What is the proper procedure for performing urethral dilatation in a patient with a urethral stricture?

Urethral Dilatation Procedure

Urethral dilation is performed by gently passing progressively larger dilators through the urethra to mechanically widen a strictured segment, and can be used interchangeably with direct visual internal urethrotomy (DVIU) for initial endoscopic management of urethral strictures. 1

Pre-Procedure Preparation

• Obtain preoperative urine cultures to guide antibiotic selection and treat any active urinary tract infections before proceeding with dilation 1, 2
• Administer appropriate prophylactic antibiotics following AUA Best Practice Policy guidelines to reduce surgical site infections 1
• Determine stricture length and location using retrograde urethrography (RUG), voiding cystourethrography (VCUG), or urethro-cystoscopy prior to non-urgent procedures to guide treatment planning 1

Technique

• Use filiform dilators or graduated sounds passed through the urethra with gentle, progressive advancement 3, 2
• Perform with or without guidewire placement depending on stricture complexity and location 1
• Exercise extreme gentleness to minimize complications such as bleeding and urethral perforation 2
• For meatal or fossa navicularis strictures, simple dilation can be performed as first-line treatment for uncomplicated cases 1

Post-Procedure Management

• Place a urethral catheter following dilation to divert urine from the intervention site and prevent urinary extravasation 1
• Remove the catheter within 24-72 hours after uncomplicated dilation, as there is no evidence that prolonged catheterization beyond 72 hours improves outcomes 1
• Catheters may remain longer based on surgeon judgment or patient convenience 1

Expected Outcomes and Limitations

• Success rates range from 35-70% for short strictures (<2 cm), with highest success in bulbar strictures less than 1 cm 1
• Success rates drop dramatically for strictures >2 cm, with very low success for strictures longer than 4 cm 1, 3
• Risk of recurrence is greatest at 6 months, with approximately 40% recurrence at 12 months for strictures <2 cm 3
• For each 1 cm increase in stricture length, the risk of recurrence increases by 1.22-fold 3

Critical Decision Points

For recurrent strictures after failed dilation, urethroplasty should be offered instead of repeated endoscopic management, as failure rates exceed 80% with repeat procedures 1. Repeated dilation may create longer strictures and increase complexity of subsequent reconstruction 1.

For recurrent bulbar strictures <3 cm, drug-coated balloon dilation may be considered, showing 83.2% freedom from intervention at 1 year versus 21.7% with standard dilation alone 1.

In patients not candidates for urethroplasty, intermittent self-catheterization after dilation (performed for >4 months) can maintain temporary urethral patency and reduce recurrence rates 1.

Common Pitfalls

• Avoid repeated dilations for penile urethral strictures, as these have expected high recurrence rates and should proceed directly to urethroplasty 1
• Do not perform dilation on strictures associated with hypospadias, lichen sclerosus, or prior failed endoscopic manipulation without considering urethroplasty 1
• Recognize that dilation and DVIU have equivalent outcomes and can be used interchangeably based on surgeon preference and available equipment 1