Evaluation of Direct Visual Internal Urethrotomy in The Management of Anterior Urethral Strictures

Evaluation of Direct Visual Internal Urethrotomy in The Management of Anterior Urethral Strictures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Direct Visual Internal Urethrotomy in The Management of Anterior Urethral Strictures Ahmed Farei, Khaled Alkohlany, Majdi Alshami, Mahmood Shaif, Nasser Albaddai, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8089958/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Male urethral stricture continues to be a common and challenging urologic condition. Despite the high failure rate of endoscopic urethrotomy, direct visual internal urethrotomy (DVIU) remains the most commonly performed procedure for the treatment of urethral strictures. It is an effective short-term treatment, but the long-term success rate is low. In this article, we reported the outcome of endoscopic management of anterior urethral stricture. Objective: The aim of the study was to evaluate the outcome of endoscopic urethrotomy. Study design: This is a prospective descriptive study in patients admitted to General Military Hospital (GMH) Sana’a in the period between Jan. 2023 to September. 2025. Patients and methods: Forty-two patients with anterior urethral stricture are included, whom underwent endoscopic urethrotomy The mean age of the patients is 41.5 years ranging between 19-72 years. All patients were evaluated by history, local and systemic physical examination, and radiological assessment according to each case. Results: Of 42 patients presented to the hospital, the most common etiology was iatrogenic (38.1%), followed by blunt trauma (31%), penetrating trauma (14.3%), idiopathic (9.5%), and inflammation (7.1%). The most common site of urethral stricture was bulbar (35.7%), followed by penile (28.6%), membranous (28.6%), and Pan-urethra (7.1%) of cases. The overall complication rate was 26.2%, with reccurnce of stricture (42.8%) being the most common. The only significant difference was observed in relation to stricture length and location. Conclusion: Endoscopic management is usually the first option for many cases of anterior urethral stricture, because of being simple, cost-effective and its repeatability. However, for strictures that are longer than 2 cm, and in patients whom multiple DVIU attempt failed reconstruction urethroplasy is advised. Figures Figure 1 Figure 2 Intrduction and Aim of the Study Male urethral stricture continues to be a common and challenging urologic condition ( 1 ). Urethral stricture refers to the anterior urethral disease or a scarring process involving the spongy erectile tissue of the corpus spongiosum with resultant spongiofibrosis and urethral narrowing ( 2 ). The etiology of urethral stricture disease mainly involves idiopathic, iatrogenic, external trauma, infection, and lichen sclerosus. In males, a sharp increase in incidence is observed after the age of 55 years, with a mean age of 45.1 years ( 3 , 4 ). Overall, the incidence is estimated to be 229–627 per 100,000 males ( 3 ). The anterior urethra is most frequently affected (92.2%), in particular, the bulbar urethra (46.9%) ( 4 ). Various options for the management of urethral stricture disease are available, ranging from urethral dilatation, internal urethrotomy (IU), urethral stenting, and progressing to anastomotic and substitution urethroplasty ( 5 ). The oldest and simplest form of management is urethral dilation, which can be performed with different devices and is generally considered a palliative maneuver ( 6 ). Since its introduction by Sachse in 1974, the use of direct visual internal urethrotomy (DVIU) has increasingly been embraced in urologic practice across many hospitals. It involves cutting the urethral stricture with a urethrotome under direct vision at the 12 o’clock position ( 7 ). Recent surveys conclude that most urologists perform DVIU as the initial management of urethral strictures ( 8 – 10 ). According to previous studies, the claimed success rates vary widely from 8% to 95% ( 11 , 12 ). Several studies have attempted to decrease the recurrence rate; however, long-term results of randomized studies are lacking, and no protocol has satisfactorily overcome this problem ( 13 ). In Yemen, during the last seven years due to the war situation in the country, we noted an increased rate of cases with urethral strictures—particularly due to male genital injuries and prolonged catheterization. Therefore, we are encouraged to do this study as no studies have been published evaluating the outcome of DVIU as the primary approach in our community. Patients and Methods This is a prospective study conducted on 42 patients for whom DVIU was done for the management of anterior urethral stricture. The study was conducted in General Military Hospital (GMH) Sana’a in the period between Jan. 2023 to September. 2025. All patients were assessed with history, physical examination, retrograde urethrogram, voiding cystourethrogram, Ultrasound and post-void residual urine measurement, and cystoscopy. To evaluate the treatment results, we studied the following parameters: age, symptoms of lower urinary tract obstruction stricture etiology, length and location of stricture, and a number of previous urethrotomies if present. Patients who underwent VIU for stricture post-anastomotic urethroplasty were excluded. Following urethrotomy, a 18Fr urethral catheter was inserted and kept in situ for 10 days, then removed in OPD. All patients were trained to use self-catheterisation twice a week for the first 3 months, then once a week for the next 3 months, and then twice a month up to a year. Patients are scheduled to revisit after 1 months, after 2 months, after 3 months, and after 4 months. During these visits, post-voiding residual urine, Urethral Stricture Surgery Patient Reported Outcome Measures (USS-PROM) questionnaires are routinely administered. Additional urethrography and/or cystoscopy are only performed in case of obstructive voiding symptoms. Results The current study included 42 patients who underwent DVIU for anterior urethral stricture between Jan 2023 and September. 