Direct Vision Internal Urethrotomy (DVIU)

Overview

A urethral stricture occurs when a scar caused by swelling, injury, or infection blocks or slows the flow of urine in this tube. A urethral stricture can cause pain in some people. The most common procedures for urethral stricture disease are direct visual internal urethrotomy (DVIU) and urethral dilatation.

What is Urethral Stricture Disease?

You may have a urethral stricture if you have unusual urinary symptoms or difficulty urinating. The urethra is the tube that transports urine from the bladder to the penis. It passes through the prostate gland and the lower part of the penis. It resembles a long tubular donut with the urine running through the hole in the middle and the urethral sponge as the spongy part of the donut. A urethral stricture occurs when the urethral lining scars and the hole narrows, making it difficult for urine to pass through.

A urethral stricture can cause a very slow urinary stream or make completely emptying your bladder difficult. You may feel the need to urinate again immediately after using the restroom, or you may have a frequent or urgent need to urinate. This condition can also cause pain, bleeding, and an inability to urinate. A urethral stricture can cause permanent bladder damage, recurrent urinary tract infections (UTIs), blood in the urine, urine backup in the kidneys, and kidney damage over time.

A urethral stricture is frequently caused by trauma, such as a car or bike accident, or by complications from a medical procedure, such as urethral catheter placement, radiation treatment, or prostate surgery. A urethral stricture can be caused by an infection of the urethra or gonorrhea (a sexually transmitted disease).

To test for a urethral stricture, we might perform a physical exam or one of these diagnostic tests:

Imaging test with X-rays called a retrograde urethrogram (with contrast dye) to assess the length of the stricture and density of the stricture
Urine flow test and ultrasound to see how the urine flow is affected by the urethral stricture
Ultrasound to determine if you have more than usual urine left in your bladder after urination
Cystoscopy, where we gently insert a small, bendable, lubricated fiberoptic scope into your urethra under local anesthesia to see the location and appearance of the stricture

Treatment options for a urethral stricture include:

Active surveillance, which means closely monitoring the stricture
Dilating or stretching the stricture to treat the symptoms
Urethrotomy, or cutting the stricture through a scope
Urethroplasty, or surgical reconstruction of the urethra; which is often the most effective approach

If you have a light, filmy, short stricture with no scar tissue in the urethral sponge (called spongiofibrosis), we often treat with active surveillance, urethral dilation, or an endoscopic urethral incision rather than surgery.

If you have a recurrent stricture, a dense or long stricture, or both, we will most likely perform a urethroplasty. Under general anesthesia, we perform urethroplasty in the hospital. This delicate procedure usually resolves the urethral stricture and any spongiofibrosis. Most of the time, it is a long-term solution. A urethroplasty is performed by removing the section of the urethra with the stricture and scar tissue. If the stricture is long, we may also add new tissue to help reshape the urethra, such as a graft from the mouth (a buccal mucosal graft) or a flap of skin.

What is a Urethrotomy?

Urethrotomy is a surgical procedure used to treat urethral stricture disease. It is also known as direct vision internal urethrotomy. It is an outpatient procedure that involves widening a narrowed urethra with a urethrotome or a surgical knife passed through a cystoscope. Urethrotomies are typically performed on men because urethral strictures in women are extremely rare.

Dilation and urethroplasty are two alternatives to a urethrotomy. Dilation is the process of inserting thin rods (dilators) of increasing size into your urethra in order to stretch out the stricture and widen the narrowing. Urethroplasty is the open surgery reconstruction or replacement of a narrowed urethra when the stricture is too long to be treated with less invasive cystoscopy with urethrotomy. What your doctor will advise you to do is largely determined by the severity of your urethral stricture as well as the success or failure of previous procedures you may have had to undergo to treat it in the past.

What is Direct Vision Internal Urethrotomy?

A Direct Vision Internal urethrotomy, also known as DVIU, is a procedure used to treat urethral strictures. Urethral strictures are narrowings of the urethra that can cause difficulty urinating and ejaculation changes. While women can develop urethral strictures, DVIU should only be used to treat male urethral strictures.

