ORIGINAL RESEARCH

Holmium laser vs. conventional (cold knife) direct visual internal

urethrotomy for short-segment bulbar urethral stricture:

Outcome analysis

Ankur Jhanwar, MD; Manoj Kumar, MD; Satya Narayan Sankhwar, MD; Gaurav Prakash, MD

King George’s Medical University, Lucknow, India

Cite as: Can Urol Assoc J 2016;10(5-6):E161-4. http://dx.doi.org/10.5489/cuaj.3382

Published online May 12, 2016.

The three most commonly performed procedures for urethral

stricture disease are urethral dilatation, optical urethrotomy,

and urethroplasty.

Abstract

We are curently in an era focused on minimally inva-

sive endoscopic procedures; however, urethral stricture

is one of the rare medical issues for which the success rate

of open reconstructive urethroplasty is far better than more

minimally invasive alternatives.

Introduction: Our goal was to analyze the outcome between hol-

mium laser and cold knife direct visual internal urethrotomy (DVIU)

for short-segment bulbar urethral stricture.

Methods: We conducted a prospective study comprised of 112

male patients seen from June 2013 to December 2014. Inclusion

criterion was short-segment bulbar urethral stricture (≤1.5cm).

Exclusion criteria were prior intervention/urethroplasty, pan-anter-

ior urethral strictures, posterior stenosis, urinary tract infection,

and those who lost to followup. Patients were divided into two

groups; Group A (n=58) included cold knife DVIU and group B

Cold knife optical internal urethrotomy was popularized

after the work of Sachse in 1974. Since then, several other

endoscopic alternatives have been included in the urological

armamentarium for the treatment of urethral stricture disease.

Holmium laser was one of them, introduced for the treatment

of urethral stricture disease in the early 90s. Holmium YAG

laser works based on vaporization at a wavelength of 2140

nm and its depth of penetration is approximately 0.5mm.

Other lasers used for urethral stricture disease include car-

bon dioxide, Nd:YAG, KTP, argon, and excimer lasers, but

superiority of one laser over the other has not been mentioned

(

n=54) included holmium laser endourethrotomy patients. Patient

followup included uroﬂowmetry at postoperative Day 3, as well

as at three months and six months.

Results: Baseline demographics were comparable in both groups.

A total of 107 patients met the inclusion criteria and ﬁve patients

were excluded due to inadequate followup. Mean stricture length

was 1.31 ± 0.252 cm (p=0.53) and 1.34 ± 0.251 cm in Groups A

and B, respectively. Mean operating time in Group A was 16.3 ±

4,5

in literature. Urethrotomy has been performed either under

general or regional anaesthesia. Some authors reported excel-

6,7

lent results under local anaesthesia.

.78 min and in Group B was 20.96 ± 2.23 min (p=0.0001). Five

patients in Group A had bleeding after the procedure that was

managed conservatively by applying perineal compression. Three

patients in Group B had ﬂuid extravasation postoperatively. Qmax

Methods

(

ml/s) was found to be statistically insigniﬁcant between the two

This prospective study — conducted after obtaining ethical

review board committee approval and an informed written con-

sent from all included patients — looked at patients in the urol-

ogy department of a tertiary care teaching institute in Northern

India from June 2013 to December 2014. A total of 107 patients

of aged 17‒64 years met the inclusion criteria of having short-

segment bulbar urethral stricture (≤1.5cm), evident by symp-

toms of weak urinary stream and conﬁrmation on radiological

studies (i.e., retrograde urethrography [RGU] and micturating

cystourethrography [MCU]). Exclusion criteria were patients

with multiple strictures, pan-anterior urethral strictures, poster-

ior stenosis, failed prior intervention, lichen sclerosis changes,

urinary tract infection, and those lost to followup.

groups at all followups.

Conclusions: Both holmium laser and cold knife urethrotomy are

safe and equally effective in treating short-segment bulbar urethral

strictures in terms of outcome and complication rate. However,

holmium laser requires more expertise and is a costly alternative.

Introduction

Urethral stricture is one of the oldest known urological prob-

lems and it continues to be common and often challenging.

