Endoluminal and Endoscopic Management of Urethral Stricture

Main Article Content

Siu Yip Martin Mak
Wayne Lam
James Hok-Leung Tsu


urethral stricture, urethral dilatation, optical urethrotomy, direct internal visual urethrotomy, endoscopy


Background and Objective
Urethral stricture in the male population is one the oldest described urological condition. Significant vari-ability in clinical practice means that standardized management of urethral stricture remains controversial. Since the first description of modern-day direct visual internal urethrotomy (DVIU) by Sachse in 1974, this, alongside with various endoscopic treatment techniques, continues to be by far the most commonly performed procedures for the management of urethral strictures. This article aims to summarise and review the latest literature on endoscopic management of urethral strictures.

Material and Methods
We conducted a Pubmed and Medline search to identify publications related to endoscopic management of male urethral strictures between 1980 and 2019. Preference was given to recent and larger studies. Original research articles, review articles, abstracts, and opinion articles were included. Keywords used for the search were “male urethral stricture,” “urethrotomy,” “DVIU,” “urethral dilation,” “urethral stent”, “intermittent self-catheterisation”, “mitomycin C”, “steroids”, and “urethroplasty.”

Recent Findings
The long-term efficacy of endoscopic management of urethral stricture is poor. Recent novel advances with adjunct treatment have yet to demonstrate improvement in long-term treatment success. Repeated endoluminal or endoscopic treatments, especially for long and recurrent urethral strictures, are ineffective. They appear to delay patients from receiving definitive treatments, and potentially increase complexity and decrease the success rate of any future urethral reconstructive treatment.

There is overwhelming evidence to suggest limited long-term efficacy of endoluminal or endoscopic treat-ments for urethral stricture. Novel adjunctive therapies showed promising initial results, but none have yet to demonstrate durable efficacy. Endoscopic treatment of urethral stricture disease should only be reserved for patients who are not willing to undergo reconstructive surgery, or not fit for anesthetics.


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1. Mundy A, Andrich D. Urethral strictures. BJU Int 2010;107(1):6–26. doi:10.1111/j.1464-410x.2010.09800.x.
2. Nuss G, Granieri M, Zhao L, Thum D, Gonzalez C. Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported question-naire to measure outcomes. J Urol 2012;187(2):559–62.
3. Rourke K, Hickle J. The clinical spectrum of the present-
ing signs and symptoms of anterior urethral stricture: detailed analysis of a single institutional cohort. Urology 2012;79(5):1163–67. doi:10.1016/j.urology.2012.01.044.
4. Bertrand L, Warren G, Voelzke B et al. Lower uri-nary tract pain and anterior urethral stricture disease: prevalence and effects of urethral reconstruction. J Urol 2015;193(1):184–89. doi:10.1016/j.juro.2014.07.007.
5. Hampson L, McAninch J, Breyer B. Male urethral strictures and their management. Nat Rev Urol 2013;11(1):43–50. doi:10.1038/nrurol.2013.275.
6. Lubahn J, Zhao L, Scott J et al. Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol 2014;191(1):143–47. doi:10.1016/j. juro.2013.06.054.
7. Santucci R, Joyce G, Wise M. Male urethral stricture disease. J Urol 2007;177(5):1667–74. doi:10.1016/j. juro.2007.01.041.
8. Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L. Contemporary urethral stricture characteristics in the developed world. Urology 2013;81(1):191–97. doi:10.1016/j.urology.2012.08.062.
9. Das S. Urology in ancient India. Indian J Urol 2007;23(1):2. doi:10.4103/0970-1591.30253.
10. Schultheiss D, Truss M, Jonas U. History of direct vi-sion internal urethrotomy. Urology 1998;52:729–34. doi:10.1016/s0090-4295(98)00318-5.
11. Sachse H Treatment of urethral stricture: transure-thral slit in view using sharp section. Fortschr Med 1974;92:12–15.
12. Liu J, Hofer M, Oberlin D et al. MP15-01 Changing practice patterns in the treatment of urethral stricture amongst American urologist. J Urol 2015;193(4S). doi:10.1016/j.juro.2015.02.884.
13. Song L, Xu Y, Wang K et al. Changing trends in the aetiology and management of male urethral stricture disease: A survey from 13 centres in China. Urol Sci 2015;26(2):S32. doi:10.1016/j.urols.2015.06.024.
