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ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 4  |  Page : 192-197
 

Stricture urethra in children: An Indian perspective


Department of Pediatric Surgery and Paediatric Urology, Christian Medical College Hospital, Vellore, Tamil Nadu, India

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Susan Jehangir
Department of Paediatric Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_146_17

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   Abstract 


Background: Pediatric urethral stricture and its treatment have functional implications in the growing child.
Subjects and Methods: A retrospective study of records on urethral strictures encountered in our institution between January 2005 and May 2016 yielded 23 boys against a backdrop of 19,250 admissions during the same period; stenosis and strictures after hypospadias repair were not included in this study. Demographic data were collected from the charts, and the success of repair was assessed clinically by success of repair was assessed clinically by observing for presence or absence of symptoms such as dribbling, straining at voiding, adequacy of urinary stream and radiologicaly by assessing the micturition phase of voiding cystourethrogram. Success was defined as successful initiation, flow, and completion of voiding with radiological evidence of reestablishment of urethral continuity.
Results: The most common cause of urethral stricture was perineal or pelvic trauma (56.5%). Three after surgery for anorectal malformation (13.04%) and 2 (8.6%) followed otherwise unspecified urethritis. Transperineal and transpubic anastomotic routes were used for surgery. Redo surgery was required in 47.8%. The overall success rate was 82%. A self-catheterizable mitrofanoff channel was created as part of the primary procedure in 63.6% (7/11) or after the failure of the first procedure in 36.3% (4/11).
Conclusion: The majority of urethral strictures are long-segment strictures or those with complete disruption not amenable to endoscopic techniques. The aim of the surgery is to obtain end-to-end opposition of healthy proximal and distal urethra. The route – transperineal or transpubic – which will give the best access to the ends of the urethra is determined by the location and extent of the stricture and the alteration in anatomy as a consequence of the pelvic fracture. Even after the introduction of laser and endoscopic techniques, surgical repair is required to tackle the majority of urethral strictures in children.


Keywords: Anastomotic repair, pediatric urethral stricture, posttraumatic urethral stricture


How to cite this article:
Herle K, Jehangir S, Thomas RJ. Stricture urethra in children: An Indian perspective. J Indian Assoc Pediatr Surg 2018;23:192-7

How to cite this URL:
Herle K, Jehangir S, Thomas RJ. Stricture urethra in children: An Indian perspective. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2018 Dec 10];23:192-7. Available from: http://www.jiaps.com/text.asp?2018/23/4/192/242707





   Introduction Top


The pediatric perineum is narrow, tissues are fragile, and the caliber of the urethra is small. By following Warwick's publication in 1977,[1] transperineal primary repair is now universally acceptable as the procedure of choice for pediatric urethral stricture repair. There is growing experience with the use of endoscopic techniques for adult urethral stricture. With refinements in instruments, many pediatric urologists now advocate endoscopic techniques for small-segment strictures. As technical advancements lead to newer less invasive modalities, it is imperative to evaluate the results of conventional methods to facilitate comparison. With this in view, we studied our results with primary anastomosis for pediatric urethral stricture.


   Subjects and Methods Top


A retrospective search of the hospital information system, after obtaining Ethical Committee clearance, for urethral stricture in children aged up to 15 years from January 2005 to May 2016 yielded 23 children, all boys. Data on etiology, stricture length, and treatment were tabulated, and the operative findings, imaging, and outcome were recorded after study of their inpatient and outpatient records. The success of surgery was defined by a record of a satisfactory voiding stream observed clinically along with full caliber urethral continuity shown on a voiding cystourethrogram (VCUG). The patients were analyzed as two groups based on the location of the proximal end of the stricture by VCUG findings: Group 1 anterior urethral stricture (n = 10) and Group 2 posterior urethral stricture (n = 13).

All cases of posttraumatic strictures were operated after a minimum of 6 months from the time of trauma. They were maintained on a suprapubic catheter (SPC) diversion as per Johanson principle.[1] A combined retrograde urethrogram with VCUG was performed to know the site and extent of stricture. The route for repair was chosen based on this imaging. A transpubic route was chosen in cases with the proximal end of the stricture from the bladder neck up to the lower border of the verumontanum. A transperineal route was chosen for cases with stricture commencing at bulbomembranous junction or more distally.

