My decision regarding Stage One Johanson urethroplasty for sub-meatal/ fossa navicularis urethtral stricture: A STITCH IN TIME SAVES NINE

Here’s my research and underlying arguments to go for surgery:

WHAT IS THE PROBLEM?

The fact that I now HAVE a stricture can’t be avoided. Its cause was also unavoidable. While fixing the bigger issue (cancer) this smaller issue was unavoidable, given my body’s existing anatomy.

“Distal urethral strictures confined to the fossa navicularis and meatus comprise approximately 18% of all anterior urethral strictures.”

“for whatever reason a scar develops as a consequence of changes in the structure and function of the urethral epithelium and the sub?epithelial spongy tissue causing a fibrotic narrowing of the urethra. Secondary changes in the epithelium more proximally develop there afterwards causing a progressive stricturing of an increasing length of the urethra from before backwards” [Source]

My previous notes/ research on this issue:

Tests needed before urethroplasty

Dealing with sub-meatal urethral stricture: meatoplasty and dilation (related: fossa navicularis strictures)

Complications after prostate surgery – Stricture/Bladder Neck Contracture >> Optical Urethrotomy

Injury to penis by catheter after prostate surgery/ referred pain in the penis from surgery

IDENTIFYING THE PRECISE LOCATION AND EXTENT OF THE STRICTURE

“Since the catheter utilized in retrograde urethrography may obscure much of the distal urethra, voiding urethrography can often provide superior radiographic assessment of the distal urethra.” [Source] [Sanjeev: In my case, the radiographer managed to get a clear image from only the use of the retrograde technique, at the very end of his process while the radioactive liquid was squirting out. The video is a bit clearer but the picture below is good enough. It clearly shows the abrupt narrowing and the location and extent (length) of the stricture:

MY ISSUE IS PARTICULARLY CHALLENGING 

“Distal urethral strictures confined to the meatus and fossa navicularis are particularly challenging because: (I) consideration must be given not only to establishment of durable patency of the urethra but also maintenance of glans cosmesis; and (II) these strictures are frequently related to lichen sclerosus, an inflammatory process which can cause local tissue destruction and a propensity for disease recurrence following treatment.” [Source]

THE “RECONSTRUCTIVE LADDER” HAS BEEN TOTALLY DISCREDITED

“Traditionally, distal anterior urethral strictures have been treated with dilatation and internal urethrotomy, respecting the so-called reconstructive ladder. Open surgery has usually been chosen as a last option. However, it has now been realized that these minimally invasive options do not have a durable effect and may further compromise the quality of the local tissue for future reconstruction” [Source] – Management of the stricture of fossa navicularis and pendulous urethral strictures: Shrawan K. Singh, Santosh K. Agrawal, and Ravimohan S. Mavuduru, Indian J Urol. 2011 Jul-Sep; 27(3): 371–377.

“The notion that the urologist should proceed up the “reconstructive ladder”, exhausting endoscopic procedures and simple procedures before pursuing complex reconstruction has been refuted in the literature. This approach is often ineffective and does not limit patient morbidity, decrease disease progression, or minimize cost. Instead, a more prudent approach to the treatment of distal strictures is to determine which singular or staged intervention offers the patient the highest likelihood of durable patency with the least morbidity, while honoring patient-related goals. Ultimately, decision-making should be individualized, based on stricture burden, etiology, and patient motivation. [Source]- Distal urethroplasty for fossa navicularis and meatal strictures, Elodi J. Dielubanza, Justin S. Han, and Chris M. Gonzalez, Transl Androl Urol. 2014 Jun; 3(2): 163–169

i.e. goal should be to FIX THE ISSUE PERMANENTLY IN ONE GO, NOT TO DRAG IT OUT IN THE IDLE HOPE/ DELUSION?  THAT IT WILL SOMEHOW GET FIXED. IT WON’T. THIS SURGERY IS A CLASSIC CASE OF A STITCH IN TIME FIXES NINE.

DILATION SHOULD BE STRICTLY AVOIDED:

“Given the dearth of evidence of long term efficacy and the potential for patient discomfort, strong consideration should be given to avoidance of dilation in favor of reconstructive approaches.” [Source]

“The clearest argument for referral for urethroplasty lies in the futility of repeat urethrotomy or dilation. Dilation is particularly unreliable. In 1949 Scardino and Hudson published the declaration that urethral dilation for stricture was “useless”. Modern series show at least an 88% failure rate for a first urethral dilation and we predict second dilations have a 100% failure rate. Somehow this concept has gotten lost with time.” [Source: Should We Centralize Referrals for Repair of Urethral Stricture? – Richard A. Santucci, Journal of Urology, The, 2009-10-01, Volume 182, Issue 4]

“Yet today alone dozens of patients worldwide will likely undergo repeat urethrotomy, and doctor and patient will hope for success that will likely never come. These are the patients who should be referred to a urologist with knowledge of urethroplasty whether near or far. For most patients referral for urethroplasty instead of additional ineffective urethrotomy should be the standard of care.”   [Source: Should We Centralize Referrals for Repair of Urethral Stricture? – Richard A. Santucci, Journal of Urology, The, 2009-10-01, Volume 182, Issue 4]

[Sanjeev: given the speed of recurrence in my case, dilation was guaranteed to fail. It is good I did not try it and have gone straight for urethroplasty after a single DVIU urethrotomy. ]

LAST QUESTION: IMMEDIATE SURGERY OR SHOULD I WAIT?

