Internal Urethral Urethrotomy

Internal urethral urethrotomy procedure

Internal urethral urethrotomy is an endoscopic surgery, which is minimally invasive and employs an internal incision through the scar tissue of the urethra.

Indications

• Short segment urethral strictures (less than 2 cm)
• Strictures which result in urinary blockage.
• Patients who are unsuitable to undergo open urethroplasty.
• Recurrent strictures (but repeated IUU with decreasing success rates)

Preoperative Preparation

Evaluation:

• Uroflowmetry
• Retrograde urethrogram (RUG)
• Cystoscopy or ultrasonography.

Medical preparation:

• Antibiotic prophylaxis
• Evaluation of anaesthetic fitness.

Patient instructions:

• Preoperative empty bladder.
• NPO (nil per oral) in case of general anaesthesia.

Procedure Steps

Anaesthesia:

• Depending on the patient and the location of the stricture, spinal, general, or local anaesthesia.

Cystoscopy/Endoscopy:

• A urethroscope is pushed down into the urethra to see the stricture.

Incision of the Stricture:

• The stricture is cut using a cold knife or laser generally at the 12 o clock position to avoid the corpus spongiosum to minimise the possibility of bleeding.
• Incision can be continued until normal lumen of urethra is obtained.

Dilation (optional):

• Light dilation can be done so as to have sufficient lumen size.

Catheterization:

• The insertion of a Foley catheter (3-7 days depending on the length and severity of the stricture) after the procedure to prevent recurrence is carried out to give time to heal.

Postoperative Care

• Watch urinal retention, blood in the urine, or infection.
• Antibiotics as prescribed
• Catheter care instructions
• Promote proper hydration.
• Repeat urethrogram as necessary.

Factors Affecting Internal urethral urethrotomy surgery cost India

The following are the big variables that affect the amount that you may pay to have such a procedure as internal urethral urethrotomy:

Infrastructure and type of hospital

• A massive multispecialty private hospital in a metro city will be more expensive than either a smaller hospital or non-specialist centre. 
• High-end infrastructure (e.g., high level operating theatre, laser equipment, high-end ward) increases cost. 

Geographical location / city

• Prices vary within India: in metro cities (Delhi, Mumbai, Gurgaon), the prices tend to be higher when compared to minor towns. 
• Pricing is influenced by regional cost of living, overheads and demand of the hospital.

Experience of surgeon / reputation

• An urologist with a high number of years of experience or one who specialises in urethral surgery might charge a lot. 
• Higher cost might be warranted by increased success rates.

Difficulty of the stricture / procedure needed

• Short simple stricture requires a routine internal urethrotomy that is cheaper in comparison to long strictures, recurrent stricture, and complex stricture (which may necessitate increased equipment or urethroplasty). 
• In case of complications, previous operations, bad tissue, several segments etc -cost increases.

Technology/technique applied

• Internal urethrotomy may be performed through a cold knife, a lasering method, a visual/optical endoscope and so on. Laser or more sophisticated endoscopic forms are more expensive. 
• It is important in the equipment and time that you spend in the operating room.

Pre-operative and diagnostic preparation

• Retrograde urethrogram, micturating cystourethrogram, ultrasound, uroflowmetry test increase the cost. 
• In the event of comorbidities or extra imaging, this will increase the costs.

Anaesthesia and stay at hospital

• The mode of doing the procedure, be it under local, regional (spinal) or general anaesthesia, does not make a difference, as general, is more expensive. 
• Cost depends on length of stay in hospital, type of room (standard vs private vs deluxe), and recovery monitoring.

Discharge services, catheterisation, follow-up

• The expenses can cover catheterisation, subsequent visits, prescription of drugs, complications. More prolonged post-operative hospitalization or catheter retention is more expensive. 
• In case the stricture has come back and requires another procedure, this is an additional expense.

Internal urethral urethrotomy technique

To cut a urethral stricture inside and re-open a normal lumen with minimal trauma and recurrence

Required Equipment

• Cystoscope / urethroscope (flexible or rigid)
• Cold knife urethrotome or laser (e.g., Holmium laser).
• Guide wire (in some cases)
• Dilators (not required, but optional after incision)
• Foley catheter (typically 14–18 Fr)

Step-by-Step Technique:

Patient Preparation

• Position: Lithotomy position (legs elevated and separated).
• General, spinal or local anaesthesia based on the location of stricture and the patient factors.
• Sterile prep: Perineum and penis washed; sterile draping is used.
• Bladder: This is empty or partially filled so as to be easily observed.

