RECURRENT BULBAR URETHRAL STRICTURE IN THE REGION OF AN ARTIFICIAL URINARY SPHINCTER

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Transcript of RECURRENT BULBAR URETHRAL STRICTURE IN THE REGION OF AN ARTIFICIAL URINARY SPHINCTER

  • RECURRENT BULBAR URETHRAL STRICTURE IN THE REGION OF ANARTIFICIAL URINARY SPHINCTER

    MEGAN DEBELL AND HUNTER WESSELLS*From the Section of Urology, The University of Arizona College of Medicine, Tucson, Arizona

    KEY WORDS: urethral stricture; urinary sphincter, artificial; urinary incontinence; urinary retention; bladder

    Urethral complications due to the artificial urinary sphinc-ter include spongiosal atrophy and device erosion.1 To ourknowledge stricture in the region of the urethral cuff has notbeen reported as a long-term complication of artificial uri-nary sphincter implantation. We report a case in which arecurrent urethral stricture beneath the cuff has been suc-cessfully managed with periodic filiform and follower dila-tion.

    CASE REPORT

    A 66-year-old man with a history of radical retropubicprostatectomy underwent placement of a 4.5 cm. cuff, 61 to70 cm. water pressure regulating balloon AMS 800 pros-thesis (American Medical Systems, Inc., Minnetonka, Min-nesota) in May 1996 to treat worsening stress urinaryincontinence. Convalescence was uneventful, and the pa-tient had significant improvement in continence and qual-ity of life.

    In October 1998 the patient presented with a severalmonth history of decreased force of urinary stream andstraining to void. Cystoscopic examination revealed a stric-ture of the bulbar urethra in the region of the cuff with anapproximately 10Fr caliber. A retrograde urethrogram con-

    firmed a single stricture in the region of the sphincter cuff(fig. 1).

    In May 1999 the sphincter was deactivated, a long fili-form was placed under direct vision, and follower dilationof the urethra was performed to 18Fr caliber. Intraopera-tive urethroscopy revealed the stricture to be well dilated.A 16Fr Foley catheter was left in place for 1 day and thedevice was reactivated 1 week later. The patient noticedmarked improvement in the force of stream and decreasedeffort to void.

    The patient had 2 recurrences of this stricture in Novem-ber 1999 and October 2000 with decreased force of streamand straining to void. On both occasions urethroscopy con-firmed stricture recurrence and the patient underwent ure-thral dilation under local anesthesia using filiform and fol-lowers to 20Fr caliber (fig. 2). Catheter drainage wasmaintained for 1 week with each recurrence with reactiva-tion after another week. Dilation has been successful with noevidence of erosion and continued full function of the artifi-cial sphincter.

    DISCUSSION

    Dilation of a urethral stricture proximal to a functionalartificial urinary sphincter has been described, as well as theuse of artificial urinary sphincters after treatment of anas-tomotic strictures. 2, 3 However, the occurrence of a stricturein the region immediately beneath the artificial urinarysphincter has not been reported despite the wide use of thisdevice.1 Possible etiologies of the stricture in our case includeprogression of preexistent stricture disease, spongiofibrosisas a result of the artificial urinary sphincter or a healederosion of the cuff.

    The location of the stricture made treatment challeng-

    Accepted for publication April 12, 2001.*Financial interest and/or other relationship with Pfizer and TAP

    Pharmaceuticals.

    FIG. 1. Urethrogram demonstrates narrowing (arrow) of bulbarurethra, which corresponded exactly to area of cuff. Urethra did notfill proximal to stricture.

    FIG. 2. Cystoscopic view of urethral stricture before third dilation.Manual palpation of cuff confirmed location in region of artificialurinary sphincter.

    0022-5347/01/1663-1006/0THE JOURNAL OF UROLOGY Vol. 166, 10061007, September 2001Copyright 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A.

    1006

  • ing. We reasoned that radial dilation would gradually di-late the stricture and pose a smaller risk of cuff exposurethan would internal urethrotomy. Westney et al used bal-loon dilation of a stricture proximal to the artificial uri-nary sphincter, which would be another acceptable treat-ment modality in this instance.2 Our patient was satisfiedwith periodic dilation of the urethra. However, if the fre-quency of dilation increased substantially, removal of thedevice, open excision of the stricture and later reimplan-tation of another artificial urinary sphincter may be re-quired.

    REFERENCES

    1. Elliott, D. S. and Barrett, D. M.: Mayo Clinic long-term analysisof the functional durability of the AMS 800 artificial urinarysphincter: a review of 323 cases. J Urol, 159: 1206, 1998

    2. Westney, O. L., Del Terzo M. A. and McGuire, E. J.: Balloondilation of posterior urethral stricture secondary to radiationand cryotherapy in a patient with a functional artificial ure-thral sphincter. J Endourol, 13: 585, 1999

    3. Meulen, T., Zambon, J. V. and Janknegt, R. A.: Treatment ofanastomotic strictures and urinary incontinence after radicalprostatectomy with UroLume wallstent and AMS 800 artificialsphincter. J Endourol, 13: 517, 1999

    RECURRENT URETHRAL STRICTURE IN REGION OF ARTIFICIAL URINARY SPHINCTER 1007

    RECURRENT BULBAR URETHRAL STRICTURE IN THE REGION OF AN ARTIFICIAL URINARY SPHINCTERCASE REPORTDISCUSSIONReferences