14. Cheung M, Lam K. Anterior urethral strictures. Surg Pract 2018;22(1):23–29. doi:10.1111/1744-1633.12298.
15. Tonkin J, Jordan G. Management of distal anterior urethral strictures. Nat Rev Urol 2009;6(10):533–38.
16. Holm-Nielsen A, Schultz A, Møller-Pedersen V. Di-
rect Vision Internal Urethrotomy. A Critical Review of 365 Operations. Br J Urol 1984;56(3):308–12. doi:10.1111/j.1464-410x.1984.tb05393.x.
17. Heyns C, Steenkamp J, De kock M, Whitaker P. Treat-ment of Male urethral strictures: Is repeated dilation or Internal Urethrotomy useful? J Urol 1998;160(2):356–58. doi:10.1016/s0022-5347(01)62894-5.
18. Lipsky H, Hubmer G. Direct Vision urethrotomy in the management of urethral strictures. Br J Urol 1977;49(7):725–28. doi:10.1111/j.1464-410x.1977. tb04561.x.
19. Iversen Hansen R, Guldberg O, Møller I. Internal Ure-throtomy with the sachse urethrotome. Scand J Urol Nephrol 1981;15(3):189–91. doi:10.3109/00365598109179600.
20. Naudé A, Heyns C. What is the place of internal ure-throtomy in the treatment of urethral stricture disease? Nat Clin Pract Urol 2005;2(11):538–45. doi:10.1038/ ncpuro0320.
21. Pansadoro V, Emiliozzi P. Internal Urethrotomy in the management of anterior urethral strictures. J Urol 1996:73–75. doi:10.1097/00005392-199607000-00020.
22. Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol 2010;183(5):1859–62. doi:10.1016/j.juro.2010.01.020.
23. Gibod L, Le portz B. Endoscopic urethrotomy: does it live up to its promises? J Urol 1982;127(3):433–35. doi:10.1016/s0022-5347(17)53849-5.
24. Giannakopoulos X, Grammeniatis E, Gartzios A, Tsoumanis P, Kammenos A. Sachse urethrotomy versus endoscopic urethrotomy plus transurethral resection of the fibrous callus (Guillemin’s technique) in the treat-ment of urethral stricture. Urology 1997;49(2):243–47. doi:10.1016/s0090-4295(96)00450-5.
25. Pain J, St. J. Collier St. J. Collier D. Factors Influenc-ing recurrence of urethral strictures after endoscopic urethrotomy: the role of infection and peri-operative antibiotics. Br J Urol 1984;56(2):217–19. doi:10.1111/ j.1464-410x.1984.tb05364.x.
26. Greenwell T, Castle C, Andrich D, Macdonald J, Nicol D, Mundy A. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically ef-fective nor cost-effective. J Urol 2004;172(1):275–77. doi:10.1097/01.ju.0000132156.76403.8f.
27. Steenkamp J, Heyns C, de Kock M. Internal urethrotomy versus dilation as treatment for male urethral stric-tures: a prospective, randomized comparison. J Urol 1997;157(1):98–101. doi:10.1016/s0022-5347(01)65296-0.
28. Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-Term followup of bulbar end-to-end anasto-mosis: a retrospective analysis of 153 patients in a single center experience. J Urol 2007;178(6):2470–73. doi:10.1016/j.juro.2007.08.018.
29. Santucci R, Mario L, McAninch J. Anasto-motic urethroplasty for bulbar urethral stricture: analysis of 168 patients. J Urol 2002:1715–19. doi:10.1097/00005392-200204000-00030.
30. Stephenson R. ISRCTN - ISRCTN98009168: The OPEN Trial: open urethroplasty versus endoscopic urethrotomy: clarifying the management of men with recurrent urethral stricture. Isrctn.com. http://www. isrctn.com/ISRCTN98009168. Published 2019. Ac-cessed October 10, 2019.
31. Buckley J, Heyns C, Gilling P, Carney J. SIU/ICUD consultation on urethral strictures: dilation, internal urethrotomy, and stenting of male anterior urethral strictures. Urology 2014;83(3):S18–S22. doi:10.1016/j. urology.2013.08.075.
32. Wong S, Aboumarzouk O, Narahari R, O’Riordan A, Pickard R. Simple urethral dilatation, endoscopic urethrotomy, and urethroplasty for urethral stricture disease in adult men. Cochrane Database Syst Review 2012. doi:10.1002/14651858.cd006934.pub3.
