Efficacy of Repeated Utilization of Direct Vision Internal Urethrotomy (DVIU) in Pediatric Urethral Stricture Disease
Michael Pintauro, MD1, Avinash Maganty, MD2, Valentina Grajales, MD3, Paul Rusilko, DO1, Rajeev Chaudhry, MD4, Omar Ayyash, MD4.
1UPMC, Pittsburgh, PA, USA, 2University of Michigan, Ann Arbor, MI, USA, 3MD Anderson Cancer Center, Houston, TX, USA, 4Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
Background: Pediatric stricture disease is uncommon. Direct vision internal urethrotomy (DVIU) is commonly used in both pediatric and adult patients. Contemporary evidence in the adult population suggests repeated DVIU leads to decreased success rates. We sought to determine if this was also true in the pediatric population.
Methods: We performed a retrospective review of pediatric patients who underwent surgical treatment of urethral stricture disease with DVIU over a 15-year period (2005-2020). Patients with less than 1 year of follow up were excluded. Data was collected for patient demographics, prior history of hypospadias, number of procedures, location of stricture, length of stricture, time to recurrence, and patient symptoms. Logistic regression for predictors of DVIU failure were also assessed. Time-to-failure analysis was used to assess durability of treatment.
Results: We identified 28 patients who underwent 1 DVIU; of those, 4 patients underwent 2 DVIU; of those who underwent two DVIU, 1 patient underwent a 3rd DVIU. Success rates were 46.4%, 0%, and 0%, respectively. The median time to failure for primary DVIU was 8.0 months; further DVIU had similar median time to failure rates of 11.5 months and 8 months for 2 and 3 DVIU, respectively (Figure 1). Patients who underwent more than one DVIU required a significantly greater total number of procedures (including urethroplasty) than those who underwent 1 DVIU (p=0.01). Patients who underwent 2 or 3 DVIU had significantly higher rates of prior hypospadias repair than those who underwent a single DVIU (p=0.043). On Multivariate analysis, predictors of stricture recurrence after first DVIU include history of hypospadias (OR 2.59, 95% CI: 0.28-37.04), non-cogenital cause of hypospadias (OR 1.4, 95% CI 0.18-13.38), and older age (OR 1.23, 95% CI 1.03 - 1.59).
Conclusions: Primary DVIU offers a minimally invasive treatment option for urethral stricture, although success rates remain low. Repeat DVIUs appear to offer reduced success rates, mimicking data seen in adult populations. Should patients fail initial DVIU, strong consideration should be given to proceeding with formal urethroplasty rather than a repeat DVIU.
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