RECONSTRUCTIVE SURGERY Comparison of Urethral Dilation with Amplatz Dilators and Internal Urethrotomy Techniques for the Treatment of Urethral Strictures Onur Karsli1, Murat Ustuner1*, Omur Memik1, Emre Ulukaradag1 Purpose: The most common option for the management of urethral stricture (US) is direct visual internal urethrot- omy (DVIU), because it is an easy and minimally invasive technique but the low success and high recurrence rates of this technique make urologists research for different types of therapeutic alternatives in stricture treatment. In this study we aimed to compare the internal urethrotomy with amplatz dilation for the treatment of male US. Materials and Methods : A total of sixty patients, who have been operated due to urethral stricture were enrolled into this study. Group 1 was treated with amplatz renal dilators and the group 2 was treated with cold knife ure- throtomy. All patients were evaluated for Qmax preoperatively and at the first, 3rd, 9th and 12th months postop- eratively. Results: In the 3 month uroflowmetry results, mean Q max values were 15.6 ± 2 ml/sec in amplatz group and 15.5 ± 1.6 ml/sec in DVIU group. There was no statisticaly difference between the two groups. However the Q max values in the postoperative 9 and 12 months were significantly decreased in the DVIU group. In the DVIU group 9 recurrences (36%) appeared and 2 of these reccurrences were in the first 3 months, whereas in the amplatz group no recurrences appeared in the first 3 months. The urethral stricture recurrence rate up to the 12 month follow up was statistically significant for group 1 when it is compared with group 2. Conclusion: In our experience, amplatz dilation is a good option as the initial treatment for urethral stricture. Keywords: amplatz dilators; internal urethrotomy; urethral strictures; urethral strictures recurrences; uretral strictures treatment INTRODUCTION Urethral stricture (US) is one of the oldest known issue of urology due to the difficulty of diagnosis, treatment and risk of recurrence. US disease is defined as narrowing of the urethral lumen because of fibro- sis, which occurs in urethral mucosa and surrounding tissues. The etiology could be idiopathic, iatrogenic, post-traumatic and also includes infectious and lichen sclerosus(1). Although it is rare, familial stricture espe- cially seen in adults can be considered in etiology(2). Treatment of the stricture depends on the localization, length and type(3). Although urethral dilation is one of the oldest modality, the most common option for the management of US is direct visual internal urethrot- omy (DVIU), because it is an easy and minimally in- vasive technique(4). Endoscopic urethrotomy was first described in 1974 by Sachse with the use of a cold-knife technique to incise the stricture segments(5). Despite its widespread acceptance as the first-line option, the suc- cess rates after initial DVIU is reported to be 8%–76% (6-8). Low success and high recurrence rates of this tech- nique make urologists research for different types of therapeutic alternatives in stricture treatment (9). Recent- ly Akkoc et al. described amplatz dilation techniques University of Health Sciences, Derince Training and Research Hospital, Department of Urology, Kocaeli, Turkey. *Correspondence: University of Health Sciences, Derince Training and Research Hospital, Department of Urolo- gy, Kocaeli, Turkey. Tel: +905065021260. Fax : +902622334641. E-mail: muratustuner@gmail.com. Received June 2018 & Accepted January 2019 for the treatment of US as an effective and safe tech- nique(10). In this study we aimed to compare internal urethrotomy with amplatz dilatation for the treatment of US. To the best of our knowledge, this is the first clinical trial in the literature comparing the outcomes of amplatz dilation with DVIU. MATERIALS and METHODS Study Population In this retrospective study, we analyzed the data from 60 patients who were diagnosed with US and operated in our department between 2016 and 2017. The diag- nose of US was made by clinical history, uroflowmetry and urethrography. The records of patients’, physical examination, complete blood count, serum biochemical analysis, urine analysis and urine culture were retro- spectively reviewed. The patients with active