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The Endoscopic Treatment of Post-Traumatic Membranous Urethral Strictures
The best approach to post-traumatic membranous urethral strictures is open surgical management, usually cys-tostomy followed by delayed bulboprostatic anastomosis. The success rate with these techniques exceeds 90% . In recent years, endoscopic management of membranous urethral strictures has been proposed [2-5]. Endoscopic treatment may be a reasonable alternative option in selected patients who refuse open surgery or who are at high risk for surgery.
Other indications include previous surgery of the anterior urethra and hypospadia repair, when adequate mobilization of the urethra cannot be obtained and distal urethra blood supply may be impaired.
Endoscopic treatment can provide acceptable results in nearly 50% of patients and achieve satisfactory voiding in two-thirds of previously untreated patients.
Urethroplasty remains the gold standard of treatment of membranous urethral strictures. Good results have been reported in 105 patients with perineal or transpubic anastomosis, with success rates of 95% and 97%, respectively . However, even in referring centers, recurrence rates can be as high as 20%, with prolonged follow-up (96 months) . At 10 years, Mundy  observed 12% and 31% recurrence rates in 141 patients treated with transperineal bulboprostatic anastomotic urethroplasty, or patch urethroplasty, respectively. Open urethroplasty of the posterior urethra is a complex operation and the hospital stay is usually prolonged [9, 10].
The endoscopic technique [4, 5] is based on three surgical principles: 1) only complete section of the block of scar tissue can achieve definitive good results; 2) a strip of epithelial tissue is preserved at the 6 and 12 o'clock positions in order to hasten the epithelialization process at the stricture site; and 3) hydraulic self-dilatation will maintain the operated membranous urethra open while the process of epithelialization is in progress.
The operation (O Fig. 10.1) is performed in the lithotomy position. The stricture is incised at 3 and 9 o'clock
□ Fig. 10.1A-D. Operative technique. A Incision of the scar tissue at 3 and 9'clock. B The block of scar tissue is divided into two halves, upper and lower. C Resection of the scar tissue is performed, leaving a strip of intact mucosa at 12 o'clock. D The strip of mucosa leads a faster re-epithelialization
□ Fig. 10.1A-D. Operative technique. A Incision of the scar tissue at 3 and 9'clock. B The block of scar tissue is divided into two halves, upper and lower. C Resection of the scar tissue is performed, leaving a strip of intact mucosa at 12 o'clock. D The strip of mucosa leads a faster re-epithelialization positions with a cold knife in order to preserve the mucosa at 6 and 12 o'clock. The two incisions are prolonged with a Collings knife, dividing the scar tissue block into two halves, upper and lower. With a cutting loop, all excess fibrous tissue is fully resected, until the scar is completely removed and healthy tissue is encountered. The strips of healthy mucosa, at the 6 and 12 o' clock positions, are preserved in order to obtain fast and multidirectional epithelialization and to prevent stricture recurrence
(O Fig. 10.2). At the end of the procedure, a wide opening is obtained between the prostatic and the bulbar urethra (O Fig. 10.3). An indwelling Foley catheter is left for 48 h, and the patient is usually dismissed on the 4th postoperative day. Hydraulic self-dilatation is started at discharge and performed for the first 6 postoperative months.
Patients undergo urethrocystogram and uroflow at 1, 3, 6, and 12 months. After the 1st year, urethrocystogram is performed yearly.
In our personal series, 23 patients with severe strictures of the membranous urethra following pelvic fracture and complete disruption of the urethra, were treated endoscopically for 16 years. The cause of pelvic injury was an automobile accident in 17 patients and work-related trauma in six patients.
At a median follow-up of 61 months, 19 patients were evaluable. Thirteen patients required more than one procedure. Excellent results (peak flow >15 ml/s) were obtained in seven patients (37%), satisfying results (peak flow between 10 and 15 ml/s) in three (16%), and poor results (peak flow <10 ml/s) in nine (47%). The complication rate was 32%, including urinary infection in three patients, postoperative bleeding not requiring transfusion in two patients and mild stress incontinence in one patient.
In conclusion, of the 19 patients in follow-up, seven (37%) required open urethroplasty with bulboprostatic anastomosis.
The endoscopic treatment of membranous urethral strictures for complete traumatic urethral obliteration has been described in several reports with small series [11-15].
However, in 1995 El Abd  published the largest series of patients treated with endoscopy for post-traumatic membranous urethral stricture.
A 58% success rate was reported in 396 patients treated with urethrotomy. Follow-up was 2 years. Success was defined as »good stream, continence and no further urethrotomy or dilatation.«
Strictures of the membranous urethra following complete traumatic disruption are surrounded by abundant scar tissue, often with a fistulous tract connecting the prostatic and bulbar urethras.
In our opinion, cold-knife urethrotomy is likely to be unsuccessful because the dense fibrous tissue remains stiff, inelastic, and unable to open to a wider caliber. The urogenital diaphragm and the sphincter mechanism support the development of early adherences of the urethrotomy, which may result in recurrent stricture. For this reason, extensive resection of all scar tissue must be performed to obtain a good and definitive result. The preserved strips of intact mucosa at the 6 and 12 o' clock positions help the epithelialization process, with fast coverage of the underlying tissue, thus preventing the growth of fibroblasts and recurrent strictures.
In several patients, multiple procedures may be required in order to obtain complete resection of all the scar tissue.
The limited number of patients does not allow us to identify prognostic factors and to select patients who will benefit from an endoscopic procedure.
The only significant prognostic indicator of a good result is the chance to achieve complete resection of the block of scar tissue.
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