Elsevier

Journal of Pediatric Urology

Volume 16, Issue 6, December 2020, Pages 843.e1-843.e9
Journal of Pediatric Urology

“When ablation goes wrong”- urethral strictures after ablation of posterior urethral valves-characteristics, management and outcomes”

https://doi.org/10.1016/j.jpurol.2020.09.001Get rights and content

Summary

Background

Post-ablation urethral strictures are a rare but devastating complication following transurethral ablation of posterior urethral valve which can be more difficult to treat than the valve itself. Though with the miniaturization of scopes the incidence of these strictures has decreased, sadly they still continue to occur. Hence, literature on these strictures is also limited due to the rarity of occurrence.

Objective

To analyze the management strategies and outcomes of post-valve-ablation urethral strictures managed in a tertiary care center.

Materials and methods

A retrospective review of all boys with the diagnosis of urethral strictures who had undergone management in our center from January 2000 to July 2017, with a minimum follow-up data for 12 months following interventions was done and among them the subset who developed strictures following valve ablation were identified. We also included those patients who had been referred for management of strictures following ablation elsewhere and had all their preoperative and operative details recorded. Out of a total of 199 boys who had undergone management of stricture during this time period, 13 boys with stricture of urethra following valve ablation were identified and studied. The history, presentation, timeline of events leading to stricture formation, possible predisposing factors, characteristics of strictures, mode of management and outcomes were recorded.

Results

Among the 13 boys, 5 had developed strictures following in-house fulguration while 8 developed strictures following ablation elsewhere. The median age at diagnosis in these patients was 8 years (range, 3–18). The length of stricture varied from very short in the proximal bulbar to long penobulbar stricture. Median length of strictures was 10 mm (range: 3–35). Of the 9 patients who underwent primary endoscopic intervention, 8 had successful outcomes (88.7%) while one patient ultimately required open urethroplasty. Of the 4 patients who had open intervention, except the patient who underwent meatoplasty, the rest needed multiple surgical and endoscopic interventions. Median follow up period was 20 months (range: 12–68).

Conclusion

Urethral Stricture disease continues to be a rare but significant complication of valve ablation. Post ablation stricture can happen in any part of the urethra. Our data suggests that if a DVIU or dilatation is to be implemented for the treatment of a stricture after ablation, it may be most suitable for short, proximal strictures. Proper technique of valve ablation by a dedicated pediatric urologist using a proper sized resectoscope with proper isolation of electrode from the rest of urethral wall is crucial to prevent these strictures.

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Summary Fig.. Flow diagram showing various primary treatment modalities used in management of Post valve ablation strictures. Key: DVIU- Direct vision internal urethrotomy; BNI-Bladder neck incision; UCF -Urethrocutaneous fistula.

Introduction

Posterior urethral valves (PUV) are the most common cause of congenital bladder outlet obstruction in boys with an estimated incidence ranging from 1 in 2000 to 1 in 25,000 live births [1]. With improvement in miniaturization of instruments in urology, transurethral fulguration of PUV has become the most widely accepted and practiced technique of valve ablation all over the world. Urethral strictures are a rare but serious complication of PUV fulguration with incidence ranging from 25% by Myers and Walkers in 1981 to 0% in series by Nijman et al. [2,3]. However, the true rate of strictures is difficult to define due to a lack of series with long-term follow up. Presentation is likely with poor flow, urinary tract infection or rarely acute retention. Sometimes these patients present with concomitant bladder neck contracture when the fulguration has been combined with bladder neck incision. Due to rarity of theses strictures, there is also not much literature on the characteristics of these strictures, how these post fulguration strictures should be treated, which modality of management (open or endoscopic) can be used for these strictures and whether the success of theses modalities is similar to strictures of other etiologies. Though a proper technique of fulguration with a proper sized resectoscope is the best way to prevent such strictures theses stricture continue to happen because of the unavailability of proper pediatric instruments and lack of expertise while dealing with the fragile pediatric urethra. Urethral stricture is a debilitating condition because, if not managed properly, it can lead to severe impairment of quality of life by affecting continence and potency. In this regard, to define further the treatment of post-fulguration strictures, we recently reviewed 13 such cases which were treated in our tertiary center over a period of 16 years.

Our study pertains to the presentation of these rare urethral strictures following valve ablation, distribution of anatomical site, their management by endoscopic and open techniques and analysis of the results.

Section snippets

Materials and methods

After obtaining an institutional review board approval, operative logs from the previous 16 years from January 2000 to July 2017 were reviewed and all children and adolescents ≤18 years old who had undergone management for stricture urethral disease in our tertiary center and had at least 1 year of eligible follow-up data were identified. Operative reports and office charts were then used to identify the subset of patients who developed urethral strictures following PUV ablation. In patients

Results

During the study period, we had treated 199 patients of pediatric urethral strictures at our center, among whom we identified 13 boys with strictures following valve fulguration who had a minimum follow-up period of 12 months. Of these 5 were following “in house” fulgurations while 8 were referred from outside for management of stricture following fulguration. Though three out of thirteen boys had a history of urethral catherization, none had a stricture diagnosed before valve fulguration.

Discussion

In the present study, we retrospectively reviewed 13 children who had valve-ablation related strictures and were managed by endoscopic or open surgery over a period of 17 years. Those undergoing endoscopic management in general, had short segment and pliable strictures while those undergoing open surgery mostly had complicated strictures. The success rate of endoscopic procedure compared to open surgery as the primary procedure were superior, though this was mainly due to the difference in case

Conclusions

To conclude, the possibility of urethral stricture though rare, should always be kept in mind as a possibility while dealing with symptoms post-ablation in cases of PUV. As with strictures of other etiologies, primary endoscopic management give good results for focal, proximal bulbar strictures with open intervention reserved for longer segment, near obliterative strictures and in those failing endoscopic measures. Proper patient selection for each modality is crucial to give best outcomes.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

None.

Acknowledgement

None

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