Should a cystoscopy be performed before urethral dilation?

Cystoscopy Before Urethral Dilation

Yes, cystoscopy should be performed before urethral dilation to confirm the diagnosis, assess stricture characteristics, and guide appropriate treatment planning.

Diagnostic Evaluation of Urethral Strictures

Proper evaluation before urethral dilation is essential for several reasons:

1. Confirmation of diagnosis: Cystoscopy directly visualizes the stricture, confirming its presence and characteristics 1

2. Assessment of stricture characteristics:

   • Location (anterior vs posterior urethra)
   • Length (critical for treatment selection)
   • Severity of narrowing
   • Surrounding tissue quality

3. Treatment planning: The American Urological Association (AUA) guidelines explicitly state that "endoscopy and/or radiological imaging of the urethra is essential for confirmation of the diagnosis, assessment of stricture severity, and procedure selection" 1

Evidence-Based Approach

The AUA guidelines provide clear recommendations:

• "Clinicians should use urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography to make a diagnosis of urethral stricture" (Moderate Recommendation; Evidence Strength: Grade C) 1

• "Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture" (Expert Opinion) 1

• "Determination of urethral stricture length and location allows the patient and urologist to engage in an informed discussion about treatment options, perioperative expectations, and expected outcomes following urethral stricture therapy" 1

Benefits of Pre-Dilation Cystoscopy

1. Prevents complications: Blind dilation without proper visualization can lead to:

   • False passage formation
   • Rectal injury
   • Bleeding
   • Urethral trauma

2. Guides appropriate treatment selection: Different stricture characteristics require different approaches:

   • Short (<2 cm) bulbar strictures: May respond to dilation or DVIU (35-70% success)
   • Longer strictures (>2 cm): Very poor response to dilation, may need urethroplasty (90-95% success) 1

3. Improves outcomes: Cystoscopy has been shown to be superior to urethrography alone in evaluating strictures, particularly short ones that can be treated during the same procedure 2

Clinical Application

When a urethral stricture is suspected:

1. Start with non-invasive assessment (uroflowmetry, post-void residual)
2. Perform cystoscopy to directly visualize the stricture
3. Consider complementary imaging (RUG, VCUG) for complete assessment
4. Based on findings, select appropriate treatment:
   • For short bulbar strictures: Consider dilation, DVIU, or urethroplasty
   • For longer strictures: Urethroplasty is preferred
   • For urgent situations: Dilation over guidewire or suprapubic cystostomy

Pitfalls to Avoid

1. Blind dilation without visualization: Increases risk of complications and may miss important characteristics of the stricture

2. Repeated dilations without definitive treatment: The AUA guidelines warn against repeated endoscopic maneuvers, as they "increase patient morbidity and may delay the time to anastomotic reconstruction" 1

3. Inadequate assessment of stricture length: Strictures >2 cm have very low success rates with dilation or DVIU 1

4. Failure to consider underlying cause: Cystoscopy may reveal conditions like lichen sclerosus that require specific management approaches

In conclusion, cystoscopy before urethral dilation is not merely recommended but essential for proper diagnosis, treatment planning, and optimal patient outcomes.