Direct internal visual Urethrotomy (UIVD) and urethral dilatation are the most common procedures for urethral stenosis.
This approach is attractive for both urologists and patients as minimally invasive.
The original description of the urethral dilation was delineated by the great Indian wise surgeon of the pre-medieval times in his seminal work The Susruta Samahita, where he mentioned the procedure in detail “In a case of Niruddhaprakasha (stenosis of the urethra), an open tube in Both ends made of iron, wood or shellac should be lubricated with clarified butter and gently introduced into the urethra.
More extensive and thicker tubes should be appropriately introduced every three days. The passage of the urethra should be dilated in this way, and emollient foods should be administered to the patient. Since then, the practice of dilation has not changed significantly. The UIVD became popular after the initial report of Sachse in 1972.
In the 1980s, the concept of intermittent self-catheterization (SC) after an IVDU took shape to decrease the recurrence of stenosis. This article analyzes the developments in UIVD that have occurred later and tries to delineate its role in the current treatment of urethral stenosis.
Materials and methods:
We searched the Pubmed database with the words “internal urethrotomy” and “self-catheterization with internal urethrotomy.” All documents dealing with this topic were analyzed. Cross-references of retrieved articles were also seen. Studies were analyzed to identify predictors of success for UIVD.
The initial studies showed excellent results with UIVD, with success rates ranging from 50% to 85%. However, these studies reported only short-term results. Recent studies with longer follow-ups have shown a poor success rate ranging between 6% and 28%.
The length of the stenosis and the degree of fibrosis (luminal narrowing) were predictors of response. Repeated Urethrotomy was associated with poor outcomes.
Studies involving intermittent self-catheterization after UIVD have not shown any role in ISD in the short term. One study reported beneficial effects if continued for more than a year. Many studies have demonstrated long-term complications with SC and high attrition rates.
UIVD is associated with poor long-term cure rates. It remains the first-line treatment for bulbar urethral strictures of 1 cm with minimal spongiofibrosis.
There is no role for repeated Urethrotomy since the results are uniformly poor. When used for more than one year on a weekly or biweekly basis, ISD may delay the onset of recurrence of narrowing.
The classic VIU described by Sachse includes a single cut made at the noon position in the scar tissue until the scar is completely cut.
Concerns have been expressed about the correct position of the incision: some authors advocate multiple radial incisions on the premise that it would allow a better incision of the scar. However, no differences are reported due to superficial versus various incisions.
Laser urethrotomy using different lasers has been tried to improve the results. In a prospective randomized study, Jablonski et al. superior results demonstrated using a yttrium aluminum garnet laser doped with neodymium.
In this study, recurrence rates after laser urethrotomy were 30% compared with 65% with UIVD during a 12-month follow-up. However, other studies have reported similar success rates after the laser incision and the cold blade.
Intralesional injection of medications such as corticosteroids and mitomycin and intraurethral captopril gel has been used to decrease the fibrotic response after UIVD; however, there are no long-term follow-up data available to determine the true benefit of such strategies.
Duration of catheterization after Urethrotomy
The reported duration of catheterization after Urethrotomy ranges from 1 day to 3 months. So far, there is no convincing evidence that the prolongation of catheterization duration impacts the outcome.
Contrary to popular belief, Albers et al. reported that leaving the urethral catheter in place for three days or less is associated with lower recurrence rates (34%) than going it for 4-to 7 days or seven days (recurrence rates of 43% and 65%, respectively). Most studies reported a catheterization duration of 1 to 4 days.
After introducing internal visual optical Urethrotomy, numerous reports in the 1970s and 1980s highlighted the effectiveness of UIVD, with reported success rates ranging from 50% to 80%. Smith et al. reported on 39 patients who underwent UIVD with a success rate of 82% during a mean follow-up of 1 year.
A multicenter survey involving 177 patients administered in five urology departments in the United Kingdom demonstrated an 81% success rate at a 4-year follow-up.
The authors of this work concluded with the statement, “The selective internal urethrotomy procedure is, in our opinion, the best primary method for the treatment of urethral stricture, and this is expected to reduce the indications for anastomotic or replacement urethroplasty.”
The enthusiasm was combined with poor results of urethroplasty in contemporary series. However, most of these studies were not controlled and did not specify details of the characteristics of the stenosis, for example, location, degree of spongiofibrosis, and etiology.
The criteria for the results were not standardized either, since some authors reported subjective measures while others reported variable uroflowmetry data. In addition, very few studies reported long-term follow-up of more than one year.
Long-term efficacy of Urethrotomy
Despite the initial enthusiasm and good results reported in previous studies, more recent articles have shown a poor long-term success rate for Urethrotomy.
Albers et al. reported 937 patients treated with internal primary visual Urethrotomy in two centers (Group 1, administered at the University of Mainz, and Group 2, issued at the University of Bonn in Germany). The average follow-ups in these two groups were 4.6 years and 3.2 years, respectively.
The recurrence rate of stenosis in Group 1 was 26.9%, while in Group 2, it was 44.6%. Subgroup analysis revealed a higher prevalence of idiopathic stenosis in Group 1 and iatrogenic stenosis in Group 2.
These authors concluded that idiopathic stenosis has a more favorable prognosis. Pansodoro et al. reported on 224 patients with a mixed pattern of urethral stricture disease administered by internal Urethrotomy.