Multiple treatment modalities have evolved over the years.

CUAJ • May-June 2016 • Volume 10, Issues 5-6

2016 Canadian Urological Association

E161

Jhanwar et al.

Prior to intervention patients underwent complete physic-

al examination, urine routine with culture and sensitivity,

uroﬂowmetry, and blood investigation. The site and size

of urethral stricture was noted. Appropriate antibiotic was

administered pre- and post-intervention.

Per urethral catheter removal and voiding trial was given

at postoperative Day 3 in both groups.

Statistical analysis

Patients were allocated into either Group A or Group B

in a 1:1 ratio. Group A consisted of those who underwent

cold knife (Sachse) procedure and Group B of those who

underwent holmium laser internal urethrotomy. Patients

were followed with uroﬂowmetry (as there was no uniformly

accepted method of followup after DVIU) and any com-

plaints noted at postoperative Day 3, as well as after three

and six months. The Visual Analogue Scale score (VAS) was

taken in both groups at three, six, 12, and 24 hours pos -

toperatively. Our protocol for postoperative analgesics was

patients demand or VAS >5. Operating time was calculated

from insertion of cystoscope into meatus to the removal of

urethrotome or laser ﬁbre with the cystoscope out of meatus.

The results were presented in mean ± standard deviation

(SD) and percentages. The unpaired t-test was used to

compare two independent means. Paired t-test was used

to compare the variables in preoperative and postopera-

tive periods. A p value <0.05 was considered statistically

signiﬁcant. All the analysis was carried out using SPSS 16.0

versions (Chicago, Inc., U.S.).

Results

Baseline demographics were comparable in both groups

(Table 1). Data from 107 patients were analyzed. Five

patients were excluded due to inadequate followup. The

mean + SD age in Groups A and B was 39.38 ± 13.4 and

38.13 ± 12.3 years, respectively (p=0.61). The mean ± SD

operating time in Group A was 16.3 ± 1.78 minutes, while

in Group B it was 20.96 ± 2.23 minutes (p=0.0001). The

mean length of stricture in Group A was 1.31 ± 0.252 cm

and in Group B was 1.34 ± 0.251cm (p=0.53).The mean

VAS (pain score) in Group A was 4.1 ± 1.68 and in Group

B was 3.9 ± 1.59. The duration of per urethral catheteriza-

tion was 72 hours in both groups. Preoperative Qmax (ml/s)

in Group A was 5.3 ± 1.98 and in Group B was 5.8 ± 2.1

(p=0.207). The mean Qmax (ml/s) on postopertive Day 3,

as well as at three months and six months in Group A was

21.4 ± 2.75, 23.4 ± 2.71, and 23.7 ± 2.74, respectively.

The mean Qmax (ml/s) on postopertive Day 3, as well as at

Technique

Both the procedures were done under local anaesthesia

using mixture of 20 ml of 2% lignocaine jelly mixed with

ml of 1% lignocaine solution, pushed slowly into the

urethral lumen with the help of syringe and left for 5‒7 mins.

Cold knife

In lithotomy position, a cystoscopic-assisted guidewire was

negotiated beyond the stricture site. Once the position of the

guidewire in the urinary bladder was conﬁrmed, the cysto-

scope was withdrawn and the Sachse cold knife urethrotome,

using 21 Fr sheath and 0 degree telescope, advanced into the

urethra. The stricture was incised at the 12 o’clock position

Table 1. Baseline demographics, pre- and postoperative

data

(

single or multiple times until it adequately opened up and

allowed negotiation of the scope into the bladder). While

withdrawing the scope, the stricture site was inspected; if

there was some ﬁbrosis remaining, then it was incised. A

Foley catheter (14 Fr) was then placed per urethraly.

