Transüretral rezeksiyon sonrası gelişen üretra darlıklarında internal üretrotomi sonuçları ve literatürün gözden geçirilmesi

Outcomes of internal urethrotomy after transurethral resection related urethral strictures and literature review

Özet

TUR-P sonrası üretral darlık gelişme insidansı %1.5-29 arasındadır. TUR-P sonrası üretra darlığı gelişimine etki edebilecek bazı etmenler öne sürülmüştür fakat, etiyolojisi halen tam olarak anlaşılamamıştır. Bu çalışmamızda Transüretral Prostat Rezeksiyonu (TUR-P) sonrası üretra darlığı gelişen hastaları kolaylaştırıcı etmenler açısından değerlendirmeyi ve bu hastaların internal üretrotomi sonuçlarını literatür ile karşılaştırmayı amaçladık. 1998-2001 yılları arasında, TUR-P sonrası üretra darlığı gelişen 60 hasta çalışmaya dahil edildi. Hastalar kolaylaştırıcı risk etmenleri açısından incelendi ve bu hastalara yapılan İnternal Üretrotomi sonuçları literatür ile karşılaştırıldı. Ortalama yaş 67.6 (51-80), ortalama takip süresi 19 ay (5-36) idi. Darlıkların büyük çoğunluğu bülböz ve membranöz üretrada idi. TUR-P sonrası darlık gelişimi ile hasta yaşı, rezeksiyon süresi, ameliyat sonrası sonda kalış süresi arasında istatistiksel olarak anlamlı ilişki saptandı. Toplam 11 hastada istenmeyen yan etki gelişti. İstenmeyen yan etkiler, sıklık sırasına göre kanama, epididimorşit, ateş ve false road idi. İnternal üretrotomi ile tedavi edilen hastaların %84'ünde başarılı sonuç elde edildi. Sonuç olarak, TUR esnasında üretra darlığı gelişme riskini azaltmak amacıyla travmatik etkisi olan rezeksiyon ve ameliyat sonrası sonda kalış süresinin mümkün olduğu kadar kısa tutulması gerekir. İnternal üretrotomi, TUR sonrası gelişen darlıkların tedavisinde, girişimin kolay yapılabilmesi, birçok kere uygulanabilmesi, belirgin istenmeyen yan etkilerin olmaması nedeni ile en çok başvurulan tedavi yöntemidir.

Abstract

Introduction: Urethral stricture is one of the complex issues of urology due to the difficulty of diagnosis, treatment and risk of recurrence. The incidence of urethral stricture after Transurethral Resection of Prostate (TUR-P) surgery has been reported to be 1.5-29%. Some factors have been suggested to have effect on developing urethral stricture after TUR-P surgery but, the etiology remains controversial. The treatment depends on the localization, length and nature of the stricture. Urethrotomy has been considered an effective treatment for urethral strictures for more than 15 years with a success rate of 56 to 95%. Recently, visual endoscopic internal urethrotomy is the most popular technique. The aim of this study was to evaluate the patients with urethral stricture after TUR-P surgery, according to the risk factors and internal urethrotomy outcomes of these patients. Materials and Methods: From 1998 to 2001, 720 patients who had TUR-P surgery were studied retrospectively. Sixty patients with urethral stricture after TUR-P surgery were included in the study. Patients were evaluated for risk factors such as age, time of resection, urethral catheter type, urethral catheter diameter, postoperative duration period of catheter, size of resectoscope and urinary infection. Uroflowmetry was performed in all patients, localization and length of stricture was determined by retrograde urethrocystography. Visual endoscopic internal urethrotomy procedure was performed in patients with urethral stricture. Patients were followed-up at 3 months interval. At each follow-up the prognosis was evaluated by anamnesis, uroflowmetry and retrograde urethrocystography. Internal urethrotomy outcomes of these 60 patients were compared with the literature. Results: The mean age was 67.6 (51-80) and the median follow-up was 19 (5-36) months. Strictures were mostly localized at bulbous and membranous urethra. 26-F resectoscope was used in the 53.3 % patients. Mostof the patients had operation period between 45-60 minutes. The mean postoperative urethral c atheterduration was 3.7 days. The majority of postoperatively used urethral catheters were latex and had a diameter of 20 F. Statistically significant relationship between developing stricture and patients' age, time of resection and postoperative urethral catheter duration period was determined. Complication was occurred in 11 patients. Hemorrhage, epididymo-orchitis, fever and false road were found to be frequent. Thirty-four patients had complete recovery, 16 had partial recovery and 10 patients had persistence; overall success rate was 84%. Conclusion: The role of trauma on the development of urethral stricture has been largely known for a long time. Especially, TUR-P is one of the most frequent causes of trauma in urologic surgery and has been the subject of much discussion and conflicting data has been published. Most authors stressed that the patients' age, size of the resectoscope sheath, time of resection, duration of transurethral catheterization, urinary infection are predisposing factors for development of postoperative urethral strictures. According to our results, the resection time and postoperative urethral catheter duration time may be short enough to prevent urethral stricture development after TUR-P surgery. Internal urethrotomy is a favorable method for the treatment of urethral stricture due to its easy use, low complication rate and feasibility fo r more than oncetime.