2025. The mean age of the patients was 41.5 years ranging between 19-72 years. Predominant symptoms were dysuria and poor stream, which occurred in 30 (71.4%) and 29 patients (69 %) of the cases respectively. Other symptoms included recurrent urinary tract infection in 22 patients (52.4%), urine retention in 12 patients (28.6%), and interrupted urine stream in 8 patients (19%). At the time of evaluation 32 patients (76.2%) had not undergone treatment, with just 10 patients (23.8%) having previous DVIU. The most common etiology was iatrogenic in 16 patients (38.1%), followed by blunt trauma in 13 patients (31%), penetrating trauma in 6 patients (14.3%), idiopathic in 4 patients (9.5%), and inflammation in 3 patients (7.1%). ( Figure 23 ). The site of urethral stricture was bulbar in 15 cases (35.7%), penile in 12 cases (28.6%), membranous in 12 cases (28.6%), and Pan-urethra in 3 cases (7.1%). The stricture length as measured by the cystoscope sheath ranged from 0.5 to 2 cm. Stricture length was less than 1 cm in 13 cases (31%), whereas it was 1–2 cm in 21 cases (50%) and more than 2 cm in 8 cases (19%) ( Table.2 ). All the patients were discharged on the first postoperative day and were asked to re-visit on the tenth postoperative day for catheter removal and clean intermittent catheterization (CIC) instructions. Complications –excluding recurrence– were minimal including 10 cases (23.8%) of macroscopic hematuria and one case (2.4%) of epididimyo-orchitis, with an overall complication rate of 26.2%. None of the cases of urethral bleeding required a blood transfusion. Epidimyo-orchitis was managed conservatively. However, Seven of the patients had prolonged hospital stay for observation. During the follow-up period ( range 4-12 months ), 35 patients (83.3%) were committed to CIC. Recurrence of LUTS was seen in 24 patients (57%) presented with deterioration in the urinary flow. Only 5 patients (11.9%) presented with urine retention. Eventually, out of the 42 patients, 24 patients (57.1%) had a successful outcomes, whereas 9 patients (21.4%) underwent recurrent DVIU, and 9 patients (21.4%) were prepared for open urethroplasty for definitive treatment. Coloration was made between the final outcome and etiology, location, and length of stricture to identify the risk of recurrence. ( Figure.24 ) ( Table.3 ) Table 3: Correlation between final outcome and stricture characteristic Intraoperative Findings Final Outcome p-value Improved Recurrent VIU Urethroplasty Stricture Location Penile 10 2 0 .003* Bulbar 9 3 3 Membranous 4 4 4 Panurethra 1 0 2 Nature Obliterative 6 1 3 .804 Non-Obliterative 18 8 6 Number Single 17 8 2 .034* Multiple 7 1 7 Length <1cm 11 2 0 2cm 1 1 6 *Statistically significant Statistically significant differences were found when we assessed the relation of recurrence with factors such as stricture length (P = 0.001) and location (P = .003) Discussion Male urethral strictures continue to be a common and challenging urologic condition ( 8 ). Urologists play a critical role in the evaluation and management of urethral stricture disease (USD), which accounts for nearly 1.5 million office visits per year ( 14 ). Many treatment methods have been described according to localization, length of stricture, the density of fibrous tissue in the area of stricture, choice of patient or surgeon, and experience of the surgeon ( 15 ). The use of direct vision urethrotomy in the management of urethral strictures has steadily increased since its introduction by Sachse in 1974 ( 6 , 16 ). Despite the high failure rate of visual internal urethrotomy (VIU), it remains the most commonly performed procedure for the treatment of urethral strictures ( 9 ). As such, a shift in management towards earlier urethroplasty has been seen in recent years, which has higher success rates and better reported patient outcomes ( 17 ). It has been suggested that the reasons for repeated urethrotomy are lack of urethroplasty expertise among urologists and perverse financial incentives preventing the referral of patients to centers with expertise ( 12 ). In the USA, physician reimbursement for urethroplasty is approximately twice the amount for urethrotomy, suggesting that there is a financial disincentive to performing urethroplasty ( 7 ). In our country, due to the blockade, political crisis, and economic deterioration, there is limited access to fellowship-trained reconstructive surgeons, even at referral hospitals. Our study was conducted on a total of 42 cases of anterior urethral stricture at the Urology Department, General Military Hospital (GMH), Sana’a, Yemen, aiming to evaluate the outcome of DVIU as the primary approach in our community. In a study by Ramyil et al. on 70 patients, the main causes of stricture were infection in 61.4% of patients, trauma in 15.7%, idiopathic in 14.3%, and iatrogenic in 8.6% ( 18 ). Another study showed idiopathic as the most common cause of urethral stricture ( 4 ). In the current study, the most common causes of urethral stricture were trauma in 45.3% of patients, iatrogenic in 38.1%, idiopathic in 9.5%, and inflammation in 7.1%. Jin et al. reported an overall complication rate of cold-knife urethrotomy of 6.5%, with the most common complications being erectile dysfunction (5%), urinary incontinence (4%), extravasation (3%), UTI (2%), haematuria (2%), epididymitis (0.5%), urinary retention (0.4%), and scrotal abscess (0.3%) ( 19 ). In a study by Ankur et al. on 55 patients with anterior urethral stricture undergoing internal urethrotomy, 5 patients (9.1%) had urethral bleeding, and 2 patients (3.63%) had a fever ( 20 ). A study by Susanta et al. with 60 patients reported a postoperative UTI rate of 15%, urinary extravasation in 8.3%, and urethral bleeding in 1.7% ( 21 ). In the current study, out of 42 cases who underwent DVIU, 10 cases (23.8%) were complicated with urethral bleeding, and one patient had epididymo-orchitis, with an overall complication rate of 26.2%. None of the patients developed