Why might I need a Direct Vision Internal Urethrotomy?

If you have an untreated urethral stricture (scar tissue narrowing the urethra), you can consider a DVIU as a treatment option. This procedure is simple and frequently effective. Injections of local medications that slow or prevent scar recurrence can help DVIUs.

Preparing for your Direct Vision Internal Urethrotomy

You will be seen by the physician and anesthesiologist prior to surgery, and if necessary, you will have a pre-admission appointment with the hospital.

Change in Health Status

Notify your surgeon if you develop a cold, influenza, a bladder infection, diarrhea, or any other infection before your surgery.

Pre-Operative Diet Instructions

Unless otherwise directed by your surgeon or anesthesiologist, patients of all ages must adhere to the following dietary restrictions prior to surgery:

Eight hours before the Scheduled Start of your Surgery: Eat no solid foods, including pulp juices (e.g., orange juice, nectars), lozenges, candy, chewing gum, or mints. Full liquids, such as milk, cream, and jello, should not be consumed. You can continue to drink up to eight ounces of clear liquids until SIX hours before your surgery. Water, clear juices (e.g., apple, grape), black tea, and black coffee are examples of clear liquids.
Six hours before the Scheduled Start of your Surgery: DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
Exceptions: If you are pregnant, morbidly obese, or have diabetes, renal failure, or stomach acid reflux with heartburn, do not take anything by mouth for eight hours, except your usual medications.

Pre-Operative Cleaning Instructions (bathing and showering instructions)

Showers are recommended the night before and the morning of surgery, just prior to your arrival. All adults must shower with either Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason for this is to remove as much bacteria from your skin as possible before surgery. Please notify your doctor or nurse if you are allergic to any of these products. Shower in the following manner:

Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

Pre-Operative Medication Instructions

Please follow the following guidelines for taking your medications before surgery, unless otherwise directed by your surgeon or anesthesiologist:

One Week Prior to Surgery: Stop taking aspirin and any aspirin-containing medications (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles for the presence of aspirin.
Two Days Prior to Surgery: Stop taking all nonsteroidal anti-inflammatory drugs (etodolac, fenoprofen, ibuprofen, ketorolac, maproxen, meclofenarnate, mefenamic acid, naproxen).
Day Before Your Surgery: Normally, you would begin the pre-operative Bowel Preparation for this surgery at this time. There is no bowel prep required for this procedure because it is not close to the bowel and injury is extremely unlikely.

On the Morning of your Surgery:

Do not take digitalis medicines.
Do not take oral antidiabetes medicines (e.g., chlorpropamide, glyburide, glypizide, tolazamide, tolbutamide.
Take half of your usual morning dose. Insulin dosage If you are driving a long distance the morning of surgery or if your surgery is scheduled for the afternoon, skip the morning insulin dose.
All of your other morning doses of regularly prescribed medications should be taken with a small sip of water. Use your asthma inhalers and bring them to the hospital with you.

Patients undergoing sedation for operative or diagnostic procedures must refrain from eating, drinking, or taking anything by mouth for a specified period prior to their surgery or procedure. This is done to avoid complications caused by nausea or vomiting while you are unconscious.

If you vomit while unconscious, there is a chance that the vomit will enter your lungs and cause serious complications such as pneumonia. These complications may necessitate an extension of your hospital stay following surgery. As a result, unless otherwise instructed by an anesthetist, patients are frequently instructed to have nothing by mouth after midnight the night before their operation.

How Direct Vision Internal Urethrotomy is done?

The traditional VIU consists of a single cut made in the scar tissue at 12 o'clock until the scar is completely incised. Concerns have been raised about the correct position of the incision: some authors advocate multiple radial incisions, claiming that this will allow for better scar incision. However, there has been no reported difference in outcome between single and multiple incisions.

