Can Bipolar Vaporization be Considered an Alternative Energy ...

Clinical Urology

Bipolar Energy for Treating Urethral Strictures

International Braz J Urol

Vol. 34 (5): 577-586, September - October, 2008

Can Bipolar Vaporization be Considered an Alternative Energy Source in the Endoscopic Treatment of Urethral Strictures and Bladder Neck Contracture? Erem K. Basok, Adnan Basaran, Cenk Gurbuz, Asif Yildirim, Resit Tokuc Department of Urology, S.B. Istanbul Goztepe Training and Research Hospital, Istanbul, Turkey

ABSTRACT Objective: We evaluated the outcome of bipolar energy by using PlasmaKinetic™ cystoscope instruments in the treatment of urethral stricture and bladder neck contracture. Materials and Methods: 7ZHQW\WZRPDOHSDWLHQWVZLWKXUHWKUDOVWULFWXUHDQG¿YHZLWKEODGGHUQHFNFRQWUDFWXUHZHUH treated by endoscopic bipolar vaporization. The most common etiology for stricture formation was iatrogenic (85.2%) and WKHPHDQVWULFWXUHOHQJWKZDVPP$OOSDWLHQWVZHUHHYDOXDWHGZLWKXUHWKURJUDSK\DQGXURÀRZPHWU\RQHPRQWKDQG PRQWKVDIWHUVXUJHU\8UHWKURVFRS\ZDVURXWLQHO\SHUIRUPHGDWWKHHQGRIWKH¿UVW\HDU3UHRSHUDWLYHPHDQPD[LPXPÀRZ UDWH4PD[ ZDVP/VIRUXUHWKUDOVWULFWXUHDQGPHDQ4PD[ZDVP/VIRUEODGGHUQHFNFRQWUDFWXUH7KHUHVXOWV ZHUHFRQVLGHUHGDV³VXFFHVVIXO´LQSDWLHQWVZKHUHUHVWHQRVLVZDVQRWLGHQWL¿HGZLWKERWKXUHWKURJUDSK\DQGXUHWKURVFRS\ 0LQLPXPIROORZXSZDVPRQWKVUDQJHWR  Results: 7LVVXHUHPRYDOZDVUDSLGEOHHGLQJZDVQHJOLJLEOHDQGH[FHOOHQWYLVXDOL]DWLRQZDVPDLQWDLQHGWKURXJKRXWWKH YDSRUL]DWLRQRIWKH¿EURWLFWLVVXH3RVWRSHUDWLYHPHDQ4PD[ZDVP/VDQGWKHVXFFHVVUDWHZDVIRUXUHWKUDO VWULFWXUHDWPHDQIROORZXSWLPHRIPRQWKV7KHVXFFHVVUDWHZDVZLWKDPHDQIROORZXSWLPHRIPRQWKV IRUEODGGHUQHFNFRQWUDFWXUHDQGWKHPHDQ4PD[ZDVP/VSRVWRSHUDWLYHO\ Conclusions:7KHVWXG\VXJJHVWVWKDWELSRODUYDSRUL]DWLRQLVDVDIHLQH[SHQVLYHDQGUHOLDEOHSURFHGXUHZLWKJRRGUHVXOWV minimal surgical morbidity, negligible blood loss, and thus, it could be considered as a new therapeutic option for the endoscopic treatment of urethral stricture and bladder neck contracture. Key words: urethra; urethral stricture; endoscopy; vaporization; bipolar energy Int Braz J Urol. 2008; 34: 577-86

A recent survey of stricture management in the United States showed that most urologists   GR QRW SHUIRUP XUHWKURSODVW\ ZKLOH  WR  ZRXOG FRQWLQXH WR PDQDJH WKH VWULFWXUH E\ minimally invasive means despite predictable failure. Many urologists have selected the use of endoscopic procedure as primary approach, but, currently, this apSURDFKLVQRORQJHUMXVWL¿HGEDVHGRQVWXGLHVUHSRUWHG LQWKHOLWHUDWXUH  Although internal urethrotomy continues to be the most commonly used procedure, the optimal

INTRODUCTION The management of urethral stricture and bladder neck contracture include periodic dilatation, blind internal urethrotomy, optical urethrotomy with or without monopolar electrocautery or various laser treatment and definitive open urethroplasty. Although long term results RIRSHQXUHWKURSODVW\VXUJHU\DUHH[FHOOHQWRSHQ urethroplasty surgery can be challenging and timeconsuming.