33. Mundy A, Andrich D. Urethral strictures. BJU Int 2010;107(1):6–26. doi:10.1111/j.1464-410x.2010.09800.x.
34. Hjortrup A, Sørensen C, Sanders S, Moesgaard F, Kirkegaard P. Strictures of the male urethra treated
by the Otis method. J Urol 1983;130(5):903–904.
35. Carlton F, Scardino P, Quattlebaum R. Treatment of
urethral strictures with internal urethrotomy and 6 weeks of silastic catheter drainage. J Urol 1974;111(2):191–93. doi:10.1016/s0022-5347(17)59924-3.
36. Albers P, Fichtner J, Bruhl P, Muller S. Long-term results of internal urethrotomy. J Urol 1996:1611–14. doi:10.1097/00005392-199611000-00017.
37. Yuruk E, Yentur S, Cakir O, Ertas K, Serefoglu E, Semercioz A. Catheter dwell time and diameter affect the recurrence rates after internal urethrotomy. Türk Üroloji Dergisi/Turkish J Urol 2016;42(3):184–89. doi:10.5152/tud.2016.90490.
38. Tian Y, Wazir R, Yue X, Wang K, Li H. Prevention of stricture recurrence following urethral endo-scopic management: what do we have? J Endourol 2014;28(5):502–508. doi:10.1089/end.2013.0538.
39. Karakus S, Koku N, Parmaksiz M, Ertaskin I, Kilin-caslan H, Deliaga H. The effect of urethral catheter size on meatal stenosis formation in children under-going tubularized incised plate urethroplasty. Urol J 2014;10(4):1095–8. doi:10.22037/uj.v10i4.1669.
40. Pitkämäki K, Tammela T, Kontturi M. Recurrence of urethral stricture and late results after optical urethrotomy: comparison of strictures caused by toxic latex catheters and other causes. Scand J Urol Nephrol 1992;26(4):327–31. doi:10.3109/0036559 9209181221.
41. Jin T, Li H, Jiang LH, Wang L, Wang KJ. Safety and efficacy of laser and cold knife urethrotomy for urethral stricture. Chin Med J 2010;123(12):1589–95. doi:10.3760/cma.j.issn.0366-6999.2010.12.020.
42. McDermott D, Bates R, Heney N, Althausen A. Erectile impotence as complication of direct vision cold knife urethrotomy. Urology 1981;18(5):467–69. doi:10.1016/0090-4295(81)90291-0.
43. Graversen P, Rosenkilde P, Colstrup H. Erectile Dysfunction following direct vision internal ure-throtomy. Scand J Urol Nephrol 1991;25(3):175–78. doi:10.3109/00365599109107943.
44. Shaw N, Venkatesan K. Endoscopic management of urethral stricture: review and practice algorithm for management of male urethral stricture dis-ease. Curr Urol Rep 2018;19(3):19. doi: 10.1007/ s11934-018-0771-6.
45. Steenkamp JW, Heyns CF, De Kock M. Outpatient treatment for male urethral strictures— dilatation versus internal urethrotomy. S Afr J Surg 1997; 35:125–30.
46. Yee D, Gelman J, Skarecky D, Ahlering T. Fossa na-vicularis strictures in robotic radical prostatectomy due to 22f catheters. J Urol 2007;177(4S):271–71. doi:10.1016/s0022-5347(18)31052-8.
47. Gelman J, Liss M, Cinman N. Direct vision balloon dilation for the management of urethral strictures. J Endourol 2011;25(8):1249–51. doi:10.1089/ end.2011.0034.
48. Herschorn S, Carrington E. S-shaped coaxial dilators for male urethral strictures. Urology 2007;69(6):1199–201. doi:10.1016/j.urology.2007.02.066.
49. Akkoc A, Aydin C, Kartalmis M, Topaktas R, Altin S, Yilmaz Y. Use and outcomes of amplatz renal dilator for treatment of urethral strictures. International Braz J Urol 2016;42(2):356–64. doi:10.1590/s1677-5538. ibju.2014.0578.
50. Baskin L, Constantinescu S, Howard P et al. Bio-chemical characterization and quantitation of the collagenous components of urethral stricture tissue. J Urol 1993;150(2 Part 2):642–47. doi:10.1016/ s0022-5347(17)35572-6.