To improve outcomes, different lasers have been used in laser urethrotomy. In an attempt to reduce the fibrotic response after DVIU, intralesional injections of medications such as corticosteroids and mitomycin, as well as intraurethral captopril gel, have been used; however, no long-term follow-up data are available to determine the true benefit of such strategies.

In the Recovery Room

While you’re in the recovery room, your condition will be monitored. You can expect a nurse to check the following at regular intervals:

Your vitals—blood pressure, temperature, pulse, and respiration rate.
The severity of pain you’re feeling, as well as the effectiveness of the pain relief medication given to you.
How much urine you’re passing and how easily you're doing so.

You may be given an IV (intravenous) drip through which pain medication (which is often unnecessary) and fluids are injected into your bloodstream. You may also be given an oxygen mask to help you breathe. When you're fully awake and comfortable, you'll be transferred to a ward until your discharge.

Duration of Catherization after DVIU

The catheter that was implanted during the surgery will most likely need to be removed after a few days. The main goal is to keep the space open and allow it to heal naturally. Meanwhile, you can expect the following:

Your healthcare provider will instruct you on how to self-catheterize or manage the one that is already in place.1 Your practitioner will also tell you when you should return to the office or hospital for removal.
Antibiotics may be prescribed by your healthcare provider following surgery to reduce the likelihood of infection. To further reduce the risk, you should practice good hygiene.
You’ll be able to move around and will likely be able to return to work after some days.
You should abstain from sexual intercourse for a couple of weeks. Your healthcare provider will be in the best position to tell you how long exactly you should abstain.
Avoid strenuous activities and intense exercise until your practitioner gives you the go-ahead.
It is critical not to strain during bowel movements. As a result, it is recommended that you drink plenty of fluids and follow a high fiber diet for a few days after surgery to avoid constipation. You may also need to take laxatives or stool softeners. This should be discussed with your physician.

What can I expect after my Procedure?

Following this procedure, patients are usually required to wear a urinary catheter for 2-3 days. The catheter's purpose is to allow urine to pass through the scar area. A small amount of blood in your urine is normal. The surgery is not particularly painful.

The urine stream should improve immediately after the catheter is removed. This is usually at its peak immediately following surgery and may gradually slow down. Your doctor will check your urine stream on a regular basis, usually several times in the first six months and then less frequently if it remains stable.

What are the Risk of Procedure?

There are certain complications that can occur after you undergo a urethrotomy. Some of the most common ones are:11

Urethral pain: It’s normal to feel a burning sensation or discomfort when you’re urinating for a few days post-surgery.
Bleeding: It is common to pass a small amount of blood with your urine. This should go away within a week of your surgery. If it persists or you notice clots, notify your healthcare provider.
Infection: If you suspect you have a urinary tract infection following surgery, you should contact your doctor right away. Fever and chills are telltale signs of an infection.
Recurrence of stricture: It is very likely that your urethra will narrow or form a stricture again. You may need to have another similar surgery or a urethroplasty depending on the outcome of further consultation with your healthcare provider.

Some otherwise uncommon and serious complications are:

Excessive bleeding
Swelling of the penis
Inability to pass urine

If any of these three events occur, you should immediately notify your healthcare provider.

Smoking is one of the major factors that increases the risk of complications after surgery. Smoking can have a negative impact on the healing process. To reduce your risk of developing serious complications, you should start nicotine replacement therapy before your surgery. In any case, if you smoke, you should tell your healthcare provider, who will then advise you on the best course of action.

Bleeding disorders and blood-thinning medications can also increase your risk of complications. If you have a blood clotting disorder or are taking medication that reduces your body's blood clotting abilities (such as aspirin), notify your healthcare provider.

Conclusion

DVIU is a therapeutic option that successfully treats roughly half of the patients while having a low complication rate. Complications from DVIU should not preclude its use as a therapeutic modality for children with urethral strictures. If the child fails the initial DVIU, all further attempts at endoscopic urethral stricture correction should be abandoned in favor of definitive urethroplasty.