Urethral stricture disease (USD) remains a significant and often recalcitrant urologic condition frequently encountered by the majority of urologists. Treatment algorithms for management of recurrent stricture often involve attempts at endoscopic management prior to progression to more definitive surgical interventions such as urethroplasty. The range of pathologies that manifest with urethral obstruction is expansive, and vigilance must be maintained to ensure that morbid and ominous conditions such as urethral cancer have been adequately ruled out prior to interventions for stricture disease.
In general, direct vision internal urethrotomy (DVIU) is a modality best utilized for the initial formal opening of a short, defined membranous stricture ( Fig. 97.1 ). DVIU presents a more controlled alternative to urethral dilation in most circumstances, potentially allowing diminished circumferential fibrosis and resultant decrease in stricture recurrence. In very select instances DVIU may also be utilized in the management of panurethral disease when reconstructive options are not feasible as well as intervention for anastomotic strictures following urethroplasty procedures. Caution should be employed with regard to recurrent DVIU in the management of USD as repeat incisions portend lower probability of success. Multiple incisions are prone to devascularize tissue and precipitate further spongiofibrosis and progression of stricture disease. Several intrinsic factors are critical to consider as they influence success of DVIU including stricture length, location, recurrence, and etiology. In general, strictures with dense fibrosis greater than 2 cm are poor candidates for endoscopic management with DVIU ( Fig. 97.2 ).
Several modalities may be employed to perform DVIU and herein we will discuss classic cold-knife techniques and newer modifications utilizing holmium laser technology. Additional guidance concerning postoperative management of the DVIU patient is provided along with current concepts regarding progression to definitive urethroplasty.
Preoperative Evaluation
Evaluation of the stricture anatomy is classically performed using retrograde urethrogram, if possible in conjunction with voiding cystourethrogram, and often augmented by office cystoscopy. In addition to traditional preoperative anesthesia evaluation, urine culture prior to surgery may assist with tailoring perioperative antibiotics, particularly if the patient has a history of urinary tract colonization or infection. Immediately preoperatively patients should be administered antibiotics per the AUA best practice policy for antibiotic prophylaxis. Appropriate agents may be dictated by local antibiograms and usually treatment regimens are recommended for less than or equal to 24 hours in routine situations. Many DVIU cases are limited in time and purely endoscopic in nature; therefore, DVT prophylaxis outside of early postoperative ambulation is not generally required except for high-risk patients. Patients should always be prepared preoperatively for potential need for placement of suprapubic drainage as occasionally the anatomy does not permit access in a retrograde fashion.
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Place the patient in the dorsal lithotomy position with stirrups and appropriate padding to prevent neuropraxia. Following betadine or hibiclens skin preparation and draping, a 22F rigid cystoscope is used to directly visualize the stricture ( Fig. 97.1 ). It is critical at this juncture to not traverse the stricture with the cystoscope as this produces dilation and subsequent healing of such injury likely represents a different process than healing of a controlled urethrotomy. Via the cystoscope working channel, a guidewire is then advanced into the bladder ( Fig. 97.3 ). Guidewire passage is a critical component of this procedure and should not be omitted as the risk of bleeding obscuring the urethra or substantial damage precluding retrograde navigation to the bladder is an ever-present risk. Guidewire passage in exceptionally complex cases may require confirmation with fluorography. If primary urethrotomy is to be performed with a cold knife, the cystoscope is then removed and the urethrotome obtained. The urethrotome consists of a visual obturator or a blind obturator with an irrigation sheath and a cold knife oriented to the 12 o’clock position. The urethrotome contains a trigger mechanism such that the knife is only deployed past the sheath when the rings are opened. The urethrotome is inserted to the level of the stricture with the visual obturator utilizing a 0-degree lens or with the blind obturator to a portion of urethra distal to the stricture. It is critical for appropriate visualization of the knife and urethra that an angled lens not be employed with the urethrotome.
