Urological Open Access Journal, 2012, 2, 16-19
Published Online February 2012 (http://www.SciRP.org/journal/uoaj)
The Role of Dilation and Internal Urethrotomy as a Risk
Factor of Failure in Patients Who Undergoing One-Stage
Bulbar Oral Graft Urethroplasty
Guido Barbagli1, Giorgio Guazzoni2, Salvatore Sansalone1, Giuseppe Romano1, Massimo Lazzeri3*
1Center for Reconstructive Urethral Surgery, Arezzo, Italy
2Department of Urology, University-Hospital San Raffaele, Milan, Italy
3Clinical Researc h Institute “Prof. M. Fanfani”, Flore nce, Italy
Received November 27, 2011; revised January 18, 2012; accepted January 28, 2012
ABSTRACT
Purpose: To test the hypothesis if dilation or direct visual internal urethrotomy (DVIU) are predictive of urethroplasty
failure. Retrospective study, from 1999 to 2010, including184 patients (median age 37 years) who underwent ventral
onlay oral graft urethroplasty for bulbar strictures. Exclusion criteria were traumatic strictures, lichen sclerosus, failed
hypospadias repair, failed urethroplasty, panurethral strictures, and incomplete medical ch arts. Pre-operative evaluation
included clinical history, physical examination, urine culture, residual urine measurement, uroflowmetry, urethrography,
ultrasound and urethroscopy. Surgery was considered a failure when any post-operative instrumentation was needed.
Median follow-up was 48 months. Out of 184 patients, 38 (20.7%) had not undergone previous treatment, 7 (3.8%) had
undergone dilation, 81 (44%) DVIU and 58 (31.5%) DVIU associated with dilation. Out of 184 patients, 157 (85.3%)
were successful and 27 (14.7%) failures. Out of 38 patients who had not undergone previous treatment, 33 (86.8%)
were successful; out of 7 patients who had undergone dilation, 6 (85.7%) were successful; out of 81 patients who had
undergone DVIU, 72 (88.9%) were successful; out of 58 patients who had undergone DVIU and dilation, 46 (79.3%)
were successful. According to the number of previous DVIU, ventral graft urethroplasty for bulbar strictures showed
high failure rat e in pati e nt s w ho ha d u ndergone m ore tha n fo ur DVI U as s oci at ed or not wi t h dil a t i on.
Keywords: Urethral Stricture; Direct Vision Internal Urethrotomy; Dilation; Urethroplasty
1. Introduction
Reconstructive urethral surgery has greatly improved in
both safety and effectiveness in the last 10 years and
urethral stricture should be now considered an open sur-
gical disease [1]. Dilation and direct vision internal ure-
throtomy (DVIU) are now regarded as neither cost-ef-
fective nor efficacious as a long-term strategy [1-3]. In
2010, Santucci and Eisemberg evaluated the success rate
of DVIU in a series of 76 patients with simple urethral
strictures and concluded that the success rates were no
higher than 9% for the first or subsequent urethrotomy
during the observation period [4]. However, dilation and
DVIU ar e the most common pro cedures used by the ma-
jority of urologists in the United States [5-7]. Recently,
several authors analyzed the trends in male urethral
stricture management in the United States using the data
from the 1992-2001 Medicare claims [8]. These authors
concluded that despite the poor overall efficacy of dila-
tion and DVIU, urethroplasty rates were the lowest of all
treatments [8]. In 1996, 1997, 1998, three articles in the
literature, including one on a large series of patients,
showed that repeated dilation or DVIU are not clinically
effective [9-11]. For many years, these three articles were
considered and quoted in the literature as fundamental
milestones on this topic. In 2004, Greenwell et al. em-
phasized that repeated dilation and DVUI are neither
clinically effective nor cost-effective [12]. The best way
to primarily treat short bulbar urethral strictures, using
DVIU or open urethroplasty, represents a controversial
issue in the literature. Wright et al. suggested that the
most cost-effective strategy for the management of short
bulbar urethral strictures is to reserve urethroplasty for
patients in whom a single DVIU has failed [13]. On the
contrary, Rourke and Jordan suggested that treatment for
short bulbar urethral strictures with primary reconstruc-
tion is less costly than treatment with DVIU [14]. Should
repeated failed dilation or DVIU be considered a risk
factor for the outcome of urethroplasty? Literature on
this topic is found to be lacking. Successful posterior
*Corresponding author.

