What is the next step in managing a 7cm penile urethral stricture in a 70-year-old man with Parkinson's disease (PD) and a history of myocardial infarction (MI) after transurethral resection of the prostate (TURP)?

From the Guidelines

The next step in managing a 7cm penile urethral stricture in this 70-year-old man with Parkinson's disease and history of MI after TURP would be to perform a urethroplasty, specifically a staged approach with buccal mucosal graft, as recommended by the most recent guidelines 1. Given the length of the stricture (7cm), direct vision internal urethrotomy or dilation would likely have poor long-term success rates, with failure rates of >80% for repeated endoscopic procedures 1. The patient's age and comorbidities (Parkinson's disease and previous MI) necessitate careful preoperative assessment, including cardiac clearance and optimization of his Parkinson's medications. The first stage would involve opening the strictured urethra ventrally and placing the buccal mucosal graft, followed by a second procedure 4-6 months later to tubularize the neourethra. Perioperative management should include appropriate antibiotic prophylaxis (typically a fluoroquinolone or cephalosporin), continued Parkinson's medications to prevent exacerbation, and cardiac monitoring. Postoperatively, the patient will need a suprapubic catheter for urinary diversion for approximately 3-4 weeks after each stage. This approach is preferred because the extensive length of the stricture makes endoscopic management futile, while the staged approach reduces surgical risk in a patient with significant comorbidities compared to a single-stage procedure. Key considerations in the management of this patient include:

• The need for careful preoperative assessment and optimization of comorbidities 1
• The importance of choosing the most appropriate surgical approach based on the length and location of the stricture, as well as the patient's overall health status 1
• The potential benefits and risks of different treatment options, including endoscopic management, urethroplasty, and suprapubic catheterization 1

From the Research

Management of Penile Urethral Stricture

The management of a 7cm penile urethral stricture in a 70-year-old man with Parkinson's disease and a history of myocardial infarction after transurethral resection of the prostate (TURP) can be considered based on the following options:

• Daily urethral self-dilation
• Permanent perineal urethrostomy
• Augmentation urethroplasty with penile skin flap
• Augmentation urethroplasty with oral mucosa graft
• Two-stage urethroplasty

Consideration of Patient Factors

Given the patient's age and medical history, including Parkinson's disease and myocardial infarction, the choice of management should take into account the potential risks and benefits of each option. The patient's condition may influence the decision towards a more suitable approach, considering the need for minimal complications and optimal outcomes.

Review of Evidence

Studies have compared different techniques for managing urethral strictures:

• A study from 2 found that there is little difference in success between penile urethroplasty techniques, suggesting that single-stage buccal mucosal graft (BMG) may be preferred due to fewer operations and lower complication rates.
• Another study from 3 compared anterior urethroplasty and perineal urethrostomy, finding similar improvements in urinary function and stable sexual function after surgery, with perineal urethrostomy having a lower failure rate.
• The use of perineal urethrostomy has been increasing over the past decade, as reported in 4, with higher success rates compared to BMG and skin flaps, particularly in older patients with longer strictures.
• A study from 5 found that definitive perineal urethrostomy is often performed in older patients with worse cardiovascular conditions, panurethral stricture disease, and longer strictures, and may be explicitly chosen by well-informed patients.

Potential Next Steps

Based on the evidence, the potential next steps for managing the patient's 7cm penile urethral stricture could be:

• Considering perineal urethrostomy as a viable option, given the patient's age and medical history, as supported by 3, 4, and 5
• Evaluating the patient's suitability for augmentation urethroplasty with oral mucosa graft or penile skin flap, taking into account the potential risks and benefits, as discussed in 2
• Discussing the options with the patient, considering their preferences and values, to make an informed decision about the best course of treatment.