Upcoming posts...

My urologist informs me that a software routine is under testing for the DaVinci Robotic Surgical System with regards to the buccal mucosal onlay graft, and penile flap onlay graft urethroplastic procedures. We should see their availability by mid-2012, he stated that it will allow for better positioning of the graft with more precise suturing capabilities, and a shorter O.R. time.

Also, another pharmaceutical company is looking into manufacturing Urised <---LET'S HOPE THIS HAPPENS

That's all folks!  Enjoy your Christmas and New Year holidays!

Still taking time off for the holidays, but an update anyway..

December 7th, 2011: Things have been piling up on both coasts, so we're going to take  a few days off from posting. The Urethral Stricture Support Blog will be monitored daily. Please feel free to post responses, questions or commentary.

Have a wonderful Christmas Season!

December 19th, 2011: A New Jersey licensed urologist has agreed to do two posts (commencing in mid-January). We may try to establish a live chat should the stats stay in an upward direction.

OPINION: How best to proceed with life after receiving the diagnosis of urethral stricture disease PART 2

*"Scott", continued: Our urologist wanted him to undergo an immediate open urethroplasty, and explained that the procedure offered the best chance for cure. Without it, he felt that "Scott" would be looking at a receiving a partial urostomy within a very few years. The family conceded, and he eventually went to Cornell Presbyterian Medical Center in New York City. He underwent several individual "staged" surgeries, the last of which was a plastic reconstructive procedure. I do not know the eventual outcome, however, he did function well for at least three years afterwards.

Optical urethral surgery has only been around since the early 1950's.  Rigid cystoscopes which were pioneered because of WWII had the reputation of causing damage to the urethra when passed past the penile urethra, and into the bulbar aspect of the structure. This damage was often resultant in strictures, and visual procedures were reserved for only penile-area defects, and T.U.R.P. (trans urethral resection of the prostate). In the early 1970's, advances in fiber optics allowed for the development of the flexible cystoscope, and the inception of visual internal urethral procedures as we know them today.

When you combine all of this information, it becomes somewhat apparent that the best way in which to persevere is to know your condition, your body, and your psyche thoroughly. While this disorder/disease/malady is not rare, it is not at the forefront of medical priority, sans a very few research institutions and reconstructive urologists. Education is the key to living with the diagnosis of urethral stricture stenosis.

Per: Moderator Tim

OPINION: How best to proceed with life after receiving the diagnosis of urethral stricture disease PART 1

*In 1992, my urologist asked if I would speak to a 16 year old and his family after they received the news that the young adult had been diagnosed as having a rather severe case of urethral stricture disease. The case was so severe that a cystoscope-guided dilitation with filiform and followers was attempted, and the filiform was unable to thread itself through the stricture, and into the bladder. (*I will elaborate more on this later) "Scott" was only the second person whom I had encountered besides myself who had a stricture. The other was a friend, and the subject of difficult urination came up after he complained of "dreading each and every trip to the bathroom", he then proceeded to tell me what a stricture was, and that he had been diagnosed at age 17. We compared notes, and our experiences were quite similar.

There are no accurate statistics of the percentage of the male population with the malady. The co-moderator of this forum goes to a prominent west-coast urologist, who informed him of two (other) current patients. My urologist, located near Philadelphia, Pennsylvania, once elaborated (after my not needing dilitation for almost three years - post urethrotomy) that he was somewhat out of practice with the filiform and followers. This leads me to believe that far less than a fraction of one percent of a general urologists practice is composed of stricture-related disorders. I know for a fact that he has over 9,000 active patients.

These observations lead me to the conclusion that for our own well-being, we should educate ourselves to the highest degree possible regarding all aspects of urology. You never know when your knowledge of your case will be necessary in procuring adequate treatment while away from home. Dealing with urinary tract infections has always been my key task health-wise. Yet there are some with the problem who have never had trouble with a UTI. We are each individual, with specific traits, requiring different approaches. The fact that there are a total of around twenty urological surgeons who specialize in urethral reconstruction serving an estimated population of 309 million does not lend confidence that there is enough of a market for a surgeon to be proficient in dealing with complex cases.

