Can preoperative transurethral catherization reduce the risk of urethral stricture after endoscopic treatment of the prostate?

Urethral strictures are a well-known complication following endoscopic treatment of benign prostatic hyperplasia (BPH). Although the exact cause remains unclear, repetitive instrument movement and pressure-induced ischemia are likely contributing factors. While the incidence seems lower after enucleation compared to transurethral resection of the prostate, it remains important to prevent this iatrogenic complication. A small randomized trial suggested a benefit from preoperative urethral dilatation, though findings were constrained by limited sample size and follow-up. Similarly, studies comparing resectoscope sizes have not yet demonstrated significant differences in stricture rates. Drawing parallels with ureteral stricture prevention, where prestenting with a ureteral catheter is commonly used, we hypothesize that preoperative transurethral catheterization may relax and dilate the urethra, potentially lowering the risk of stricture formation. Clinical observations support this: patients with preoperative indwelling catheters before endoscopic treatment of BPH often display a more compliant urethra during surgery. While mechanical irritation remains a theoretical concern of placing a catheter, the relaxing effect may outweigh potential harm, much like DJ-stent use in the ureter. A prospective study will be conducted within the EAU Endourology Consortium to evaluate this hypothesis, incorporating force-sensing dilators and standardized follow-up with uroflowmetry and cystoscopy at 3 and 6 months. If successful, preoperative catheterization may offer a simple, low-risk strategy to reduce urethral strictures in BPH surgery, particularly in patients with a narrow urethra.