Ratan Simmi K, Sharma Nitesh Kumar, Saxena Gaurav, Neogi Sujoy
Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India.
Department of Pediatric Surgery, All India Institute of Medical Sciences, Kalyani, West Bengal, India.
J Indian Assoc Pediatr Surg. 2025 Jul-Aug;30(4):452-458. doi: 10.4103/jiaps.jiaps_299_24. Epub 2025 Apr 14.
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.
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.
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.
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.
尿道狭窄（US）是指涉及海绵体的瘢痕形成过程（海绵体纤维化）。与成人相比，儿童发病率相当低，前尿道（阴茎部和球部）是最常见的部位。在美国，医源性和创伤后原因比特发性、感染性和炎症性原因更常见。内镜下尿道内切开术（IU）（狭窄长度<2 cm的US）或开放性重建手术（狭窄长度>2 cm的US）是主要的治疗选择。然而，额外的治疗，如局部应用丝裂霉素C（MtMC），可提高内镜治疗的成功率。在本报告中，我们介绍了一系列儿童患者，他们在接受IU治疗后，甚至在重建手术后仍出现复发性短尿道狭窄（<2 cm），我们试图将MtMC与IU联合应用的益处进行扩展。
连续5例复发性短尿道狭窄（<2 cm）的儿童患者（创伤性尿道狭窄重建术后[2例]、后尿道瓣膜电灼术后即医源性尿道狭窄[2例]和先天性尿道狭窄[1例]）接受了IU治疗及MtMC局部应用。IU术后，经膀胱镜在膀胱颈部直肠指诊同时局部滴注2 ml浓度为0.5 mg/ml的MtMC。所有患者均采用症状评分（国际前列腺症状评分[I-PSS]）来评估症状的严重程度。在6个月的随访期间，于不同时间点进行症状缓解和尿流的定期主观评估、膀胱镜复查管腔内径是否足够、超声检查、尿流率测定、逆行尿道造影以及二巯基丁二酸扫描。
患者的平均年龄为8.4±1.9岁。MtMC应用前I-PSS评分的平均值为24分（重度）。应用MtMC后，患者报告尿流变通畅，且在拔除导尿管后持续超过4周。当尿流变细时，再次进行MtMC应用。再次干预的时间间隔增加了4 - 6周，在随后不同时间间隔的膀胱镜检查中，尿道腔明显改善（改善70% - 80%）。MtMC应用后I-PSS评分的平均值为11分（中度）。在早期随访中，6个月时进行的二巯基丁二酸扫描显示上尿路未出现进一步恶化。尿流率测定（呈平台状提示存在解剖或功能性静态膀胱流出道梗阻）和排尿后残余尿量检查结果（残余尿量约50%）不太理想。
就症状缓解而言，MtMC应用已证明其在短期随访中治疗难治性尿道狭窄具有潜在益处，所有病例的I-PSS评分提高40% - 50%即证明了这一点。