I cannot speak for all urologists in general, but mine was an advocate of the proactive approach with regards to my condition. I would often leave his office with a copy of the latest urology journal, or other pertinent medical publication (with the agreement that it would be returned within two weeks), and within two years of diagnosis, I had (literal) volumes of photocopied articles, a Tabor's Medical Encyclopedia, a Gray's Anatomy, and two books on urological nursing in the 20th Century. This information helped make sense of the decisions my urologist made. Furthermore, with the help of the nursing publications, I discovered methods for avoiding urinary infections, and methods of care important after each subsequent surgery. What it all boils down to is that we each must develop a system keyed to provide the optimum of care, as this will help minimize hospitalizations, and possibly surgeries.

* Returning to "Scott": When I met him, he had undergone an emergency suprapubic catheter insertion (a catheter and urinary drainage system inserted directly into the bladder) as a result of a stricture which could not be resolved by dilitation. He had the procedure performed in the ER of a local hospital, it was deemed necessary because it was thought that he was about to encounter a urinary reflux (due to the fact his bladder was so full). His stricture was thought to be nearly 4 centimeters in length, which is fairly long. Our urologist wanted him to go to one of the teaching hospitals in Philadelphia, but his parents were apprehensive, as their primary physician informed them that the problem could be dealt with adequately in a local setting. His exact words were "it's not open heart surgery".

I explained that (at that time) eleven years had passed since being diagnosed. I had undergone around forty - plus dilitations, two urethrotomies, a urethroplasty (failing at that very moment), one emergency dilitation (similar to his event), a suprapubic catheter failure, and that if I had it to do over, I would have searched for a specialist in strictures and their care. By that point in time, the scarring to my urethra was already substantial, and had I been given the option to seek out a surgeon/specialist at a teaching hospital, that my outcome would have been far different.

Levaquin, off patent in 2010 - Levofloxacin now has full availablity in the U.S.

Late last year, Janssen's (actually Miles Pharmaceuticals) powerhouse fluroquinolone - LEVAQUIN, had its patent protection expire. What had been a $29.00 USD (per tablet, with a ten-tablet average per script) medication) as of July, 2011, has three generic rivals. Dr.Reddy's Labs (India, Mexico), Teva Pharmaceuticals (Israel, USA), and Greenstone, Ltd (Michigan, USA) each have approved versions of the medication available to the pharmaceutical market.

It has taken almost six months for availability and distribution to "hit every corner" of the U.S., Dr. Reddy's was the first available in my hometown in Pennsylvania. I've had no problems with the quality of any of Reddy Labs' offerings in the past, even though they've had issues .  Teva is a first-rate producer of pharmaceuticals, the "Cadillac" of generic drug makers (IMHO, Mylan is of equivalent stature). My pharmacist, whom I interviewed for this post, has had little experience with Greenstone, so I won't elaborate with regards to them.

Why has levofloxacin been so slow to saturate the market??  Primarily because of the costs involved with product liability insurance coverage borne by the manufacturer, distributor, and the pharmacy's liability carrier. Levofloxacin has a myriad of bad side effects, including effects on the heart, tendons, severe insomnia, and more. At least 50% of the retail cost of the generic med will reflect that liability cost, all of this adds up, and is the main reasoning behind the "slow to market" appearance of this life-saving, powerful anti-infective.

Per: Moderator Tim

Many thanks to MSP, R.Ph. for his help in compiling this info!!

Your urologist is recommending urethrotomy PART 2

The big day is here, you have arrived at the appointed coordinates, signed-in, filled out 739 individual sheets of paper asking everything from your mother's maiden name to your preferred brand of underwear (Hanes). You'll be instructed to disrobe and change into a cotton gown (you know, the famous type where your ass hangs out), told to hop on up into a hospital bed where the nurse will again ask what type of surgery you are having (this is a good thing, a safety procedure which helps assure that you won't receive an incorrect surgery), have your vital's checked (temp, pulse, BP, pulse oximetry), and have an IV started (usually in the hand, one "prick", and it's done). You may be given an IV sedative or other pre-surgical medication at this time, also, an IV antibiotic such as gentamycin may be administered prior to your being wheeled into the surgical theater.

