Initial Treatment for Post-TURP Urethral Stricture
For the initial treatment of a post-TURP urethral stricture, surgeons may offer urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty depending on the stricture characteristics, with endoscopic management (dilation or DVIU) being appropriate first-line options for short bulbar strictures. 1
Treatment Selection Algorithm Based on Stricture Characteristics
Location and Length Assessment
- Before selecting treatment, clinicians should determine the length and location of the urethral stricture using urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography 1
- This assessment is crucial for informed treatment selection and patient counseling 1
Short Bulbar Strictures (<2 cm)
- Initial treatment options:
- Urethral dilation
- Direct visual internal urethrotomy (DVIU)
- Urethroplasty 1
- Success rates for endoscopic management (dilation or DVIU) range from 35-70% 1
- Both dilation and DVIU have similar success and complication rates and can be used interchangeably 1
- Cold knife and laser incision techniques appear to have similar success rates 1
Longer Strictures (≥2 cm)
- Urethroplasty should be offered as initial treatment due to low success rates of DVIU or dilation 1
- Success rates for endoscopic treatment of strictures >2 cm are very low 1
- For strictures >4 cm, endoscopic treatment has only a 20% success rate 1
Penile Urethral Strictures
- Urethroplasty should be offered due to expected high recurrence rates with endoscopic treatments 1
- These strictures are more likely related to hypospadias, lichen sclerosus, or iatrogenic etiologies, making them less responsive to dilation or DVIU 1
Post-Procedure Management
Catheterization
- Urethral catheter may be safely removed within 72 hours following uncomplicated dilation or DVIU 1
- No evidence supports leaving the catheter longer than 72 hours to improve safety or outcomes 1
- Catheters may be left longer for patient convenience or if early removal might increase complication risk 1
Self-Catheterization
- For patients who are not candidates for urethroplasty, self-catheterization after DVIU may be recommended to maintain temporary urethral patency 1
- Self-catheterization for >4 months after DVIU reduces recurrence rates compared to <3 months 1
Special Considerations for Post-TURP Strictures
- Post-TURP strictures can occur anywhere in the urethra with an incidence between 2.2-9.8% 2
- Most cases present within 6 months of transurethral surgery 2
- For strictures near the sphincter (proximal bulbar), special attention must be paid to preserve continence 3
- Modified ventral onlay graft urethroplasty may be suitable for sphincter urethral strictures to preserve continence 3
Recurrent Strictures Management
- For recurrent anterior urethral strictures following failed dilation or DVIU, urethroplasty should be offered instead of repeated endoscopic management 1
- Failure rates of repeated endoscopic procedures exceed 80% 1
- For recurrent bulbar urethral strictures <3cm, DVIU/dilation combined with drug-coated balloons may be considered 1
- Drug-coated balloon treatment has shown improved freedom from intervention at 1 year (83.2%) compared to DVIU/dilation alone (21.7%) 1
Common Pitfalls and Caveats
- Repeated endoscopic treatments may cause longer strictures and increase the complexity of subsequent urethroplasty 1
- Stricture recurrence risk is highest at 6 months post-procedure 4
- Patients should be informed that the success of subsequent reconstructive procedures may be lower following repeated endoscopic surgeries 1
- Surgeons who do not perform urethroplasty should consider referring patients to surgeons with expertise in this technique 1