577

Bipolar Energy for Treating Urethral Strictures

Plasma-Cise™ and Plasma-Cut™ (Figure-1). The study was performed in accordance with the Helsinki Declaration of the World Medical Association, and written informed institutional research consent was obtained from all patients. The strictures were localized in the urethra and the bladder neck in 22 and 5 patients, and treated with Plasma-Cise™ and Plasma-Cut™ in DQGSDWLHQWVUHVSHFWLYHO\7KHPRVWFRPPRQ cause of stricture was iatrogenic (85.2%), followed E\WUDXPD 7KHORFDWLRQRIWKHVWULFWXUHZDV SHQLOHEXOEDUDQGPHPEUDQRXVXUHWKUDLQDQG patients, respectively (Table-1). Four of bladder neck contractures were detected after radical retropubic prostatectomy and one after ileal neobladder. The stricture length was measured by both uroradiography and urethroscopy using a ureteric FDWKHWHU DIWHU H[FLVLQJ WKH VFDU WLVVXH7KH DYHUDJH OHQJWKRIWKHVWULFWXUHVZDVPPUDQJHWR mm). Twenty-two patients had untreated strictures and the remaining were previously treated by cold-knife urethrotomy in three and urethroplasty in two. There ZDVVLQJOHVWULFWXUHLQDQGPXOWLSOHLQSDWLHQWV

management is still widely debated, because the UHFXUUHQFHUDWHVUDQJHEHWZHHQDQGLQWKH ORQJWHUP $VDQDOWHUQDWLYHHQHUJ\VRXUFHWKH ¿UVWELSRODUGHYLFHIRUHQGRXURORJLFDOSURFHGXUHVZDV Gyrus device using PlasmaKinetic™ Endourology System (Gyrus PlasmaKinetic™ System, Medical, Maple Grove, MD). Bipolar energy enables an instant incision and vaporization of the stricture, and contribXWHVWRGHFUHDVHGUHFXUUHQWVFDUWLVVXHIRUPDWLRQ  Thus, current prospective pilot study was conducted WR HYDOXDWH HI¿FDF\ DQG VDIHW\ RI 3ODVPD.LQHWLFŒ cystoscope instruments in the treatment of urethral strictures and bladder neck contractures.

MATERIALS AND METHODS  %HWZHHQ 0D\  DQG 'HFHPEHU  WZHQW\VHYHQPDOHSDWLHQWVWR\HDUVROGPHDQ DJH   ZLWK XUHWKUDO VWULFWXUHV RU EODGGHU QHFN contractures underwent endoscopic bipolar vaporization using PlasmaKinetic™ cystoscope instruments:

Figure 1 – Gyrus PlasmaKinetic™ Endourology System and cystoscope instruments: Plasma-Cise™ and Plasma-Cut™.

