Comparison of neodymium-doped yttrium aluminum garnet laser treatment with cold knife endoscopic incision of urethral strictures in male patients

Safety and efficacy of lasers compared to cold knife in direct visual internal urethrotomy: a systematic review and Meta-analysis

Cold knife urethrotome was introduced in 1971 and it had an 80% success rate. New advancements in this field have shed light on the use of various lasers such as carbon dioxide, Nd: YAG, KTP, Argon, Ho: YAG, and excimer lasers. It has been observed that cold knife urethrotomy has a higher recurrence rate than laser urethrotomy, but the superiority of either treatment modality has not been established yet. Data were thoroughly searched through PubMed, Scopus, and clinicaltrials.gov. We also used clinicaltrials.gov for ongoing and published research. The data was analyzed via R studio version 2023.12.1 (oceanstorm). For dichotomous variables, Odds Ratio (OR) were used to pool data and standardized mean difference was used for continuous variables with 95% confidence intervals (CIs). A total of 14 studies including 1114 participants were included in this meta-analysis. The results of the combined analysis revealed significant relation with a mean difference of 0.99 (95% CI: 0.37; 1.62), and favored laser group. The overall results have shown the laser to have a significant favorable profile demonstrating a recurrence, Odds Ratio of 0.42 (95% CI:0.27;0.65). Patients with laser therapy had a lower risk of complication rate (OR 0.49, 95% Cl: 0.35; 0.67). All the findings obtained by the analysis in this study favour lasers significantly over the cold knife technique especially when mean Qmax, with recurrence and complications taken into account.

Comparison of laser versus cold knife visual internal urethrotomy in the treatment of urethral stricture (stricture length <2 cm): A systematic review and meta-analysis

PURPOSE

There is still controversy regarding the safety and efficacy of cold knife visual internal urethrotomy and laser incisions for the treatment of urethral stricture. This study aims to compare the results of postoperative long-term and short-term maximum urinary flow rates (Qmax), surgical time, postoperative complications, and 1-year recurrence rates between the cold knife and laser surgery.

METHODS

We searched databases including Embase, PubMed, Cochrane, and Clinical Trials.gov to identify relevant literature published in English up to September 2023. We used Stata to compare various parameters. This study is registered in PROSPERO (CRD42023471634). Nine comparative experiments were conducted, involving a total of 659 participants.

RESULTS

The laser group showed significantly better results compared to the cold knife group in terms of postoperative 12-month maximum urinary flow rate (mean differences [MD] 2.131; 95% [1.015, 3.249], P < .0001), postoperative bleeding (RR 0.277, 95% [0.079, 0.977], P = .046), and 1-year recurrence rate (RR 0.667, 95% [0.456, 0.976], P = .037). However, there were no significant differences in postoperative 6-month and 3-month Qmax, surgical time, urethral leakage complications, overall complications, and Visual Analog Scale (VAS) scores.

CONCLUSION

The current study results suggest that laser urethral incision has greater advantages in the long-term (12 months), 1-year recurrence rate, and bleeding complications compared to cold knife urethral incision in the treatment of urethral stricture (<2 cm). Therefore, laser urethral incision may be a better choice for patients with urethral stricture.

Comparison between cold knife and laser urethrotomy for urethral stricture: a systematic review and meta-analysis of comparative trials

BACKGROUND

Previous study compared limited number of parameters post the treatment of cold knife and laser urethrotomy for urethral stricture and controversy about the superiority of those two techniques still remains. This study aims to update the evidence and provide better clinical guidance.

METHOD

We systematically searched Pubmed, Embase, ClinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials for articles comparing cold knife and laser urethrotomy for urethral stricture. Parameters including maximum urinary flow (Q_max), recurrence, reoperation, complications, operation time, and Visual Analog Scale (VAS) pain score were compared using RevMan 5.3.

