Direct Internal Visual Urethrotomy (DVIU)

The Direct Internal Visual Urethrotomy or simply urethrotomy is a surgical procedure that is usually performed under spinal or general anesthesia in the operating theater. The DVIU allows the incision of the urethral stricture. It is perform with an endoscopic instrument, known as urethrotome, that is advanced through the urethra. This instrument has a knife blade that is deployed by the surgeon, and which faces in the upward direction. The sharp blade cut the stricture internally to enlarge the lumen of the urethra. The stricture is usually incised between 4 and 8 o’clock positions, where the corpus spongiosum is thicker and the risk of urine extravasation or corpus cavernosum injury is lower. Once the stricture is opened, an indwelling catheter is placed to keep the urethra open while it heals, which usually takes between 1 and 3 days. The indications for this procedure are very specific. In men, DVIU is recommended only for short (<2cm) bulbar strictures that have not been previously treated. Repeated DVIU is not recommended due to low chances of success and high risk of complications including urine extravasation, urethral bleeding and abscess. Moreover, reiterated DVIUs may worsen the length and severity of the stricture increasing the complexity of open surgery (urethroplasty). In female, DVIU can be performed as primary option if the stricture is identified in the urethra, away from the bladder neck. Repeated DVIU is not a recommended option also in female patients.

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Urethral Dilation with Optilume® (paclitaxel-coated balloon)

Urethral Dilation with Optilume® is a medical procedure used to treat anterior urethral stricture in males. The treatment involves using a small catheter equipped with a balloon coated with a drug called paclitaxel. The procedure is performed in the operating room, with the patient under spinal anesthesia to ensure a painless intervention. It typically lasts about 30 minutes and is considered very safe and effective. The first stage of Urethral Dilation with Optilume® involves inserting the small catheter into the urethra through a procedure known as urethroscopy. This is an examination that allows doctors to visualize the lumen of the urethra. Once the catheter is correctly positioned, the balloon at its tip is inflated, gently dilating the area of stenosis. This process helps to improve urinary flow by facilitating the passage of urine through the urethra. During the dilation process (usually 7 to 10 minutes), the balloon will release the drug paclitaxel, which acts locally for a specific period (several days after the operation). This drug is used to prevent narrowing and excessive regrowth of fibrotic tissues, helping to keep the urethra dilated and functional. Once the procedure is complete, the balloon is deflated, and the catheter is removed. A urinary catheter is placed to keep the urethra open and is usually left in place for one or two days. Urethral Dilation with Optilume® is a less invasive procedure compared to traditional urethrotomy, as it does not involve incising the urethral mucosa, minimizing the risk of bleeding and laceration of paraurethral structures such as the cavernous bodies. Typically, the patient can return home the day after the intervention. The use of Optilume® is also recommended by the European Association of Urology (EAU) guidelines in patients who experience recurrence of urethral stenosis after urethrotomy or simple dilation.

 

Definitive management

 

Urethroplasty:

Urethroplasty is an open surgical procedure that aims to reconstruct or replace the urethra which presents as narrowed due to scar tissue and spongiofibrosis. It is carried under spinal or general anesthesia and requires hospitalization.

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Preoperative investigations

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Before surgery, patients are carefully examined by the urologist who will assess the site and extension of the urethral stricture relying on urethroscopy and RGU/VCUG. Physical examination of the genitals and perineum are very important in this phase to assess the presence of collateral diseases such as lichen sclerosus or infections. Abdominal ultrasound scan can also be requested preoperatively. Blood samples and chest X-ray are usually part of the anesthesiological assessment. 

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Patient positions for surgical procedures​

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During surgery, the patients is positioned according to the site of the stricture. In strictures involving only the pendulous urethra, the patient is placed in supine position. Instead, when the stricture involved the bulbar or posterior urethra, the patient is placed in social lithotomy position, where legs are supported by Allen’s stirrups.

Female patients are always positioned in social lithotomy position. To allow the exposition of the urethra, stay sutures are placed to divaricate the labia minora.