578

Bipolar Energy for Treating Urethral Strictures

WKURJUDSK\DQGXURÀRZPHWU\&RPELQHGDQWHJUDGH and retrograde urethrography was performed in two patients with previously placed suprapubic tube. Any active urinary tract infection was treated and routine prophylactic antibiotics were administered before surgery. All patients received general or spinal anesthesia. For safety purposes, a guidewire or 5F ureteral catheter was passed through the stricture whenever possible (Figure-2). Core-through vaporization was performed for obliterative strictures in two patients with suprapubic tube. The procedure was performed E\XVLQJD)F\VWRVFRSHDQG3ODVPD.LQHWLFŒF\Vtoscope instruments were easily passed through the 5F working channel of the cystoscope (Figure-1). Vaporization was performed at 12 o’clock for XUHWKUDOVWULFWXUHVDQGDWDQGR¶FORFNIRUEODGGHU FRQWUDFWXUHVXVLQJZDWWYDSRUL]DWLRQSRZHUVHWWLQJ DQGVRGLXPFKORULGHVROXWLRQIRULUULJDWLRQ1R desiccation was done. An 18 Fr. urethral catheter was OHIWLQWKHEODGGHUIRUKRXUVDIWHUWKHSURFHGXUH Uroflowmetry and urethrography were performed one month after surgery and repeated HYHU\  PRQWKV$OO SDWLHQWV ZHUH HYDOXDWHG XVLQJ urethroscopy 12 months after the procedure to asVHVVWKHRXWFRPH'XULQJWKHIROORZXSLIPD[LPXP ÀRZUDWH4PD[ ZDVP/VXUHWKURVFRS\ZDV SHUIRUPHGWRH[FOXGHUHFXUUHQWVWULFWXUH7KHUHVXOWV

Table 1 – Site and etiology of the stricture. N Patients (%) Site Urethra Penile Bulbar Membranous Bladder neck Etiology Iatrogenic TURP TUR-BT RP RRP Ileal neobladder Traumatic

22 (81.5)    5 (18.5)       

TURP = transurethral resection of prostate; TUR-BT = transurethral resection of bladder tumor; RP = retropubic simple prostatectomy; RRP = retropubic radical prostatectomy.

All patients were evaluated preoperatively EDVHGRQSUHYLRXVPHGLFDOKLVWRU\SK\VLFDOH[DPLQDtion, urine culture, ultrasound of the upper tract, ure-

Figure 2 – A)- Preoperative urethrography showing urethral stricture (arrowhead). B)- Postoperative urethrography showing widely patent urethra after bipolar vaporization.

579

Bipolar Energy for Treating Urethral Strictures

Figure 3 – A guide-wire was passed through the stricture whenever possible and vaporization was performed.

were considered as “successful” in patients in whom WKH4PD[ZDV•P/VZLWKRXWDQ\REVWUXFWLYH symptoms and with no evidence of recurrent stricture ZLWK XUHWKURJUDSK\ RU XUHWKURVFRS\ )LJXUH    7KHRXWFRPHZDVGH¿QHGDVD³IDLOXUH´LIWKHSDWLHQW needed any intervention after initial treatment due to UHVWHQRVLV 7KHIROORZXSZDVWRPRQWKV PHDQPRQWKV 3UHRSHUDWLYHPHDQ4PD[ZDV P/VUDQJHWR LQSDWLHQWVZKRKDGXUHWKUDO VWULFWXUHDQGP/VUDQJHWR LQSDWLHQWVZKR had bladder neck contracture. The overall mean Q PD[ZDVP/VUDQJHWR EHIRUHVXUJHU\LQ patients. Statistical analysis was carried-out using the 1&663$66'LIIHUHQFHVEHWZHHQWKHSUHRSHUD-

WLYHDQGSRVWRSHUDWLYHPHDQ4PD[YDOXHVRISDWLHQWV ZHUHDQDO\]HGE\WKH:LOFR[RQWHVW'LIIHUHQFHVZHUH FRQVLGHUHGVLJQL¿FDQWIRUS

RESULTS In 25 patients, we passed a guidewire or 5 )UXUHWHUDOFDWKHWHUZLWKRXWDQ\WHFKQLFDOGLI¿FXOW\ Core-through vaporization was applied in two cases with obliterative strictures, successfully. Blood loss ZDVQHJOLJLEOHDQGH[FHOOHQWYLVXDOL]DWLRQZDVPDLQtained throughout the procedure. The average operaWLYHWLPHZDVPLQXWHVUDQJHWR $OOSDWLHQWV were continent after removing the catheter and able

580

Bipolar Energy for Treating Urethral Strictures

Table 2 – Mean Q max of patients that did not require a subsequent procedure depending on location of the stricture. Location Urethra Bladder neck