Transperineal urethroplasty was done according to the principles of Turner-Warwick.[2] With the child in a lithotomy position, either a midline perineal incision or an inverted U-shaped incision was made through the skin, subcutaneous tissue, and Colles' fascia to uncover the urethra within the bulbospongiosus muscle. The bulbospongiosus muscle was incised in the midline and retracted away with mastoid retractors to expose the native urethra. The distal end of the urethral stricture was identified by passing a Lister's bougie through the external urethral meatus. The distal urethra was separated from the corpora cavernosa bodies using scissor and bipolar dissection and disconnected from the terminal fibrosis that marked the stricture site. The fibrosed end was trimmed back to healthy lumen, with freshening of the edges; a few interrupted 4/0 chromic catgut sutures were taken radially to tack the mucosa to the wall and prevent retraction during the anastomosis. The urethra was mobilized sufficiently from the corpora cavernosa to gain elasticity and length for the anastomosis. The proximal urethral end was identified by passing a bougie through the SPC - a finger in the rectum acting as a guide, and a sufficient length of the proximal urethra was freed up and trimmed back to healthy urethra. A tension-free anastomosis was then performed with Vicryl 4-0 after spatulating both ends of the urethra. If required, the fusion plane between the corpora cavernosa was slit to give a shorter, more direct line for the distal urethral to reach the proximal urethra. A silastic tube or catheter was left in place as a stent for 3 weeks.

For the transpubic repair, the distal urethra was dissected as described. However, for the dissection of the proximal end, an infraumbilical midline incision was made. The pubis was cleared of its muscular attachments for 1–2 cm on either side of the symphysis reaching the inferior aspect of the pubis both anteriorly and posteriorly. A Gigli wire saw was then used to cut and remove a segment of pubic bone. This gave additional access to defining and freeing the end of the proximal urethra. After dissecting the urethral end clear off periurethral fibrosis and callus, the pelvic diaphragm is divided in the midline to give a shortened and more direct path for the two ends of the urethra to meet. Anastomosis was performed by spatulating the urethral ends and suturing with interrupted 4/0 Vicryl sutures. The lower abdominal incision was closed in layers over a suction drain, without replacing the excised bone segment. Postoperatively, the patients were, hence, advised maximum bed rest. [Figure 1] shows the representative micturating cystourethrogram images of stricture urethra and successful repair.
Figure 1: Preoperative and postoperative voiding cystourethrogram images

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In two instances, when a perineal approach was used, long-segment strictures where the approximation of ends was difficult were managed with tissue interposition. A pedicled preputial flap as described by Bal et al.[3] was effective; however, a buccal mucosal-free graft in another was not.

The silastic tube periurethral stent across the anastomosis was retained for a period of 3 weeks and removed at the time of VCUG. If the VCUG showed smooth continuity without extravasation, a trial of voiding was done by clamping the SPC. The SPC was removed after the patient voided to completion with a good stream.


   Results Top


Patients

The mean age at surgery was 10.4 years in Group 1 and 11.3 years in Group 2. Nearly 52% of urethral strictures were posttraumatic. Traumatic strictures were seen in older children. The length of stricture was comparable in both groups with an average of 1.5 cm (range 0.5–3). The demographic profile of the two groups is summarized in [Table 1].
Table 1: Demographic profile of study cases

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Etiology

The etiologies of stricture in our study and the mechanisms of traumatic strictures are tabulated in [Table 1].

Outcomes

A total of 23 boys underwent a total of 32 procedures. At the time of writing of this paper, 82% (19/23) have had a successful outcome.

Of the 13 children in Group 2, 4 (30.7%) voided well after one operation, 6 (46%) did so after a second procedure, and 1 after third procedure giving a final success rate of 83%. In this last instance, after the second surgery, a cystoscope could be passed through a residual stricture, but the child was unable to void. A preputial tube ventral onlay was performed using Bal et al.'s. technique[3] was successful, and he now voids normally per urethra.

In Group 2, the transperineal repair was done in nine children, and the transpubic repair was done in four children. Two children who were operated by transperineal route the first time underwent a redo procedure by transpubic route. this was due to the difficult access transperineally in view of dense fibrosis. The average length of stricture operated by transperineal was 1.2 cm and in transpubic route was 2 cm. The outcomes of repair were independent of etiology of stricture (P = −0.5) and length of stricture (P = −0.9). A total of four cases (2 each in Groups 1 and 2) had preputial skin flap (n = 3), or buccal mucosal flaps (n = 1) used as tissue interposition repair. [Table 1] and [Table 2] summarize the results in anterior and posterior strictures.
Table 2: surgical outcomes in each group

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The follow-up ranges from 6 months to 2 years. On follow-up, there were two cases in posterior stricture group with incontinence. Both children had stricture close to bladder neck and were operated by transpubic route. They continue to use mitrofanoff channel for clean intermittent catheterization.