G. BARBAGLI ET AL. 17
urethroplasty after pelvic trauma has been noted to de-
crease greatly if there was previous urethral manipulation
[15]. On the contrary, oral graft urethroplasty for anterior
urethral strictures has not been shown to significantly
lead to poorer outcome if previous DVIU was unsuc-
cessful [16]. Recently, Breyer et al. studied the patient
risk factors that promote urethroplasty failure in a cohort
of 443 patients [17]. These authors found that stricture
length (greater than 4 cm) and prior failed DVIU or ure-
throplasty are predictive of failure after urethroplasty
[17]. We retrospectively reviewed a large and homoge-
neous series of patients who underwent ventral onlay
graft urethroplasty for bulbar urethral strictures to inves-
tigate if previous failed dilation or DVIU were pred ictive
of urethroplasty fa ilure.
2. Methods
The current study is an observational, descriptive and
retrospective study of consecutive adult male patients
evaluated and treated for bulbar urethral strictures. Study
inclusion criteria were: male patient aged 14 to 80 years
who had undergone ventral onlay oral graft bulbar ure-
throplasty.
Exclusion criteria were traumatic strictures, pan-ure-
thral strictures, malignant urethral lesions, previous
failed urethroplasty, genital lichen sclerosus, failed hy-
pospadias repair and incomplete data on personal medi-
cal charts. All data from May 1999 until June 2010 were
retrospectively collected.
Pre-operative evaluation included clinical history, phy-
sical examination, urine culture, residual urine measure-
ment, uroflowmetry, retrograde and voiding cystoure-
thrography, urethral ultrasound and urethroscopy. All
patients underwent ventral onlay oral graft bulbar ure-
throplasty by a single surgeon (GB), without significant
changes in our standard technique [18]. Patients were
discharged from the hospital 3 days after surgery and
voiding cystourethrography was performed 3 weeks later.
Clinical outcome was cons idered a failure when any post-
operative instrumentation was n eeded, including d ilation.
Uroflowmetry and urine culture were repeated every 4
months in the first year and annually thereafter. When
symptoms of decreased force of stream were present and
the uroflowmetry was less than 12 ml per second, ure-
thrography, urethral ultrasound and urethroscopy were
repeated. Median follow-up was 48 months (range 12 to
145 months).
The study design allowed us to evaluate if repeated
failed dilation and DVIU were predictive of failure after
ventral onlay oral graft bulbar urethroplasty. As the study
was an investigative retrospective observational analysis
and the sample size of some sub-groups was very small,
comparative predictive statistics were not performed.
Descriptive statistical analysis was used.
3. Results
Between May 1999 and June 2010, 184 patients under-
went one-stage ventral onlay oral graft urethroplasty for
bulbar urethral strictures. Median patient age was 37
years (range 14 to 80 year s).
Stricture length was 1-2 cm in 3 patients (1.6%), 2 - 3
cm in 9 (4.9%), 3 - 4 cm in 33 (17.9%), 4 - 5 cm in 90
(48.9%), 5 - 6 cm in 43 (23.4%), and > 6 cm in 6 (3.3%)
patients. Stricture etiology was unknown in 146 (79.4%)
patients, catheter in 22 (11.9%), instrumentation in 13
(7.1), infection in 3(1.6%).
Out of 184 patients, 38 (20.7%) had not undergone
previous treatment, 7 (3.8%) had undergone periodic
dilation, 81 (44%) DVIU and 58 (31.5%) DVIU associ-
ated with periodic dilation (Table 1).
