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SURGERY FOR BULBOUS URETHRAL STRUCTURES IN BOYS - WHAT IS THE OPTIMAL SURGICAL STRATEGY?

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SURGERY FOR BULBOUS URETHRAL STRUCTURES IN BOYS - WHAT IS THE OPTIMAL SURGICAL STRATEGY?
David A. Diamond, M.D., Jiang Xuewu, M.D., Stuart B. Bauer, M.D., Bartley G. Cilento, Jr., M.D., Joseph G. Borer, M.D., Hiep Nguyen, M.D., Marc Cendron, M.D., Ilina Rosoklija, M.P.H., Alan B. Retik, M.D..
Children's Hospital, Boston, MA, USA.

Background:
The optimal management of bulbous urethral strictures in children is not well defined. We compared our long-term experience with direct vision internal urethrotomy (DVIU) and open repair with the objective of defining an optimal surgical strategy.
Methods:
Sixty-three patients who had undergone DVIU or open repair of a bulbous urethral stricture with long-term follow-up studies were reviewed. Forty-six (73%) were treated with one or more DVIU's only. Seventeen (27%) had open urethroplasty, 13 end to end and 4 patch graft or tube repairs. Eight of the 17 required urethroplasty only, whereas 9 had a combined approach of open and endoscopic repair (initially open 2, initially DVIU 7). Of those having initial DVIU then open repair, only one patient (1/2 failures) had more than one DVIU.
Patients undergoing DVIU only were a mean of 13.7 years (5 mos to 21 yrs) and those undergoing open urethroplasty were a mean of 15.2 years (8-21 yrs).
Follow-up assessment entailed either VCUG, RUG, cystoscopy or flow rate or a combination. Mean follow-up was 30 months for those undergoing DVIU and 16 months for those having open urethroplasty.
Results:
When DVIU was the initial approach, one procedure was successful in 53% (28/53). Multiple DVIU's increased the success rate to 59% (43/73). Patients undergoing an initial DVIU required a mean of 1.6 procedures (84/53).
When open repair was the initial approach one procedure was successful in 80% (8/10). This group required a mean of 1.2 procedures (12/10).
A combined (DVIU/open) approach was successful in 78% (7/9). Success was greater if the initial approach was open (100%, 2/2) versus DVIU (71%, 5/7).
Conclusions:
Open reconstruction is more successful than DVIU as an initial approach to bulbous urethral strictures. Initial DVIU is successful in half and is minimally invasive. Repeat attempts at DVIU add little to overall success. Success with a combined approach (DVIU/open) approximates that of initial open reconstruction. We advocate only one initial attempt at success with DVIU followed by open urethroplasty, if necessary.


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