Cold knife

DVIU

Holmium

laser

Parameter

p value

Age

39.38 ± 13.4 38.13 ± 12.3

1.31 ± 0.252 1.34 ± 0.251

0.61

0.53

Mean length of stricture

Mean operating time

Preoperative Qmax (ml/s)

16.3 ± 1.78

5.3 ± 1.98

20.96 ± 2.23

5.8 ± 2.1

0.0001

0.207

The holmium laser

Postoperative Qmax (ml/s)

At Day 3

At 3 months

Once the stricture site was located, the holmium laser ﬁbre

21.4 ± 2.75

23.4 ± 2.71

23.7 ± 2.74

21.7 ± 2.73

23.6 ± 2.72

23.8 ± 2.78

0.569

0.703

0.851

(

365 µm) was introduced through a side channel of 17

Fr sheath and 0 degree scope. The holmium laser (Versa

PowerSuite) with power settings (0.6‒1.2 Joules, 6‒12

Watts) was used. To avoid thermal injury, the ﬁbre was

placed a few mm away from the scarred tissue. The stricture

was incised at the 12 o’clock position and once the scope

was negotiated beyond the stricture and up to the bladder,

the scope was withdrawn slowly and a 14 Fr foley catheter

was inserted per urethrally.

At 6 months

Complications

Bleeding

Fever

12.7%

9.6%

0.764

Fluid extravasation

Mean VAS pain score

4.1 ± 1.68

3.9 ± 1.59

0.51

Number of patients

require reintervention

(7.27%)

4 (7.69%)

DVIU: direct visual internal urethrotomy; VAS: Visual Analogue Scale.

E162

CUAJ • May-June 2016 • Volume 10, Issues 5-6

Holmium laser vs. conventional urethrotomy for urethral stricture

impact on outcome. Albers et al reported that urethral cath-

eterization left for ≤3 days following DVIU is associated with

lower recurrence rate compared with longer duration (34%

vs. 43%). Dutkiewicz et al reported increased chance of

Cold knife

_u_r_i_n_a_r_y_t_r_a_c_t_i_n_f_e_c_t_i_o_n_f_o_l_l_o_w_i_n_g_p_r_o_l_o_n_g_e_d_c_a_t_h_e_t_e_r_i_z_a_t_i_o_n_.13

Holmium laser

In their studies, Heyns et al and Steenkamp et al reported

4,15

‒4 days of catheterization following urethrotomy.

No major complications occurred in our study. Five

patients (9.1%) in Group A had bleeding, two patients in

each group had fever, and three patients (5.7%) in Group B

had ﬂuid extravasation. All were managed conservatively.

No patient in our study had post-procedural incontinence

or impotence.

Preoperative Postoperative At 3 months At 6 months

Day 3

Fig. 1. Qmax (ml/s) at followup between two modalities.

As the outcome criteria is not standardized following

DVIU, we followed our patients with uroﬂowmetry (Qmax

ml/s). In this study, we did not observe any statistically signiﬁ-

cant difference in followup Qmax between the two groups.

Hussain et al reported that good results are achieved if

post-procedure Qmax is >15ml/s and there is no need for

three months and six months in Group B was 21.7 ± 2.73,

3.6 ± 2.72, and 23.8 ± 2.78, respectively (Fig. 1).

Discussion

Urethral stricture is the narrowing of urethral lumen due to

ﬁbrosis secondary to inﬂammation or trauma. Different treat-

ment modalities with variable results are available. The one

that is most appealing to urologists and patients is DVIU, as

it is a minimally invasive, outpatient, endoscopic procedure.

DVIU as a surgical treatment for urethral stricture was

popularized after the initial report of Sachse in 1974.³^,⁸Since

any other intervention. In this study, four patients in Group

A required one more urethrotomy, two at three-month and

two others at six-month followups. Similarly, four patients in

Group B required another intervention, one at three-month

and three at six-month followups. In all eight patients, Qmax

was <10 ml/s, which was considered failure according to

our protocol. The recurrence in Group A might have been

due to inadequate division of ﬁbrous tissue leading to non-

separation of scarred tissue and, subsequently, no healing by

secondary intention. The recurrence in Group B might have

been due to inadequate cutting of scarred tissue, as there

is lack of sense of depth perception with holmium laser.

