Direct Vision Internal Urethrotomy (DVIU)

My Clinical Approach

Direct vision internal urethrotomy is one of the most widely used first-line treatments for urethral stricture, precisely because it is simple, quick, and minimally invasive. That is exactly what also makes it one of the most easily overused treatments, when applied repeatedly to strictures that will not durably benefit from a simple incision.

My approach always starts with a full mapping of the stricture — location, length, aetiology, number of previous treatments — before any treatment option is discussed. DVIU is not a solution for every stricture, and honest counselling about the likelihood of recurrence is as much a part of the treatment as the procedure itself.

• Full pre-procedure mapping (urethrography, urethroscopy where needed) before any decision.
• Clear counselling that DVIU opens the stricture, it does not remove the underlying scar.
• For a recurrent stricture after two endoscopic treatments: discussion of Optilume or urethroplasty, not automatic repetition.
• For penile or lichen sclerosus-related strictures: endoscopic incision is not the recommended first choice.
• Individualised decision-making, based on findings rather than a blanket rule.

What Is Direct Vision Internal Urethrotomy (DVIU)

Direct Vision Internal Urethrotomy (DVIU) is an endoscopic procedure in which the scarred segment of the urethra is incised from the inside, temporarily widening the urethral lumen and improving urine flow.

In contemporary practice, DVIU is often considered a first-line treatment for selected strictures, precisely because it is simpler and faster than open reconstructive surgery — but this does not mean it is always the right choice.

DVIU, Sachse, Laser: Terminology

The broad, internationally recognised term is DVIU, which in its classic form is also referred to as Sachse urethrotomy.

Both techniques belong to the same family of treatments (DVIU) — the essential difference is the cutting tool, not the underlying philosophy of the procedure.

How a Stricture Forms

Scar tissue (fibrosis) around the urethral lumen causes progressive narrowing. Possible causes include prior instrumentation or catheterisation, trauma, infection/inflammation, previous urethral surgery, lichen sclerosus, or — often — the cause remains idiopathic, with no clearly identifiable trigger.

For a full discussion of causes, symptoms, and overall treatment strategy, see the urethral stricture page. This page focuses specifically on endoscopic incision as a treatment option.

How DVIU Works

This cycle explains why DVIU is not a one-time definitive treatment for every patient: healing can reform scar tissue at the same site.

DVIU Does Not Remove the Scar

During healing, fibrosis can re-form at the same site, resulting in restenosis. This explains why recurrence is a central topic in every discussion about DVIU — it is not a failure of the technique, but an inherent characteristic of the method.

Which Stricture Is Suitable for DVIU

According to EAU guidelines, DVIU has a better chance of success in selected strictures with the following characteristics:

We do not give a single absolute length cutoff in centimetres as a universal rule — the decision is made combining all of the above characteristics, individualised per patient.

Bulbar vs Penile Stricture

The bulbar urethra is the segment near the perineum, before the urethra enters the penis. It is the location where there is the strongest evidence for selected, successful use of DVIU.

The penile urethra has different anatomy, a different recurrence risk, and a different reconstructive strategy. According to EAU guidelines, DVIU performs clearly worse in the penile urethra and may provoke venous leakage from the corpora cavernosa with a subsequent risk of erectile dysfunction — which is why its use is discouraged there. The favourable outcomes seen in the bulbar urethra should not be automatically extrapolated to the penile urethra.

Long & Obliterative Strictures

As length, fibrosis, and complexity increase, the suitability of a simple endoscopic incision strategy decreases. EAU guidelines recommend against using DVIU or dilatation as the sole treatment for long strictures (over about 2cm) — these usually require reconstructive assessment.

An obliterative stricture — near-complete or complete obstruction of the urethral lumen — is a different clinical problem from a simple, nonobliterative stricture. DVIU is not a universal solution for an obliterated urethral segment, and in such cases a reconstructive approach is discussed earlier in the diagnostic pathway.

Spongiofibrosis

Spongiofibrosis is fibrosis of the corpus spongiosum surrounding the urethra — essentially, the “depth” of the scar beyond the lumen itself.

The more extensive the spongiofibrosis, the more significant the underlying scar disease, and the more likely a reconstructive approach may be needed instead of a simple endoscopic incision. DVIU incises the lumen but does not correct the spongiofibrosis around it — this is one reason why an apparently “good” result may not be durable.

Primary Episode vs Recurrence

Diagnosis Before the Procedure

Before DVIU, we need to know the location, length, degree of narrowing, depth of fibrosis, and history of previous treatments. Tests that may be used include:

Retrograde Urethrography

Retrograde urethrography provides important information for treatment planning: site, length, calibre, and the presence of multiple strictures. This is not an optional test when an invasive treatment is being planned — it is a core mapping tool before any decision about DVIU, dilatation, or reconstruction.

Urethroscopy

Direct endoscopic examination can confirm the narrowing, lumen, and — where accessible — proximal anatomy. Where relevant, flexible cystoscopy can contribute to the evaluation of the lower urinary tract.

How the Procedure Is Performed

This description is deliberately high-level — it is not a surgical technique manual.

Cold Knife (Sachse) vs Laser

Classic optical Sachse urethrotomy uses a mechanical “cold knife” under direct vision. Incision of the scar tissue can alternatively be performed with laser (e.g. Holmium) in selected practice settings.

