Cystoscopic Local Application of Mitomycin-C following Internal Urethrotomy for Recurrent Short Urethral Strictures in Children: A Preliminary Experience.

BACKGROUND

Urethral stricture (US) refers to the scarring process involving the corpus spongiosum (spongiofibrosis). Incidence in children is quite low as compared to adults, with anterior urethra (penile and bulbar) being the most common site. Iatrogenic and posttraumatic causes in the US are more frequent than the idiopathic, infective, and inflammatory causes. Either endoscopic internal urethrotomy (IU) (size < 2 cm US) or open reconstructive procedures (size > 2 cm US) are the main treatment options. However, additional therapy, such as the local application of Mitomycin C (MtMC), improves endoscopic success rates. In the current communication, we present a series of children with recurrent short US (<2 cm) following IU and even after reconstructive procedures, wherein we have tried to extend the benefit of MtMC application in combination with IU.

MATERIALS AND METHODS

Five consecutive children with recurrent short US (<2 cm) (following reconstructive procedures in traumatic US [ = 2], post fulguration of posterior urethral valves, i.e. iatrogenic US [ = 2] and congenital US [ = 1]) underwent treatment by IU and local application of MtMC. Cystoscopic local instillation of 2 ml of MtMC at a concentration of 0.5 mg/ml was done after IU with simultaneous per rectal finger occlusion of the bladder neck. The symptom score (International Prostate Symptom Score [I-PSS]) was utilized in all the patients to gauge the severity of symptoms. Periodic subjective assessment of symptom relief and urinary stream, cystoscopic reassessment for adequacy of intraluminal diameter, ultrasonography, uroflowmetry, retrograde urethrograms, and dimercaptosuccinic acid scans were carried out at different time points during the 6-month follow-up.

RESULTS

The mean age of the patients was 8.4 ± 1.9 years. The mean pre-MtMC I-PSS score was 24 (severe). Post-MtMC application, the patients reported a symptomatically better urinary stream that was sustained beyond 4 weeks of catheter removal. When the urinary stream used to get thinned out, additional sittings of MtMC application were carried out. The time interval for re-intervention increased by 4-6 weeks, and on subsequent cystoscopic examinations at different time intervals, the urethral lumen was far much better (70%-80% improvement). The mean post-MtMC I-PSS score was 11 (moderate). During the early follow-up, the upper urinary tracts did not show any further deterioration as evidenced by DMSA scan done at 6 months. Uroflowmetry (plateau-shaped suggestive of static bladder outflow obstruction either anatomical or functional) and postvoid residual urine findings (~50% residual) were less encouraging.

CONCLUSION

In terms of symptomatic relief, MtMC application has demonstrated its potential benefit on short follow-up for treating resistant US, as evidenced by a 40%-50% improvement in I-PSS score observed in all cases.