Direct Visual Internal Urethrotomy (DVIU) in the Management of Male Urethral Strictures. A Single Center Experience about 44 Patients ()
1. Introduction
Urethral strictures are common for urologists in Sub-Saharan Africa and constitute one of the oldest urological conditions [1] [2] . They are defined by a more or less extensive narrowing of the urethral lumen that impedes the free flow of urine from the bladder to the outside, regardless of its location and etiology [3] [4] . If infectious causes are declining in developed countries, in favor of post-traumatic and iatrogenic causes, urethral strictures are increasingly observed in our context, and their management remains a challenge for the urologist [3] [5] . Many techniques have been proposed to treat urethral strictures, including internal endoscopic urethrotomy. It was described by Maisonneuve and Otis, who performed it blindly, and later by Saches who, in 1973, developed the method under direct visual control [6] . Since then, DVIU has become the first-line treatment for urethral strictures for most authors [4] [7] . Several studies have been carried out on the contribution of endoscopic internal urethrotomy in the management of urethral strictures. Djé et al. in the Ivory Coast conducted a study on 140 patients and Zango et al. in a previous study in Burkina Faso had evaluated the feasibility of this technique and the short-term results in a short hospital series in the management of urethral strictures [7] [8] . This study was initiated to evaluate the contribution of this technique in the management of male urethral strictures at the Souro Sanou University Hospital.
2. Patients and Methods
This was a retrospective cross-sectional study conducted in a single center, the urology division of the Souro Sanou University Hospital in Bobo Dioulasso between January 1st, 2014, and December 31st, 2021. The study focused on patients’ medical records treated with endoscopic internal urethrotomy. Patients included in the study had a diagnosis of urethral stricture based on preoperative imaging by retrograde urethrogram (RUG) or Voiding Cystourethrogram (VCUG) with negative urine culture and were treated by DVIU. The included patients were those without spongiofibrosis or urethrocutaneous fistulas. For each patient, the collected data included patient demographics, the cause of urethral stricture, stricture characteristics, operative details and follow-up information. The DVIU was performed using a cold knife urethrotome, by incising the stricture at 12 o’clock under endoscopic guidance (Figure 1). The procedure was carried out under locoregional anesthesia with indwelling urethral catheter, which was left in place for three to seven days. In the absence of uroflowmetry, postoperative functional results were evaluated based on the quality of urination immediately after removal of the urinary catheter, at three months (3 months) and six months (6 months). Thus, these results were classified into three categories:
· Good: absence of dysuria, easy urination with a good urinary stream
· Satisfactory: slight dysuria, urination with effort, weak urinary stream
· Failure: frank dysuria, difficult or impossible urination
The procedure was considered successful if there was absence of symptoms or
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Figure 1. (a) Endoscopic view showing a narrowing in the form of a “black hole”, (b) Incision of the roof of the narrowed area with a cold knife.
signs of recurrent stricture and if patient had ability to pass urine. The overall success rate took into account the functional postoperative results judged as good and satisfactory. Data were analyzed using Epi.Info software version 7 and results displayed using tables and figures. Descriptive statistics for numerical variables in our study are given as mean ± standard deviation and the categorical data are given as frequency (n) and percentage (%).
3. Results
1) Frequency
The hospital frequency of urethral strictures (US) accounted for 11.15% of all urological pathologies during the study period. During the study period, 44 patients underwent DVIU out of a total of 471 recorded cases of urethral strictures, representing a proportion of 9.34%. Four patients have needed a second procedure for treatment, with a total of 48 procedures performed. The annual frequency of DVIU was 6 procedures per year.
2) Age and residence of the patients:
The mean age of the patients was 53.2 ± 18.2 years with extreme ages ranging from 18 to 80 years old.
3) Residence of the patients
54.5% (24/44) of the patients came from rural areas while 45.5% (20/44) came from urban areas.
4) Professional occupation
The majority of patients (47.2%) were farmers, followed by retired and traders in equal proportions (18.2%), civil servants (9.2%) and students (6.7%). Professional occupation of patient is presented in Table 1.