After your surgeon's fifth cup of coffee and a pit-stop in the bathroom, the OR staff will transfer you over to a gurney for transport to the OR. You will again be asked which procedure you are having performed (this is one time when being a smartass doesn't pay), asked to transfer onto the operating table, and placed into the lithotomy (OB/GYN) position, stirrups and all. Your choice of anesthesia will be started and this is what happens next:

THE PROCEDURE:

1. Your urinary meatus will be exposed and cleansed with a Povidone-iodine wipe (Betadine), and approximately 30 cc's (one fluid ounce) of a viscous topical anesthetic containing lidocaine (usually Anestacon) will be instilled into your urethra, then held in the urethra by applying a crown clamp to the base of the head of the penis (the penile corona). Depending upon your choice of anesthesia, your physician may choose to begin immediately (using the viscous anesthetic as a lubricant for the cystoscope), or wait a few minutes for it to take effect.
2. A cystoscope with a trans-urethral injection system will be inserted into the urethra, and the surgeon will inject lidocaine (a local anesthetic) into the length of the stricture at various points using a technique called "infiltration".
3. The cystoscope/injection system will be withdrawn, and a cutting device called a urethrotome will be attached to the cystoscope and inserted.  A safety guide filament will be threaded through the stricture, and into the bladder. This helps the surgeon position the urethrotome in a safe aspect for performing the incisions into the stricture Next, the surgeon will guide the urethrotome to the face of the stricture and a small blade towards the tip of the instrument will be deployed using a trigger mechanism to cut the stricture at locations he or she believes will provide optimum relief. The urethrotome/safety guide/cystoscope will then be withdrawn, and an appropriately sized catheter will be inserted and connected to a urinary drainage system (catheter hose and bag).  
4. You will be instructed on the care and emptying of the catheter/drainage system/bag, and given prescriptions for an antibiotic/systemic antibacterial, a urinary analgesic (pyridium or prosed), a few days of a minor pain medication (there is usually very little pain associated with urethrotomy), and instructed to see the surgeon in three to seven days for removal of the catheter.

Youtube video showing a DVIU, or Direct Visual Internal Urethrotomy

Per: Moderator Tim

Your urologist is recommending urethrotomy PART 1

If you are a novice at the lifestyle routine of the stricture patient, your first urological surgery per se may cause feelings of anxiety in anticipation of your date with the O.R.  Trust me, put your mind at ease, it's not all that bad, in fact, most everyone with whom I've corresponded would rather undergo a urethrotomy than have an office dilitation (with metal sounds).  Minor disclaimer: the in-dwelling catheter afterwards isn't a walk in the park, but the surgery is not all that uncomfortable.

A day-or-two before the procedure, you'll be ordered to report to the hospital or surgery center for a routine pre-surgery workup, which may include a chest x-ray, electrocardiogram (EKG), blood work (chem 36 profile), an evaluation of pulmonary status, and an anesthesia interview. During the anesthesia interview, an anesthesiologist or certified registered nurse anesthetist (CRNA) will ask questions about your health, your knowledge of the procedure, and your preferences of anesthesia.  You will be given the choice of three options:

• Procedural sedation: (once referred to as "conscious sedation"), a method of anesthesia which uses a benzodiazepine such as midazolam or diazepam (both members of the Valium family) to relax you during the initial phase of the procedure. The surgeon or anesthetist may also elect to add a narcotic pain medication, usually fentanyl citrate into the IV established soon after your arrival. These meds are all rapidly metabolized, and will allow you to leave the facility within six hours post-procedure.
• Spinal anesthesia: a method of anesthesia whereby an anesthetic is injected directly into the spinal column for means of blocking the impulses of pain and sensation from the area of the surgical procedure. There are two types of spinal anesthesia, the first is known as an epidural, the second is referred to as a spinal block.  Spinal anesthesia is most often employed in the patient who has contraindications for general anesthesia.
• General anesthesia, "a.k.a. going under, getting knocked out", a method of anesthesia which today most often employs a hypnotic known as propofol. Yes, the same med which contributed to the death of Michael Jackson, but a medication with a stellar safety record. Sometimes a barbiturate may be employed, however, most anesthesiologists prefer to use propofol becaues it is rapidly metabolized, and allows for the almost immediate awakening of the patient. In the event general anesthesia is selected, an endotracheal tube will be inserted to assure a secure airway.

Stay tuned for chapter two....