51. Elliott S, Minneapolis, MN, Virasoro R, DeLong J et al. One-year safety and efficacy outcomes on a novel drug coated balloon (DCB) for urethral stricture disease – The ROBUST I STUDY. J Urol 2019;201(Supple-ment 4). doi:10.1097/01.ju.0000555762.12516.b4.
52. ROBUST III- Re-Establishing Flow Via Drug Coated Balloon For The Treatment Of Urethral Stricture Disease - Tabular View - ClinicalTrials.gov. Clinical-trials.gov. https://clinicaltrials.gov/ct2/show/record/ NCT03499964?view=record. Published 2019. Ac-cessed October 14, 2019.
53. Redón-Gálvez L, Molina-Escudero R, Álvarez-Ardura M, Otaola-Arca H, Alarcón Parra R, Páez-Borda Á. Predictors of urethral stricture recurrence after en-doscopic urethrotomy. Actas Urológicas Españolas (English Edition) 2016;40(8):529–33. doi:10.1016/j. acuroe.2016.07.008.
54. Zehri A, Ather M, Afshan Q. Predictors of recur-rence of urethral stricture disease following optical urethrotomy. Int J Surg 2009;7(4):361–64. doi:10.1016/j. ijsu.2009.05.010.
55. Pal D, Kumar S, Ghosh B. Direct visual internal urethrotomy: Is it a durable treatment option? Urol Ann 2017;9(1):18. doi:10.4103/0974-7796.198835.
56. Merkle W, Wagner W. Risk of recurrent stricture following internal urethrotomy: prospective ultrasound study of distal male urethra. Br J Urol 1990;65(6):618–20. doi:10.1111/j.1464-410x.1990.tb14831.x.
57. Harraz A, El-Assmy A, Mahmoud O et al. Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral stric-tures? Arab J Urol 2015;13(4):277–81. doi:10.1016/j. aju.2015.07.007.
58. Milroy E, Cooper J, Wallsten H et al. A new treatment for urethral stricture. Lancet 1988;331(8600):1424–27. doi:10.1016/s0140-6736(88)92238-6.
59. Hussain M, Greenwell T, Shah J, Mundy A. Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int 2004;94(7):1037–39. doi:10.1111/j.1464-410x.2004.05100.x.
60. Abbar M, Gelet A, Cuzin B, et al. A quiet revolution: the Wallstent urethral prosthesis (Urolume AMS). Prog Urol 1993:3:771–7.
61. Kepenne V, Andrianne R, Alzin H, et al. Recurrent urethral stenosis treated with a Urolume Plus stent implantation: intermediate multicenter follow-up. Acta Urol Belg 1997;65(1):19–25.
62. Baert L, Verhamme L, Van Poppel H, Vandeursen H, Baert J. Long-term consequences of urethral stents. J Urol 1993;150(3):853–55. doi:10.1016/ s0022-5347(17)35631-8.
63. Palminteri E. Stents and urethral strictures: a lesson learned? Eur Urol 2008;54(3):498–500. doi:10.1016/j. eururo.2007.11.065.
64. De Vocht T, Van Venrooij G, Boon T. Self-ex-panding stent insertion for urethral strictures: a 10-year follow-up. BJU Int 2003;91(7):627–30. doi:10.1046/j.1464-410x.2003.04200.x.
65. Sneller Z, Bosch R. Restenosis of the urethra despite indwelling wallstent. J Urol 1992;148(1):145–46. doi:10.1016/s0022-5347(17)36539-4.
66. Djordjevic M. Treatment of urethral stricture dis-ease by internal urethrotomy, dilation, or stenting. Eur Urol Suppl 2016;15(1):7–12. doi:10.1016/j. eursup.2015.10.001.
67. Wong E, Tse V, Wong J. Durability of Memokath™ urethral stent for stabilisation of recurrent bulbar urethral strictures - medium-term results. BJU Int 2014;113:35–39. doi:10.1111/bju.12457.
68. Jordan G, Wessells H, Secrest C et al. Effect of a tem-porary thermo-expandable stent on urethral patency after dilation or internal urethrotomy for recurrent bulbar urethral stricture: results from a 1-year rand-omized trial. J Urol 2013;190(1):130–36. doi:10.1016/j. juro.2013.01.014.
