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Management - DVIU/VIU

Direct Visual Internal Urethrotomy (Visual Internal Urethrotomy) is considered primary form of treatment for the stricture urethra today. Many patients are diagnosed to have a stricture in the urethra when a urologist is performing endoscopy of the urinary tract.

Indications: Short Bulbar Stricture less than 1.5cms

Not indicated in 1) Penile Urethra 2) Long Bulbar Stricture 3) Membranous Urethra

Site of DVIU – if the narrow urethral opening is eccentric then the stricture should be incised towards the centre of the urethra.  A terumo guide wire is passed through the narrow stricture urethra into the bladder.

If the urethral opening is central, many Urologists incised the spongiofibrotic urethra towards 12 O’ Clock position. Ideally, we have to incise urethra towards 6 O’ Clock position and if required at 2 and 10 O’ Clock position mimicking Mercedes Benz sign. The bulbar urethra lies dorsally in the corpora spongiosa and is attached to the corpora cavernosa dorsally. There is a rare chance of incising corpora cavernosa during urethrotomy and may lead to severe bleeding and impotence. As the urethra is anchored to the corpora cavernosa dorsally there is hardly any space for the urethral lumen to expand.

If we incise the stricture at 6 O’ Clock or 4 and 8 O’ Clock, we encounter large amount of spongy tissue to incise and allow the urethral lumen to expand. 
Number of DVIU in passed 3 DVIU are recommended for the cure of stricture urethra. The current thinking is if one DVIU does not cure stricture the second will not so only DVIU is recommended.

Post urethroplasty recurrent urethral strictures are at times amenable to DVIU as the first choice.

Management - Stents

There are two types of urethral stents temporary and permanent.  Most are made up of stainless steel or Nitinol.  Absorbable stents made up of Vicryl are also available. 

Indication : recurrent short bulbar stricture. Patient unfit for surgery or refuse a surgery.

Contra indication:  penile urethral stents are painful during erection. Stents inserted into the membranous urethra after core through urethrotomy for pelvic fracture urethral distraction defects also get blocked due to over growth of fibrosis.

The success rate of urethral stents inserted in the bulbar urethra is quoted in region of 80% a stent may migrate distally forming a stricture at the proximal end exposed part of the urethral stent not covered by urothelium may be encrusted with stones.  Overgrowth of excessive epithelization may block the lumen and may need repeated resection.  In those patients where the stent has to be removed endoscopic removal of the stent may be possible with some single wire stents but mesh stents need open surgery for removal and the patient may be left with a long defect in the bulbar urethra and surgical repair of the urethral defect after stent removal may not be easy.

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