urinary infection were treated with the appropriate antibiotics before the operation. All patients were evaluated by urethrography preoperatively and the stricture lengths were measured. Exclusion criterias of the study were stricture longer than 2 cm, meatal stenosis, posterior urethral strictures, and history of US treatment. Patients were informed about a new dilatation technique. The Urology Journal/Vol 17 No. 1/ January-February 2020/ pp. 68-72. [DOI: 10.22037/uj.v0i0.4662] Vol 17 No 01 January-February 2020 69 patient was operated with amplatz dilation in case he accepted this technique. As a result, there were two groups of patients and each group had 30 patients. The patients in Group 1 were treated with amplatz renal di- lators and group 2 were treated with DVIU. All patients were re-evaluated by uroflowmetry at the first, 3rd, 9th and 12th month postoperatively and Qmax values were recorded. During the follow-up period, if the patients had com- plaints of voiding difficulty and the maximum flow rate (Qmax) was < 10 ml/s, urethroscopy and urethrogra- phy were planned. If urethral strictures were present at urethroscopy and urethrography, these were accepted as recurrent strictures and the same procedure was per- formed again. The procedure was accepted as a suc- cessful one when the patient did not complain of any voiding difficulty and the Qmax was greater than 12 mL/sec(11). The primary endpoint measures of the study was deter- mined as an increase of Qmax. The secondary endpoint of the study was determined as the recurrence time of the stenosis. Surgical technique Written information consent was obtained from patients for both surgical procedure. All patients were operated by the same surgeon. All the patients underwent into urethrotomy under spinal or general anesthesia in the lithotomy position. Cephazolin sodium 1 g. i.v. was ad- ministered for preoperative antibiotic prophylaxis. A 20.5 F urethrotome was used for the cold knife ure- throtomy group. A safety guide wire was first passed through the stricture and the urethrotomy was per- formed at 12 o’clock. For all patients, a 20 F Foley ure- thral catheter was inserted and left in the bladder for 7 days at the end of the procedure. For amplatz dilation, all patients underwent cystoscopy at lithotomy position under spinal or general anesthe- sia. A 0.038-inch hydrophilic guidewire was introduced into the working channel after the location of the steno- sis was seen with the cystoscope (Figure 1). The cys- toscope was then removed and amplified renal dilators between 10F to 22F were sequentially delivered to the bladder over the guide wire (Figure 2 and 3). After the dilation procedure, the urethra was evaluated with cystoscopy and the procedure ended by attaching a 20F foley urethral catheter and removed at postoperative 7th day (Figure 4). Statistical analysis Independent-Samples T test, and Fisher’s exact test were used for comparing the groups of patients. P < 0.05 was considered statistically significant. The com- puter software that was used was Statistical Package for Social Sciences (SPSS 12.0.1; SPSS Inc., Chicago, IL, USA). RESULTS There were two groups of patients treated for urethral stricture. Group 1 was the amplatz dilation group and the group 2 was cold knife urethrotomy group. In both two groups there were 30 patients. The mean age of group 1 was 60.7 ± 6.3 years and in group 2 was 59.3±4.6 years. The etiology of urethral strictures were idiopathic in 20 (33,3%) and iatrogenic in 40 (66,6%) patients. Iatrogenic causes were attributed to transurethral resection of prostate, transurethral resec- tion of bladder tumor and urethral catheterization. There was no statistically significant difference between the two groups for age (P = .79). The mean preoperative Qmax values for group 1 and 2 were 4.9 ± 0.8 and 4.6 ± 0.4 ml/sec, respectively (P = .22). There was no statis- tically difference between two groups (Table 1). Mean operation time was shorter in amplatz group (15 ± 1.8 minutes) when compared with cold-knife group (15.9 ± 3.5 minutes) but it was not statistically significant (P = .21). When we compared the 3 month uroflowmetry results, mean Q max values were 15.6 ± 2 ml/sec in amplatz group and 15.5 ± 1.6 ml/sec in DVIU group. There was no