69. Horiguchi A, Shinchi M, Masunaga A, Ito K, Asano T, Azuma R. Do transurethral treatments increase the com-plexity of urethral strictures? J Urol 2018;199(2):508–14. doi:10.1016/j.juro.2017.08.100.
70. Lapides J, Diokno A, Silber S, Lowe B. Clean, Inter-mittent self-catheterization in the treatment of urinary tract disease. J Urol 1972;107(3):458–61. doi:10.1016/ s0022-5347(17)61055-3.
71. Lawrence W, MacDonagh R. Treatment of urethral stricture disease by internal urethrotomy followed by intermittent ‘low-friction’ self-catheterization: prelimi-nary communication. J R Soc Med 1988;81(3):136–39. doi:10.1177/014107688808100306.
72. Jackson M, Veeratterapillay R, Harding C, Dorkin T. Intermittent self-dilatation for urethral stricture disease in males. Cochrane Database of Systematic Reviews. 2014. doi:10.1002/14651858.cd010258.pub2.
73. Ivaz S, Veeratterapillay R, Jackson M, et al. Intermittent self-dilatation for urethral stricture disease in males: A systematic review and meta-analysis. Neurourol Uro-dynamics 2015;35(7):759–63. doi: 10.1002/nau.22803.
74. Harriss D, Beckingham I, Lemberger R, Lawrence W. Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures. Br J Urol 1994;74(6):790-792. doi:10.1111/ j.1464-410x.1994.tb07127.x.
75. Tammela TL, Permi J, Ruutu M, et al. Clean intermittent self-catheterization after urethrotomy for recurrent urethral strictures. Ann Chir Gynaecol Suppl 1993;206:80–3.
76. Lubahn J, Zhao L, Scott J et al. Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol 2014;191(1):143–47. doi:10.1016/j. juro.2013.06.054.
77. Ayyildiz A, Nuhoglu B, Gulerkaya B et al. Ef-fect of intraurethral Mitomycin-C on healing and fibrosis in rats with experimentally induced ure-thral stricture. Int J Urol 2004;11(12):1122–26. doi:10.1111/j.1442-2042.2004.00959.x.
78. Mazdak H, Meshki I, Ghassami F. Effect of mitomy-cin c on anterior urethral stricture recurrence after internal urethrotomy. Eur Urol 2007;51(4):1089–92. doi:10.1016/j.eururo.2006.11.038.
79. Ali L, Shahzad M, Orakzai N, Khan I, Ahmad M. Efficacy of mitomycin C in reducing recurrence of anterior urethral stricture after internal optical ure-throtomy. Korean J Urol 2015;56(9):650. doi:10.4111/ kju.2015.56.9.650.
80. Farrell M, Lawrenz C, Levine L. Internal urethrotomy with intralesional mitomycin c: an effective option for endoscopic management of recurrent bulbar and bulbomembranous urethral strictures. Urology 2017;110:223–27. doi:10.1016/j.urology.2017.07.017.
81. Mazdak H, Izadpanahi M, Ghalamkari A et al. Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. Int Urol Nephrol 2009;42(3):565–68. doi:10.1007/ s11255-009-9663-5.
82. Yıldırım M, Kaynar M, Ozyuvali E et al. The ef-fectiveness of local steroid injection after internal urethrotomy to avoid recurrence. Archivio Italiano di Urologia e Andrologia 2016;87(4):295. doi:10.4081/ aiua.2015.4.295.
83. Tavakkoli Tabassi K, Yarmohamadi A, Mohammadi S. Triamcinolone injection following internal ure-throtomy for treatment of urethral stricture. Urol J 201;8(2):132–6.
84. Ergün O, Güzel A, Armağan A, Koşar A, Ergün A. A prospective, randomized trial to evaluate the efficacy of clean intermittent catheterization versus triamci-nolone ointment and contractubex ointment of catheter following internal urethrotomy: long-term results. Int Urol Nephrol 2015;47(6):909–13. doi:10.1007/ s11255-015-0990-4.
85. Hudak S, Atkinson T, Morey A. Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration. J Urol 2012;187(5):1691–95. doi:10.1016/j. juro.2011.12.074.
86. Culty T, Boccon-Gibod L. anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a negative impact on the final out-come. J Urol 2007;177(4):1374–77. doi:10.1016/j. juro.2006.11.092.
87. Breyer B, McAninch J, Whitson J et al. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol 2010;183(2):613–17. doi:10.1016/j. juro.2009.10.018.