Out of 184 patients, 157 (85.3%) were successful and
27 (14.7%) failures (Table 1). Out of 38 patients who
had not undergone previous treatment before the ure-
throplasty, 33 (86.8%) were successful and 5 (13.2%)
failures; out of 7 patients who had undergone dilation, 6
(85.7%) were successful and 1 (14.3%) failure; out of 81
patients who had undergone DVIU, 72 (88.9%) were
successful and 9 (11.1%) failures; out of 58 patients who
had undergone DVIU and dilation, 46 (79.3%) were
successful and 12 (20.6%) failures (Table 1). The suc-
cess rate according to the number of previous DVIU
(from 1 to 15) is summarized in Table 2, and the success
rate according to the number of previous DVIU (from 1
to 10) and dilation in Table 3.
4. Discussion
The role of failed previous urethral manipulation using
Table 1. Previous treatment and success rate.
Previous treatmentN. patients success rate % failure rate %
none 38 (20.7%) 33 (86.8%) 5 (13.2%)
dilation 7 (3.8%)6 (85.7%) 1 (14.3%)
DVIU 81 (44%)72 (88.9%) 9 (11.1%)
DVIU + dilation 58 (31.5%) 46 (79.3%) 12 (20.6%)
total 184 157 (85.3%) 27 (14.7%)
Table 2. Number of previous DVIU and success rate.
N. of previous DVIUN. patients success rate %
1 DVIU 34 33 (97.1%)
2 DVIU 26 25 (96.2%)
3 DVIU 10 8 (80%)
4 DVIU 4 4 (100%)
5 DVIU 3 1 (33.3%)
6 DVIU 1 0 (0%)
10 DVIU 2 1 (50%)
15 DVIU 1 0 (0%)
total 81 72 (88.9%)

G. BARBAGLI ET AL.
18
Table 3. number of previous DVIU + dilation and success
rate.
N. of previous DVIU + dilation N. patients success rate %
1 DVIU + dilation 21 17 (80.9%)
2 DVIU + dilation 13 12 (92.3%)
3 DVIU + dilation 9 7 (77.8%)
4 DVIU + dilation 7 6 (85.7%)
5 DVIU + dilation 5 3 (60%)
8 DVIU + dilation 1 0 (0%)
10 DVIU + dilation 2 1 (50%)
total 58 46 (79.3%)
dilation and/or DVIU as a risk factor of failure in patients
who undergoing open urethral reconstruction has not yet
been fully investigated and reported in the literature.
Culty and Boccon-Gibod reported that in patients who
undergo anastomotic urethroplasty for post-traumatic ure-
thral strictures, any previous urethral manipulation has a
negative impact on the final outcome [15]. Waxman and
Morey suggested that endoscopic treatment of urethral
strictures using dilation or urethrotomy exacerbates scar
formation, thus adding to stricture length and severity
and complicating subsequent open repair [19]. Morey sug-
gested that previous endoscopic manipulation has re-
peatedly been associated with higher failure rates fol-
lowing open urethroplasty [1]. Unfortunately, these au-
thors do not provide any review in the literature or a
personal study on a series of patients supporting this
sentence, thus we can only suppose that this is a personal
opinion with out any supporting ev idence [1,19]. In 2010,
Breyer et al. reported a multivariate analysis of risk fac-
tors for long- term urethroplasty outcome in a large series
of patients [17]. In this study, prior failed DVIU is re-
ported as one of the factors predictive of failure after
urethroplasty [17]. The authors investigated 443 patients
who underwent urethrop lasty, grouping tog ether differen t
stricture diseases by etiology (trauma or failed hypo-
spadias repair), type of repair (anastomotic, graft, flap,
combined) and length (from 1 to greater than 4 cm) [17].
In so various a mixture of patients, it is really difficult to
identify previous DVIU as the true cause of stricture re-
currence. Urologists commonly increase their sample size
by combining patients with different strictures, different
etiologies, different locations and different surgical repair
[20]. When performed in penile, bulbar or posterior tracts,
or in strictures due to trauma, lichen sclerosus or failed
hypospadias repair, the urethroplasty requires completely
different surgical steps and presents completely different
complication rates, and outcomes [20]. Although this
approach may allow the data to re ach a significant power,
it fails to provide hom ogeneous groups [20].
