INTERNAL URETHROTOMY AS A CHOICE OF TREATMENT ON A RECURRENT URETHRAL STRICTURE
INTERNAL URETHROTOMY AS A CHOICE OF TREATMENT ON A RECURRENT URETHRAL STRICTURE

Summary/Abstract: A urethral stricture is scarring in or around the urethra that narrows or blocks the passageway through which urine flows from the bladder. The aim of the present case report was to evaluate the outcome of direct vision internal urethrotomy (DVIU) in the management of deaf-mute patient with recurrent bulbar urethral stricture. On September 2019 a 38 year old deaf-mute young male patient presented with dysuria, decreased urinary stream with very thin jet, incomplete emptying and associated with fever. Because of high temperature (39 ̊C) and fever, he was hospitalised and treated on a department for infectious disease for the last 4 days. He was treated with cephalosporines (Ceftriaxone 2x2 gr i.v. daily). After the urologist was consulted he was transferred to the urology department.The anamnesis was difficult and the relevant information were taken from his mother and his wife. He was a physical worker, married and with two children. There was a positive history of trauma in childhood 24 years ago when he was injured by a falling bicycle. About 16 years later he sought help in urology unit because of acute urinary retention (RUC). An urethral catheterization wasn’t possible due to the urethral obstruction caused by stricture even with catheter 8-Fr, so suprapubic cystostomy was performed. Afterward, internal uretrhotomy was done at the urologic clinic in Skopje. Over all this years, he never did urethral dilatation for unknown reasons, probably due to a misunderstanding with his urologist. His complaints about urinating difficultiesfollowed in weakening of the urinary stream and frequent urinary tract infections began 2 years ago. Upon receipt the following searches were made, laboratory results: white blood cell count 18,7 x 109/l; red blood cell count 4,2 x 109/l; hemoglobin level 13.4 g/dl; platelet count 396 x 109/l; C-reactive protein 36 mg/l. Urine analysis showed erythrocyturia with pyuria and with abundant bacteria. Urine culture was positive for E. Coli (103 CFU/ml) and according the antibiogram Ciprofloxacin 2x200 mg i.v. daily. On the second day an 17-Fr urethrocystoscopy performed which revealed a severe stricture of a bulbar urethra with urethral calibration <6 Fr. Retrograde urethrography (RUG) done 18 months ago showed narrowed urethral lumen 1,3 cm in length on thebulbar part. Uroflowmetry showed flow rate below 7 ml/s. Ultrasound of the urinary tract and intravenous urography as supplementary investigations doesn’t detect any abnormality of the urinary tract. Patient was counseled about the possibility of the recurrence of the stricture doing internal urethrotomy and was given urethroplasty as a modus of choise. As a family they decided for internal urethrotomy. Under general anesthesia we performed internal urethrotomy ie direct vision internal urethrotomy (DVIU). With a cold-knife we made transurethral incision at 12h to release scar tissue, on wich urethra dilated and we reached to pass through to the urinary bladder. We exam the orifices which were orthotopic and we saw cystitic changes of the urinary bladder. The incision was very hard because of the fibrosis of recurrent stricture of the urethra. The duration of the intervention was just under 25 minutes. The internal urethrotomy finished without any complication and on the end we placed catheter Fr 20. The patient was discharged on the fifth postoperative day with urinary catheter in situ which was removed 3 weeks later. Six month after the intervention, every 4 weeks we stretch the urethra using metal dilator Fr 18. The last measured maximum flow rate (Qmax) in uroflowmetry was 24 ml/s and the last urineculture was sterile.

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