“With a flow rate of less than 5?ml/second, abnormalities such as those listed above are much more likely and the patient is potentially at risk of acute retention, although this is a lot less common than one would expect from the severity of the narrowing of the urethra that is seen in such a situation. In these patients treatment is advisable even if symptoms of voiding difficulty are not troublesome.” [Source: Management of urethral strictures, A R Mundy, Postgrad Med J. 2006 Aug; 82(970)]

My current flow rate is around 6.5 ml/ second. However, the trend in my case is VERY STRONG: a steep (but slowing) decline in the size of the opening (lumen) of the urethra. The average urine flow has reduced from over 18ml/sec 10 days after urethrotomy to an average of around 6.5 ml/sec, less than 4 weeks from the urethrotomy. The decline from 18 ml to around 6.5 has occurred in a mere two weeks.

Although the level has stabilised for around four days, it would be a delusion to imagine that the end of scarring has been reached. It is barely four weeks from urethrotomy. My flow rate is likely to quickly reduce below 5ml/ second, going into the danger zone.

The question is: should I undergo surgery at this stage or should I wait for it to get worse before finally getting the surgery done?

THERE IS NO RISKLESS WAY FORWARD

SCENARIO 1: THE STRICTURE GETS WORSE (99.9 PER CENT PROBABILITY)

a) It is futile to imagine that the stricture will somehow remain at the current level. There is no evidence in the literature that strictures stabilise or disappear or settle down on their own. The probability of the stricture getting worse and needing the same (or more severe surgery) is 100 per cent. IT IS FUTILE TO THINK THAT THIS ISSUE WILL SOMEHOW “STABILISE”. For instance, I had first thought it might stabilise at 12> ml/sec, but that didn’t happen. Then I thought it might stabilise at 8-9 ml but that didn’t happen. In my case:

a) I have a particularly strong tendency to scar (as illustrated by the heavy scarring observed by the surgeon inside my abdomen at the time of the radical prostatectomy); and

b) the underlying epithelial and spongiforous tissue has clearly been affected. If left untreated, the damage could spread and lead to a LONGER stricture, making things much more difficult to treat in the future.

b) Severe damage can occur the more I delay: “More pressure is needed from the bladder muscle to pass urine out through a stricture (it acts like a bottleneck). Not all urine in the bladder may be passed when you go to the toilet. Some urine may pool in the bladder. This residual pool of urine is more likely to become infected. This makes you more prone to bladder, prostate and kidney infections. A ball of infection (an abscess) above the stricture may also develop. This can cause further damage to the urethra and tissues below the bladder. Cancer of the urethra is an extremely rare complication (Sanjeev: but not zero probability) of a long-standing stricture.” [Source]

SCENARIO 2: THE STRICTURE STABILISES AT THE CURRENT LEVEL (0.1 PER CENT PROBABILITY)

Even in the best case (0.1 per cent chance) if the stricture stabilises, its existence will prevent any normal catheter being used in my case in the future. There will almost certainly be circumstances in my life in the future when I need a catheter – for some surgery or other. Each time that happens my existing stricture will force a major surgery to install a suprapelvic catheter. That is not just an additional cost (and pain) but an additional risk of further complications. If I can fix this issue now, I’ll be able to use a normal catheter in the future, when it becomes necessary.

SO IT IS CLEAR THAT FIXING THE PROBLEM AT THE EARLIEST IS THE BEST OPTION.

DECISION

Go ahead with the surgery.

PROS

  • FIX THE ISSUE ONCE AND FOR ALL. A STITCH IN TIME SAVES NINE.
    • I’m extremely fortunate that the proposed surgery HAS A VERY HIGH PROBABILITY OF FIXING the problem PERMANENTLY – since no graft is involved: only a diversion of the urethral exit point, with only the healthy portion of the urethtra being used and the rest blocked off. (If I choose to undergo Stage Two, there will be a risk of recurrence of some other scar tissue – however, that might be cosmetically and functionally desirable, and should be considered after continence is achieved: State Two should be done before ED has been sorted out. ED is fixed then there is horrible pain while a catheter is in place post-surgery (see patient’s report here). [Note: Ensure that the surgeon excises the ENTIRE damaged portion of the urethra so a clean “bed” is available for State Two, and scarring does not spread across the system]
    • One can’t escape surgery – or worse complications. Better to bite the bullet and prevent complications. The surgeon is not available again till 25 October and the other potential surgeon (whom I’d have otherwise met on 16 October) might not have had any vacancy till well into October/early November. A delay at this stage will leave me exposed to a HUGE risk of Emergency Department suprapubic catheter. That would complicate things badly, cost time and money, disrupt the incontinence recovery, AND NOT PREVENT THIS SAME (OR MORE COMPLICATED) SURGERY IN THE FUTURE. [Btw, Suprapubic catheter is no walk in the park. It causes significant pain and spasming – see patient report. And any surgery can lead to complications. The fewer the surgeries you have in your life the better. Better to bite the bullet and not ruminate.]
  • WILL ALLOW QUICK RESUMPTION OF INCONTINENCE TREATMENT:
    • The surgery will impose minimal disruption (barely two weeks) on my attempt to regain continence.

CONS

  • There will be adjustments to make after Stage One surgery. On the other hand, if these adjustments are excessive, I can undergo Stage Two surgery. Therefore there is a further remedy available.

The decision is now crystal clear. IMMEDIATE SURGERY IS THE BEST YOU CAN DO, GIVEN THE PREVAILING STATE OF KNOWLEDGE. In the future, if you continue to live, new long term remedies might become available. The goal at this stage is to minimise further damage.

DECISION HAS BEEN MADE. TIME TO MOVE ON TO OTHER THINGS.

sabhlok

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