. Well from the U. K. Did 100 and 26 patients of all types. So not only above our structures for penal structures followed for two years and presented in and um published in 2000 and four and she went a little further to look at what was going on with these patients that failed and if a failure was performed, if a failure happened with one endoscopic intervention, it was common to offer the patient another endoscopic an intervention. And in her study failures had three or more incisions during the short observation period and all of them failed. The advent of a self catherization protocol to keep the stricture open, didn't do that because it did not keep them open. It was tried in a quarter of the patients and Tasman studied and once it was stopped, the stricture occurred. So this was one of these were some of the main articles that we used to talk about the importance of a good urethra plastic surgeon and medical centers to give more long term success. Looking more closely at Pans Adoro and Heinz, his study and Pans Adoro. It was a prospective trial randomized controlled trial. There was a 58% recurrence rate of five years after the first optical incision or your throttle me. There was 100% recurrence rate through the second or third. So this is the one that I usually quote my patient high recurrence rate after one and then a 0% success rate. After the 2nd and 3rd chris Hines study looked at again perspective. After four years, there was a 40% recurrence rate and then 100% after the second, one by almost four years and then 100% after the third by year and a half to the interval of the success rate gets smaller and smaller as we go and add incision. All your theories and not only do they fail, they tend to add complexity to the stricture and make it more long and angry for subsequent reconstructive procedures. Chirchir length was a determinant and chris uh dr Heinz study that looked at the ones that were more prone to have success were short structures less than two centimeters. Whereas those that were between two and four were intermediate to those that were greater than four, which had very horrible 20% success rates had two years. So if we look at these structures um And look at the location, penal urethral strictures in the two studies that allow those in place, penal urethral strictures did horribly poorly with the scene, 16% success rate. Whereas ball bar strictures which tend to be more focal, had a little better success rate. This is one that looked at the uh rich Santucci did a little update on this within 2010, where he looked a little bit on subsequent Devi I us and contemporary series and came up with even a poorer success rate with the first success rate. Um AD. V. I. You buy four years. Almost 85% have been structured and even more poorly moving forward. So these are the things why we as reconstructive urologist are touting the importance of your recent reconstruction versus Dvu. Now what about using an office dilation versus of urethra everywhere? You obviate the need for a general anesthetic and an operation. Well dilation was even worse unfortunately because it's less aggressive. It's a less aggressive less um a therapy that has less long term success rate. So this would be what was commonly done every six weeks. A patient would go to the office and have an office dilation and be good for four and come in on fumes for the last two weeks to have another one. So this is something we want to move away from. So why do I need to evaluate include these slides at all? If everyone knows at our stage in 2021 that these procedures don't work. Well steve Brandis who's at Columbia now did a great study on practice patterns and this was a few years back in 2000 and seven where he did a postal survey of urologists, where he got Um 431 neurologist too. Uh he queried about their management of stricture disease and he got a fairly good response and presented the EU in 2007. Now this is some people think it's not a common disease, which strictures are common. In fact, 63% of urologists treat between six and 20 strictures a year. So this isn't like a penal cancer case that comes along once a year. This is a common occurrence and neurologists treat this procedure this entity commonly. And if you in query these urologists the most commonly performed procedures for dil ations. Uh in 93% of patients D. V. I. You and 85% of urologists. And then in 2000 and seven we still had an endo urethra spent option and according of them were putting urethral stents in people, Laser your throttle mies will perform 20% of the time. Um And most of them do not perform urethra classes at all over half and those that did perform them only a third, a third of them performed between one and five cases per year. And if you know as a urologist, if you're doing something uncommon late life 125 a year, it's not something you get fairly proficient at And only .7% performed 11 cases a year. And those were the ones that answered the questionnaire. Um a temple, we do over 110 free throws a year, so we have a very high volume urethral classy center here. But this was an important study to say that even with the data we knew at this point the urologist in the field were doing this endoscopic management in preferential treatment then to sending these patients to reconstructive urologist for