What is the next step in managing a 7 cm post-traumatic urethral stricture after Transurethral Resection of the Prostate (TURP) in a 70-year-old man with Parkinsonian tremors and a history of Myocardial Infarction (MI)?

Management of 7 cm Post-TURP Urethral Stricture in a 70-Year-Old with Parkinsonian Tremors and MI History

For this 70-year-old man with Parkinsonian tremors, history of myocardial infarction, and a 7 cm post-TURP urethral stricture, the most appropriate next step is augmentation urethroplasty with oral mucosal graft rather than daily self-catheterization, perineal urethrostomy, or penile skin flap techniques. 1

Assessment of Patient and Stricture Factors

Patient-Specific Considerations:

• 70-year-old male with significant comorbidities:
  • Parkinsonian tremors (affecting manual dexterity)
  • History of myocardial infarction (cardiovascular risk)
• Long stricture (7 cm) in penile and bulbar urethra following TURP

Stricture Characteristics:

• 7 cm length (considered a long stricture)
• Post-TURP etiology (iatrogenic cause)
• Penile and bulbar urethral involvement

Treatment Decision Algorithm

1. Rule out endoscopic management options:

   • Endoscopic procedures (dilation/DVIU) have >80% failure rates for strictures >2 cm 1
   • The 7 cm length makes endoscopic management inappropriate as primary treatment

2. Evaluate self-catheterization feasibility:

   • Parkinsonian tremors significantly impair manual dexterity
   • Self-catheterization requires fine motor skills
   • Long stricture (7 cm) would make self-catheterization technically difficult and likely unsuccessful
   • Self-catheterization is only recommended for patients who are not candidates for urethroplasty 1

3. Consider definitive surgical options:

   • Urethroplasty is the recommended treatment for recurrent or long urethral strictures 1
   • Options include:
     • Augmentation with oral mucosal graft
     • Augmentation with penile skin flap
     • Perineal urethrostomy

4. Select optimal surgical approach:

   • Oral mucosal graft is the first-choice graft material for urethroplasty 1
   • Penile skin flaps have higher rates of post-void dribbling and penile skin problems 1
   • Perineal urethrostomy is typically reserved for patients who have failed multiple urethroplasties or are poor surgical candidates

Rationale for Oral Mucosal Graft Urethroplasty

1. Superior tissue characteristics:

   • Oral mucosa has excellent tissue properties for urethral reconstruction
   • Higher patient satisfaction compared to skin flaps 1
   • Lower complication rates than penile skin flaps

2. Better outcomes for long strictures:

   • Success rates of 82-90% for oral mucosal graft urethroplasty 2
   • Appropriate for the 7 cm length of this stricture

3. Consideration of patient comorbidities:

   • Single-stage procedure reduces anesthetic exposure for a patient with cardiac history
   • Less morbidity than multi-stage approaches

Why Other Options Are Less Suitable

1. Daily self-catheterization:

   • Contraindicated due to Parkinsonian tremors affecting manual dexterity
   • High failure rate with long strictures (7 cm)
   • Would only provide temporary relief and likely lead to stricture recurrence 1

2. Perineal urethrostomy:

   • Generally reserved for patients who have failed multiple urethroplasties
   • Represents a salvage procedure rather than first-line treatment
   • Significant lifestyle adjustment for the patient

3. Penile skin flap:

   • Not recommended when oral mucosa is available 1
   • Higher complication rates and lower patient satisfaction
   • More complex surgical procedure with higher morbidity

Perioperative Considerations

• Preoperative evaluation:

  • Cardiac clearance given history of myocardial infarction
  • Management of Parkinsonian symptoms perioperatively
  • Consider suprapubic cystostomy for "urethral rest" prior to definitive urethroplasty 1

• Surgical planning:

  • Single-stage procedure preferred to minimize anesthetic exposure
  • Adequate oral mucosal harvest (typically from cheek)
  • Dorsal or ventral graft placement based on stricture location

Follow-Up Protocol

• Monitor for symptomatic recurrence following urethroplasty 1
• Urethrocystoscopy, ultrasound urethrography, or retrograde urethrography at 3-month intervals initially 1
• Long-term follow-up to detect late recurrences

In conclusion, augmentation urethroplasty with oral mucosal graft represents the optimal management strategy for this patient with a long post-TURP urethral stricture and significant comorbidities, offering the best balance of efficacy, durability, and consideration of the patient's specific circumstances.