In our study, clean intermittent catheterization (CIC) was

advised for all patients following their procedure. Our proto-

col for CIC was once-daily for a week, then twice-weekly for

three weeks, then once-weekly for three months. Surprisingly,

no patient found difﬁculty in doing CIC. The theory behind

CIC following DVIU is that the process of self-catheterizsation

prevents the scar from contracting while it matures. Lawrence

et al conducted a study on 42 patients and demonstrated

excellent results for postoperative CIC for three months.¹⁷

Kjaeergard et al and Harris et alalso observed lower recur-

1984, different lasers have been introduced in the stricture

treatment armamentarium. No currently available data

report superiority of one laser over another. The advantage

of Ho:YAG laser is its coagulation ability and shallow absorp-

tion (0.5 mm); it is presumed to reduce scar tissue formation.

In their studies, Steenkamp et al (1997), Choong et al

(

1997), and Munks et al (2010) reported that the procedure

of internal urethrotomy is very well-tolerated by the patient

under local anesthesia. Similarly, in this study we also use

local anesthesia and observed that patients tolerate the pro-

cedure well.

In their study of 51 male patients with single, iatrogenic

stricture, Atak et al observed shorter operative time in laser-

treated patients (n=21, 16.4 ± 8.04 minutes) vs. cold knife-

treated patients (n=30, 23.8 ± 5.47 minutes). Kamal reported

18,19

mean operative time of 22.3 minutes using a diode laser.

rence rate in those who were on CIC.

In our study, mean operative time for the cold knife group

was 16.3 ± 1.78 minutes, which is shorter than in the study

done by Atak et al (23.8 ± 5.47 minutes) and longer than the

In our study, we did not observe any statistically signiﬁ-

cant difference between the recurrence rates in both group.

Four patients had recurrence in each group. This result may

be due to short-term followup and strict inclusion criteria,

as it may be different for long-term followup; other seg -

ments may have different recurrence rates, which was not

analyzed in this study.

,11

study by Jain et al (7.44 minutes).

The mean operative

time in the holmium laser group was 20.96 ± 2.23 minutes

in our study, which is comparable to the study done by Jain

et al (19.8 minutes). The VAS score in Groups A and B was

.1 ± 1.68 and 3.9 ± 1.59, respectively.

In our study, catheter removal and voiding trial was given

Jin et al did a meta-analysis including 3230 cases from

44 articles. They reported a better success rate with hol-

mium laser urethrotomy compared to cold knife technique

(74.9% vs. 68.5%).

on Day 3, as there is no convincing evidence in the literature

that increasing the duration of catheterization has a positive

CUAJ • May-June 2016 • Volume 10, Issues 5-6

E163

Jhanwar et al.

Ather MH, Zehri AA, Soomro K, et al. The saꢀety and eꢀfcacy oꢀ optical urethrotomy using a spongiosum

block with sedation: A comparative nonrandomized study. J Urol 2009;181:2134-8. http://dx.doi.

org/10.1016/j.juro.2009.01.017

The limitations of our study were selection of only short-

segment bulbar urethral stricture and short followup.

Sachse H. Die transurethrale scharꢀe Schlitzung der Harnrohrenstriktur unter Sicht. Munsch Med Wschr

974;116: 2147.

Conclusion

Atak M, Tokgoz H, Akduman B, et al. Lowpower holmium: YAG laser urethrotomy ꢀor urethral stricture

disease: Comparison oꢀ outcomes with the coldkniꢀe technique. Kaohsiung J Med Sci 2011;27:503-7.

http://dx.doi.org/10.1016/j.kjms.2011.06.013

Both conventional (cold knife) and holmium laser urethrot-

omy are equally effective in terms of outcome and safety for

short-segment bulbar urethral stricture. The holmium laser

offers a signiﬁcant advantage with its coagulation ability.

However, use of holmium laser requires more expertise and

its availability is a limitation. As urethral stricture may recur,

further long-term comparative studies comparing these two

modalities are required.

