Direct vision internal urethrotomy in the management of bulbar urethral strictures: long term follow up and factors predicting treatment failure.

Introduction: Evaluation of long term results, risk factors for treatment failure and complications in a contemporary cohort of patients with bulbar urethral strictures managed with direct vision internal urethrotomy (DVUI).

Methods: We retrospectively reviewed 140 consecutive patients who underwent internal urethrotomy in a single institution between January 2012 and October 2020, with a minimum follow up of 24 months. Most urethral strictures had a iatrogenic origin (89.3%), length under 2 cm (75%) and were located at the mid-bulbar urethra (56.4%). Main variable was treatment failure, defined as recurrent urethral stricture at the same location in urethrography or urethroscopy, or the need of dilation, internal urethrotomy or open urethral reconstruction. Secondary variables analysed were length of stricture, suspected etiology, previous endoscopic procedures, hospital stay, days of catheterization and postoperative complications such as infections or haematuria.

Results: Treatment failure occurred in 61.4% patients (104). Idiopathic strictures and those under 2 cm had better outcomes. Strictures longer than 2 cm and those with previous endoscopic procedures demonstrated a higher failure rate. More than 90% of recurrences occurred within the first two years of follow up. Complications of DVIU were scarce with postoperative urinary tract infection/urosepsis in 5.7% and prolonged haematuria in 10%. Mean hospital stay was 2.9 days.

Conclusion: DVIU is a safe and simple technique, with reasonable efficacy in primary cases of bulbar urethral strictures under 2 cm length. Strictures longer than 2 cm or recurrent cases might be better approached through drug-coated balloon dilation or open urethral reconstruction. Follow up after DVIU must be at least 24 months.