One of the ma in st rengths of ou r w o r k is reportin g o n a
group of homogeneous u rethral conditions. We selected a
homogeneous series of patients with the same stricture
location (bulbar), (excluding those with panurethral stric-
tures, traumatic strictures, lichen sclerosus, failed hypo-
spadias repair, failed urethroplasty) treated by the same
surgeon (GB) with the same standard surgical technique
(ventral oral mucosal graft). The subgroups we identified
presented similar characteristics as well, even if the num-
ber of patients enrolled in the single groups were differ-
ent, since patients who had undergone more than 4 DVIU
were not as numerous as patients who had undergone less
than 4 DVIU (Tables 2 and 3).
The results of our present survey are similar to the re-
sults we previously reported in 2001, 93 patients under-
went bulbar urethroplasty (27 end-to-end; 40 dorsal skin
graft urethroplasty; 26 two-stage repair), and in 46 pa-
tients (49%), the urethroplasty was performed as primary
repair, and in 47 (51%) the urethroplasty was performed
after failed DVIU [16]. Primary urethroplasty showed an
85% success rate and urethroplasty after failed DVIU
showed an 87% success rate [16]. The present survey in a
more homogenous series of patients seems to confirm
that failed DVIU does not influence the results of ure-
throplasty. Ventral onlay oral graft bulbar urethroplasty
in 38 patients with no previous urethral instrumentation
had an 86.8% success rate, and in 81 patients with pre-
vious DVIU had an 88.9% success rate (Table 1). The
success rate of urethroplasty decreased to 79.3% in 58
patients with previous DVIU associated with dilation
(Table 1). However, owing to the small size of some
subgroups, we were not able to set a predictive model for
urethroplasty outcome or to set a strong conclusions. Our
study is not devoid of limitations. First of all, we recog-
nized that our data may be considered evidence of a low
level, due to the fact that external validity still needs to
be checked out by our centre in international multicenter
studies. In our present survey, the success rate of ventral
onlay oral graft bulbar urethroplasty greatly decreases
only when at least 4 endoscopic procedures had been
previously performed (Tables 2 and 3), which seems to
be in contrast with the current opinions reported in the
literature [1,7,15,19 ]. But these preliminary data strongly
require to be confirmed in a more large series of patients,
because in our study the number of patients who had
undergone more than 4 DVIU and dilation was so small
(Tables 2 and 3) that it is difficult to compare with the
large number of patients who had undergone less than 4
DVIU and dilation (Table 1). In the future, it would be
interesting to investigate, in a largest series of patients, if
other types of surgical techniques (end-to-end, aug-
mented anastomotic repair, dorsal onlay graft urethro-
plasty) currently used in bulbar urethral reconstruction
provide the same results in patients with a history of pre-
viously failed endoscopic treatment, as we reported in
2001 [16]. The main flaw of our study is a lack of any

G. BARBAGLI ET AL.
19
robust statistical analysis: however, we think that these
preliminary data deserves attention. Periodic dilation and
DVIU, despite the poor overall efficacy, still are the most
common procedures used by the majority of urologists in
the United States and urethroplasty rates were the lowest
of all treatments [5-8]. The curren t literature suggests that
urethral stricture should be considered an open surgical
disease, because dilation and DVIU are now regarded as
neither cost-effective nor efficacious as a long-term stra-
tegy [1]. The current trend is to reserve urethroplasty for
patients in whom dilation or DVIU has failed. The ques-
tion is if failed dilation or DVIU should be considered a
risk facto r for the outc ome of uret hroplasty.
In summary, in our preliminary survey, the role of di-
lation and DVIU as a risk factor of failure in patients
who undergoing one-stage bulbar oral graft urethroplasty
seems to be limited in patients presenting a history of
more than 4 DVIU. But more studies including a largest
series of patients are necessary to investigate the role of
failed endoscopic procedures in the outcome of open
surgery.
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