post-operative extravasation or other significant complications. This rate is comparable to 27.1% reported by Salako et al. ( 22 ). The reported duration of catheterization following urethrotomy ranges from 1 day to 3 months. There is no convincing evidence that extending the duration of catheterization impacts the outcome ( 23 ). Most studies have reported a catheterization duration of 1–4 days ( 24 , 25 ). The urethral catheter size does not contribute significantly to the formation of a urethral stricture ( 26 ). We used an 18F Foley catheter, which stayed in the urethra for ten days routinely in all patients. Heyns et al. found that after a single dilation or urethrotomy in patients who did not experience restricture within 3 months, the estimated stricture-free rate (SFR) was 50–60% at 48 months ( 25 ). Studies have shown success rates of 32–90% and recurrence rates of 38–75% after internal urethrotomy ( 15 , 27 ). In the current study, our SFR was 78% at 12 months, which is approximately similar to Yenice et al., who reported an SFR of 71% at 12 months ( 28 ). Stricture-free rate at 3 months was achieved in 24 (57.1%) patients after primary urethrotomy, and 9 (21.4%) achieved SFR at 7 months after a second urethrotomy. Patients who underwent three or more procedures had high failure rates and were advised to undergo urethroplasty. Nielsen et al. found that iatrogenic strictures had higher recurrence rates than inflammatory or traumatic strictures ( 13 ), whereas another study showed better results for iatrogenic strictures ( 29 ). Two studies found inflammatory strictures after long-term catheterization or genital infection to be associated with a higher chance of recurrence ( 30 , 11 ). Others have found no relationship between stricture etiology and risk of recurrence ( 11 , 25 ). In the current study, no statistically significant difference (P = 0.441) was found when etiology was considered a predictive factor for recurrence. When stricture location was considered a predictive factor for recurrence after internal urethrotomy, most studies claimed better SFR with bulbar urethral strictures than proximal and distal strictures ( 31 , 11 , 25 ). Pansadoro and Emiliozzi showed recurrence in 58% of bulbar strictures after the first urethrotomy, whereas 84% of penile strictures recurred ( 11 ). In our current study, there was a statistically significant difference (P = 0.003) when stricture location was considered a predictor of recurrence, with membranous location as the highest predictor, followed by bulbar. Stricture length is an important predictive factor for recurrence after internal urethrotomy ( 32 , 11 , 1 , 25 ). Pansadoro and Emiliozzi reported recurrence in 71% of strictures > 10 mm after the first urethrotomy, whereas 18% of strictures 10 mm after the first urethrotomy, whereas 28% of strictures < 10 mm recurred ( 1 ). In the current study, we also found a statistically significant difference (P = 0.001) when stricture length was compared with SFR. Previous studies showed that frequent and regular self-urethral calibration could reduce stricture recurrence rates ( 33 , 1 , 34 ). Harriss et al. showed that biweekly intermittent self-dilatation (ISD), continued for longer than 12 months, had a much lower rate of stricture recurrence (16%) compared with the group that performed clean intermittent catheterization (CIC) for 6 months (40%) ( 35 ). Studies using varying self-dilatation schedules after DVIU, ranging from daily to weekly, demonstrated that stricture recurrence rates were significantly lower among patients performing self-dilatations ( 36 ). Although the optimal protocol remains uncertain, data suggest that performing self-dilatation for more than four months after DVIU reduces recurrence rates compared with patients performing self-dilatations for less than three months ( 37 , 25 ). In the current study, all our patients were advised to use 16Fr and 18Fr urethral catheters twice a week for the first 3 months, then once a week for the next 3 months, and then twice a month up to a year. We found that most recurrences occurred when patients decreased the frequency of self-urethral calibration (> 6 months). Conclusion Visual internal urethrotomy is a simple and popular treatment for male urethral stricture. DVIU is indicated as first line therapy because of its minimal complications and good out-come Most of the recurrences were found to occur within one year. Recurrence of urethral stricture after primary DVIU is mostly due to patients’ lack of commitment to CIC as instructed. Failure of DVIU for long-term stricture-free rate is poor when stricture length is longer than 2 cm thus, definitive curative reconstruction should be planned. There is however need for more studies on a prospective basis with a larger patient cohorts to assess the long-term outcomes in our environment. Declarations Human Ethics and Consent to Participate: This study was approved by the Ethics and Research Committee of the General Military Hospital, Sana’a, Yemen (Approval No: GMH-URO-2025-17). All participants provided written informed consent prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki (2013 revision) . Funding: This research received no external funding . All expenses were covered by the authors. Clinical trial number: not applicable. Author Contribution A.F., K.A., and M.A. conceptualized and designed the study. A.F., M.S., and W.A. collected and analyzed the clinical data. N.A. supervised the study, wrote the main manuscript text, and coordinated correspondence. A.A.-S. and A.S. prepared the figures and tables. All authors contributed to interpreting the results, reviewed, and approved the final manuscript. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author (N.A.) on reasonable request. Due to patient confidentiality and ethical considerations, data are not publicly available. References Albers P, Fichtner J, Brühl P, Müller SC. Long-term results of internal urethrotomy. J Urol. 1996;156:1611–4. Bhargava S, Chapple CR, Bullock AJ, et al. Tissue-engineered buccal mucosa for substitution urethroplasty. BJU Int. 2004;93:807–11. Alwaal A, et al. 