Bladder outlet obstruction due to stenosis or stricture of the posterior urethra is a common urologic diagnosis whose etiology can often be traced to prior urethral manipulation or iatrogenic trauma1. Urologic procedures that can precipitate scar formation at the bladder neck or posterior urethra include simple or radical prostatectomies, endoscopic bladder outlet procedures, and repeated instrumentation for management of recurrent stone disease2. Obstruction at the level of the bladder outlet often presents as one or more lower urinary tract symptoms (LUTS.) In patients with a history of urethral manipulation, a poor response to medical therapy, and uroflowmetry findings suggestive of a mechanical obstruction, urethrocystoscopy or retrograde urethrography should be performed to determine the length and location of urethral stricture. While AUA guidelines state that dilation or direct visualization internal urethrotomy (DVIU) should be offered for bulbar strictures measuring less than 2 cm in length, recent evidence suggests that DVIU with or without mitomycin C may have utility in the management of bladder neck or vesicourethral anastomotic contractures3-5.
To demonstrate a technique for minimally invasive endoscopic management of posterior urethral strictures, including those at the bladder neck and vesicourethral anastomosis.
Herein, we have included endoscopic video footage from three patients with posterior urethral strictures, including one at the bladder neck, one at the vesicourethral anastomosis, and one in the bulbomembranous urethra. In each patient, we perform a DVIU with incisions at the 5 and 7 o'clock positions to widen the urethral lumen, followed by injection of 2 mg mitomycin C in a total volume of 5 mL sterile water.
Herein, we describe our technique for the endoscopic management of posterior urethral strictures, including those in the prostatic urethra and bladder neck. MMC injection, in conjunction with traditional DVIU, adds minimally to the complexity and length of the procedure but may substantially improve long-term surgical outcomes4,5.
DVIU with subsequent MMC injection is a viable minimally invasive approach for the treatment of posterior urethral strictures. While more data is needed to better understand the long-term success rates of these procedures, this approach should be considered for patients with a bladder outlet obstruction secondary to a short stricture of the posterior urethra, bladder neck, or vesicourethral anastomosis.
Urology. 2023 Oct 20 [Epub ahead of print]
Roger Klein, Robin Vasan, Cailey Guercio, Paul Rusilko
UPMC Department of Urology, UPMC, 3471 Fifth Ave, Suite 801, Pittsburgh, PA15213. Electronic address: ., UPMC Department of Urology, UPMC, 3471 Fifth Ave, Suite 801, Pittsburgh, PA15213. Electronic address: ., UPMC Department of Urology, UPMC, 3471 Fifth Ave, Suite 801, Pittsburgh, PA15213. Electronic address: ., UPMC Department of Urology, UPMC, 3471 Fifth Ave, Suite 801, Pittsburgh, PA15213; UPMC Department of Plastic Surgery, 3601 Fifth Ave #6B, Pittsburgh, PA15213. Electronic address: .