A little info on antibiotics and systemic anti-bacterials PART 2

Cephalosporins:   a class of oral and parenteral medications first synthesized from penicillin in the latter part of the 1940's in Italy. In the 1960's, Cephalexin, sold by Eli Lilly under the brand-name of "Keflex" became the most widely prescribed form of the medication (a similar medication, Keflin, was a close second). There have been five generations in the evolution and synthesis of this class of antibiotics, and are still a very useful adjunct in the treatment of infections in the world today. Cephtriaxone, (Rocephin, Roche Pharmaceuticals) is one of the most often prescribed intravenous antibiotics used in hospitals and in home-care today. Note: Because of the fact the drug is an analog of penicillin, there is the possibility of cross-allergency with this class of medication. Discuss this with your prescriber and pharmacist if you are penicillin allergic.

Ampicillin and amoxicillin, which are technically cephalosporins but not classified as such are often employed in the treatment of UTI's in children and adolescents (when susceptibility permits). When combined with potassium clavuante to form (Augmentin, GSK Pharmaceuticals), amoxicillin can be used in the treatment of more severe infections and susceptible sexually transmitted diseases.

Tetracyclines:  The most frequently used antibiotic in this class is a second-generation medication known as doxycycline hyclate. It is a semi-synthetic antibiotic, the base material used in its synthesis being oxytetracycline, and was first synthesized by Pfizer Pharmaceuticals in the early 1960's.  Common brand names are Vibramycin, Vibra-tabs, and Doryx (timed-release capsules). Doxycycline provides the benefit of once-daily dosing (in the 100 mg strength) for the treatment of uncomplicated urinary tract infection.  Minocycline, (Minocin, Lederle) a somewhat "cousin" to Doxycycline, has also proven useful in the treatment of UTI's, and is usually prescribed twice daily.  In 2009, the FDA added minocycline to its Adverse Event Reporting System; a list of medications under investigation by the FDA for potential safety issues. It is believed there is a correlation between minocycline and certain pediatric autoimmune disorders.  Tetracycline hydrochloride, the parent of these second generation medications is now seldom used in the treatment of urinary tract infections because of bacterial resistance.  It is still used in the treatment of chlamydia trachomatis.

Note: avoid sunlight when taking any of the tetracycline class antibiotics because of photosensitivity. Also, it is advisable to avoid taking any form of antacid containing aluminum or magnesium, or the consumption of milk within a few hours of taking the medication. Tetracyclines chelate, or bind to minerals very easily, reducing the availability of the medication in your system. Pediatric usage (under 12 years of age) is usually contraindicated because this class of medication can discolor teeth and have adverse effects on bone formation.

Nitrofurantoin:  was specifically developed for use in the treatment of susceptible urinary tract infections. It was discovered in the late 1950's, and came into favor during the latter-part of the 1960's. Common brand names are Furadantin, Macrobid, and Macrodantin.  It is generally a well tolerated medication, and is useful only in non-complicated UTI's. It is of little benefit in the treatment of bacterial prostatitis, or skin-structure infections.

Fluroquinolones:  Ciprofloxacin (Cipro, Miles Pharmaceuticals) was the first widely available second generation fluroquinolone anti-infective marketed in the U.S., beginning in 1986. It is the most commonly prescribed of its class of medications,  and seems to be the go-to drug for most practitioners (it is listed among the $4.00 generics at Wal*Mart).  It was initially marketed for the treatment of both complicated and uncomplicated urinary tract infections and prostatitis, and is well-tolerated by most patients. That said, in the mid-1990's, a correlation between tendon rupture, tendinitis, and ciprofloxacin was discovered, and appropriate precautions were recommended for its prescribing and usage. Concomitant administration of antacids containing aluminum and magnesium within five hours of taking ciprofloxacin is contraindicated. Milk should be avoided when taking this medication.

Norfloxacin (Noroxin, Merck Pharmaceuticals) was the second widely available form of the second generation fluroquinolone class of anti-infectives approved in the United States. It was initially marketed for the treatment of both complicated and uncomplicated urinary tract infections and prostatitis, but has since fallen out of favor because of a myriad of adverse side-effects including tendinitis, tendon rupture, hypersensitivity, hepatic (liver) disorders - including hepatitis. It is rarely prescribed in the United States.

Levofloxacin (Levaquin, Janssen Pharmaceuticals) is the strongest commonly prescribed member of the fluroquinolone family. It comes complete with all of the side effects listed for the rest of this class of medications, and carries two FDA Black Box warnings regarding the danger of prescribing levofloxacin. At $29.00 US per 500 mg tablet, it is cost-prohibitive, and reserved for only the most serious of urinary tract infections. Moxifloxacin (Avalox, Merck Pharmaceuticals) is slightly less expensive than Levaquin, and carries similar side effect liability.