statisticaly difference between the two groups (P = .89). However the Q max values in the postoperative 9 and 12 months were significantly decreased in the DVIU group (P = .001) (Table 2). In the cold knife group 9 recurrences appeared and 2 of these reccurrences were in the first 3 months, where- as in the amplatz group no recurrences appeared in the first 3 months. Recurrence-free rate at 3 months was similar between two (P = .23). The urethral stricture recurrence rate up to the 12 month follow up was statis- Parameters Amplatz group DVIU Group P Age 60.7 ± 6.3 59.3 ± 4.6 0.79 a Preoperative Qmax value (mL/sec) 4.9 ± 0.8 4.6 ± 0.4 0.22 a Operative time (min) 15 ± 1.8 15.9 ± 3.5 0.21 b Recurrence/no recurrence, n (%), 3th month 0/30 2/28 0.49 b Recurrence/no recurrence, n (%), 12th month 4/25 9/21 0.02 b Table 1. Characteristics in study groups and comparability of groups treated. a: Independent Samples T test. b: Fisher’s exact test. Qmax Group Before the operation 3th months 9thmonths 12thmonths Amplatz 4.9 ± 0.8 15.6 ± 2 15 ± 1.8 14.2 ± 1.3 DVIU 4.6 ± 0.4 15.5 ± 1.6 13.4 ± 1.4 11.9 ± 1.2 P 0.22* 0.89* 0.001* 0.0001* * Independent Samples T test. Table 2. Operative outcomes Table 3. Surgical technique and complication Operation time Complication Group Min Bleeding n(%) UTI n(%) Amplatz 15±1.8 1 (3.3) 1(3.3) DVIU 15.9±3.5 3 (10) 2(6.6) P 0.21 0.61 0.55 Urethral Strictures and Amplatz Dilation- Karslı et al. tically significant for group 1 when it is compared with group 2 (P = .02) (Table 1). The major postoperative complications were urethral bleeding and urethral tract ınfections (UTI). For the Amplatz group, only one patient reported as one epi- sode of urethral bleeding. However, in the DVIU group, 3 patients had urethral bleeding (Table 3). DISCUSSION In this study we compared amplatz dilation and DVIU, and as a result we found that amplatz dilation is more safe and effective technique for urethral stricture. In our experience, amplatz dilation a is good option as the ini- tial treatment for urethral stricture. The first known treatment modality of urethral stric- ture in history was dilation(12). Metal or bougie ure- thral dilation offers several advantages over internal urethrotomy. They avoid the need for general, spinal or intravenous anesthesia. It is a simpler, less-invasive, and potentially office-based procedure that requires less degree of surgical expertise and equipment(12,13). Be- cause the traditional dilatation procedure is performed in a blind fashion and potential technical complications at the time of the procedure such as excessive bleed- ing, urethral perforation with extravasation, rectal in- jury, and false path(14). To prevent these complications several modalities have been developed. Gelman et al. described direct vision balloon dilation for the trament of US and they suggested this technique(14).Yu et al re- ported High-pressure balloon dilation for male anteri- or urethral stricture and they found that this technique was effective and safe. Moreover they suggested such an alternative treatment modality for anterior urethral stricture disease(15). The amplatz dilation method have been described by Akkoc et al.(10) which we used in this study. The principle of conventional DVIU is to achieve epi- thelial regrowth by the incision of the scar tissue. The major disadvantage of DVIU is that the depth of the scar tissue cannot be estimated accurately during the procedure and resulting in imprecise incision of the scar tissue. It is possible that the incision of the urethral stric- Figure 1. The image of hydrophilic guidewire which was intro- duced into the uretrhral stenosis area under cystoscopy Figure 3. The image of 22 F amplatz dilator which was introduced from external meatus to the bladder by using guide wıre for the urethral stenosis area Figure 2. The image of 10 F amplatz dilator which was introduced from external meatus to the bladder by using guide wıre for the urethral stenosis area Figure 4. The image of post dilatation procedure Urethral Strictures and Amplatz Dilation- Karslı et al. Reconstructive Suegery 70 Vol 17 No 01 January-February 2020 71 ture may not reach the healthy tissue, so that it can not minimize the stricture recurrence effectively. Urethral epithelium metaplasia (stratified