BJU International 2002 90 (3cr), 351 CASE REPORTS
Anastomotic urethroplasty for remnants of a urethral stent 7 years after insertion
S.H.
Ho and V.T.
Joseph*
Department of Urology, Changi General Hospital, and * Department of Paediatric Surgery, Kandang Kerbau Women's and Children's Hospital, Singapore
Case report
Comment  References Authors
A 43-year-old man had a 3-cm Memotherm self-expanding stent placed 7 years earlier for a 1-cm bulbar urethral stricture secondary to infection by a sexually transmitted disease. Subsequently he developed hyperplastic granulation tissue overgrowth and a stricture distal to the stent. Endoscopic resection and dilatation failed, and later at 2 years after insertion he underwent an endoscopic removal of the stent. However, the procedure was difficult because of massive tissue overgrowth and the stent could only be removed in pieces, leaving a 1-cm segment in situ. A second endoscopic removal session was scheduled but the patient declined further treatment and was lost to follow-up. He recently presented again with acute urinary retention and a urethrogram showed narrowing within the lumen of the remnant stent. Subsequent cystoscopy showed a urinary calculus, corresponding to the area of narrowing seen in the urethrogram. He underwent holmium laser intracorporeal lithotripsy with vaporization of the overgrown hypertrophic tissue. Six months later (7 years after the initial insertion) he presented again in acute urinary retention. A urethrogram showed recurrent hypertrophic tissue with strictures at both the proximal and distal ends of the 1 cm remnant of the stent (Fig. 1a,b). Through a mid-line perineal incision he underwent excision with a primary anastomotic urethroplasty. A healthy segment of distal urethra was initially identified to assist in the dissection of the urethra. The urethra proximal and distal to the stent was mobilized and the segment of urethra containing the remnant stent excised with a 1-cm margin of healthy urethral tissue on both ends. A primary spatulated anastomosis was created with interrupted polydioxanone suture 5/0 over a 16 F urinary catheter. A suction drain was left in place for 48 h and the urinary catheter removed after 7 days. A review at 6 weeks with a urethrogram showed complete recovery (Fig. 1c); he had no voiding symptoms and a peak urinary flow rate of 12 mL/s.
Comment
Case report  References Authors The success of various urethral stents, e.g. the UroLume, Memotherm and Memokath, in treating recurrent urethral strictures has led to their wider use in recent years [1]. The incidence of re-stenosis secondary to hyperplastic tissue re-growth or a recurrent stricture either proximal or distal to the stent has been reported to be up to 50% [2]. Most of these conditions can be treated successfully with endoscopic resection or placement of a second stent. Intractable re-stenosis leading to the removal of stents is rare [3]. Open surgical excision and reconstruction may be necessary in these unfortunate circumstances. In the present patient part of a Memotherm stent was retained for 5 years before causing complete obstruction and urinary retention. Complete removal after re-epithelization by the urothelium may be difficult when there is a massive hyperplastic overgrowth and distal stenosis. Damage to the covering urothelium is unavoidable. End-to-end anastomosis after excision should be the urethroplasty technique of choice whenever possible. The segment of urethra containing the remnant stent was excised with the surrounding fibrotic tissue. The spongiofibrosis did not extend extensively beyond the proximal and distal margins of the stent, and could be safely excised with no concern of shortening the urethra. Furthermore, urethral length can be obtained by mobilizing it from the corpora cavernosa. Good results were achieved at 2 months of follow-up, as shown by a normal urethrogram, satisfactory flow rate and a satisfied patient.
References
Case report Comment Authors
Authors
Case report Comment S.H. Ho, MBBS, FRCS, Registrar.
V.T. Joseph, MBBS, FRCS, Senior Consultant. Correspondence: S.H. Ho, Department of Urology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
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BJU International 2002 90 (3cr), 351
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