Cystoscopy with Internal Optical Urethrotomy (IOU)

Definition

cystoscopy = placing a small telescope into the bladder

internal = within a structure (in this case the urethra)

optical = under direct vision through the scope

tomy = “tome” or to cut

This procedure is done to open up a stricture (scar tissue) in the urethra.

The most common reasons to have a stricture are:

• a history of prior urethral procedure
• an old injury to the urethra
• history of gonorrhea or other infection (urethritis) involving the urethra

Soft strictures and scars that are very short may respond to simple office dilatation (gentle spreading with specialized instruments). Other may need a more formal procedure to maximize results and diminish the incidence of recurrence. Strictures can occur in different places throughout the length of the urethra. They also range in length. Success of the procedure correlates with location of the stricture, shorter length, and whether this is the first IOU procedure. Re-do procedures and those for longer strictures have a higher failure rate.

The symptoms characteristic of a urethral stricture are those of “obstructive” urination pattern.

The most common symptoms are:

• straining (need to push to begin urination)
• hesitancy (delayed onset of urination following the urge to urinate)
• slow or diminished force of stream
• a thin or forked (split or coming out as a spray) stream
• intermittence (urine stream that starts and stops)
• sensation of incomplete emptying

Other symptoms that may be associated are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).

Preparation

There is no particular preparation for this procedure. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. For simple office dilatation procedures, you may eat prior to the procedure.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water.

If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti- inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure usually takes less than one hour depending on the length, density, and location of the stricture. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups). If the extent of the stricture is not clear, we might do a special x-ray (urethrogram) by injecting contrast dye into the urethra through a catheter. This may have already been done prior to the day of the IOU. If we realize that the length of the stricture is too long to safely or effectively perform an IOU, we may stop the procedure at this point.

After the urethrogram, the cystoscope (which has continuous fluid running through it) is carefully inserted up to the area of the stricture. We may insert a small wire through the tiny, scarred opening to act as a guide. The stricture is sometimes opened with a tiny knife. In other instances, we may use a special type of blade instrument that has an electric current. Lastly, certain types of lasers are useful in opening scar tissue. Once we are satisfied that the channel is sufficiently open, we advance the scope into the bladder. We then examine the bladder to ensure that everything is within normal limits. At the end of the procedure, a catheter may be placed into the bladder to allow proper healing of the opened channel.

Post Procedure

If the procedure is done in a hospital or ambulatory center, you will be in the recovery room until you are ready to be discharged home. If done in the office, you will be sent home shortly after the procedure.

It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients, this resolves within a couple of hours, but could last until the catheter is removed. Some patients require medications to help relax the bladder while the catheter is in. Your catheter will be attached to a bag. The urine will either be clear or minimally tinged with blood. The bag can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. You will usually be given a larger bag for overnight urine collection while you are sleeping. We assure you that it is quite simple.

Sometimes, we may instruct you on how to catheterize yourself (to dilate the scar periodically) for a period of time after the procedure.

Expectations of Outcomes

Usually, patients are very satisfied after the procedure. The improvements that are typically noted immediately after the operation are:

• stronger force of stream
• decreased standing around waiting for the urination to commence
• decreased need to push
• loss of forking (splitting) of the urine stream
• loss of intermittence (i.e. where the flow used to start and stop and start, etc.)
• loss of the sensation that you are “not really emptying your bladder”

Occasionally, it may be difficult to control the urine for a period of time. You may notice that you are still voiding frequently and with some urgency (sensation that forces you to get to the bathroom quickly). These symptoms can take a long time to disappear. In patients that were significantly obstructed for a prolonged period, these symptoms may never fully resolve.

Nocturia (getting up at night to urinate) is typically the last symptom to resolve. In many instances, it may become less frequent, but never fully disappear. The reason is that nocturia can be due to dozens of other physiological issues and also because the night-time ritual becomes somewhat habitual.

*Uncommonly, the stricture cannot be opened. The two most common reasons are that it is too long and dense, or that a wire cannot be successfully passed beyond the area. In certain cases of the latter, it may be risky to cut the scar “blindly”. If this were the case, we may need to place a suprapubic catheter into your bladder. A suprapubic catheter is a small tube that is inserted into the bladder through a tiny hole in the lower abdomen. It, too, would be initially attached to a drainage bag. The tube would remain temporarily until further management is discussed with you in the office. Please refer to the literature on suprapubic catheter placement.

Possible Complications of the Procedure

ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes, which may include, but are not limited to:

• Hematuria (Blood in the Urine): Typically, there is no bleeding from this procedure. In rare instances, a blood vessel may open. The bleeding is almost always minimal and self-limited. Rarely, the bleeding may form small clots that would need to be irrigated out through the catheter. Recurrent bleeding following removal of the catheter is very uncommon.
• Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation.

This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.

If you have symptoms of any of the above, you must contact us immediately or go to the nearest emergency room.

• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as an IOU. However, in any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain.

We may sometimes ask the medical doctors to be involved with the management of either of these problems:

• Recurrent Urethral Stricture: A recurrence of the stricture can occur weeks, months, or even years after this sort of procedure. Each time the procedure is repeated, the incidence of recurrence is greater. The incidence of recurrence is also proportional to the initial length of the stricture being opened.
• Urinary Incontinence: If your bladder was obstructed for years by a stricture, and possibly also by your prostate, it may have learned to over-compensate by squeezing with more force. The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel.
• Incontinence, however, is quite rare after an IOU procedure because the sphincters controlling the continence are more proximal (closer to the bladder) than is the urethral stricture.
• Urinary Retention: Sometimes a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If you presented with long-standing urinary retention (complete inability to urinate), this may not resolve following an IOU procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
• Perforation: If the incision or cut is deep, a hole can be made through the urethra. This actually may be a desired result in cases of severe, dense strictures. In this regard, it is not necessarily a complication. This finding does not change the course of the case. It heals within a few days to a week over the catheter that is left in place anyway.
• Occasionally, fluid from the scope can go through the hole and cause swelling of the penis. The treatment, again, is to leave the catheter in for a few days, perhaps institute a short course of antibiotics, and just allow the swelling to resolve over the next 1-3 days.
• Erectile Dysfunction: According to the literature, anywhere from 1-2% of patients complain of some degree of erectile dysfunction (ED or impotence) after any instrumentation of the urethra.

This problem has always been quite puzzling to urologists in that a sound “cause and effect relationship” has not been demonstrated. It is more common when water has caused swelling of the penis.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.