According to the AUA guideline on urethral stricture disease, surgeons may offer urethral dilation, direct vision internal urethrotomy (DVIU), or urethroplasty for the initial treatment of a short (<2 cm) bulbar urethral stricture. DVIU provides favorable long-term outcomes in short strictures, especially when the stricture is <1 cm and located in the bulbar urethra. Urethroplasty can also be considered initially but involves increased anesthesia requirements and higher morbidity compared to DVIU. However, no studies have compared DVIU and urethroplasty in terms of both surgical outcomes and patient-reported outcomes (PROMs). This study aimed to compare the efficacy of DVIU and urethroplasty from both perspectives.

We retrospectively reviewed 69 patients with untreated, non-traumatic, single, short (<2 cm) bulbar urethral strictures treated between 2004 and 2024. Patients were fully informed of both treatment options and chose either DVIU or anastomotic urethroplasty (AU). Anatomical success was defined as the smooth passage of a 17Fr endoscope into the bladder without resistance during cystoscopy at 6 months postoperatively. Clinical success was defined as the absence of any need for additional treatment. As PROMs, maximum flow rate (Qmax), post-void residual (PVR), urethral stricture surgery patient-reported outcome measure (USS-PROM), and Sexual Health Inventory for Men (SHIM) scores were evaluated preoperatively and at 3, 6, and 12 months postoperatively.

Among the 69 patients, 22 underwent DVIU and 47 underwent AU (30 excision and primary anastomosis, 17 non-transecting AU). The median age was 68.5 years (IQR: 43.3-75.8) in the DVIU group and 47 years (IQR: 36-66) in the AU group. Preoperative urinary retention was observed in 13.6% of DVIU patients and 42.6% of AU patients. The median stricture length was significantly longer in the AU group (10 mm, IQR: 7-13) than in the DVIU group (5 mm, IQR: 5-8.25, p=0.003). While clinical success rates were comparable between the groups (DVIU: 90.9%, AU: 95.7%, p=0.42), anatomical success was significantly higher in the AU group (44.4% vs. 93.6%, p<0.001). Both groups demonstrated significant postoperative improvements in lower urinary tract symptoms (LUTS) score, LUTS-related quality of life (QOL), peeing score, and EQ visual analog scale (EQ-VAS) (all p<0.001). AU resulted in significantly greater improvements in Qmax and peeing score (p=0.004 and p=0.04, respectively).

Both DVIU and AU are effective treatments for short bulbar urethral strictures. However, AU provides superior anatomical success and greater improvement in urinary flow rate. Selecting the most appropriate surgical approach based on patient age and lifestyle is essential for optimal outcomes.