5) Causes of urethral strictures.
The causes of urethral strictures were predominantly iatrogenic, accounting for 43.2% (n = 19) followed by infectious causes (27.3%), traumatic causes (20.4%), and idiopathic causes (9.1%) as presented in Table 1.
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Table 1. Descriptive characteristics of patients.
6) Reasons for patient consultation
The main reasons for patient consultation were urinary retention, whether acute or chronic (47.7%), dysuria (40.9%), and infectious complications such as urinary tract infections or orchi-epididymitis (6.8%).
7) Preoperative imaging of urethral Stricture by RUG or VCUG
The retrograde urethrogram (RUG) or Voiding urethrocystogram (VCUG) were performed in all patients and allowed for the confirmation of the diagnosis of urethral stricture by specifying the number of strictures, their location, and associated anomalies. A single urethral stricture was found in 36 patients (81.8%), while 8 patients (18.2%) presented with multiple strictures, illustrated in Figure 2. The location of the stricture was bulbar in 32 patients (72.7%), perineal-bulbar in 5 patients (11.4%), and anterior penile in 7 patients (15.9%) as shown in Table 1. RUG images revealed associated anomalies in the form of bladder diverticulum in three (3) patients, four (4) patients had vesicoureteral reflux, and five (5) cases of trabeculated bladder were noted.
8) Mode of anesthesia
Rachi anesthesia was the main mode of anesthesia in 38 patients (86.4%) and general anesthesia in 6 patients (13.6%). Antibiotic prophylaxis was systematically applied to all patients.
9) Procedure occurrence
Single DVIU was performed as a first-line procedure in 40 of our patients (90.9%) and four patients (9.1%) required a second endoscopic internal urethrotomy.
10) Hospital stay
The average hospital stay was 4.2 days ± 3.2 days, with extremes of 1 day and 14 days.
11) Post-operative functional results
Postoperative functional results were evaluated based on the quality of micturition after removal of the urinary catheter as uroflowmetry was not available in our urology division. The overall success rate (good and satisfactory results) at the removal of the urinary catheter was 72.7%. This rate fell to 69.1%, at three months and to 67.5% after 6 months. In Table 2 was summarized the distribution of patients according to the final functional outcome of the DVIU.
12) Postoperative complications
During the procedure, five cases (5) of extravasation of blood or irrigation
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Figure 2. (a) RUG images showing a single bulbar stricture; (b) Multiple strictures (red arrow) at different locations.
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Table 2. Distribution of patients according to the outcome of the procedure.
*Two (2) patients were lost to follow-up at the 3 months postoperative visit and four (4) at the 6 months postoperative visit.
fluid into the scrotum were reported and two (2) cases of false routes with postoperative edema of the penis were observed. Cases of liquid infiltration of the scrotum were treated by incisions for draining the subcutaneous tissue with the evacuation of the irrigation fluid by compression of the scrotum, followed by a suspensory scrotal dressing and treatment with anti-inflammatory drugs and prophylactic antibiotics. No cases of death were reported in our series.
