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.

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Peter Dornan method to achieve continence

INCONTINENCE: An aggressive approach to treatment by Peter Dornan

Peter Dornan is a Brisbane physiotherapist who has a special interest in prostate cancer.

He is currently leader of the Brisbane Prostate Cancer Support Network.

STANDARD TREATMENT OPTIONS

  1. Behavioural Intervention
  • Pelvic floor exercises
  • Biofeedback/electrical stimulation
  • Modifications in diet and fluid intake
  • Bladder training
  1. Pharmacological intervention
  2. Surgical

 

NEW APPROACH

The working hypothesis of this program centers on expanding the philosophy involved with Behavioural Intervention  particularly in relation to pelvic floor activity, based on the role of the pelvic

floor in providing bladder neck support and supplementary urethral closure

pressure. (DeLancey 1990, Gosling et al 198I).

Fig 1 Male Pelvis showing location of Pelvic Floor Muscles

 

The prime focus is to develop a highly efficient (super fit) neuromuscular and vascular system which controls all of the structures which form the pelvic and abdominal cavities, including pelvic floor muscles.

Fig 2 Detail of Pelvic Floor Muscles

Further, as there are seven command centers which control bladder voidance and continence, it is essential that a specific intense system of exercises be undertaken to improve all reflex

circuitry relating to this control.

For incontinence involving nerve damage, and I refer particularly here to the “nerve-sparing” operation for men who have undergone a radical prostatectomy, any nerve damage in this instance should be a neuropraxia (compression or stretching of the nerve), and the pathway should reactivate by nine months to two years. However, recent evidence suggests that the main damage during surgery is probably to the blood vessels supplying the nerves, and this may be one reason for long-term neural deficiency (R.Appell,1999). In view of this speculation, the extended hypothesis of this program is to dynamically and functionally retrain elements of the local vascular, muscular and neural system to the extent that a collateral circulation may be introduced, therefore leading to a more normal bladder control situation. (This is not unreasonable. An average man can increase the width of his iliac artery from 6mm to 12mm by dedicated aerobic training).

The program aims to achieve these goals at four levels.

1.To gain control, strength, power, endurance and speed of muscle contraction of the pelvic floor muscles.

2.To dynamically and functionally retrain and integrate the pelvic floor muscles with the abdominal muscles.

3.To dynamically and functionally retrain components of the reflex circuitry mechanism involved with continence.

4.To aerobically condition elements of the local vascular system supplying neural and other structures in the pelvic region.

PROGRAM

FIRST LEVEL:

Pelvic Floor Exercises:

These are standard but specific exercises regularly prescribed for incontinence management, Initially the patient is directed to learn to correctly identify the muscles that need to be exercised.

Exercise 1:

Imagine you are at a party and you are trying desperately to prevent passing wind from the bowel. Contract the muscles around the anal sphincter which surrounds the back passage. Learn to tighten them and relax them.

Exercise 2:

Imagine you are passing urine. Now envisage trying to stop the flow of urine. Image you are releasing and then preventing the flow. Do not do this exercise while you are actually passing urine, except for a test.

Exercise 3:

Locate the perineal area (perineum) between your anus and vagina (or testicles). Imagine you are holding a red-hot needle which you aim at this region. Try to pull your perineum back inside your body and away from the needle,

Exercise 4:

When you have mastered the above exercises, try and contract the muscles involved in the above three exercises together; as if you are trying desperately not to lose any urinary or faecal matter.

The Exercise Routine

Before actually starting the exercises, it is important to understand we are trying to train the muscles for both speed of contraction and endurance+Therefore, these pelvic floor contractions need to be practiced at a fast rate and then a slow rate. (Keep in mind the pelvic floor muscles are composed predominately of slow twitch or endurance fibres).

Fast:  contractions should be performed as quickly as possible, ensuring each one is a full strong contraction: Contract – Relax, Contract- Relax (5 repetitions)

Slow: contractions are sustained for as long as five seconds: Contract -two-three-four-five, relax (5 repetitions)

Be aware that the muscles may tire quickly. As soon as you can achieve an efficient contraction of the first three exercises working together (i.e. Exercise No. 4) it is not necessary to do them individually

again -simply do exercise No.4 only.

Regularity: A reasonable goal in the early stages is to try and complete the full program twice a day. As you achieve fitness, add one or two more sessions.

Do not have unrealistic goals; for instance, attempting ten sessions a day may lead to boredom and probably non?compliance. The bottom line, however, is you must never give up; YOU MUST

PERSIST.

SECOND LEVEL

Integration of pelvic floor muscle activity with abdominal muscle activity

Once the patient has gained control of the pelvic floor muscles, then all muscles involved with pelvic and trunk stability should be dynamically and functionally retrained. At this stage it is important to gain strength, speed and endurance of the abdominal muscles, particularly the rotators (Fig 3), the transversus (Fig 4) and multifidis muscles.

Fig 3: The Abdominal Muscles highlighting The Rotators

 

Recent research has shown a strong link between abdominal muscle activity and pelvic floor activity.

Obliciuus Externus, Obliquus lnternus and Transversus Abdominis contraction has been shown to occur automatically during a maximal pelvic floor contraction.(Sapsford, Hodges, Richardson et al, 2001).