Cystoscopic Assessment

• Pass the urethroscope via the external urethral meatus.
• Look at the urethra and identify the stricture part.
• Measure stricture length, lumen diameter and tissue quality.
• In case the stricture is very narrow a guide wire can be put across it to be safe.

Incision of the Stricture

• Insert the urethrotome (cold knife or laser) into the cystoscope.

CUT the stricture at 12 o clock position:

• Lateral or ventrally position should be avoided to avoid bleeding or damage of corpus spongiosum.
• The incision is continued till some normal urethral caliber is re-established.
• In cases of long strictures, several short incisions can be done as opposed to one long incision.

Optional Dilation

• Soft dilation can be done after incision to provide sufficient lumen.
• Do not use aggressive dilation to cause additional trauma and scarring.

Catheterization

• Place a Foley catheter (typically 14-18 Fr) through the urethra.
• Wait 3-7 days according to stricture length and the choice of the surgeon.

Catheter allows:

• Urine drainage
• Urethral healing
• Minimized chances of early recurrence.

Internal urethral urethrotomy for urethral stricture

Internal urethral urethrotomy (IUU) is a minor endoscopic surgery that is applied to treat urethral strictures, abnormal constrictions of the urethra that block the passage of urine. The process includes making an incision on the scar tissue within the urethra to put back to a normal lumen.

Indications

• Short strictures of the urethra (typically not exceeding 2 cm)
• Individual, plain, simple strictures.
• Strictures that result in symptoms like difficulty with urination, weak stream or urinary retention.
• Recurrent strictures and in which open surgery is not possible.
• Patients who are not fit to undergo open urethroplasty.

Internal urethrotomy indications and procedure

The internal urethrotomy (also known as Optical Internal Urethrotomy (OIU) when using a cystoscope) is a relatively low-invasiveness procedure to treat urethral strictures, where scar tissue is incised within the urethra in order to open it and resume urine flow.

Indications

Internal urethrotomy is mostly used when the urethra is strictured. Particular symptoms are:

Short urethral strictures- urethras:

• Typically ≤ 2 cm in length
• Single plain simple strictures.

Symptomatic strictures:

• Weak urinary stream
• Difficulty voiding
• Urinary retention

Recurrent strictures:

• This is particularly where open urethroplasty is not an option.
• Comorbidity that rules out open surgery in patients.

Contraindications:

• Multiple or long-segment strictures.
• Dense fibrotic strictures
• Active infection of the UTI.
• Special population (pediatric patients are required to have congenital anomalies)

Procedure

Preoperative Preparation:

• Investigations: Retrograde urethrogram (RUG), micturating cystourethrogram (MCU), uroflowmetry.
• Antibiotic prophylaxis
• Anaesthesia examination: General, spinal or local anaesthesia.
• Position of patient: Lithotomy position.

Surgical Steps

Cystoscopic Assessment:

• Insert urethroscope in order to see stricture.
• Assess the stricture length, lumen size, and tissue quality.

Incision of Stricture:

• Apply cold knife urethrotome or laser.
• Make an incision at 12 o’clock position (dorsal aspect) to avoid corpus spongiosum.
• Keep on extending the incision until normal lumen is restored.

Optional Dilation:

• Light dilation can be done where there is need.
• Vesicles should not be used aggressively to avoid additional scarring.

Catheterization:

• Insert Foley catheter (14 -18 Fr) 3-7 days.
• Keeps the patency and heals.

Conclusion

Internal urethral urethrotomy is a simple, safe and effective operation that has been proven to treat short, uncomplicated urethral strictures. It has fast symptom resolution, maintains urethral integrity, and gets one to recover faster than open surgery. Its success is, however, in the long run, restricted by recurrence, which is particularly the case in more or repeated strictures. To maximize the results, it is necessary to select the patient carefully, use proper technique (incision in 12 o’clock position), and provide proper catheterization in the postoperative period. IUU is still a primary endoscopic intervention of appropriate urethral strictures, whereas complex cases or recurrence are still left to open urethroplasty.

Internal urethral urethrotomy treatment India GetWellGo

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FAQ

Is the procedure painful?

• The surgery is pain free under anaesthesia.
• There can be mild pain during the removal of the catheter in the process of urinating.

What is the recovery time?

• Normal activities resume in a few days in the majority of the patients.
• The hard work needs to be avoided within approximately 1 week.

Is the procedure repeatable?

• Yes, repeat IUU can be done in recurrent strictures but the success decreases with each repetition. In several recurrences, the open urethroplasty can be prescribed.

Do I require a catheter following the operation?

• Yes, a Foley catheter is usually kept in 3-7 days in order to heal and decrease the probability of recurrence.