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J Ayub Med Coll Abbottabad. 2011;23:22–5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers invited by journal 26 Dec, 2025 Editor invited by journal 02 Dec, 2025 Editor assigned by journal 25 Nov, 2025 Submission checks completed at journal 25 Nov, 2025 First submitted to journal 11 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8089958","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":566329817,"identity":"520d3cf7-2cc9-4679-94ad-62081a5ba992","order_by":0,"name":"Ahmed Farei","email":"","orcid":"","institution":"General Military Hospital, Sanaa","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Farei","suffix":""},{"id":566329818,"identity":"c2c5b189-9ec3-4aa0-b8dd-a3e711777be5","order_by":1,"name":"Khaled Alkohlany","email":"","orcid":"","institution":"Sana'a 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01:17:14","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65417,"visible":true,"origin":"","legend":"","description":"","filename":"6183c2294c0e487db1ba3825c4bedbce1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8089958/v1/1c7f614c27e6728ebd51b1fb.xml"},{"id":99260325,"identity":"fffad2e7-3f07-43d2-b4de-d427185035b5","added_by":"auto","created_at":"2025-12-31 01:17:15","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79358,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8089958/v1/f93c11530104a20bbbb35848.html"},{"id":99260317,"identity":"dedd2864-2f75-4978-a989-05516615e4ad","added_by":"auto","created_at":"2025-12-31 01:17:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":91586,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 23: Causes of stricture\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"23.png","url":"https://assets-eu.researchsquare.com/files/rs-8089958/v1/be2e0c06e9a0b3a5d47b8ad9.png"},{"id":99318593,"identity":"61105fcf-d05e-407c-8390-5e3a337b9d70","added_by":"auto","created_at":"2025-12-31 16:33:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103805,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 24: Final outcome according to cause of stricture\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"24.png","url":"https://assets-eu.researchsquare.com/files/rs-8089958/v1/55af88fbf13b109c24a14334.png"},{"id":99324136,"identity":"a69927a4-d9e1-4d13-8c61-71f5081cb6ae","added_by":"auto","created_at":"2025-12-31 16:46:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":829797,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8089958/v1/fa0556ad-067c-4228-8182-1e993e80cd98.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Direct Visual Internal Urethrotomy in The Management of Anterior Urethral Strictures","fulltext":[{"header":"Intrduction and Aim of the Study","content":"\u003cp\u003eMale urethral stricture continues to be a common and challenging urologic condition (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Urethral stricture refers to the anterior urethral disease or a scarring process involving the spongy erectile tissue of the corpus spongiosum with resultant spongiofibrosis and urethral narrowing (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe etiology of urethral stricture disease mainly involves idiopathic, iatrogenic, external trauma, infection, and lichen sclerosus. In males, a sharp increase in incidence is observed after the age of 55 years, with a mean age of 45.1 years (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Overall, the incidence is estimated to be 229\u0026ndash;627 per 100,000 males (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The anterior urethra is most frequently affected (92.2%), in particular, the bulbar urethra (46.9%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVarious options for the management of urethral stricture disease are available, ranging from urethral dilatation, internal urethrotomy (IU), urethral stenting, and progressing to anastomotic and substitution urethroplasty (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The oldest and simplest form of management is urethral dilation, which can be performed with different devices and is generally considered a palliative maneuver (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince its introduction by Sachse in 1974, the use of direct visual internal urethrotomy (DVIU) has increasingly been embraced in urologic practice across many hospitals. It involves cutting the urethral stricture with a urethrotome under direct vision at the 12 o\u0026rsquo;clock position (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent surveys conclude that most urologists perform DVIU as the initial management of urethral strictures (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). According to previous studies, the claimed success rates vary widely from 8% to 95% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies have attempted to decrease the recurrence rate; however, long-term results of randomized studies are lacking, and no protocol has satisfactorily overcome this problem (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Yemen, during the last seven years due to the war situation in the country, we noted an increased rate of cases with urethral strictures\u0026mdash;particularly due to male genital injuries and prolonged catheterization. Therefore, we are encouraged to do this study as no studies have been published evaluating the outcome of DVIU as the primary approach in our community.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis is a prospective study conducted on 42 patients for whom DVIU was done for the management of anterior urethral stricture. The study was conducted in General Military Hospital (GMH) Sana\u0026rsquo;a in the period between Jan. 2023 to September. 2025.\u003c/p\u003e \u003cp\u003eAll patients were assessed with history, physical examination, retrograde urethrogram, voiding cystourethrogram, Ultrasound and post-void residual urine measurement, and cystoscopy. To evaluate the treatment results, we studied the following parameters: age, symptoms of lower urinary tract obstruction stricture etiology, length and location of stricture, and a number of previous urethrotomies if present. Patients who underwent VIU for stricture post-anastomotic urethroplasty were excluded.