In another study (Saps ford and Hodges 2001), it was found that pelvic floor activity preceded abdominal muscle activity. This was viewed as the pelvic floor being activated as part of the motor

program in normal activation of the abdominals.

To train this integrated mechanism effectively, it is important to ensure that, during exercise, the abdominal muscles are deliberatelyactivated at the same time as the pelvic floor muscles, (that is, while performing the fourth pelvic floor exercise).

There are many variations and levels of abdominal exercises. The patient’s fitness status will determine this. Generally I prefer to start with the traditional “crunch” exercise.

  • Lie on your back with your knees bent, feet flat on the floor, hands behind your head.
  • Brace your abdominal muscles as if you are about to be dealt a blow to them (Le. flatten your navel to the floor)
  • Co-activate your pelvic floor muscles -(pull them all on together)
  • With your hands balancing your head, raise your head and shoulders as in a half sit-up (or “crunch”), while holding the pelvic floor contractions on, then lower your head and shoulders
  • If you need more resistance, hold a weight behind your head.

If you are grossly unfit, start with three repetitions

As you get fitter, you can build up to the “bicycle manoeuvre”.

  • Lie on your back, with your hands behind your head
  • Prepare by co-contracting your braced abdominal and pelvic floors. Use a pedalling motion to “crunch” your left knee to your right elbow, then alternate sides, as in a cycling action.

Over weeks, or months, try and accumulate a combined session total of all abdominal exercises-, to reach at least 200 repetitions. (Elle does 400 a day – it would be nice to secretly aim for that).

THIRD LEVEL

To dynamically and functionally retrain components of the reflex circuitry mechanism involved with

continence.

This entails activities which stresses and trains the pelvic floor muscles while carrying out functional activities. Firstly, the aim is to contract the pelvic floor muscles during walking, building through to jogging, then up to hard running, eventually over hilly tracks. It is important to increase the effect of heel impact by varying the degree of difficulty of the terrain – hard, uneven surfaces. The intention here is to “joggle” the internal systems about in an attempt to stimulate, retrain and strengthen bladder control reflex circuitry.

Secondly, the patient is educated to voluntarily contract the pelvic floor muscles during other dynamic activities such as lifting, coughing, and changing postures.

FOURTH LEVEL

To aerobically condition elements of the local vascular system supplying neural and other structures of the pelvic region.

Ultimately, this involves an aerobic training program, such as cycling or running, while functionally co- activating the pelvic floor muscles. The aim is to create an enhanced (or collateral) vascular system supplying any damaged nerves in the urogenital area.

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Tests needed before urethroplasty

Uroflowmetry: Testing the urine flow rate

This is the first step.  “The normal urinary flow rate in young and middle aged men is generally greater than 15?ml/second and the flow pattern a bell shaped curve. ” “In those who have a urethral stricture the peak flow rate is typically low but the flow pattern is characteristically flat” [Source]

“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] (Sanjeev: I’m having pain while voiding)

Urethrogram

Both “RUG/VCUG is costly and some-times logistically difficult to perform, and exposes men to radiation” [Source] These tests “show the exact site and length of the stricture and most of its potential complications” [Source]

Retrograde urethrogram (RUG)

See Wikipedia entry.

The penis is postioned at approximately the 10 o’clock position. The round opaque structure in the distal penis is the inflated Foley balloon. The Foley catheter tip is faintly radiopaque, but can be better seen as a filling defect after administration of contrast.  [Source]

Voiding cystourethrogram (VCUG)

See Wikipedia entry.

The voiding urethrogram evaluates the posterior urethra. The Foley balloon is advanced into the bladder and contrast is instilled until the bladder is dilated. The bladder should be so dilated, that the patient “feels like he absolutely needs to pull off to the side of the road so he can urinate”. The Foley is then removed and the patient is encourage to urinate. Images are obtained of the open posterior urethra. As this is not a dedicated cystogram, imaging the bladder is a secondary concern. [Source]

AUGMENTED URETHROPLASTY

“If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). ” [Source]

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Aged care issues

My FB post.

THE UNDERBELLY OF AUSTRALIA: SEVERE MARKET FAILURE IN AGED CARE
I wasn’t aware of how badly run the aged care sector is in Australia. There is moral hazard at its most acute. And zero accountability.
 
 
Middle aged children who do not have the time (or capacity) to look after their parents send them to aged care homes. But these “homes” are run by extremely immoral owners whose goal is simple: rip off (a) whatever savings the family had accumulated, and (b) taxpayers. And provide zero care.
ADDENDUM
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Monitoring of urine flow rate

Average rates across the world:

Ages 14 to 45 — The average flow rate for males is 21 mL/sec. The average flow rate for females is 18 mL/sec.

Ages 46 to 65 — The average flow rate for males is 12 mL/sec. The average flow rate for females is 18 mL/sec. [Source]  SEE ALSO: http://www.malcolmfrazer.com.au/pdf/Publications/Liverpool%20Nomograms.pdf

AND THIS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808647/

MY MEASUREMENTS post urethrotomy

Final closure to the issue: urine flow test on 6 February 2018. This was considered OK, with average rate of 17.5 ml/sec – which is broadly consistent with my readings in November. The surgery has been a success.

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