N Pts

Preoperative Q max

Postoperative Q max

22 5

P/V P/V

P/V P/V

XUHWKUDOGLODWLRQ$IWHUXUHWKUDOGLODWLRQWKH4PD[ RIWKHVHSDWLHQWVZDVLPSURYHGWRP/VDQG P/V UHVSHFWLYHO\ ,Q DOO  SDWLHQWV XUHWKURVFRS\ ZDVSHUIRUPHGWRFRQ¿UPUHFXUUHQWXUHWKUDOVWULFWXUH We had no evidence of voiding dysfunction in these patients, and therefore we did not use urodynamic study in the evaluation. Of the 5 cases with bladder neck contracture,  ZHUH FXUHG ZLWK D PHDQ IROORZXS WLPH RI  PRQWKVUDQJHWR 7KHPHDQ4PD[ZDV P/VUDQJHWR SRVWRSHUDWLYHO\S  7DEOH 2QHSDWLHQWZLWKD4PD[RIP/VUHTXLUHG a second vaporization of the contracture and the other LPSURYHGZLWKIUHTXHQWXUHWKUDOGLODWLRQ4PD[ZDV LQFUHDVHGIURPP/VWRP/V 7DEOH   7KH VXFFHVV UDWH ZDV    IRU XUHWKUDO VWULFWXUH DQG    IRU EODGGHU QHFN FRQWUDFWXUH$WRWDORIRXWRISDWLHQWVZHUHFXUHG

WR YRLG VDWLVIDFWRULO\ 3RVWRSHUDWLYH 4 PD[ UDQJHG EHWZHHQWRP/VPHDQP/V LQSDWLHQWV Twenty patients without any evidence of recurrence RQXUHWKURJUDSK\YRLGHGZLWKDPHDQ4PD[RI P/VUDQJHWR DWWKHHQGRIWKH¿UVWPRQWK In 22 patients with urethral stricture, at a PHDQIROORZXSWLPHRIPRQWKVUDQJHWR PRQWKV DQGWKHSRVWRSHUDWLYH4PD[UDQJHGEHWZHHQ WRP/VPHDQP/V S 7DEOH 2). Seventeen of these patients with urethral stricture had no signs or symptoms to suggest recurrence after XUHWKURJUDSK\DQGXURÀRZPHWU\H[DPLQDWLRQVDQG WKHSRVWRSHUDWLYH4PD[UDQJHGEHWZHHQWR P/V PHDQ  P/V  5HFXUUHQW VWULFWXUH ZDV IRXQG LQ    FDVHV  RI ZKLFK XQGHUZHQW XUHWKURSODVW\4PD[ZDVP/VLQDOOFDVHV DQG ZHUHRQXUHWKUDOGLODWLRQ7DEOH 7KH4PD[ZDV P/VDQGP/VLQWZRSDWLHQWVZKRUHTXLUHG

Table 3 – Outcome of bipolar vaporization and subsequent procedures.

Site Urethra Bladder neck Etiology Iatrogenic TURP TUR-BT RP RRP Ileal neobladder Traumatic

N Pts

N (%) Pts Without Recurrence

N (%) Pts With Recurrence

22 5

 

 

  2   1 

      

 

N Pts With Subsequent Procedures Urethroplasty

Dilation

Vaporization



2 1

1

1

 

1 1 1 1



2

TURP = transurethral resection of prostate; TUR-BT = transurethral resection of bladder tumor; RP = retropubic simple prostatectomy; RRP = retropubic radical prostatectomy.