\u003c/p\u003e \u003cp\u003eFollowing urethrotomy, a 18Fr urethral catheter was inserted and kept in situ for 10 days, then removed in OPD. All patients were trained to use self-catheterisation twice a week for the first 3 months, then once a week for the next 3 months, and then twice a month up to a year.\u003c/p\u003e \u003cp\u003ePatients are scheduled to revisit after 1 months, after 2 months, after 3 months, and after 4 months. During these visits, post-voiding residual urine, Urethral Stricture\u003c/p\u003e \u003cp\u003eSurgery Patient Reported Outcome Measures (USS-PROM) questionnaires are routinely administered. Additional urethrography and/or cystoscopy are only performed in case of obstructive voiding symptoms.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe current study included 42 patients who underwent DVIU for anterior urethral stricture between Jan 2023 and September. 2025. The mean age of the patients was 41.5\u0026nbsp;years ranging between 19-72 years.\u003c/p\u003e\n\u003cp\u003ePredominant symptoms were dysuria and poor stream, which occurred in 30 (71.4%) and 29\u0026nbsp;patients (69 %) of the cases respectively. Other symptoms included recurrent urinary tract infection in 22 patients\u0026nbsp;(52.4%), urine retention in 12 patients\u0026nbsp;(28.6%), and interrupted urine stream in 8 patients\u0026nbsp;(19%). At the time of evaluation 32 patients (76.2%) had not undergone treatment, with just 10 patients (23.8%) having previous DVIU. The most common etiology was iatrogenic in 16 patients (38.1%), followed by blunt trauma in 13 patients (31%), penetrating trauma in 6 patients (14.3%), idiopathic in 4 patients (9.5%), and inflammation in 3 patients (7.1%). (\u003cstrong\u003eFigure 23\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe site of urethral stricture was bulbar in 15 cases (35.7%), penile in 12 cases (28.6%), membranous in 12 cases (28.6%), and Pan-urethra in 3 cases (7.1%). The stricture length as measured by the cystoscope sheath ranged from 0.5 to 2 cm. Stricture length\u0026nbsp;was\u0026nbsp;less than 1 cm in 13 cases (31%), whereas it was 1\u0026ndash;2 cm in 21 cases (50%) and more than 2 cm in 8 cases (19%) (\u003cstrong\u003eTable.2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"660\" height=\"291\"\u003e\u003c/p\u003e\n\u003cp\u003eAll the patients were discharged on the first postoperative day and were asked to re-visit on the tenth postoperative day for catheter removal and clean intermittent catheterization (CIC) instructions.\u003c/p\u003e\n\u003cp\u003eComplications \u0026ndash;excluding recurrence\u0026ndash; were minimal including 10 cases (23.8%) of macroscopic hematuria and one case (2.4%) of epididimyo-orchitis, with an overall complication rate of 26.2%. None of the cases of urethral bleeding required a blood transfusion. Epidimyo-orchitis was managed conservatively. However, Seven of the patients had prolonged hospital stay for observation.\u003c/p\u003e\n\u003cp\u003eDuring the follow-up period ( range 4-12 months ), \u0026nbsp;35 patients (83.3%) were committed to CIC. Recurrence of LUTS was seen in 24 patients (57%) \u0026nbsp;presented with deterioration in the urinary flow. Only 5 patients (11.9%) presented with urine retention. \u0026nbsp;Eventually, out of the 42 patients, 24 patients (57.1%) had a successful outcomes, whereas 9 patients (21.4%) underwent \u0026nbsp;recurrent DVIU, and 9 patients (21.4%) were prepared for open urethroplasty for definitive treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eColoration was made between the final outcome and etiology, location, and length of stricture to identify the risk of recurrence. (\u003cstrong\u003eFigure.24\u003c/strong\u003e) (\u003cstrong\u003eTable.3\u003c/strong\u003e)\u003c/p\u003e\n\u003cp\u003eTable 3: Correlation between final outcome and stricture characteristic\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"539\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImproved \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRecurrent VIU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrethroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStricture Location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePenile \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBulbar \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMembranous \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePanurethra\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eObliterative \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e.804\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-Obliterative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSingle \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e.034*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;1cm \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-2cm \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;2cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e*Statistically significant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eStatistically significant differences were found when we assessed the relation of recurrence with factors such as stricture length (P = 0.001) and location (P = .003)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMale urethral strictures continue to be a common and challenging urologic condition (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Urologists play a critical role in the evaluation and management of urethral stricture disease (USD), which accounts for nearly 1.5\u0026nbsp;million office visits per year (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Many treatment methods have been described according to localization, length of stricture, the density of fibrous tissue in the area of stricture, choice of patient or surgeon, and experience of the surgeon (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe use of direct vision urethrotomy in the management of urethral strictures has steadily increased since its introduction by Sachse in 1974 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite the high failure rate of visual internal urethrotomy (VIU), it remains the most commonly performed procedure for the treatment of urethral strictures (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). As such, a shift in management towards earlier urethroplasty has been seen in recent years, which has higher success rates and better reported patient outcomes (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt has been suggested that the reasons for repeated urethrotomy are lack of urethroplasty expertise among urologists and perverse financial incentives preventing the referral of patients to centers with expertise (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In the USA, physician reimbursement for urethroplasty is approximately twice the amount for urethrotomy, suggesting that there is a financial disincentive to performing urethroplasty (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our country, due to the blockade, political crisis, and economic deterioration, there is limited access to fellowship-trained reconstructive surgeons, even at referral hospitals. Our study was conducted on a total of 42 cases of anterior urethral stricture at the Urology Department, General Military Hospital (GMH), Sana\u0026rsquo;a, Yemen, aiming to evaluate the outcome of DVIU as the primary approach in our community.\u003c/p\u003e \u003cp\u003eIn a study by Ramyil et al. on 70 patients, the main causes of stricture were infection in 61.4% of patients, trauma in 15.7%, idiopathic in 14.3%, and iatrogenic in 8.6% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Another study showed idiopathic as the most common cause of urethral stricture (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, the most common causes of urethral stricture were trauma in 45.3% of patients, iatrogenic in 38.1%, idiopathic in 9.5%, and inflammation in 7.1%.\u003c/p\u003e \u003cp\u003eJin et al. reported an overall complication rate of cold-knife urethrotomy of 6.5%, with the most common complications being erectile dysfunction (5%), urinary incontinence (4%), extravasation (3%), UTI (2%), haematuria (2%), epididymitis (0.5%), urinary retention (0.4%), and scrotal abscess (0.3%) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In a study by Ankur et al. on 55 patients with anterior urethral stricture undergoing internal urethrotomy, 5 patients (9.1%) had urethral bleeding, and 2 patients (3.63%) had a fever (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study by Susanta et al. with 60 patients reported a postoperative UTI rate of 15%, urinary extravasation in 8.3%, and urethral bleeding in 1.7% (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, out of 42 cases who underwent DVIU, 10 cases (23.8%) were complicated with urethral bleeding, and one patient had epididymo-orchitis, with an overall complication rate of 26.2%. None of the patients developed post-operative extravasation or other significant complications. This rate is comparable to 27.1% reported by Salako et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe reported duration of catheterization following urethrotomy ranges from 1 day to 3 months. There is no convincing evidence that extending the duration of catheterization impacts the outcome (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Most studies have reported a catheterization duration of 1\u0026ndash;4 days (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The urethral catheter size does not contribute significantly to the formation of a urethral stricture (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). We used an 18F Foley catheter, which stayed in the urethra for ten days routinely in all patients.\u003c/p\u003e \u003cp\u003eHeyns et al. found that after a single dilation or urethrotomy in patients who did not experience restricture within 3 months, the estimated stricture-free rate (SFR) was 50\u0026ndash;60% at 48 months (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Studies have shown success rates of 32\u0026ndash;90% and recurrence rates of 38\u0026ndash;75% after internal urethrotomy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, our SFR was 78% at 12 months, which is approximately similar to Yenice et al., who reported an SFR of 71% at 12 months (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Stricture-free rate at 3 months was achieved in 24 (57.1%) patients after primary urethrotomy, and 9 (21.4%) achieved SFR at 7 months after a second urethrotomy. Patients who underwent three or more procedures had high failure rates and were advised to undergo urethroplasty.\u003c/p\u003e \u003cp\u003eNielsen et al. found that iatrogenic strictures had higher recurrence rates than inflammatory or traumatic strictures (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), whereas another study showed better results for iatrogenic strictures (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Two studies found inflammatory strictures after long-term catheterization or genital infection to be associated with a higher chance of recurrence (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Others have found no relationship between stricture etiology and risk of recurrence (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, no statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.441) was found when etiology was considered a predictive factor for recurrence. When stricture location was considered a predictive factor for recurrence after internal urethrotomy, most studies claimed better SFR with bulbar urethral strictures than proximal and distal strictures (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePansadoro and Emiliozzi showed recurrence in 58% of bulbar strictures after the first urethrotomy, whereas 84% of penile strictures recurred (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In our current study, there was a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.003) when stricture location was considered a predictor of recurrence, with membranous location as the highest predictor, followed by bulbar.