RESULTS

Seven articles involving 453 patients were eventually included. The cold-knife group had better 6-month Q_max (MD - 0.95, 95% CI - 1.49 to - 0.41) and similar 3-month and 12-month Q_max compared with the laser group. No significance was observed regarding the comparison of recurrence rate. The laser group had lower risk of bleeding (OR 0.08, 95% CI 0.01-0.43), lower rate of reoperation (OR 0.39, 95% CI 0.19-0.81) and longer operation time (MD 4.09, 95% CI 3.35-4.82). There was no significant difference in terms of other complications and VAS pain score.

CONCLUSION

Cold knife and laser urethrotomy had similar efficacy regarding short-term and long-term recurrence rate and Q_max, except that the cold-knife group had slightly better 6-month Q_max. However, the laser group had less risk of bleeding and lower rate of reoperation but also longer operation time.

Evaluation of holmium laser versus cold knife in optical internal urethrotomy for the management of short segment urethral stricture

Objectives:

Sachse cold knife is conventionally used for optical internal urethrotomy intended to manage urethral strictures and Ho: YAG laser is an alternative to it. The aim of this study was to evaluate the role of urethral stricture treatment outcomes, efficacy, and complications using cold knife and Ho: YAG (Holmium laser) for optical internal urethrotomy

Materials and Methods:

In this prospective study included, 90 male patients age >18 years, with diagnosis of urethral stricture admitted for internal optical urethrotomy during April 2010 to March 2012. The patients were randomized into two groups containing 45 patients each using computer generated random number. In group A (Holmium group), internal urethrotomy was done with Holmium laser and in group B (Cold knife group) Sachse cold knife was used. Patients were followed up for 6 months after surgery in Out Patient Department on 15, 30 and 180 post-operative days. At each follow up visit physical examination, and uroflowmetry was performed along with noting complaints, if any.

Results:

The peak flow rates (PFR) were compared between the two groups on each follow up. At 180 days (6 month interval) the difference between mean of PFR for Holmium and Cold knife group was statistically highly significant (P < 0.001). Complications were seen in 12.22% of cases.

Conclusion:

Both modalities are effective in providing immediate relief to patients with single and short segment (<2 cm long) urethral strictures but more sustained response was attained with Cold knife urethrotomy.

Male urethral strictures and their management

Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of long-term outcomes; success rates range widely from 8-80%, with long-term success rates of 20-30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85-90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.

[Sachse internal urethrotomy: endoscopic treatment of urethral strictures]

The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy (DVUI) method according to Sachse. It is an effective short-term treatment, but the long-term success rate is low. A number of factors influence the outcome of DVUI including stricture location, spongiofibrosis and previous endoscopic stricture treatment. Multiple urethrotomy has a negative impact on the success rate of subsequent urethroplasty. A thorough preoperative diagnostic work-up including combined retrograde urethrogram/voiding cystourethrogram (RUG/VCUG) and urethrocystoscopy is, therefore, mandatory to allow for patient counselling regarding the risk of stricture recurrence and other treatment options. After a failed primary DVUI, subsequent urethrotomy cannot be expected to be curative.

Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men

BACKGROUND

Strictures of the urethra are the most common cause of obstructed micturition in younger men and frequently recur after initial treatment. Standard treatment comprises internal widening of the strictured area by simple dilatation or by telescope-guided internal cutting (optical urethrotomy), but these interventions are associated with a high failure rate requiring repeated treatment. The alternative option of open urethroplasty whereby the urethral lumen is permanently widened by removal or grafting of the strictured segment is less likely to fail but requires greater expertise. Findings of Improved choice of graft material and shortened hospital stay suggest that urethroplasty may be under utilised. The extent and quality of evidence guiding treatment choice for this condition are uncertain.  

OBJECTIVES

To determine which is the best surgical treatment for male urethral stricture disease taking into account relative efficacy, adverse event rates and cost-effectiveness.  

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 21 June 2012), CENTRAL (2012, Issue 6), MEDLINE (January 1946 to week 2 June 2012), EMBASE (January 1980 to week 25 2012), OpenSIGLE (searched 26 June 2012), clinical trials registries and reference lists of relevant articles.

