What are the immediate and long-term management recommendations for a patient with a soft bulbar urethral stricture that has been dilated with a cystoscope (cystoscopy) over a wire?

Management of Soft Bulbar Urethral Stricture After Dilation

For a soft bulbar urethral stricture that has just been dilated over a wire, you should remove the urethral catheter within 24-72 hours and then engage in shared decision-making about definitive management based on stricture length, with urethroplasty strongly recommended for recurrent strictures rather than repeated endoscopic interventions. 1

Immediate Post-Dilation Management

Catheter Management

• Remove the urethral catheter within 72 hours following dilation. 1 There is no evidence that leaving the catheter longer than 72 hours improves safety or outcomes, and catheters may be safely removed after 24-72 hours. 1
• Catheters may be left in longer only for patient convenience or if early removal will increase the risk of complications in the surgeon's judgment. 1

Long-Term Management Strategy

Treatment Selection Based on Stricture Characteristics

For short bulbar strictures (<2 cm):

• You may offer urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty as initial treatment options. 1
• Dilation and DVIU have similar long-term success rates ranging from 35-70% for short strictures, with the highest success in bulbar strictures less than 1 cm. 1
• Success rates for dilation or DVIU drop dramatically for strictures longer than 2 cm. 1
• Excision and primary anastomosis urethroplasty has superior long-term success rates of 90-95% compared to endoscopic treatment. 1

Critical decision point: The higher success rate of urethroplasty must be weighed against increased anesthesia requirements, cost, and higher morbidity. 1

Management of Recurrent Strictures

If this stricture recurs after the current dilation, you should offer urethroplasty instead of repeated endoscopic management. 1 This is a moderate recommendation because:

• Urethral strictures previously treated with dilation or DVIU have failure rates exceeding 80% with repeat endoscopic procedures. 1
• Repeated endoscopic treatment may cause longer strictures and increase the complexity of subsequent urethroplasty. 1
• Research confirms that stricture length, patient comorbidity, obesity, and infectious etiology are independent predictors of recurrence after urethroplasty. 2

Alternative for Non-Surgical Candidates

For patients who are not candidates for urethroplasty, you may recommend self-catheterization after DVIU to maintain temporary urethral patency. 1

• Self-catheterization for greater than 4 months after DVIU reduces recurrence rates compared to performing self-catheterization for less than 3 months. 1
• Varying schedules from daily to weekly have demonstrated significantly lower stricture recurrence rates among patients performing self-catheterization. 1

Consideration of Urethral Rest

You may place a suprapubic cystostomy to promote "urethral rest" prior to definitive urethroplasty in patients dependent on indwelling urethral catheter or intermittent catheterization. 1

• Urethral rest via suprapubic cystostomy promotes safe transition for patients with unstable stricture being referred for urethroplasty. 1
• Tissue recovery and stricture maturation can be expected in 4-6 weeks, enabling accurate radiographic and/or endoscopic identification in preparation for definitive management. 1

Surveillance and Follow-Up

Stricture Characterization Before Definitive Treatment

• Determine the length and location of the urethral stricture using retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography before planning non-urgent intervention. 1
• This determination allows for informed shared decision-making about treatment options, perioperative expectations, and expected outcomes. 1

Common Pitfalls to Avoid

• Do not perform repeated endoscopic dilations or urethrotomies for recurrent strictures. The evidence strongly shows this approach leads to longer, more complex strictures with failure rates exceeding 80%. 1
• Do not assume all bulbar strictures are the same. Stricture length is the critical determinant—strictures <1 cm have the best endoscopic success, while those >2 cm have very low success with dilation/DVIU. 1
• Do not delay definitive urethroplasty in appropriate candidates. The 90-95% success rate of urethroplasty far exceeds the 35-70% success of endoscopic approaches, and repeated failed endoscopic procedures may compromise future reconstructive success. 1