definitive management. So only 20% would definately to send for definitive management to academic centers and a third would continue to manage with the decision and dill ations. And most believe that the literature supports that reconstructive ladder where you go until either you get tired of the patient or the patient gets tired of you. So this is an important study in my opinion to tell us what we should be doing with our patients. And in fact this is a good study. Uh that was that was used actually in the defense of med mouth case that I was involved with where someone was sued for doing a DVD you and I said, you know, even though I don't support a D. V. I. You, this is what the standard of care was in 2000 and seven. And uh the urologist that was sued was uh was exonerated by saying hey, the normal standard of care in 2000 and seven. Was this? So um So what we also know as I mentioned before, that is subsequent your throttle me negatively, in fact subsequent re through classes. So this study which was culti and then reviewed and by singing in 2010 looked at the success rate for your extra classes and patients that have undergone previous endoscopic procedures versus those that had. Okay, so group at the top was success rates, you know, 95%. And those groups had not had any and any management of their structure in those in this hash with the triangle or previous endoscopic procedures. So those had multiple procedures had a lower success rate than those that had a prior urethra plastic and failed at lower success rates too. Yeah. How about um the argument that urethra plastic is so expensive and equality uh time away from work for the patient and the operative time? Well, this was That's what this was looked at by three different studies And the most cost effective maneuver. And this was across the Atlantic and in the United States was to offer one endoscopic intervention. Work for bulb are strictures less than two centimeters prior to Urethra plastic. And everything more than two centimeters was to offer immediate urethra class. So these studies showed that dilation and your throttle we have equally poor efficacy and the urethra economy was either either cost effective or implications. Success of your throat amis although commonly performed a funeral and success of your astronomy's negatively impact subsequently re throw plastic because it can turn what could be a simple operator who approach into something more complex. I will mention some time with the end of urethral stents and coils. So our urethral stents, the future of urethral stenosis management. You know in theory they sound great right? Um They could be permanent. They can make retrievable ones. They've tried doing bio absorbable ones or ones that allude drugs like steroids to improve the efficacy. But what we found out is that long term success of all of these options doesn't come close to the operative success for urethra plastic. And um and in the U. S. As I'm entered the euro loom those of you have gray hair like I do will remember the euro loom was available and widely used in the late eighties and nineties. Um I even use some of them in the bladder neck until they were taken off the market Around 2010. So I wrote to show you some pictures of a you're a loom. This is a european which was meant to be poorest to lobby reform mucosa to grow through the stent and allow it to your theory realize what we know about foreign bodies in the urinary tract is that they tend to form stone material on them, especially if they're exposed. So the theory of a rating or allowing uh this the interstices of the uh stent to be infiltrated by your affiliation was a good sound technique. But you can see in this structure which was treated in the ball very Aretha with the stent and a subsequent your your program. The structure grew through the stent in addition to the urethra graph. So this is something that has fallen out of favor and it was also, it was all a lot of fun taking these stents out and reconstructed your easier retraces and every now and then one will walk through the office and it's something that I get excited about to operate on and to teach this residence about this particular technique. Show this part of the talk is now, is was now dealing with more simple or office or and alumina lee options for urethral stricture disease that still have a way to make your way into the practice. If you look at the goals of your patient or if the structure itself is amenable to an endoscopic or incision or your astronomy short walmart strictures. But the next component of this discussion will be the urethra plastic techniques that most of us used to definitively treat these conditions. And those are uh endoscopic I'm sorry, an instamatic repairs and non transacting repairs. Uh substitution repairs with buccal mucosa, uh single stage and two stage repairs. Penile skin flaps. And these are techniques that we have in our toolboxes. Reconstructive urologist too adequately treat this can be conditioned. I hope this was beneficial. Hope it helps you determine how you want to manage urethra plasticity patients or urethral stricture patients in the future. And the next component of this. I will hopefully be available soon, will be and more operatively based discussion on your with your plastic. I hope this was enjoyable. Thanks