The overall recurrence rate in this study was 68% at a median follow-up of 98 months. The recurrence rate was 54%, 84%, and 89% for the stenosis of the bulb, penis, and bulbopenia, respectively. Prognostic features of bulbar urethral strictures associated with good outcomes included single or primary stenosis, length less than 10 mm, and gauge wider than 15F.
In this series, 44% and 18% of recurrent stenoses were observed after more than 12 and 24 months of follow-up. Some stenoses recurred 7-8 years after the Urethrotomy. This means the importance of a prolonged follow-up to establish the success of any technique for treating urethral strictures.
In a more recent study, Santucci and Eisenberg followed 76 patients who underwent Urethrotomy between 1994-2010. In this series, the long-term success rate was only 8% during a mean follow-up of 5 years. This is the only study that has reported a meager success rate.
The etiology of the stenosis was available only in 50% of the patients, and the mean stenosis of 1.5 cm. Most stenoses involve the bulbar urethra. However, this study was retrospective and uncontrolled, with details of characteristic stenoses not delineated in many patients.
Factors associated with the recurrence of stenosis
Length of stenosis
It has been shown that the recurrence of the stenosis is directly proportional to the length of the stenosis. Pandoro et al. demonstrated a high recurrence rate for stenosis greater than 1 cm. In their study, the success rate was 71% for stenoses less than 1 cm compared to 18% for longer stenoses.
In the study by Albers et al., The recurrence rate was 28% for stenoses less than 1 cm and 51% for those greater than 1 cm. Steenkamp et al. showed that stenoses of 1 cm and 1-2 cm in length have similar recurrence rates, approximately 40% at 24 months.
Many other studies have confirmed that by increasing the length of the stenosis, the recurrence rates for UIVD are higher. In addition, a decision analysis model was constructed to determine the minimized cost treatment of the short segment bulbar urethra (2 cm).
It was shown that the management of such stenosis is less expensive using open urethral reconstruction than UIVD.
Diameter of stenosis and spongiofibrosis, infection, and duration of catheterization
The degree of spongiofibrosis associated with stenosis can also predict the recurrence of stenosis. However, spongiofibrosis is challenging to quantify. Mandhani and others used the percentage of narrowing in retrograde urethrography to indicate the reproduction of the stenosis.
Here 75% narrowing in retrograde urethrography predicted recurrence of stenosis with a 78% chance.
In a study by Merkle and Wagner, periurethral scars in ultrasound successfully predicted the recurrence of stenosis in three patients, while 11 patients without scarring had no recurrence of stenosis.
Pandoro et al. found a success rate of 69% for stenosis above 15F and 35% for those below 15F.
Untreated perioperative urinary tract infection significantly increases the recurrence rate, from 28% if it is not infected to 72% if it is infected. The use of prophylactic antibiotics could reduce recurrence rates.
The bulbar urethra has better vascularization than the pendulous urethra, and many studies have reported lower recurrence rates for bulbar urethral strictures than more distal urethral strictures.
Does the stenosis of the etiology impact the results of the UIVD?
Nielsen et al. found that iatrogenic stenoses had higher recurrence rates than inflammatory or traumatic stenoses, while another study showed better results for iatrogenic stenoses.
Two studies found that inflammatory stenoses after long-term catheterization or genital infection are associated with a higher likelihood of recurrence. Others saw no relationship between the etiology of the stenosis and the risk of recurrence.
There is no consensus on whether the etiology of stenosis predicts recurrence since different studies have proposed various etiologies for patients who respond poorly to UIVD.
The role of repeated Urethrotomy
Heyns et al. analyzed the role of repeated Urethrotomy in patients with recurrent stenosis after the first Urethrotomy. They showed that after a single dilation or a UIVD, not followed by a restriction at three months, the recurrence rate of the narrowing was 55-60% at 24 months and 50-60% at 48 months.
After a second IVDU due to stenosis recurrence at three months, the stenosis-free rate was 30-50% at 24 months and 0-40% at 48 months. After a third dilation or UIVD due to stenosis recurrence at 3 or 6 months, the free frequency of stenosis at 24 months was 0.
These authors consider that repeated Urethrotomy plays no role when the recurrence of the stenosis occurs within three months of the IVDU or recurs after a second urethrotomy.
In the series by Pansadoro et al., Only 2 of the 47 patients treated with multiple Urethrotomy achieved a good result, and a third or fourth urethrotomy always failed.
In a study involving 126 patients undergoing internal Urethrotomy, Greenwell et al. compared the results of patients undergoing Urethrotomy or urethroplasty after a failed urethrotomy (51%). These authors demonstrated that repeated Urethrotomy was not cost-effective or clinically practical.
Since the introduction of Urethrotomy by Sachse in 1972, the wheel has taken a complete turn. The first studies showed excellent results after UIVD and the poor success of the urethroplasty techniques.
However, the last two decades have witnessed a revolution in urethroplasty techniques, and many cutting-edge centers have reported excellent long-term results. Along with the expansion of urethroplasty techniques, studies have highlighted inferior long-term outcomes for UIVD.
In contemporary practice, Urethrotomy is indicated for bulbar urethral stenosis of less than 1 cm and minimal spongiofibrosis. A second urethrotomy may be displayed in patients who have a recurrence after six months or according to the patient’s preference.
For stenosis greater than 1 cm, multiple stenoses, pendulous urethral strictures and bulbar stenoses with significant spongiofibrosis, and those that recur within the first three months, Urethrotomy is associated with inferior long-term results.