There have been a few misfires among this class of medication, the most notable being Trovafloxacin (Trovan, Pfizer Pharmaceuticals), which was restricted to use in hospitals and long term care facilities shortly after its introduction into the market in 1998. It was implicated in cases of severe liver failure in the U.S., and at least six deaths in Nigeria in the mid-1990's.  Olfloxacin, (Floxin, Janssen Pharmaceuticals) was essentially withdraw from manufacture by Janssen in 2009, and is unavailable in the U.S. at this time. It, too had similar liabilities to the rest of the class of anti-infective medications.

Per: Moderator Tim

**Many thanks to my friend, Dr. R.S.H., D.P.M. for his contribution to the "antibiotics/anti-infectives" posts.

Per Dr. "Rob": IT IS IMPORTANT TO TAKE THE ANTIBIOTICS AS DIRECTED, WHEN DIRECTED, AND FOR THE LENGTH OF TIME DIRECTED BY THE PRESCRIBER. REPORT ANY ADVERSE EFFECTS TO THE PHYSICIAN IMMEDIATELY. IN THE EVENT OF SYMPTOMS OF ANAPHYLAXIS (HIVES, DIFFICULTY BREATHING, SWOLLEN THROAT, LOW BLOOD PRESSURE) SEEK IMMEDIATE EMERGENCY TREATMENT, ACTIVATE 911. FOR LESSER SIDE EFFECTS, CONTACT YOUR PHYSICIAN OR PHARMACIST.

A little info on antibiotics and systemic anti-bacterials PART 1

Most stricture patients will have encounters with urinary tract infections, or UTI's at some point during their lifetime. Here's a little primmer which should help in understanding your practitioner's choice of medication(s) for the treatment of UTI's:

• A "Urine C&S" (is a urinalysis with a culture for bacteria, fungi, or in rare(er) cases, anaerobic organisms and protozoans), which helps the practitioner decide which is the most effective treatment with the least side effect potential. Why shoot a rabbit with a cannon when a pellet gun will suffice.

Sulfonamides: a class of oral and parenteral medications developed in the 1930's, as the first widely available therapy for infections without having the liability of toxicity that arsenicals and mercuricals did. The most common of this class of drug in North America is referred to as an "SMT Combination", a mixture of sulfamethoxazole and trimethoprim. Common brand names are Septra, Septra DS, Bactrim, and Bactrim DS. They are fairly inexpensive, and very, very effective. The main liability of this classification of medication is the fact that allergies to sulfonamides are commonplace.  If prescribed for you, be sure to drink plenty of water during the usual 10-day course of treatment. The oral form of the medication is usually administered twice daily.  Discontinue use, and contact your practitioner should any itching or rash develop. In the event that breathing becomes difficult, seek emergency treatment immediately.

Penicillins:  a class of oral and parenteral medications initially discovered by Alexander Fleming in 1928, and developed in the 1940's,  mostly because of the need for an infection-fighting agent generated by WWII. The perfection of the manufacturing process largely took place in the United States, with priority just below that of the Manhattan Project. Wyeth Pharmaceuticals, of West Chester, Pennsylvania developed the first effective process for the generation of penicillin mold from orange skins in 1942, and in conjunction with the British (with the help of an Australian scientist), who discovered the properties of this, the world's first "miracle drug"

Once the go-to treatment for gram-positive organisms, penicillin, penicillin G, procaine penicillin, and penicillin V-K are now relegated to the category of "mostly ineffective" for use in UTI's, primarily due to their over use in times past, which produced strains of bacteria resistant to the medication. Penicillin was, at one time, the first-line cure for syphilis and gonorrhea.

Per: Moderator Tim

You've gotta laugh!!

 ©Grainger, Inc and Orange County Choppers, Llc

I cannot honestly believe that I am the only person on the face of this earth that sees something "funny" with regards to this motorcycle, unveiled during the 21 November 2011 "Old Rivals" episode of the Discovery Channel series American Chopper: Senior vs. Junior. 

BTW: I believe this discussion to be on topic, sort of.  If not, it's great comic relief!


Per: Moderator Tim