What is the recommended technique, anesthesia, and postoperative care for Optilum urethral dilation in adult males with short (<2 cm) bulbar or penile urethral stricture?

Optilum Urethral Dilation for Short Bulbar and Penile Strictures

For short (<2 cm) bulbar urethral strictures in adult males, the Optilume drug-coated balloon (DCB) may be offered as initial treatment with local anesthesia on an outpatient basis, with urethral catheter removal within 72 hours postoperatively. 1

Treatment Selection Based on Stricture Location

Short Bulbar Strictures (<2 cm)

• Optilume DCB dilation, standard dilation, or direct visual internal urethrotomy (DVIU) are all acceptable first-line options for previously untreated short bulbar strictures, with success rates ranging from 35-70%. 1
• Standard dilation and DVIU have similar success and complication rates and can be used interchangeably. 1
• The Optilume DCB shows superior outcomes in recurrent strictures, achieving 67% functional success and 77% freedom from retreatment at 3 years in patients with 1-4 prior endoscopic interventions. 2
• For strictures <1 cm in the bulbar location, endoscopic treatment has the highest success rates. 1

Penile Urethral Strictures

• Urethroplasty should be offered as initial treatment for penile urethral strictures rather than dilation, given expected high recurrence rates with endoscopic approaches. 1
• Penile strictures are more likely related to hypospadias, lichen sclerosus, or iatrogenic causes and are unlikely to respond to dilation except in select cases of previously untreated, short strictures. 1
• Avoid repeated endoscopic treatments in penile strictures as they may compromise subsequent reconstructive success. 1

Anesthesia Approach

• Local anesthesia is appropriate for outpatient urethral dilation procedures. 3
• This allows for same-day discharge with minimal recovery time. 3

Postoperative Care

• Remove the urethral catheter within 72 hours following the procedure. 1, 4
• No evidence supports leaving the catheter longer than 72 hours to improve outcomes. 4
• Monitor for voiding symptoms using International Prostate Symptom Score (IPSS) at follow-up visits. 2
• The risk of stricture recurrence is greatest at 6 months, with minimal risk after 12 months. 3

Critical Caveats and Pitfalls

When to Avoid Repeated Dilation

• Do not perform more than one endoscopic treatment (dilation or DVIU) for recurrent strictures—offer urethroplasty instead, as failure rates exceed 80% with repeated procedures. 4
• Repeated endoscopic treatments create longer strictures and increase complexity of subsequent urethroplasty. 4
• Each 1 cm increase in stricture length increases recurrence risk by 1.22-fold. 3

Stricture Length Thresholds

• For strictures ≥2 cm in length, offer urethroplasty as initial treatment due to very low success rates with dilation (only 20% for strictures >4 cm). 1, 4
• Urethroplasty achieves 90-95% success for bulbar strictures versus 35-70% for endoscopic approaches. 1

Special Considerations

• Always assess for lichen sclerosus in spontaneous strictures without clear iatrogenic cause, as this changes management. 5
• Perform biopsy if lichen sclerosus is suspected or if the stenosis fails initial treatment. 5
• Patients with previous hypospadias repair, prior failed endoscopic manipulation, or lichen sclerosus should be offered urethroplasty rather than dilation. 1, 5