4. Discussion
Urethral stricture remains a relatively common condition in developing countries, particularly in sub-Saharan Africa [3] [7] [8] . Over eight years of surgical activities, our department recorded 471 cases of urethral strictures, and 44 patients were treated with endoscopic internal urethrotomy. This minimally invasive technique, introduced into our arsenal of management, constitutes the second endoscopic procedure after cystoscopies. The annual frequency of performing this procedure is 6 DVIU/year, which is lower than the 10 cases annually reported by Zango B. et al. [8] in the same urology division, and the 22 cases annually reported by Djé K. in Abidjan and Guirrassy in Conakry [3] [7] . Therefore, it appears that the DVIU rate has decreased in our urology division due to the difficulties encountered in better organizing and conducting endoscopic activities, including recurrent breakdowns of the endoscopy column and the availability of consumables to ensure the continuity of endoscopic activities. The indications for endoscopic internal urethrotomy remain mainly for young patients, as found in many studies on this technique [9] [10] . The patients in our series were relatively young with a mean age of 53.2 ± 18.2 years, slightly higher than the average age of 47.8 years reported by Zango et al. [8] and lower than the average age reported by Djé et al. which was 55 years [7] . The main etiologies found in our series were endo-urethral maneuvers, urethral infections, and pelvic trauma. Specifically, we recorded 43.2% of iatrogenic etiologies, which differed from the results reported by Zango et al. [8] , who found a predominance of infectious etiologies in their study. Culty et al. [11] at Bichat Hospital in Paris reported 105 cases of traumatic urethral strictures, exclusively dominated by pelvic fractures and perineal trauma. The predominance of post-infectious etiology related to poorly or untreated urethritis is fairly constant in the literature for developing countries, especially in Africa. Thus Djé in Côte d’Ivoire, Guirassy in Guinea, Zango in Burkina Faso all reported the predominance of infectious etiology in their respective series [3] [7] [8] . A possible explanation for this difference could be the recent decline of sexually transmitted infections (STIs) in most African countries, including Burkina Faso, which previously had a high prevalence of acute gonococcal urethritis. This decline in STI prevalence is likely due to the efforts of various programs to combat STIs/HIV through multiple information and communication campaigns aimed at behavior change. In our series, the preferred location of the stricture was bulbar, accounting for 72.7% of cases, which was consistent with literature data reported by many authors [5] [12] [13] . This preference may be related to the particular anatomy of this segment of the anterior urethra, with the bulbar cul-de-sac serving as a reservoir where germs proliferate due to stasis. Similar results were reported by Djé et al. with 67.9% [7] , Benjelloun M et al. in Morocco with 73.8% [12] , and L. Redón-Gálvez et al. with 64.2% bulbar location [4] . Post-traumatic strictures would more frequently, if not exclusively, occur at the level of the membranous urethra due to the anatomy of this segment of the urethra, which is closely related to the perineal fascia, which is very vulnerable during pelvic trauma.
Single strictures represented a significant proportion of strictures in our study, accounting for 81.8%. Single strictures are the ideal indication for internal endoscopic urethrotomy. Our results are consistent with those of Tazy et al. [1] in Morocco, where the majority of patients had single strictures. The treatment outcomes were evaluated based on the quality of voiding comfort and urinary stream, which were collected through patient interviews during follow-up visits. This purely clinical evaluation is quite subjective since we did not use uroflowmetry to assess postoperative results, and only a few patients underwent control urethrocystography (VCUG). The success rate of endoscopic internal urethrotomy (DVIU) assessed at the time of removal of the urinary catheter in our patients was 72.7%. This rate decreased to 69.1% at three (3) months and 67.5% at six (6) months. The lack of follow-up and the absence of 4 patients at the 6-month postoperative control contributed to the decrease of our success rates. Our 72.7% success rate remained close to that of Zango, which was 67% [8] in Burkina Faso, and higher than Ballanger’s 57% [2] in France. DVIU is considered to be a procedure with very few complications, but it still carries risks and potential complications. Seven (7) perioperative complications were noted in our series, representing 21.8%, which is higher than the 9% reported by Guirrassy [3] . These complications were mainly due to false routes, with swelling of the penis and fluid infiltration of the scrotum. In Zango’s study, the complication rate was about 16%, also dominated by false routes [8] . In contrast to Chilton et al. [14] , we did not report any complications such as incontinence or impotence. Similarly, we did not report any cases of urethrotome blade breakage, as reported by Steenkamp [5] at Tygerberg Hospital in South Africa, an incident also reported by Zango [8] in Burkina Faso and Djé [7] in Côte d’Ivoire. Mortality was zero in our series, confirming the safety of this intervention as reported by other authors in the literature [6] [15] .
5. Conclusion
Direct visual internal urethrotomy is a simple, quick procedure, devoid of major morbidity and requiring only a short hospital stay. It can be proposed as a first-line treatment for urethral strictures when local conditions permit, as recommended by most urologic societies.