581

Bipolar Energy for Treating Urethral Strictures

 DIWHUWKHSURFHGXUHGXULQJDPHDQIROORZXS RIPRQWKVUDQJHWRPRQWKV 

than 1 mm. In recent studies, the depths of the vaporL]DWLRQUDQJHGIURP—PWR—PFRPSDUHGZLWK —PIRUWKHPRQRSRODUHQHUJ\ 7KHGHSWKRI penetration of Ho:YAG laser, which is known to be as VKDOORZLVPP  The main difference between the bipolar HQHUJ\DQGFROGNQLIHSURFHGXUHVLVWKDWWKH¿EURWLF tissue is not only incised but also evaporated with the vaporization. Thus, the recurrence of scar tissue can be GHFUHDVHG $VLQODVHUWKHUDS\ZHREVHUYHG that the tissue removal was rapid and bleeding was PLQLPDOZLWKWKHYDSRUL]DWLRQDQGVXUJLFDO¿HOGZDV visually clearer than the cold knife urethrotomy. However, the abundant corpus spongiosum around the bulbar urethra renders endoscopic treatment more successful than the bladder neck, coldknife urethrotomy is limited for short strictures in the EXOEDUXUHWKUD7KLVWHFKQLTXHKDVKLJKIDLOXUHUDWHV especially when the stricture is longer or is associated ZLWKVLJQL¿FDQWVSRQJLR¿EURVLV$VDFRPPRQFRQFHSW XUHWKURSODVW\LVWKHLGHDO¿UVWOLQHWKHUDS\LQ\RXQJHU SDWLHQWVZLWKWUDXPDWLFVWULFWXUHV :HEHOLHYHWKDW bipolar vaporization can be considered an alternative treatment before performing more invasive procedure such as urethroplasty in older patients, the majority RIZKLFKZLWKORQJHUDQG¿EURWLFLDWURJHQLFXUHWKUDO strictures and bladder neck strictures. If the bipolar WHFKQLTXH LV HYHQWXDOO\ VHOHFWHG LQ RUGHU WR DFKLHYH ORZHUUDWHVRIVSRQJLR¿EURVLVELSRODUYDSRUL]DWLRQFDQ also be used effectively in younger patients with short traumatic strictures in the bulbar urethra. The success rates of cold-knife urethrotomy DW\HDUVLVOHVVWKDQWKDWRIXUHWKURSODVW\YV  DQGLWLVZHOODFFHSWHGWKDWELSRODU3ODVPD.Lnetic™ technology has a slightly greater failure rate FRPSDUHGZLWKXUHWKURSODVW\ +RZHYHUIDLOXUH of the procedure does not affect a second repeated SURFHGXUH ,QGHHG WKLV WHFKQLTXH ZDV VXFFHVVIXO LQ   RI SDWLHQWV DQG VSDUHG WKH FDVHV IURP D far more invasive procedure such as urethroplasty. 1HYHUWKHOHVV ZH EHOLHYH WKDW LI YDSRUL]DWLRQ IDLOV repeat attempts at endoscopic correction of urethral VWULFWXUHVKRXOGEHDEDQGRQHGLQIDYRURIGH¿QLWLYH urethroplasty. The results of core-through urethrotomy have UDQJHG IURP  WR  DV UHSRUWHG E\ YDULRXV LQYHVWLJDWRUV$KLJKUHFXUUHQFHUDWHWR 