\u003c/p\u003e \u003cp\u003eStricture length is an important predictive factor for recurrence after internal urethrotomy (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Pansadoro and Emiliozzi reported recurrence in 71% of strictures\u0026thinsp;\u0026gt;\u0026thinsp;10 mm after the first urethrotomy, whereas 18% of strictures\u0026thinsp;\u0026lt;\u0026thinsp;10 mm recurred (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Other authors reported recurrence in 51% of strictures\u0026thinsp;\u0026gt;\u0026thinsp;10 mm after the first urethrotomy, whereas 28% of strictures\u0026thinsp;\u0026lt;\u0026thinsp;10 mm recurred (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In the current study, we also found a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.001) when stricture length was compared with SFR.\u003c/p\u003e \u003cp\u003ePrevious studies showed that frequent and regular self-urethral calibration could reduce stricture recurrence rates (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Harriss et al. showed that biweekly intermittent self-dilatation (ISD), continued for longer than 12 months, had a much lower rate of stricture recurrence (16%) compared with the group that performed clean intermittent catheterization (CIC) for 6 months (40%) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies using varying self-dilatation schedules after DVIU, ranging from daily to weekly, demonstrated that stricture recurrence rates were significantly lower among patients performing self-dilatations (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Although the optimal protocol remains uncertain, data suggest that performing self-dilatation for more than four months after DVIU reduces recurrence rates compared with patients performing self-dilatations for less than three months (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, all our patients were advised to use 16Fr and 18Fr urethral catheters twice a week for the first 3 months, then once a week for the next 3 months, and then twice a month up to a year. We found that most recurrences occurred when patients decreased the frequency of self-urethral calibration (\u0026gt;\u0026thinsp;6 months).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVisual internal urethrotomy is a simple and popular treatment for male urethral stricture. DVIU is indicated as first line therapy because of its minimal complications and good out-come Most of the recurrences were found to occur within one year. Recurrence of urethral stricture after primary DVIU is mostly due to patients\u0026rsquo; lack of commitment to CIC as instructed. Failure of DVIU for long-term stricture-free rate is poor when stricture length is longer than 2 cm thus, definitive curative reconstruction should be planned. There is however need for more studies on a prospective basis with a larger patient cohorts to assess the long-term outcomes in our environment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the\u0026nbsp;\u003cstrong\u003eEthics and Research Committee of the General Military Hospital, Sana’a, Yemen\u003c/strong\u003e (Approval No: GMH-URO-2025-17).\u003cbr\u003e\u0026nbsp;All participants provided written informed consent prior to enrollment.\u003cbr\u003eThe study was conducted \u003cstrong\u003ein accordance with the Declaration of Helsinki (2013 revision)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received \u003cstrong\u003eno external funding\u003c/strong\u003e. All expenses were covered by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.F., K.A., and M.A. conceptualized and designed the study. A.F., M.S., and W.A. collected and analyzed the clinical data. N.A. supervised the study, wrote the main manuscript text, and coordinated correspondence. A.A.-S. and A.S. prepared the figures and tables. All authors contributed to interpreting the results, reviewed, and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author (N.A.) on reasonable request. Due to patient confidentiality and ethical considerations, data are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlbers P, Fichtner J, Br\u0026uuml;hl P, M\u0026uuml;ller SC. Long-term results of internal urethrotomy. J Urol. 1996;156:1611\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhargava S, Chapple CR, Bullock AJ, et al. Tissue-engineered buccal mucosa for substitution urethroplasty. BJU Int. 2004;93:807\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlwaal A, et al. Epidemiology of urethral strictures. Transl Androl Urol. 2014;3:209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalminteri E, et al. Contemporary urethral stricture characteristics in the developed world. Urology. 2013;81:191e6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMangera A, Chapple C. Management of anterior urethral stricture: an evidence-based approach. Curr Opin Urol. 2010;20:453\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSachse H. Zur Behandlung der Harnrohrenstriktur: Die transurethrale Schlitzung unter Sicht mit scharfem Schnitt. Fortschr Med. 1974;92:12\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBullock TL, Brandes SB. Adult anterior urethral strictures: a national practice patterns survey. J Urol. 2007;177:685\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnger JT, et al. Trends in stricture management among male Medicare beneficiaries: Underuse of urethroplasty? Urology. 2011;77:481\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerguson GG, et al. Minimally invasive methods for bulbar urethral strictures: a survey. Urology. 