Direct Vision Internal Urethrotomy in the Management of Bulbar Urethral Strictures: Long-Term Follow-Up and Factors Predicting Treatment Failure.

Background: Evaluation of long-term results, risk factors for treatment failure, and complications in a contemporary cohort of patients with bulbar urethral strictures managed with direct vision internal urethrotomy (DVIU).

Methods: We retrospectively reviewed 140 consecutive patients who underwent internal urethrotomy in a single institution between January 2012 and October 2020, with a minimum follow-up of 24 months. Most urethral strictures had an iatrogenic origin (89.3%), length under 2 cm (75%) and were located in the mid-bulbar urethra (56.4%). The main variable was treatment failure, defined as recurrent urethral stricture at the same location in urethrography or urethroscopy, or the need for dilation, internal urethrotomy or open urethral reconstruction. Secondary variables analyzed were length of stricture, suspected etiology, previous endoscopic procedures, hospital stay, days of catheterization, and postoperative complications such as infections or hematuria.

Results: Treatment failure occurred in 61.4% of patients (104). Idiopathic strictures and those under 2 cm had better outcomes. Strictures longer than 2 cm and those with previous endoscopic procedures demonstrated a higher failure rate. More than 90% of recurrences occurred within the first 2 years of follow-up. Complications of DVIU were scarce with postoperative urinary tract infection/urosepsis in 5.7% and prolonged hematuria in 10%. The mean hospital stay was 2.9 days.

Conclusions: DVIU is a safe and simple technique, with reasonable efficacy in primary cases of bulbar urethral strictures under 2 cm in length. Strictures longer than 2 cm or recurrent cases might be better approached through drug-coated balloon dilation or open urethral reconstruction. Follow-up after DVIU must be at least 24 months.