COMMENTS Iatrogenic causes, which result in strictures anywhere in the urethra, are the most common cause in current clinical practice and the optimal management still remains widely debated. Though urethroplasty has a high success rate, endoscopic treatment LVVWLOOSUHIHUUHGE\WKHPDMRULW\RIXURORJLVWV  EHFDXVHRILWVVDIHW\DQGVLPSOLFLW\  The low success rates of cold knife urethrotomy prompted us to search for different therapeutic alternatives, and various types of lasers were attempted for this purpose. The reason for using lasers instead of cold knife depends on the basis of decreased forPDWLRQRIVFDUWLVVXH3ULPDU\H[SHULHQFHZLWKODVHUV KDYHVKRZQVXFFHVVUDWHVUDQJLQJEHWZHHQDQG 6RPHRIWKHUHFHQWUHSRUWHGVWXGLHVKDYHVKRZQ SURPLVLQJVXFFHVVUDWHVRIXSWRZLWKFRQWDFW1G YAG laser and Ho:YAG laser (1,11,12). Because of its high cost, laser treatments have not gained wide popularity for routine use. Therefore, we conducted WKLVVWXG\WRFRQ¿UPLIWKHYDSRUL]DWLRQFRXOGEHDQ alternative energy source for the treatment of urethral strictures and bladder neck contractures. The intended use of bipolar vaporization using PlasmaKinetic™ cystoscope instruments is to SHUIRUPYDSRUL]DWLRQRI¿EURXVWLVVXH7ZRW\SHVRI tip design are available; braided-tip (Plasma-Cut™) IRU¿QHU¿EURXVWLVVXHDQGVSULQJWLS3ODVPD&LVHŒ  IRUPRUHDJJUHVVLYH¿EURXVWLVVXHUHPRYDOLQVWULFWXUH or bladder neck incisions. The mechanism of the bipolar energy depends on a vapor ball that is located around the end of the device where energy is passed. 7KHKLJKIUHTXHQF\HQHUJ\SDVVHVWKURXJKWKH sodium chloride solution that is in contact with the scar tissue from the active to the return tip of the instrument. The irrigation solution forms a thin layer to convert into vapor plasma containing energy charged particles. When these high energy charged particles come in contact with the tissue, they cause disintegration through PROHFXODUGLVVRFLDWLRQ 7KLVOHDGVWRORZHU temperatures at the treatment site, so that the depth of the thermal damage of the surrounding tissue is less

582

Bipolar Energy for Treating Urethral Strictures

2.

Peterson AC, Webster GD: Management of urethral stricture disease: developing options for surgical inWHUYHQWLRQ%-8,QW  %XOORFN 7/ %UDQGHV 6%$GXOW DQWHULRU XUHWKUDO strictures: a national practice patterns survey of board FHUWL¿HGXURORJLVWVLQWKH8QLWHG6WDWHV-8URO   5DVVZHLOHU - 6FKXO]H 0 6WRFN &7HEHU ' 'H /D Rosette J: Bipolar transurethral resection of the prosWDWHWHFKQLFDOPRGL¿FDWLRQVDQGHDUO\FOLQLFDOH[SHULHQFH0LQLP,QYDVLYH7KHU$OOLHG7HFKQRO 11-21. 5. Alschibaja M, May F, Treiber U, Paul R, Hartung R: 5HFHQW LPSURYHPHQWV LQ WUDQVXUHWKUDO KLJKIUHTXHQF\ HOHFWURVXUJHU\RIWKHSURVWDWH%-8,QW  6PLWK'.KRXEHKL%3DWHO$%LSRODUHOHFWURVXUJHU\ for benign prostatic hyperplasia: transurethral electrovaporization and resection of the prostate. Curr Opin 8URO  0LFKHOL(5DQLHUL$3HUDFFKLD*/HPER$(QGWR HQGXUHWKURSODVW\ORQJWHUPUHVXOWV%-8,QW  8. Greenwell TJ, Castle C, Andrich DE, MacDonald JT, 1LFRO'/0XQG\$55HSHDWXUHWKURWRP\DQGGLODtion for the treatment of urethral stricture are neither FOLQLFDOO\ HIIHFWLYH QRU FRVWHIIHFWLYH - 8URO    0DQGKDQL$ &KDXGKXU\ + .DSRRU 5 6ULYDVWDYD A, Dubey D, Kumar A: Can outcome of internal urethrotomy for short segment bulbar urethral stricture EHSUHGLFWHG"-8URO  5RXUNH.)-RUGDQ*+3ULPDU\XUHWKUDOUHFRQVWUXFtion: the cost minimized approach to the bulbous XUHWKUDOVWULFWXUH-8URO  0DWVXRND.,QRXH0,LGD67RPL\DVX.1RGD6 Endoscopic antegrade laser incision in the treatment RIXUHWKUDOVWULFWXUH8URORJ\ 12. Perkash I: Ablation of urethral strictures using contact FKLVHOFU\VWDO¿ULQJQHRG\PLXP