Modified Seldinger-Assisted Access for Direct Visual Internal Urethrotomy in a High-Grade Urethral Stricture: A Novel Technique

Modified Seldinger-Assisted Access for Direct Visual Internal Urethrotomy in a High-Grade Urethral Stricture

This video demonstrates a novel modification of direct visual internal urethrotomy (DVIU) using a Seldinger-assisted access technique to safely negotiate a very tight, high-grade urethral stricture. To our knowledge, this is the first video documentation of this technique applied to transurethral stricture management.

Conventional DVIU relies on direct endoscopic advancement of the urethrotome under vision alone. This becomes high-risk once the residual luminal caliber narrows enough that the true lumen cannot be reliably identified, with a substantial risk of creating a false passage. We adapted the wire-guided principle standard in vascular and percutaneous renal access to transurethral instrumentation: a hydrophilic guidewire is first advanced under direct vision across the stenotic segment, using its flexible tip to probe and redirect within the true lumen far more forgivingly than the leading edge of a rigid scope sheath. Wire position across the stricture is confirmed before the urethrotome sheath is advanced over the wire as a fixed rail, decoupling the step of finding the lumen from the step of advancing the instrument through it.

Once the sheath has safely traversed the stricture under wire guidance, the wire is removed and standard cold-knife incision is performed under direct vision through the full depth of fibrotic tissue until healthy spongiosal tissue is encountered. 

By securing safe passage across the stricture before committing the cutting instrument, this technique meaningfully reduces the risk of false passage in strictures too tight for confident direct-vision negotiation alone — a common limiting factor in offering DVIU for high-grade strictures that might otherwise be deferred to urethroplasty. We present this as a reproducible, easily adoptable modification for urologists managing difficult stricture anatomy.

No technique notes provided for this video.