2011;78:701\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeeratterapillay R, Pickard RS. Long-term effect of urethral dilatation and internal urethrotomy. Curr Opin Urol. 2012;22:467\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePansadoro V, Emiliozzi P. Internal urethrotomy in anterior urethral strictures: long term follow-up. J Urol. 1996;156:73\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantucci R, Eisenberg L. Urethrotomy has much lower success rate than previously reported. J Urol. 2010;183(5):1859\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiesel T, et al. Alternative endoscopic management in urethral strictures. J Endourol. 1995;9:31\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantucci RA, et al. Male urethral stricture disease. J Urol. 2007;177(5):1667\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooperberg MR, et al. Urethral reconstruction for traumatic posterior urethral disruption: outcomes of a 25-year experience. J Urol. 2007;178:2006\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStone AR, et al. Optical urethrotomy\u0026mdash;a 3-year experience. Br J Urol. 1983;55(6):701\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlaschko SD, et al. Trends, utilization, and immediate perioperative complications of urethroplasty in the US. J Urol. 2015;85(5):1190\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamyil VM et al. Causes of urethral stricture in 70 patients. 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin et al. Complication rates of cold-knife urethrotomy. 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnkur, Jhanwar, et al. Holmium laser vs conventional DVIU for short-segment bulbar urethral stricture. Can Urol Assoc J. 2016;10:E161\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSusanta Kumar, Das et al. Postoperative outcomes after DVIU. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalako AA, et al. Management of bulbar urethral strictures by DVIU: Nigerian teaching hospital experience. Niger J Health Sci. 2017;17:35\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen. Jensen. Recurrency after optical internal urethrotomy. Urol Int. 1984;39:270\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteenkamp JW, Heyns CF, de Kock ML. Outpatient treatment for male urethral strictures\u0026mdash;dilatation vs internal urethrotomy. S Afr J Surg. 1997;35:125\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeyns CF, et al. 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Management of urethral strictures. Postgrad Med J. 2006;82:489\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan S, et al. Role of clean intermittent self-catheterisation (CISC) in recurrent urethral strictures after internal optical urethrotomy. J Ayub Med Coll Abbottabad. 2011;23:22\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8089958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8089958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMale urethral stricture continues to be a common and challenging urologic condition. Despite the high failure rate of endoscopic urethrotomy, direct visual internal urethrotomy (DVIU) remains the most commonly performed procedure for the treatment of urethral strictures. It is an effective short-term treatment, but the long-term success rate is low. In this article, we reported the outcome of endoscopic management of anterior urethral stricture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThe aim of the study was to evaluate the outcome of endoscopic urethrotomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design: \u003c/strong\u003eThis is a prospective descriptive study in patients admitted to General Military Hospital (GMH) Sana’a in the period between Jan. 2023 to September. 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and methods: \u003c/strong\u003eForty-two patients with anterior urethral stricture are included, whom underwent endoscopic urethrotomy The mean age of the patients is 41.5 years ranging between 19-72 years. All patients were evaluated by history, local and systemic physical examination, and radiological assessment according to each case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 42 patients presented to the hospital, the most common etiology was iatrogenic (38.1%), followed by blunt trauma (31%), penetrating trauma (14.3%), idiopathic (9.5%), and inflammation (7.1%). The most common site of urethral stricture was bulbar (35.7%), followed by penile (28.6%), membranous (28.6%), and Pan-urethra (7.1%) of cases. The overall complication rate was 26.2%, with reccurnce of stricture (42.8%) being the most common. The only significant difference was observed in relation to stricture length and location.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEndoscopic management is usually the first option for many cases of anterior urethral stricture, because of being simple, cost-effective and its repeatability. However, for strictures that are longer than 2 cm, and \u0026nbsp;in patients whom \u0026nbsp;multiple DVIU attempt failed reconstruction urethroplasy is advised.\u003c/p\u003e","manuscriptTitle":"Evaluation of Direct Visual Internal Urethrotomy in The Management of Anterior Urethral Strictures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 01:17:10","doi":"10.21203/rs.3.rs-8089958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-08T01:42:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232694012581303483685203794666045253941","date":"2026-01-07T14:26:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52892251092267487014260271901246939563","date":"2026-01-07T10:10:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-26T06:04:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-02T21:50:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-25T11:16:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T11:15:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-11-11T19:47:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cb8b688-39a3-47c5-b68a-4bd95058a26d","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-31T01:17:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 01:17:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8089958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8089958","identity":"rs-8089958","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}