Shoukry A I, Abouela W N, ElSheemy M S, Shouman A M, Daw K, Hussein A A, Morsi H, Mohsen M A, Badawy H, Eissa M
Pediatric Urology Department, Abu El Rish Children Hospital, Cairo University, KasrAlAiny Street, Cairo, Egypt.
Urology Department, Kasr Alainy Hospital, Cairo University, KasrAlainy Street, Cairo, Egypt.
J Pediatr Urol. 2016 Feb;12(1):42.e1-6. doi: 10.1016/j.jpurol.2015.06.016. Epub 2015 Aug 11.
The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions.
To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures.
From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation.
The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six.
One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study.
HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.
尿道狭窄的治疗极具挑战性，需要从内镜手术到开放手术干预等多种不同治疗方式的广泛专业知识。
评估逆行内镜钬：钇铝石榴石激光（Ho:YAG）尿道切开术（HLU）治疗小儿尿道狭窄的有效性和并发症。
2010年1月至2013年1月，29例平均年龄5.9岁、原发性尿道狭窄长度为0.5 - 2 cm的男性小儿患者接受了HLU治疗。16例（55%）患者狭窄长度<1 cm，13例（45%）患者狭窄长度>1 cm。15例（51.7%）患者为前尿道狭窄，14例（48.3%）患者为后尿道狭窄。14例（48.3%）患者无狭窄疾病的阳性病史，6例（20.7%）有骑跨伤，9例（31%）有医源性狭窄。所有患者术前均进行了检查，并在术后3个月和6个月通过尿流率测定和排尿性膀胱尿道造影（VCUG）进行复查。若有可疑排尿症状，则在术后12个月进行选择性尿流率测定和VCUG检查。
平均手术时间为31.7分钟（20 - 45分钟）。23例（79.3%）和18例（62.1%）患者在术后3个月和6个月时VCUG显示尿道正常，症状改善。因此，随访6个月后复发率为37.9%。术前平均最大尿流率（Qmax）为6.47 ml/s。术后3个月和6个月的平均Qmax分别为17.17 ml/s和15.35 ml/s。成功率和尿流率结果在狭窄部位、长度和病因方面未显示出任何统计学意义。另外11例未改善的患者接受了重复HLU治疗：4/11（36.3%）取得了成功结果。在7例第二次HLU治疗失败的患者中，进行了第三次治疗。然而，仅1例患者（14.2%）治愈，其余6例需要开放修复。
此前已有一项关于使用HLU治疗小儿尿道狭窄的研究发表。目前的结果与单次使用冷刀直视内尿道切开术（VIU）后的短期研究结果相似。在本研究中，狭窄的长度、位置和病因并未显著影响结果。然而，狭窄<1 cm的患者预后优于狭窄>1 cm的患者，尽管排除了狭窄>2 cm的患者。在本研究中，第二次和第三次HLU治疗患者的成功率分别为36.3%和14.2%。这与其他研究相似，其他研究报道VIU第二次治疗成功率较低。本研究受到随访时间相对较短和患者数量较少的限制。然而，这是第一项评估HLU治疗小儿狭窄的前瞻性研究。对所有患者使用尿流率测定和VCUG进行评估增加了本研究的力度。
HLU可安全用于治疗儿童原发性尿道狭窄（<2 cm），成功率较高。重复HLU（超过两次）对成功率的提升作用不大。
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