Optical urethrotomy under local anaesthesia is a feasible option in urethral stricture disease

Introduction

Urethral stricture disease is extremely common in the region serviced by our urology unit and accounts for a great deal of morbidity among men across a wide age spectrum. Cases that are complicated by perineal fasciitis may even lead to mortality – a scenario that is on the increase due to the high incidence of HIV infections in the KwaZulu-Natal province.

Young men have difficulty maintaining employment due to morbidity from urethral stricture disease. Optical urethrotomy is frequently the initial operative intervention for strictures, and has routinely been performed under spinal or general anaesthesia. This approach has a significant impact on our already oversubscribed theatre slates and also adds to the financial burden of the treatment of patients with urethral strictures. The use of intraurethral lignocaine jelly for catheterization and dilatation is routine throughout the world and is also a well-documented form of anaesthesia for optical urethrotomy. ^1–8 Urethrotomy under intracorpus spongiosum anaesthesia with lignocaine has also been reported with favourable results. ⁹ Against this background, we decided to perform optical urethrotomy under local anaesthetic and assess the patient tolerance and efficacy of this form of anaesthesia.

Materials and methods

In a prospective study over a period of ten months, 33 men who presented with radiologically proven urethral stricture disease at our institution, underwent optical urethrotomy under local anaesthesia by a single operator. After intraurethral instillation of 20 ml of 1% lignocaine, a penile clamp was placed for at least five minutes. Analgesia was supplemented by 50–75 mg intravenous pethidine administration and the patients were monitored appropriately. Perioperative antibiotic prophylaxis consisted of intravenous administration of a second generation cephalosporin. After placement of a guidewire across the stricture, a standard optical urethrotomy was performed using a 21F cold knife urethrotome. The stricture was routinely incised at the 12 o'clock position with additional incisions at the 4 and 8 o'clock postions in more dense strictures. Following successful urethrotomy, a 16F silastic urethral catheter was left in place for 4–14 days. The majority of cases were day-case procedures, although some patients required overnight admission for logistical reasons. At follow-up, patients were taught to perform self urethral dilatation and to this end were supplied an integral filiform urethral dilator (FFD 180032 – Cook Medical, Limerick, Ireland and Indiana, USA).

We considered the operation successful if the stricture was optically incised to allow urethroscope placement to the bladder and the patient was able to pass urine after removal of the urethral catheter.

Patient tolerance was assessed in the immediate postoperative period with the aid of a visual analogue score (VAS) for pain or discomfort. The patient selected a score from 0–10 with 0 representing no discomfort at all and 10 representing severe unbearable pain during the procedure. Although patient tolerance was the primary factor under assessment, additional information recorded included patient age; stricture location and description; presence or absence of supra-pubic catheter (SPC) preoperatively; whether the procedure was successful or not; and complications.

Results

A total of 33 patients with an average age of 51.8 years (range 25–96 years) were included in the study. Of the studied patients, 18 (55%) presented with acute urinary retention and were dependent on a SPC at the time of the procedure.

The majority of the strictures were located in the bulbar (10) or peno-bulbar urethra (11) and 5 patients had penile stricture. Seven patients had more than one stricture. Despite the extensive nature of the majority of the strictures, the procedure was successful in all but 3 of the 33 cases (91%). Two patients developed postoperative urinary tract infections and there was one early recurrence for which the patient required urethroplasty. The results for the primary assessment parameter – patient tolerance as depicted by VAS – are shown in Table 1. Only six patients gave a VAS of more than three out of ten. Nine patients reported no discomfort at all during the procedure. The average VAS for the 33 patients was two out of ten.

Discussion

Urethral stricture disease continues to place a considerable burden on the urological resources of developing countries like South Africa. ^3,5,8,9 While urethroplasty remains the gold standard for treatment of urethral strictures, and is the procedure of choice in certain cases, the ability to treat the majority of strictures by less invasive and time-consuming means offers obvious benefits. ^4,10 Consequently, optical urethrotomy will continue to be an important modality in the management of these patients. Furthermore, the ability to perform this procedure under local anaesthesia offers the additional benefits of reduced demand on operating theatre slates and rapid day-case surgery. ⁸ The results in this study support the findings of other investigators who have shown the procedure to be satisfactorily tolerated under local anaesthesia. ^2–9 The majority of cases in this series had severe strictures as shown by the density of the strictures and the fact that more than half of the patients were dependent on a SPC. Nevertheless, a high success rate of 91% was achieved with low complication rate. The primary factor under consideration in this study was patient tolerance. In this regard, a very favourable outcome was achieved as shown by the low average visual analogue pain score of two out of ten.

The findings in this study are in support of previous literature regarding the feasibility of performing optical urethrotomy under local anaesthesia. This approach is very well-tolerated and does not reduce the efficacy of the modality. Future studies might assess the possibility of omitting intravenous analgesia – which would simplify the monitoring requirements even further – as well as the reproducibility of these results with different operators.