SELECTION CRITERIA

We included publications reporting data from randomised or quasi-randomised controlled trials comparing the effectiveness of dilatation, urethrotomy and urethroplasty in the treatment of adult men with urethral stricture disease.

DATA COLLECTION AND ANALYSIS

Two authors evaluated trials for appropriateness for inclusion and methodological quality. Data extraction was performed using predetermined criteria. Analyses were carried out using the Cochrane Review Manager software (RevMan 5).

MAIN RESULTS

Two randomised trials were identified. One trial compared the outcomes of surgical urethral dilatation and optical urethrotomy in 210 adult men with urethral stricture disease. No significant difference was found in the proportion of men being stricture free at three years or in the median time to recurrence. The second trial compared the outcomes of urethrotomy and urethroplasty in 50 men with traumatic stricture of the posterior urethra following pelvic fracture injury. In the first six months, men were more likely to require further surgery in the urethrotomy group than in the primary urethroplasty group (RR 3.39, 95% CI 1.62 to 7.07). After two years, 16 of 25 (64%) men initially treated by urethrotomy required continued self-dilatation or further surgery for stricture recurrence compared to 6 of 25 (24%) men treated by primary urethroplasty. There were insufficient data to perform meta-analysis or to reliably determine effect size.

AUTHORS' CONCLUSIONS

There were insufficient data to determine which intervention is best for urethral stricture disease in terms of balancing efficacy, adverse effects and costs. Well designed, adequately powered multi-centre trials are needed to answer relevant clinical questions regarding treatment of men with urethral strictures.

The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures

Introduction:

Direct visual internal urethrotomy (DVIU) followed by intermittent self-dilatation (ISD) is the most commonly performed intervention for urethral stricture disease. The objective of this paper is to outline the current scientific evidence supporting this approach for its use in the management of anterior urethral strictures.

Materials and Methods:

A Pubmed database search was performed with the words “internal urethrotomy” and “internal urethrotomy” self-catheterization. All papers dealing with this subject were scrutinized. Cross-references from the retrieved articles were also viewed. Only English language articles were included in the analyses. Studies were analyzed to identify predictors for success for DVIU.

Results:

Initial studies showed excellent outcomes with DVIU with success rates ranging from 50% to 85%. However, these studies reported only short-term results. Recent studies with longer followup have shown a poor success rate ranging from 6% to 28%. Stricture length and degree of fibrosis (luminal narrowing) were found to be predictors of response. Repeated urethrotomies were associated with poor results. Studies involving intermittent self-catheterization following DVIU have shown no role in short-term ISD with one study reporting beneficial effects if continued for more than a year. A significant number of studies have shown long-term complications with SC and high dropout rates.

Conclusions:

DVIU is associated with poor long-term cure rates. It remains as a treatment of first choice for bulbar urethral strictures <1 cm with minimal spongiofibrosis. There is no role for repeated urethrotomy as outcomes are uniformly poor. ISD, when used for more than a year on a weekly or biweekly basis may delay the onset of stricture recurrence.

[Endoscopic management of urethral stricture]

Great progress has been seen in the treatment of urethral strictures since the first endoscopic urethrotomy was performed in 1893 by Felix Martin Oberländer in Dresden, Germany. With the introduction of endoscopic laser therapy and the variety of urethral reconstruction methods other ways to treat this important urologic entity became available. Despite this progress, urethrotomy still represents the preferred treatment concept for primary, short and bulbar urethral strictures. In this study we performed a 2-year retrospective analysis of 20 patients undergoing primary endoscopic urethrotomy by single bulbar or penile narrowing. A high incidence of recurrence was seen in 70% of the patients. Nevertheless, direct vision urethrotomy represented a safe and effective transitory method to treat these patients. Moreover, 80% of the patients preferred, in cases of recurrence, a repeated urethrotomy as the treatment of choice. Although the long-term results evidence high relapse rates after the first and second procedures, there have been no sufficient data in the literature which support the use of other methods. Furthermore, primary endoscopic management of urethral strictures remains a simple, safe, and cost-effective procedure that should be indicated before more invasive approaches are taken to provide relief to these patients from this limiting problem.