squamous) is seen as the primary change after urethral incision is more frag- ile than normal pseudostratified columnar epithelium (16). On the other hand, by incising the urethra via a cold knife, the underlying corpus spongiosum might be in- jured, which would lead to postoperative hemorrhage. The destroyed vascularity within the corpus spongio- sum and focal urinary extravasation through fissures on the mucosa might exacerbate the spongiofibrosis and finally turn to stricture recurrence(17). There are many investigations about use of therapeutic agents such as steroids, to avoid recurrence of stricture (18,19). Yıldırım et. al. have show that the use of local ster- oids injections with DVIU seems to decrease the high stricture recurrence rate following DVIU(20). In another study conducted by Sinanoglu et al., use of oral colchi- cine showed reducement of the recurrence of stenosis (21). Even if the results are controversial routine repeat- ed dilations after DVIU are suggested by urologists to prevent urethral stricture recurrence. Tian et al. argued that close follow-up by after DVIU is more effective than recurrent dilatations in preventing recurrence of stricture(22). There are limited randomised and prospective trials that comparing the efficacy of dilatation versus internal ure- throtomy as initial treatment for urethral strictures. In one study which was a retrospective study of 199 men with strictures treated at the Mayo Clinic, 101 (67%) patients underwent dilation and 39 (26%) patients un- derwent direct vision internal urethrotomy. At a median follow-up of 3.5 years, the probability of not requiring re-treatment within 3 years was 65% for dilation and 68% for urethrotomy, indicating that these procedures were equally efficacious as an initial treatment of bul- bar strictures(13). JW Steenkamp and CF Heyns and ML de Kock who also compared and showed that dilation and DVIU are equally effective for initial treatment of US(23). In our study, the recurrence rate was 6 % for the amplatz dilation during the 18 months follow up period. In the cold knife group, recurrence rate was 36 % dur- ing the 18 months follow up period. “Time to recurrence” is also an important parameter in urethral stricture disease(24). In the DVIU group, 2 of 30 (6,6 %) recurrences appeared within the first 3 months, whereas in the dilation group no recurrences appeared within the first 3 months in our study. Santucci et al. evaluated the success rate of DVIU as a treatment for simple male urethral strictures(8) and they found the stricture free rate after the first DVIU 8% with a medi- an time to reccurence of 7 months. This result shows a lower success rate from the previously published stud- ies which have reported the DVIU success rates to vary from 20% to 95% (25-28) and they indicate that urethroto- my is popular for being an easy technique and it is not a successful procedure. In our study we found the DVIU success rate is lower than amplatz dilation and these re- sults encourages us to suggest that the initial treatment of US should be amplatz dilation because of the higher success rate than DVIU. There are some important limitations to our study. One of them is that we did not do the measures of strictures. The other one at the end of DVIU is that we didn't measure the urethral caliber. Another limitation is the shortness of our follow-up period. Finally our study is retrospective. CONCLUSIONS Treatment modality of anterior urethral stricture disease by using guidewire-assisted urethral dilation with am- platz renal dilators is safe, effective and a minimally invasive method for the treatment of urethral strictures. It also avoids the risks which is associated with blind dilatation techniques. When it is compared with cold knife technique, it provides a better recurrence free rates during the early period. In our experience, amp- latz dilation is a good option as the initial treatment for urethral stricture. Further randomized studies compar- ing dilatation using amplatz renal dilators with DVIU are warranted. CONFLICT OF INTEREST None declared. REFERENCES 1. Mundy AR, Andrich DE: Urethral strictures. BJU Int. 2011;107:6–26. 2. Hosseini J, Kazemzadeh Azad B, Aliakbari F, Tayyebi Azar A, Hosseini MA. Familial Urethral Stricture, Five Adult patients overview. Urol J. 2019 ;16:515-516. 