0. Kamal BA. The use oꢀ the diode laser ꢀor treating urethral strictures. BJU Int 2002;87:831-3. http://

dx.doi.org/10.1046/j.1464-410x.2001.02183.x

11. Jain SK, Kaza RC, Singh BK. Evaluation oꢀ holmium laser versus cold kniꢀe in optical internal urethrot-

omy ꢀor the management oꢀ short segment urethral stricture. Urol Ann 2014;6:328-33. http://dx.doi.

org/10.4103/0974-7796.140997

2. Albers P, Fichtner J, Bruhl P, et al. Long-term results oꢀ internal urethrotomy. J Urol 1996;156:1611-4.

http://dx.doi.org/10.1016/S0022-5347(01)65461-2

13. Dutkiewicz SA, Wroblewski M. Comparison oꢀ treatment results between holmium laser endourethrotomy

and optical internal urethrotomy ꢀor urethral stricture. Int Urol Nephrol 2012;44:717-24. http://dx.doi.

org/10.1007/s11255-011-0094-8

Competing interests: The authors declare no competing fnancial or personal interests.

4. Heyns CF, Steenkamp JW, De Kock ML, et al. Treatment oꢀ male urethral strictures: Is repeated dilatation or

urethrotomy useꢀul. J Urol 1998; 160:356-8. http://dx.doi.org/10.1016/S0022-5347(01)62894-5

5. Steenkamp JW, Heyns CF, de Kock MI. Internal urethrotomy versus dilatation as treatment ꢀor male urethral

strictures.A prospective randomized comparison. J Urol 1997;157:98-101. http://dx.doi.org/10.1016/

S0022-5347(01)65296-0

This paper has been peer-reviewed.

6. Hussain M, Lal M, Askari SH, et al. Holmium laser urethrotomy ꢀor treatment oꢀ traumatic stricture urethra:

A review oꢀ 78 patients. J Pak Med Assoc 2010;60:829-32.

References

7. Lawrence WT, MacDonagh RP. Treatment oꢀ urethral stricture disease by internal urethrotomy ꢀollowed by

intermittent ‘low-ꢀriction’ selꢀ-catheterization: Preliminary communication. J Roy Soc Med 1988;81:136-8.

8. Kjaeergard B, Walter S, Bartholin J, et al. Prevention oꢀ urethral stricture recurrence using clean intermit-

tent selꢀ-cathterization. Jr J Urol 1994;73:692-5. http://dx.doi.org/10.1111/j.1464-410X.1994.

tb07558.x

9. Harriss DR, Beckingham IJ, Lembergher RJ, et al. Long-term results oꢀ intermittent low-ꢀriction selꢀ-

catheterization in patients with recurrent urethral strictures. Br J Urol 1994;74:790-7. http://dx.doi.

org/10.1111/j.1464-410X.1994.tb07127.x

de Kock ML, Allen FJ. Guidelines ꢀor the treatment oꢀ urethral strictures. S Afr J Surg 1989; 27:182-4.

Sandozi S, Ghazali S. Sachse optical urethrotomy, a modifed technique: 6 years oꢀ experience. J Urol

988;140:968-9.

Sachse H. Zur behandlung der Harnrohrenstriktur; Die transurethrale Schlitzung unter Sicht mit scharꢀen

Schnitt. Fortschr Med 1974;92:12-5.

Wein AJ, Kavoussi LR, Novick AC, et al. 10th ed. Philadelphia: Elsevier Saunders; 2012. Campbell Walsh

Urology pp. 967-73.

0. Jin T, Li H, Jiang LH, et al. Saꢀety and eꢀfcacy oꢀ laser and cold kniꢀe urethrotomy ꢀor urethral stricture.

Chin Med J (Engl) 2010;123:1589-95.

Herrmann TR, Liatsikos EN, Nagele U, et al. EAU guidelines on laser technologies. Eur Urol 2012;61:783-

5. http://dx.doi.org/10.1016/j.eururo.2012.01.010

Greenland JE, Lynch TH, Wallace DMA. Optical urethrotomy under local urethral anesthesia. Br J Urol

998;67:385-8. http://dx.doi.org/10.1111/j.1464-410X.1991.tb15167.x

Correspondence: Dr. Ankur Jhanwar, King George’s Medical University, Lucknow, India ;

drankurstanley01@gmail.com

E164

CUAJ • May-June 2016 • Volume 10, Issues 5-6