Endoscopic treatment of strictures and prostate issues
Keyhole surgery through the urethra, with no external incision — for strictures, bladder neck problems and an obstructing prostate.
What endoscopic surgery means
Endoscopic urology is performed entirely through the urethra using a fine telescope, with no external cut. It is generally quicker to recover from than open surgery, is usually a day case, and for many problems it is the correct first treatment.
It is not, however, always the best treatment, and the distinction matters. For a first short urethral stricture an endoscopic procedure is entirely reasonable. For a stricture that has already recurred twice, repeating it is simply postponing the definitive operation while adding scar tissue that makes that operation harder. Being offered the least invasive option is not the same as being offered the right one, and I will tell you which is which.
Endoscopic treatment of urethral stricture
Optical urethrotomy and dilatation
The narrowed segment is either stretched with graduated dilators or incised with a small blade passed down the telescope. Both give immediate relief of symptoms and a rapid recovery.
Their limitation is durability: the scar re-forms in the majority of men, and success falls sharply with each repeat attempt. As a one-off treatment for a short, first-presentation bulbar stricture it is appropriate. As a repeating cycle it is not, and men who have had three or four should be assessed for urethroplasty instead.
The Optilume drug-coated balloon
A balloon that dilates the stricture while delivering a drug into the urethral wall intended to interrupt the scarring process that makes conventional dilatation fail. It is a genuine addition to the range of options for short, recurrent bulbar strictures in men who wish to avoid open reconstruction. See the Optilume page for full detail, including the fertility considerations.
Self-catheterisation
Passing a catheter yourself on a regular schedule keeps a dilated stricture open by preventing the scar from contracting. It sounds worse than it is, most men manage it easily once taught, and it can maintain a good flow for years in men who are not candidates for reconstruction.
Bladder neck stenosis
Narrowing at the bladder neck, most commonly after prostate surgery or radiotherapy, causing a slow stream and incomplete emptying. It is treated endoscopically by incising the scar, and in resistant or recurrent cases by more formal reconstruction — including robotic buccal graft repair, where our unit has the largest UK experience. See robotic reconstruction and after prostate cancer surgery.
Prostate outflow obstruction
An enlarged prostate obstructing the flow of urine causes a weak stream, hesitancy, incomplete emptying, night-time waking and urgency, and if left long enough can damage the bladder and kidneys. Where medication has not worked or is not tolerated, endoscopic surgery is highly effective.
- Transurethral resection of the prostate (TURP) — the long-established reference standard, removing obstructing tissue from inside the prostate.
- Bladder neck incision — for smaller prostates where a simple incision relieves the obstruction, with a lower risk of retrograde ejaculation.
- Cystoscopy and assessment to establish whether the prostate is actually the cause, since bladder dysfunction and stricture disease produce identical symptoms and are treated completely differently.
Ejaculation is part of this conversation
Most prostate outflow operations cause retrograde ejaculation — semen passing backwards into the bladder rather than outwards. It is harmless and does not affect the sensation of orgasm, but it does affect fertility, and it matters a great deal to some men. If you may still want children, say so before surgery is planned; there are approaches that reduce this risk, and sperm storage is straightforward.
Assessment first
Endoscopic surgery is only as good as the diagnosis behind it. Assessment includes flow rate measurement and a bladder scan for residual urine, flexible cystoscopy, urethrography where a stricture is suspected, and urodynamic testing where it is unclear whether the problem is obstruction or the bladder itself. Urine is cultured and any infection treated before any instrument is passed.
Recovery
Most endoscopic procedures are day cases under general or spinal anaesthetic. Expect stinging on passing urine and some blood in the urine for a few days to two weeks. A catheter is used overnight or for a few days depending on the procedure. Most men return to desk work within a few days to a week, and avoid heavy lifting and cycling for two to four weeks.
Follow-up includes flow rate measurement, because a falling flow rate is the earliest sign of recurrence and appears well before symptoms return.
My practice
I lead the Southeast London Urethral Reconstruction Team at Guy's Hospital and perform both endoscopic and open reconstructive surgery, including the Optilume balloon. Because I offer the full range, the recommendation follows your stricture rather than the equipment available — and where I think another endoscopic procedure would simply waste your time, I will say so.
Frequently asked
How many times can a stricture be stretched before I need surgery?
As a rule, once. A single dilatation or urethrotomy for a short first-presentation bulbar stricture is reasonable. If it recurs, the chance that a second attempt lasts is low, and by the third the odds are poor while the scarring accumulates. At that point reconstruction is usually the better decision.
Will endoscopic prostate surgery affect my erections?
Erectile function is usually unchanged. Retrograde ejaculation, on the other hand, is common and expected — semen passes back into the bladder instead of outwards. It is harmless, does not change the sensation of orgasm, but does affect fertility, so it needs discussing in advance if children are a possibility.
Is self-catheterisation as bad as it sounds?
Almost universally, no. Men are understandably horrified when it is first suggested, and almost all of them manage it comfortably within a week or two of being taught. It is a reasonable long-term strategy for keeping a stricture open in men who are not suitable for, or do not want, reconstruction.
Can I have open reconstruction later if endoscopic treatment fails?
Yes. Endoscopic treatment does not rule out later urethroplasty. It does add some scar tissue each time, so if it is already clear that reconstruction will eventually be needed, going straight to it avoids months of repeated procedures.
Do I need a general anaesthetic?
Most of these procedures are performed under general or spinal anaesthetic as a day case. Some simple dilatations and cystoscopies can be done under local anaesthetic in clinic. Which applies to you is decided at assessment.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.