3. Hızlı F, Berkmen F, Günes ̧ MN, Yürür H. Outcomes of internal urethrotomy after transurethral resection related urethral strictures and literature review. Türk Üroloji Dergisi. 2005;31:417-22. 4. Van Leeuwen MA, Brandenburg JJ, Kok ET, et al. Management of adult anterior urethral stricture disease: nationwide survey among urologists in the Netherlands. Eur Urol. 2011, 60:159-66. 5. Sachse H. Zur Behandlung der Harnröhren- striktur: die transurethrale Schlitzung unter Sicht mit scharfem Schnitt. Fortschr Med. 1974;92:12–15. 6. de Kock ML, Allen FJ. Guidelines for the treatment of urethral strictures. S Afr J Surg. 1989;27:182-4. 7. Chilton CP, Shah PJ, Fowler CG, Tiptaft RC, Blandy JP. The impact of optical urethrotomy on the management of urethral strictures. Br J Urol. 1983;55:705-10. 8. Santucci RA, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol. 2010; 183:1859–62 9. Cecen K, Karadag MA, Demir A, Kocaaslan R. PlasmaKineticTM versus Cold Knife Internal Urethrotomy in Terms of Recurrence Rates: A Prospective Randomized Study. Urol Int. 2014; DOI: 10.159/000363249. 10. Akkoc A, Aydin C, Kartalmıs M, et al. Use and outcomes of amplatz renal dilator for treatment of urethral strictures. Int Braz J urol. 2016; 42: 356-64 . 11. Koca O, Sertkaya Z, Gunes M, et al. Internal urethrotomy ver- sus plasmakinetic energy for Urethral Strictures and Amplatz Dilation- Karslı et al. surgical treatment of urethral stricture (Article in Turkish). Turkish J Urol. 2011; 37:30-33. 12. Vicente J, Salvador J, Caffaratti J. Endoscopic urethrotomy versus urethrotomy plus Nd- YAG laser in the treatment of urethral stricture. Eur Urol. 1990;18:166-8. 13. Stormont TJ, Suman VJ, Oesterling JE. Newly diagnosed bulbar urethral strictures: etiology and outcome of various treatments. J Urol. 1993;150:1725-8. 14. Gelman J, Liss MA, Cinman NM. Direct vision balloon dilation for the management of urethral strictures. J Endourol. 2011;25:1249- 51. 15. YU S, Wu H, Wang W, et al. High-pressure balloon dilation for male anterior urethral stricture: single-center experience. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2016 17:722-7 16. Chambers RM, Baitera B. The anatomy of the urethral stricture. Br J Urol. 1977; 49: 545-51. 17. Isen K, Nalcacioglu V. Direct vision internal urethrotomy by using endoscopic scissors. Int Urol Nephrol. 2015 ;47:905-8. 18. Kumar S, Garg N, Singh SK, Mandal AK. Efficacy of Optical Internal Urethrotomy and Intralesional Injection of Vatsala-Santosh PGI Tri-Inject (Triamcinolone, Mitomycin C, and Hyaluronidase) in the Treatment of Anterior Urethral Stricture. Adv Urol. 2014; 2014:192710. 19. Mazdak H, Meshki I, Ghassami F. Effect of mitomycin C on anterior urethral stricture recurrence after internal urethrotomy. Eur Urol. 2007; 51:1089-92. 20. Yıldırım ME, Kaynar M, Ozyuvali E, et al. The effectiveness of local steroid injection after internal urethrotomy to avoid recurrence. Arch Ital Urol Androl. 2015;87:295–8. 21. Sinanoglu O, Kurtulus FO, Akgün FS. Long Term Effect of Colchicine Treatment in Preventing Urethra Stricture Recurrence After Internal Urethrotomy. Urol J. 2018;15:204-8. 22. Tian Y, Wazir Y, Wang J, Li H. Prevention of stricture recurrence following urethral internal urethrotomy: routine repeated dilations or active surveillance? Urol J. 2016;13:2794-6. 23. Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: a prospective, randomized comparison. J Urol. 1997 ;157:98-101. 24. Atak M, Tokgoz H, Akduman B, et al. Low- power holmium:YAG laser urethrotomy for urethral stricture disease: comparison of out- comes with the cold-knife technique. Kaohsiung J Med. 2011; 27:503-507. 25. Greenwell TJ, Castle C, Andrich DE et al: Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective not cost-effective. J Urol. 2004; 172: 275. 26. Naude AM and Heyns CF. What is the place of internal urethrotomy in the treatment of urethral stricture disease? Nat Clin Pract Urol. 2005; 2: 538. 27. Heyns CF, Steenkamp JW, De Kock ML et al: Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J Urol. 1998; 160: 356. 28. Morey A: Urethral stricture is now an open surgical disease. J Urol 2009; 181: 953. Urethral Strictures and Amplatz Dilation- Karslı et al. Reconstructive Suegery 72