Üretra Darlığında Endoskopik Cerrahi: Bıçağa Karşı Lazer

Abstract

Amaç: Üretra darlığının endoskopik cerrahisinde cold knife üretrotomi ile laser üretrotominin etkinliğini karşılaştırmayı amaçladık.

Materyal-metod: Toplam 171 hasta retrospektif olarak değerlerlendirildi. Çalışma kapsamında verileri tam olan 118 hasta 2 gruba ayrıldı (grup 1; n=53 cold knife üretrotomi, grup 2; n= 65 lazer üretrotomi). Darlığın uzunluğu, operasyon süresi, preoperatif ve postoperatif 3., 6. ve12. aylardaki Qmax değerleri, nüks olup olmadığı ve komplikasyon varlığı (kanama, extravazasyon, ateş gb) açısından iki grup karşılaştırıldı.

Bulgular: Operasyon zamanının cold knife üretrotomi yapılan hastalarda daha kısa olduğu görüldü (14.01 ± 3.86 dk vs 25.03 ± 4.43 dk, p=0.001). Postoperatif 3., 6., ve 12. aylardaki Q max değerlerinin lazer üretrotomi yapılan hastalarda daha yüksek olduğu görüldü (p=0.03, p=0.001, p=0.001). Bir yıllık takip sonucunda grup-1' de 28 (52.83%) hastada nüks saptanırken, grup-2' de 12 (18.46%) hastada nüks geliştiği gözlendi (p=0.01). Postoperatif komplikasyonlar açısından her iki grup arasında istatiksel olarak anlamlı fark izlenmedi. (p=0.209).

Sonuç: Yaptığımız bu çalışmada üretra darlığını endoskopik cerrahisinde, lazer üretrotomi tekniğinin, cold knife üretrotomiye göre yüksek Qmax değerlerine ve daha düşük nüks oranına sahip olması nedeniyle daha başarılı bir cerrahi yöntem olduğu saptanmıştır. Sonuçların prospektif, randomize çalışmalarla desteklenmesi gerekmektedir. 

Keywords

• üretral darlık,lazer üretrotomi,soğuk bıçak,nüks

Endoscopic Surgery of Urethral Strictures: Laser Versus Knife

Abstract

Aims: We aimed to compare the efficiency of cold knife urethrotomy and laser urethrotomy in endoscopic surgery of urethral strictures.

Material-Methods: A total of 171 patients were evaluated retrospectively. A 118 patients with complete data were divided into two groups (group 1; n = 53 cold knife urethrotomy, group 2; n = 65 laser urethrotomy) in the study. Length of the stricture, operation time, preoperative and postoperative 3rd, 6th and 12th-month Qmax values, recurrence and the presence of complications (such as bleeding, extravasation, fever etc.) were compared in terms of the two groups.

Results: The operation time was found to be shorter in patients who underwent cold knife urethrotomy (14.01 ± 3.86 min vs 25.03 ± 4.43 min, p=0.001). The Q max values at the postoperative 3rd, 6th and 12th months were observed to be higher in patients who underwent laser urethrotomy (p=0.03, p=0.001, p=0.001). At the end of a one-year follow-up, recurrence was determined in 28 (52.83%) patients in group 1 and 12 (18.46%) patients had a recurrence in group 2 (p=0.01). No statistically significant difference was observed between the two groups in terms of postoperative complications. (p=0.209).

Conclusions: In this study, it was determined that laser urethrotomy technique was a more successful surgical method than cold knife urethrotomy in the endoscopic surgery of urethral strictures as it has higher Qmax values and lower recurrence rate. The results should be supported by prospective, randomized studies. 

