Optical Urethrotomy

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

This procedure involves telescopic inspection of the urethra and bladder with incision of a stricture (narrowing caused by scar tissue) using a visual knife or laser fibre.

What are the alternatives to this procedure?

Observation, urethral dilatation, open (non-telescopic) repair of stricture.

What should I expect before the procedure?

If you are taking warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban, clopidogrel, ticagrelor or blood thinning medication on a regular basis, you must discuss this with your urologist because these drugs can cause increased bleeding after surgery. There may be a balance of risk where stopping them will reduce the chances of bleeding but this can result in increased clotting, which may also carry a risk to your health. This will, therefore, need careful discussion with regard to risks and benefits.

You will usually be admitted on the same day as your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel , ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

The operation is performed using a telescope passed into the penis through the water pipe (urethra). Any narrowing due to stricture can then be cut using a special internal knife or a laser probe. All the cutting takes place internally and there are no incisions or stitches. Most patients require insertion of a catheter into the bladder for 3-7 days after the procedure. Your catheter may be removed in the community, at home or in your GP surgery.

What happens immediately after the procedure?

There is often some bleeding around the catheter, as the incision has been made in the waterpipe that surrounds the catheter. This usually lasts for a short period, unless there has been a need for multiple or deep cuts. A pad will often be secured around the end of the penis to collect any blood which seeps out around the catheter; this pad is removed on the day after surgery.

Once the catheter is removed, you should be able to pass urine with an improved flow but, in the early stages, this can often be painful and bloodstained. Provided you drink plenty of fluid, this will gradually settle over a few days.

You will be asked to perform a voiding flow rate test to measure how fast you pass urine when you return to the clinic. Make sure you attend with a comfortably full bladder when you attend your clinic appointment and this measurement will be used as a baseline to compare with future measurements.

After the operation, you may be instructed in the technique of self catheterisation, using a “slippery” catheter, to keep your urethral stricture open.

This instruction usually takes place five to seven days after your operation in the outpatient clinic.

The average hospital stay is 12 to 36 hours.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Mild burning or bleeding on passing urine for a short period after the operation
• Temporary insertion of a catheter
• Need for self catheterisation to keep the narrowing from closing down again
• Recurrence of narrowing necessitating further procedures or repeat incision

Occasional (between one in 10 and one in 50)

• Infection of the bladder requiring antibiotics
• Permission for telescopic removal / biopsy of bladder abnormality / stone, if found

Rare (less than one in 50)

• Decrease in quality of erections requiring treatment.

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

When you get home, you should drink twice as much fluid as you would normally for the next 24 to 48 hours to flush your system through. You may find that, when you first pass urine, it stings or burns slightly and it may be lightly bloodstained. If you continue to drink plenty of fluid, this discomfort and bleeding will resolve rapidly.

If self catheterisation is to be used, you will be given written instructions as to how often to insert the catheter. You will also be given a contact number for the specialist nurse who can be contacted in the event of any problems.

What else should I look out for?

If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your GP immediately.

If you experience any problems with self catheterisation, contact the specialist nurse immediately.

Are there any other important points?

You will normally receive an appointment for outpatient follow up six to 12 weeks after the procedure. When you return to outpatients, please come with a full bladder if you have been asked to do another flow test on arrival.

Following a first time operation, 40% of men will not require any further treatment. However, if the stricture does recur, you may need a further procedure carried out. In the longer term, you may need to continue self catheterisation for several months; your specialist nurse or consultant will give you more details of this at your outpatient appointment.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/ or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who should I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….