Direct Vision Internal Urethrotomy

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 ).


Short stricture with visualization of proximal healthy urethra.


Dense extensive fibrosis representing poor candidate for DVIU.

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.

Jan 2, 2020 | Posted by in UROLOGY | Comments Off on Direct Vision Internal Urethrotomy

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