Is internal optical urethrotomy (IOU) appropriate as first‑line treatment for an adult male with a solitary short (<2 cm) bulbar urethral stricture and no prior extensive urethral reconstruction, and what are the technique, postoperative care, and expected success and recurrence rates?

Internal Optical Urethrotomy for Short Bulbar Urethral Strictures

Internal optical urethrotomy (also called direct visual internal urethrotomy, DVIU) is an acceptable first-line treatment option for adult males with a solitary short (<2 cm) bulbar urethral stricture who have not undergone prior urethral reconstruction, though patients must understand that success rates are modest (35-70%) and significantly lower than urethroplasty (90-95%). 1

When DVIU Is Most Appropriate

DVIU achieves its highest success rates in bulbar strictures less than 1 cm in length with minimal spongiofibrosis. 1, 2 The American Urological Association guideline explicitly states that surgeons may offer urethral dilation, DVIU, or urethroplasty for initial treatment of short (<2 cm) bulbar strictures, making this a conditional recommendation based on shared decision-making. 1

Critical Decision Points:

• Stricture length <1 cm: DVIU is most effective in this subset 1, 2
• Stricture length 1-2 cm: DVIU remains an option but with declining success rates 1
• Stricture length ≥2 cm: Success rates drop dramatically to approximately 20%, and urethroplasty should be offered as initial treatment 1

Expected Success and Recurrence Rates

The long-term success rate of DVIU for short bulbar strictures ranges from 35-70%, with most recurrences occurring within the first 12 months (peak risk at 6 months). 1, 3, 4

Specific Outcome Data:

• Primary DVIU: Stricture-free rate of approximately 60% at 12 months 3, 5
• Recurrence timing: Over 90% of recurrences occur within the first 2 years, with greatest risk at 6 months 3, 6, 4
• Strictures <2 cm: Approximately 40% recurrence rate at 12 months 4
• Strictures 2-4 cm: 50% recurrence at 12 months, increasing to 75% at 48 months 4
• Strictures >4 cm: 80% recurrence rate at 12 months 4

Predictors of Treatment Failure:

• Stricture length >2 cm (each 1 cm increase raises recurrence risk by 22%) 3, 5, 4
• Presence of spongiofibrosis 5, 7
• Unhealthy urethral mucosa 5
• Previous endoscopic procedures 3, 7
• Idiopathic strictures perform better than iatrogenic ones 3

Surgical Technique

DVIU involves endoscopic cold-knife or laser incision of the stricture scar, typically at the 12 o'clock position, and can be performed using either technique as they have similar success rates. 1

Technical Considerations:

• Can be performed as outpatient procedure under local anesthesia 6
• Cold knife versus laser incision: Both methods are equivalent and may be used interchangeably 1
• Single incision at 12 o'clock position is standard 6

Postoperative Care

The urethral catheter should be removed within 72 hours following DVIU, as there is no evidence that longer catheterization improves outcomes. 1, 2

Catheter Management:

• Standard removal time: 24-72 hours postoperatively 1
• No benefit to prolonged catheterization beyond 72 hours 1
• Catheters may be left longer for patient convenience or surgeon judgment regarding complication risk 1

Follow-Up Protocol:

• Minimum follow-up duration should be 24 months to capture the majority of recurrences 3
• Most intensive surveillance needed in first 12 months, particularly at 6 months when recurrence risk peaks 3, 6, 4

Role of Self-Catheterization

Intermittent self-catheterization after DVIU may be recommended for patients who are not candidates for urethroplasty to maintain temporary urethral patency, though short-term self-catheterization has not been shown to prevent recurrence. 1

• Long-term self-catheterization (>1 year on weekly/biweekly basis) may delay stricture recurrence 7
• Short-term self-catheterization has no proven benefit 7
• High dropout rates and long-term complications are common with self-catheterization 7

Critical Pitfalls and When to Avoid DVIU

Repeated DVIU Has Poor Outcomes:

• Second DVIU: Stricture-free rate drops to 45.5% 5
• Third or subsequent DVIU: Offers no long-term cure and should not be performed 7, 6
• Recurrence within 3 months of first DVIU: Patient should be offered urethroplasty rather than repeat endoscopic treatment 6
• Recurrence >6 months after initial procedure: Repeat DVIU may be considered, but urethroplasty remains superior 6

Patients Who Should Proceed Directly to Urethroplasty:

• Stricture length ≥2 cm 1
• Penile urethral strictures (high recurrence with endoscopic treatment) 1
• History of hypospadias repair 1
• Suspected or confirmed lichen sclerosus 1, 8
• Previous failed endoscopic manipulation 1
• Extensive spongiofibrosis 5, 7

Complications

DVIU is a safe procedure with low complication rates. 3, 6

• Urinary tract infection/urosepsis: 5.7% 3
• Prolonged hematuria: 10% 3
• Mean hospital stay: 2.9 days 3
• Most complications are minor (infection and hemorrhage) 6

Weighing DVIU Against Urethroplasty

While DVIU has lower morbidity, shorter recovery, and lower cost than urethroplasty, the significantly higher success rate of urethroplasty (90-95% versus 35-70%) must be central to the shared decision-making process. 1

Key Trade-offs:

• Urethroplasty advantages: 90-95% long-term success, definitive treatment 1
• Urethroplasty disadvantages: Increased anesthesia requirement, higher cost, greater morbidity, longer recovery 1
• DVIU advantages: Outpatient procedure, local anesthesia option, rapid recovery, lower cost 6
• DVIU disadvantages: 30-65% failure rate requiring additional procedures 1, 3, 5

Patients who opt for repeat endoscopic treatments or intermittent self-dilation instead of urethroplasty should be counseled that success of subsequent reconstructive procedures may be compromised. 1