   Discussion Top


Surgery is the cornerstone in the management of pediatric urethral strictures. Urethral strictures are uncommon in children necessitating the documentation of cumulative experience to expand the database and make evidence-based recommendations. Johanson in 1953 was the first to observe the inevitable stricture formation after complete urethral disruption.[1] Immediate repair or primary alignment of urethral disruption was shown to have high short- and long-term complications regarding incontinence, impotency and also the associated surgical risks of performing a major reconstructive procedure in a patient who may be unstable immediate posttrauma.[4] This has led to the recommendation to avoid surgical interventions in the presence of major pelvic hematomas and devitalized tissues. Repairing the urethra at a second procedure allows for fibrosis to shorten the length of the stricture, better healing, and success of repair.[1] A few researchers have reported success in selected stable and less severe traumatic patients for immediate repair. The numbers are, however, limited and require further study.[5]

In literature, the major causes of urethral strictures in children are traumatic, iatrogenic, infective, and idiopathic. In trauma involving pelvic compression, the urethra gets torn from the shearing that occurs between the puboprostatic ligaments and perineal membrane. The sharp edges of the fractured bones can also cause direct injury. Strictures of the posterior urethra are associated with anorectal malformations (ARMs) can be due to congenital dysplastic urethra or surgical injury.[6] Strictures have been reported after fulguration of posterior urethral valve and after prolonged catheterization with Foley's catheter in boys. Anterior urethral strictures can be a consequence of hypospadias repair. Lichen sclerosus et atrophicus previously known as balanitis xerotica obliterans was once a cause of progressive urethral stricture, but now it can be held in check by topical tacrolimus.

Earlier reports suggested that in children due to confines of space, more proximal urethral injuries, unassessed distraction effect, and greater displacement of the prostate, primary success was uncommon.[4],[7] The prostate and puboprostatic ligaments are not fully developed in boys, the disruption sometimes occurs across the prostatic urethra or concomitant bladder neck laceration, and the posterior urethral stricture tends to be higher.[8] Waterhouse et al. described the transpubic urethroplasty in 1973.[9] In 1977, Warwick et al. published their experience with the perineal approach to pediatric posterior urethral strictures.[7] The membranous urethra in children is quite superficial compared to adults. In literature, the results of transperineal and transpubic repair are comparable;[4] however, the transpubic repair carries the concerns of iatrogenic damage to the external sphincter and ejaculatory duct. Podesta et al.[8] in 1998 achieved an 84% success in transperineal repair and 100% in transpubic repair of posttraumatic strictures and were able to achieve it without dividing or excising the pubis. The maximum length of stricture repaired transperineally was 5 cm. In our series, we could bridge a gap of up to 3 cm stricture transperineally in a 13-year-old boy. Our >50% redo rate for posterior urethral strictures is probably from a preference to attempt a transperineal approach whenever feasible. Others also use the transpubic approach selectively when a tension-free approximation be achieved by the transperineal approach.[4],[10],[11],[12] The anastomotic repair has as high as 95% success rate even in redo cases.[13]

The use of endoscopic incision of short-segment urethral strictures is widely accepted and practiced in adults.[4] With advances in instrumentation, many pediatric urologists are now trying out with endoscopic techniques for small-segment strictures.[14],[15] Kenneth et al. (2003) reported a 42% recurrence rate with direct visual internal urethrotomy (DVIU) when used for 50 pediatric urethral strictures. They recommended to undertake urethroplasty if an attempt at DVIU failed. DVIU is used for passable strictures up to 1 cm and has been advised up to a maximum up to 2 cm.[16]

Lasers share a similar profile as cold knife DVIU in that they can use with success rates in short stricture lengths and in a primary setting. Holmium laser is commonly used. Repeated laser urethrotomies do not improve the rate of success.[17],[18] A meta-analysis presented at the international consultation on urethral strictures held in Morocco in October 2010 provided Level 1 evidence that anastomotic repair is superior to endoscopic management of pediatric urethral strictures.[19]

An appendicular mitrofanoff preserves bladder capacity, reduces chances of stone formation, and improves body image and social interactions when the treatment is prolonged and redo surgery may be required.[20] In our cohort, there were five from Group 1 who had mitrofanoff procedure done. A child in whom the repair failed and one other child with traumatic stricture and failed transperineal repair who is awaiting a redo continues to use the channel. About 7 cases out of 12 in Group 2 had mitrofanoff as an add-on procedure including two who had a failed repair. Among the remaining five children, one child who had stricture closer to bladder neck and postsurgery having incontinence continues to use the mitrofanoff channel. Three children had mitrofanoff done following failed primary repair, and one child received a mitrofanoff channel in view of long length of stricture (2 cm).