The available literature gives conflicting results: some randomised trials report lower recurrence with laser in the first year, others find no statistically significant difference after the first few months, while at longer-term follow-up (five years) some series show similarly low patency for both techniques. There is also conflicting evidence on complications — some studies report less bleeding with laser, others a higher rate of urinary retention.

DVIU vs Simple Dilatation

Both are endoluminal treatments that do not reconstruct the urethra. The available literature does not demonstrate clear superiority of one method over the other in terms of long-term patency.

DVIU vs Optilume

According to EAU guidelines, Optilume has a documented role in selected, short (under about 3cm) bulbar strictures that have already recurred after at least two prior endoscopic treatments, particularly in patients who are not suitable for or do not wish to undergo urethroplasty. It is not automatically the best choice for every stricture — its indication concerns a specific patient and disease profile.

See the full page on Optilume — drug-coated balloon dilatation for urethral stricture.

DVIU vs Urethroplasty

Urethroplasty is not an “excessive” treatment — it is the method that actually removes or reconstructs the scarred segment, with generally higher long-term patency in long, recurrent, or complex strictures, according to the available literature.

According to EAU guidelines, urethroplasty tends to have a stronger role in: recurrent strictures, longer strictures, penile urethral strictures, significant spongiofibrosis, failure of prior DVIU or dilatation, and lichen sclerosus-related disease.

How Many Times Can Urethrotomy Be Done?

According to EAU guidelines, repeating endoscopic urethrotomy or dilatation more than twice is not recommended when urethroplasty is a viable option for the specific patient.

Repeated endoscopic procedures can increase the length and complexity of the stricture and delay definitive reconstruction, according to the available literature. The decision to “try again” with the same endoscopic treatment should be made consciously, not out of inertia.

Intermittent Self-Dilatation (ISD)

In selected patients after DVIU, intermittent self-dilatation / self-catheterisation may be used, aiming to stabilise or delay recurrence.

Catheter, Anaesthesia, Hospital Stay

After Catheter Removal

Expected temporary symptoms may include dysuria, urgency, frequency, and mild haematuria. Flow may appear immediately improved — however, this initial improvement in flow does not prove that the stricture will not recur.

A universal antibiotic course is not given to every patient — the need for prophylaxis or treatment depends on preoperative urine status and the individual protocol, always in line with relevant urological infection guidelines.

Work, Exercise, Sexual Activity

DVIU concerns the urethra, not the corpora cavernosa. However, it should not be presented as carrying zero sexual side effects. If the stricture affected the force of ejaculatory flow, a change may occur after treatment, without this being a universal claim for every patient.

How We Monitor for Recurrence

Follow-up usually combines symptoms, uroflowmetry, post-void residual (PVR) measurement, validated symptom questionnaires, and — where indicated — urethroscopy or urethrography. Routine invasive cystoscopy at fixed intervals is not recommended for every patient.

Urinary flow (Qmax) may improve after DVIU, but a single Qmax value should not be used as the sole definition of recurrence.

Recurrence may present as: recurrent weak stream, straining, rising post-void residual, recurrent urinary tract infections, urinary retention, or objective narrowing on imaging — diagnosis should not rely on a single symptom alone.

Success Rates: What You Should Know

In the international literature, patency rates after DVIU vary widely — from about 8% to 77% in retrospective series with at least one year of follow-up — precisely because these studies include heterogeneous stricture populations and different definitions of “success”. In carefully selected patients with a first episode of a short (1–2cm), nonobliterative bulbar stricture, a five-year patency of up to about 70–71% has been reported in one of the larger series — but this does not apply universally to every patient, and most recurrences occur within the first year.

Studies may define “success” as: no need for reintervention, adequate lumen on imaging, improved flow, or symptom improvement. Percentages from different studies with different definitions of success are not always directly comparable.

Stricture After Prostate Surgery

Stenosis after transurethral resection of the prostate (TURP), thermal techniques (TURis, HoLEP), or radical prostatectomy is not always the same clinical problem — it may be an anterior urethral stricture, a bladder neck contracture, or a vesicourethral anastomotic stenosis. These are not all managed in the same way.

In stenosis close to the external sphincter or the anastomosis, endoscopic treatment can affect continence risk — it should not be presented as zero-risk for continence in every case.

Lichen Sclerosus & Traumatic Strictures

Strictures related to lichen sclerosus often have different biology and tend to be longer, involve the penile urethra, and recur more frequently. The reconstructive strategy can differ significantly — repeated DVIU is not recommended as a definitive strategy in this context.

Post-traumatic strictures may have different fibrosis, location, and severity, and often require reconstructive planning from an early stage — the indications for DVIU should not be generalised to this patient population.

Acute Urinary Retention

In acute urinary retention due to a stricture, catheterisation may be needed if it can be done safely, or a suprapubic catheter (cystostomy) may be placed when passage through the urethra is not safe — the choice depends on the anatomy and location of the stricture.

The Patient's Journey

Frequently Asked Questions

Related Topics

Scientific References

1. EAU Guidelines on Urethral Strictures 2026 — uroweb.org
2. Barbagli G et al. Long-term outcome of direct vision internal urethrotomy for short bulbar urethral strictures. BJU Int.
3. Greenwell TJ et al. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. BJU Int. 2004;94(7):1051–1055.
4. Jin T et al. Safety and efficacy of laser and cold knife urethrotomy for urethral stricture. Systematic review.