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      The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures


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          Direct visual internal urethrotomy (DVIU) followed by intermittent self-dilatation (ISD) is the most commonly performed intervention for urethral stricture disease. The objective of this paper is to outline the current scientific evidence supporting this approach for its use in the management of anterior urethral strictures.

          Materials and Methods:

          A Pubmed database search was performed with the words “internal urethrotomy” and “internal urethrotomy” self-catheterization. All papers dealing with this subject were scrutinized. Cross-references from the retrieved articles were also viewed. Only English language articles were included in the analyses. Studies were analyzed to identify predictors for success for DVIU.


          Initial studies showed excellent outcomes with DVIU with success rates ranging from 50% to 85%. However, these studies reported only short-term results. Recent studies with longer followup have shown a poor success rate ranging from 6% to 28%. Stricture length and degree of fibrosis (luminal narrowing) were found to be predictors of response. Repeated urethrotomies were associated with poor results. Studies involving intermittent self-catheterization following DVIU have shown no role in short-term ISD with one study reporting beneficial effects if continued for more than a year. A significant number of studies have shown long-term complications with SC and high dropout rates.


          DVIU is associated with poor long-term cure rates. It remains as a treatment of first choice for bulbar urethral strictures <1 cm with minimal spongiofibrosis. There is no role for repeated urethrotomy as outcomes are uniformly poor. ISD, when used for more than a year on a weekly or biweekly basis may delay the onset of stricture recurrence.

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          Most cited references48

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          Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful?

          We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures. Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments. Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001). Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.
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            Urethrotomy has a much lower success rate than previously reported.

            We evaluated the success rate of direct vision internal urethrotomy as a treatment for simple male urethral strictures. A retrospective chart review was performed on 136 patients who underwent urethrotomy from January 1994 through March 2009. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth and fifth urethrotomy. Patients with complex strictures (36) were excluded from the study for reasons including previous urethroplasty, neophallus or previous radiation, and 24 patients were lost to followup. Data were available for 76 patients. The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. Urethrotomy is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success rates were no higher than 9% in this series for first or subsequent urethrotomy during the observation period. Most of the patients in this series will be expected to experience failure with longer followup and the expected long-term success rate from any (1 through 5) urethrotomy approach is 0%. Urethrotomy should be considered a temporizing measure until definitive curative reconstruction can be planned. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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              Internal urethrotomy in the management of anterior urethral strictures: long-term followup.

              We evaluated the long-term results of internal urethrotomy for anterior urethral strictures. Between 1975 and 1990, 224 patients underwent internal urethrotomy for anterior urethral strictures. Median followup was 98 months (range 60 to 216). The recurrence rate after 1 urethrotomy was 68% overall, and 58% for bulbar, 84% for penile and 89% for penile bulbar urethral strictures. Repeated urethrotomies did not improve the success rate. Prognostic characteristics of bulbar urethral strictures associated with good results included single or primary strictures, length shorter than 10 mm. and caliber wider than 15F. Preoperative infection and etiology of the strictures did not correlate with results. Multiple urethrotomies achieve only temporary improvement and can be compared to repeated dilations. Alternative treatments should be considered for penile strictures and after failure of initial urethrotomy.

                Author and article information

                Indian J Urol
                Indian Journal of Urology : IJU : Journal of the Urological Society of India
                Medknow Publications (India )
                Jul-Sep 2011
                : 27
                : 3
                : 392-396
                [1]Department of Urology, Manipal Hospital, Airport Road, Bangalore, India
                Author notes
                For correspondence: Dr. Deepak Dubey, Consultant in Urology and Renal Transplantation, Department of Urology, Manipal Hospital, Airport Road, Bangalore - 560 037, India. E-mail: drdeepakdubey@ 123456gmail.com
                Copyright: © Indian Journal of Urology

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


                urethral stricture,internal urethrotomy
                urethral stricture, internal urethrotomy


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