   Conclusion Top


We report our experience with surgical repair of urethral strictures in 23 children over an 11 years period. Trauma was the most common cause of stricture in children. Primary surgery was successful in 43.4% (10/23), and redo was successful in the first instance in 72% (8/11) and at the second instance in 50% (1/2). The outcomes of surgery in 2 post-ARM strictures were poor. Anastomotic repair irrespective of the route (transperineal and/or transpubic) had an overall success rate of 82% after redo procedures. Anastomotic repair still stands as the best method of repair of urethral stricture in children though associated with morbidity of surgery and prolonged hospital stay.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Johanson B. Reconstruction of the male urethra in strictures. Application of the buried intact epithelium technic. Acta Chir Scand. 1953;176 Suppl 176:1–89.  Back to cited text no. 1
    
2.
Turner-Warwick R. A personal view of the management of traumatic posterior urethral strictures. Urol Clin North Am 1977;4:111-24.  Back to cited text no. 2
    
3.
Bal HS, Kurian JJ, Sen S. The use of pedicled prepucial skin flap urethroplasty for proximal bulbomembraneous urethral stricture in children. Ann Pediatr Surg 2017;13:38-42.  Back to cited text no. 3
    
4.
Ranjan P, Ansari MS, Singh M, Chipde SS, Singh R, Kapoor R, et al. Post-traumatic urethral strictures in children: What have we learned over the years? J Pediatr Urol 2012;8:234-9.  Back to cited text no. 4
    
5.
Qu Y, Zhang W, Sun N, Huang C, Tian J, Li M, et al. Immediate or delayed repair of pelvic fracture urethral disruption defects in young boys: Twenty years of comparative experience. Chin Med J (Engl) 2014;127:3418-22.  Back to cited text no. 5
    
6.
Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L, et al. Contemporary urethral stricture characteristics in the developed world. Urology 2013;81:191-6.  Back to cited text no. 6
    
7.
Koraitim MM. Posttraumatic posterior urethral strictures in children: A 20-year experience. J Urol 1997;157:641-5.  Back to cited text no. 7
    
8.
Podestá ML. Use of the perineal and perineal-abdominal (transpubic) approach for delayed management of pelvic fracture urethral obliterative strictures in children: Long-term outcome. J Urol 1998;160:160-4.  Back to cited text no. 8
    
9.
Waterhouse K, Abrahams JI, Gruber H, Hackett RE, Patil UB, Peng BK. The transpubic approach to the lower urinary tract. J Urol 1973;109:486–90.  Back to cited text no. 9
    
10.
Zhou FJ, Xiong YH, Zhang XP, Shen PF. Transperineal end-to-end anastomotic urethroplasty for traumatic posterior urethral disruption and strictures in children. Asian J Surg 2002;25:134-8.  Back to cited text no. 10
    
11.
Singh SK, Pawar DS, Khandelwal AK, Jagmohan. Transperineal bulboprostatic anastomotic repair of pelvic fracture urethral distraction defect and role of ancillary maneuver: A retrospective study in 172 patients. Urol Ann 2010;2:53-7.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Mundy AR. Anastomotic urethroplasty. BJU Int 2005;96:921-44.  Back to cited text no. 12
    
13.
Aggarwal SK, Sinha SK, Kumar A, Pant N, Borkar NK, Dhua A, et al. Traumatic strictures of the posterior urethra in boys with special reference to recurrent strictures. J Pediatr Urol 2011;7:356-62.  Back to cited text no. 13
    
14.
Singla M, Jha MS, Muruganandam K, Srivastava A, Ansari MS, Mandhani A, et al. Posttraumatic posterior urethral strictures in children – Management and intermediate-term Follow-Up in Tertiary Care Center. Urology 2008;72:540-3.  Back to cited text no. 14
    
15.
Helmy TE, Sarhan O, Hafez AT, Dawaba M, Ghoneim MA. Perineal anastomotic urethroplasty in a pediatric cohort with posterior urethral strictures: Critical analysis of outcomes in a contemporary series. Urology 2014;83:1145-8.  Back to cited text no. 15
    
16.
Launonen E, Sairanen J, Ruutu M, Taskinen S. Role of visual internal urethrotomy in pediatric urethral strictures. J Pediatr Urol 2014;10:545-9.  Back to cited text no. 16
    
17.
Shoukry AI, Abouela WN, ElSheemy MS, Shouman AM, Daw K, Hussein AA, et al. Use of holmium laser for urethral strictures in pediatrics: A prospective study. J Pediatr Urol 2016;12:42.e1-6.  Back to cited text no. 17
    
18.
Jhanwar A, Kumar M, Sankhwar SN, Prakash G. Holmium laser vs. conventional (cold knife) direct visual internal urethrotomy for short-segment bulbar urethral stricture: Outcome analysis. Can Urol Assoc J 2016;10:E161-4.  Back to cited text no. 18
    
19.
Buckley JC, Heyns C, Gilling P, Carney J. SIU/ICUD consultation on urethral strictures: Dilation, internal urethrotomy, and stenting of male anterior urethral strictures. Urology 2014;83:S18-22.  Back to cited text no. 19
    
20.
Freitas Filho LG, Carnevale J, Melo Filho AR, Vicente NC, Heinisch AC, Martins JL, et al. Posterior urethral injuries and the mitrofanoff principle in children. BJU Int 2003;91:402-5.  Back to cited text no. 20
    


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