Can the use of a visual obturator-assisted resectoscope reduce the incidence of urethral strictures after TURP?: a multicenter propensity-matched study

PURPOSE: Urethral stricture (US) is a significant long-term complication of transurethral resection of the prostate (TURP), often linked to mechanical trauma during instrument insertion. This study evaluated whether advancing the resectoscope sheath under direct vision using a visual obturator reduces postoperative US incidence compared to blind insertion. MATERIALS AND METHODS: A retrospective multicenter study was conducted across four centers involving patients who underwent bipolar TURP between 2020 and 2025. After applying propensity score matching to minimize baseline bias, 962 patients were analyzed (481 per group: visual vs. blind obturator). Primary outcomes included US incidence, perioperative variables, and functional results (Qmax). Subgroup analysis was performed based on prostate volume. RESULTS: The overall US incidence was 12.4%. Patients in the visual obturator group had a significantly lower US rate compared to the blind group (7.7% vs. 17.0%, p < 0.001). Visual guidance also correlated with a significant reduction in overall postoperative complications and acute urinary retention. Subgroup analysis revealed that the protective effect of the visual obturator was most pronounced in prostates > 60 cc. While traditional predictors like operative time and prostate volume showed modest discriminatory ability for US risk in the blind group, their impact was mitigated in the visual group. Both groups showed improved Qmax, with a higher baseline and more stable trend in the visual cohort. CONCLUSION: Direct vision advancement of the resectoscope sheath using a visual obturator significantly reduces the risk of urethral stricture and postoperative morbidity. This technique offers a simple, effective strategy to minimize urethral trauma, particularly in larger prostates, and should be considered for routine use.