Endoscopic Resection of Urethral Inflammatory Granulomas

Inflammatory granulomas within the urethra are relatively uncommon but pose unique diagnostic and therapeutic challenges for urologists. These lesions, often discovered incidentally during evaluations for lower urinary tract symptoms (LUTS) or hematuria, can mimic more sinister pathology like urethral cancer. Accurate identification is crucial to avoid unnecessary aggressive treatments while ensuring timely intervention when necessary. The etiology of these granulomas is diverse, ranging from prior instrumentation and infection to systemic inflammatory conditions, making a thorough workup essential before proceeding with any surgical approach. This article will delve into the endoscopic resection techniques used for managing urethral inflammatory granulomas, highlighting the considerations involved in diagnosis, surgical planning, execution, and postoperative care.

The management of these lesions requires a careful balance between definitive treatment and minimizing iatrogenic injury to the urethra. While biopsy is often necessary to rule out malignancy, complete excision can be difficult due to the location and fragility of the urethral wall. Endoscopic resection offers a less invasive alternative to open surgery, allowing for both diagnosis via tissue sampling and removal of the granuloma. However, it’s important to recognize that endoscopic approaches are not without risks; potential complications include urethral stricture formation, bleeding, and perforation. Therefore, surgeons must possess expertise in urethroscopic techniques and a clear understanding of anatomical landmarks within the urethra to achieve optimal outcomes.

Diagnosis and Preoperative Assessment

Accurate diagnosis is paramount before considering any form of resection. Urethral inflammatory granulomas frequently present as solitary lesions but can occasionally be multiple. Patients may report symptoms such as dysuria, frequency, urgency, hematuria, or even obstructive voiding symptoms if the granuloma significantly narrows the urethral lumen. However, many patients are asymptomatic, with the lesion detected incidentally during cystoscopy for other indications. Initial evaluation typically includes a detailed history and physical examination, followed by:

• Urinalysis to assess for infection or hematuria
• Urethral cytology, particularly if malignancy is suspected
• Cystoscopy with biopsy – this is often the cornerstone of diagnosis
• Imaging studies (e.g., MRI) may be considered in select cases to evaluate lesion extent and surrounding structures, though they are not always necessary

Differentiating between benign granulomas and malignancy can be challenging based on cystoscopic appearance alone. Biopsy specimens should be sent for histopathological analysis to confirm the diagnosis and rule out urethral carcinoma or other more serious conditions. The differential diagnosis includes urethritis, foreign body reactions (especially after instrumentation), and systemic inflammatory diseases like Crohn’s disease or sarcoidosis. A thorough review of the patient’s medical history, including prior urological procedures and underlying health conditions, is critical for guiding diagnostic workup and treatment planning. It’s essential to identify any potential contributing factors to prevent recurrence after resection.

The preoperative assessment should also evaluate the patient’s overall health and surgical risk factors. Patients with significant comorbidities or bleeding disorders may require additional optimization before undergoing endoscopic resection. A discussion of the risks, benefits, and alternatives to surgery should be held with the patient, ensuring informed consent is obtained. Preoperative antibiotic prophylaxis is typically administered to reduce the risk of postoperative infection.

Endoscopic Technique and Resection Methods

The majority of urethral granulomas are amenable to endoscopic resection using a standard 70-degree cystoscope or a dedicated urethroscope. The procedure is usually performed under spinal or general anesthesia, depending on patient preference and lesion location. A crucial initial step involves careful visualization of the urethra and identification of the granuloma. Gentle insertion of the scope is essential to avoid further trauma to the urethral wall.

Resection can be accomplished using several techniques:

1. Transurethral Resection of Bladder Tumor (TURBT) loop: This is often the preferred method for larger granulomas, allowing for precise excision and hemostasis. The loop is used to carefully dissect around the lesion, minimizing damage to surrounding urethral tissue.
2. Cold cut resection: Involves using a cold knife or scissors through the cystoscope to excise smaller lesions. This technique minimizes thermal injury but may be associated with more bleeding.
3. Laser ablation/resection: Utilizing lasers like holmium laser enucleation of the prostate (HoLEP) style laser, can offer precise tissue ablation and coagulation, reducing bleeding risk. It is especially useful for highly vascular lesions or those in difficult-to-reach locations.

During resection, frequent irrigation with saline solution is necessary to maintain visibility and prevent clot formation. Careful attention should be paid to hemostasis throughout the procedure. Electrocautery can be used to control bleeding points, but it must be applied judiciously to avoid excessive thermal injury and subsequent stricture formation. Minimizing urethral trauma during resection is paramount.

Postoperative Management and Potential Complications

Postoperative care focuses on minimizing complications and promoting healing. A Foley catheter is typically placed for a period of 3-7 days postoperatively to allow the urethra to heal and prevent urinary leakage. The duration of catheterization depends on the size and location of the resected lesion, as well as the patient’s individual risk factors. Patients are instructed to increase their fluid intake to promote urinary flow and reduce the risk of clot formation.

Potential complications following endoscopic resection include:

• Urethral stricture: This is the most common long-term complication, occurring due to scarring from the surgical trauma or thermal injury. Stricture can cause obstructive symptoms and may require further intervention, such as urethral dilation or urethroplasty.
• Bleeding: Minor bleeding is expected immediately postoperatively but significant hemorrhage is rare. Prolonged catheterization helps minimize bleeding risk.
• Perforation: Although uncommon, urethral perforation is a serious complication that requires immediate recognition and management.
• Infection: Postoperative infection can occur despite prophylactic antibiotics and may necessitate further treatment with intravenous antibiotics or drainage of any associated abscesses.

Patients should be monitored closely for signs of complications during the postoperative period. Follow-up cystoscopy is typically performed 6-8 weeks after resection to assess for recurrence, stricture formation, and overall healing. Long-term follow-up is recommended to monitor for delayed complications and ensure continued urinary function. Patient education regarding potential complications and warning signs is crucial for early detection and management of any issues that may arise. A proactive approach to postoperative care can significantly improve patient outcomes and minimize the risk of long-term morbidity.