Management of Urethral Stricture Disease: Systematic Review of Dilation, Direct Vision Internal Urethrotomy, and Urethroplasty

Abstract

Introduction: Urethral stricture disease causes significant morbidity. Many endoscopic treatments (dilation, direct vision internal urethrotomy [DVIU]) have high recurrence rates. This review compares long-term success of endoscopic vs. open urethroplasty.

Methods: We searched CENTRAL, Embase, and clinicaltrials.gov (2000–2024) for RCTs and observational studies with ≥24 months follow-up. Inclusion: adult men with bulbar urethral stricture ≤2 cm. Primary outcome: stricture recurrence (need for reintervention). Success defined as no further procedure.

Results: Six RCTs (n=632) and 15 cohorts (n=2,843) contributed. Urethroplasty success at 24 months was 85–92%, versus 32–44% for DVIU and 28–38% for dilation. For strictures >2 cm, urethroplasty success (82%) vs. DVIU (18%). DVIU success was higher for single, short (<1 cm) strictures (56% at 24 months). Complications: urethroplasty 15% (mostly temporary erectile dysfunction), endoscopic <5%.

Discussion: Urethroplasty is superior for durable cure of bulbar strictures, especially >2 cm, but is more invasive. Most trials excluded patients with previous hypospadias or lichen sclerosus, limiting generalizability.

Conclusions: Open urethroplasty is the gold standard for recurrent or long urethral strictures. Endoscopic management is reasonable only for a first, short (<1 cm), non-occlusive bulbar stricture. Patients should be counseled on recurrence rates when choosing dilation or DVIU.