Keywords

• urethral stricture,laser urethrotomy,cold knife,nux

References

1. 1. Sachse H. Treatment of urethral stricture: transurethral slit in view using sharp section. Fortschr Page Med. 1974; 92: 12-15.
2. 2. Jin T, Li H, Jiang LH, Wang L, Wang KJ. Safety and efficacy of laser and cold knife urethrotomy for urethral stricture. Chin Med J. 2010;123(12):1589–95.
3. 3. Waseem Aboulela, Mohammed S, El Sheemy Mahmoud Shoukry, Ahmed M Shouman, Ahmed I.Shoukry, Waleed Ghoneima1 Mohamed El Ghoneimy, et all. Visual internal urethrotomy for management of urethral strictures in boys: a comparison of short-term outcome of holmium laser versus cold knife. Int Urol Nephrol. 2018 Apr;50(4):605-609. doi: 10.1007/s11255-018-1809-x.
4. 4. Torres Castellanos L, Moreno Bencardino MC, Bravo-Balado A, García Mayorga CA, Vargas Manrique I, Fernández N. Evaluation of the Efficacy and Safety of Laser versus Cold Knife Urethrotomy in the Management of Patients with Urethral Strictures: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Urol Int. 2017;99(4):453-459. doi: 10.1159/000478026. Epub 2017 Jul 12.
5. 5. Hussain M, Lal M, Askari SH, et al. Holmium laser urethrotomy for treatment of traumatic stricture urethra: A review of 78 patients. J Pak Med Assoc 2010;60:829-32.
6. 6. Herrmann TR, Liatsikos EN, Nagele U, et al. EAU guidelines on laser technologies. Eur Urol 2012;61:783-95. http://dx.doi.org/10.1016/j.eururo.2012.01.010.
7. 7. Farrell MR, Sherer BA, Levine LA. Visual internal urethrotomy with intralesional mitomycin c and short-term clean intermittent catheterization for the management of recurrent urethral strictures and bladder neck contractures. Urology. 2015;85(6):1494–9.
8. 8. Hampson LA, Mcaninch JW, Breyer BN. Male urethral strictures and their management. Nat Rev Urol. 2014;11(1):43–50.

9. 9. Dubey D. The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures. Indian J Urol (Internet). 2011;27(3):392.
10. 10. Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol. 2010;183(5):1859–62.
11. 11. Al Taweel W., Seyam R. Visual internal urethrotomy for adult male urethral stricture has poor long-term results. Adv Urol. 2015;2015: 1–4.
12. 12. Pal D, Kumar S, Ghosh B. Direct visual internal urethrotomy: is it a durable treatment option? Urol Ann (Internet). 2017;9(1):18.
13. 13. 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(4):295–8.
14. 14. Kumar S, Kishore L, Sharma AP, Garg N, Singh SK. Efficacy of holmium laser urethrotomy and intralesional injection of Santosh PGI tetra-inject (triamcinolone, mitomycin c, hyaluronidase and nacetyl cysteine) on the outcome of urethral strictures. Cent Eur J Urol. 2015;68(4):462–5.
15. 15. Tamsin J. Greenwell, Carissa Castle & David L. Nicol (2016) Clean intermittent self-catheterization does not appear to be effective in the prevention of urethral stricture recurrence, Scandinavian Journal of Urology, 50:1, 71-73. DOI: 10.3109/21681805.2015.1086888.
16. 16. Atak M, Tokgöz H, Akduman B, Erol B, Dönmez I, Hancı V, Türksoy O, Mungan NA. Low-power holmium:YAG laser urethrotomy for urethral stricture disease: comparison of outcomes with the cold-knife technique. Kaohsiung J Med Sci. 2011 Nov;27(11):503-7. doi: 10.1016/j.kjms.2011.06.013.
17. 17. Ankur Jhanwar, Manoj Kumar, Satya Narayan Sankhwar, Gaurav Prakash. Holmium laser vs. conventional (cold knife) direct visual internal urethrotomy for short-segment bulbar urethral stricture: Outcome analysis. Can Urol Assoc J 2016;10(5-6):E161-4. http://dx.doi.org/10.5489/cuaj.3382.
18. 18. Albers P, Fichtner J, Bruhl P, et al. Long-term results of internal urethrotomy. J Urol 1996;156:1611-4. http://dx.doi.org/10.1016/S0022-5347(01)65461-2.
19. 19. Dutkiewicz SA, Wroblewski M. Comparison of treatment results between holmium laser endourethrotomy and optical internal urethrotomy for urethral stricture. Int Urol Nephrol 2012;44:717-24. http://dx.doi. org/10.1007/s11255-011-0094-8.