Management of 7 cm Post-TURP Urethral Stricture in a 70-year-old with Parkinson's and MI History
Augmentation urethroplasty with oral mucosal graft is the most appropriate treatment for this patient with a long (7 cm) penile-bulbar urethral stricture following TURP.
Patient Assessment and Stricture Characteristics
This case involves a 70-year-old man with several important clinical factors:
- 7 cm urethral stricture (considered a long stricture)
- Post-TURP etiology (iatrogenic cause)
- Penile-bulbar location
- Comorbidities: Parkinson's disease with tremors and history of myocardial infarction
Treatment Decision Algorithm
Step 1: Evaluate Stricture Length and Location
- The 7 cm length classifies this as a long stricture (≥2 cm)
- For strictures ≥2 cm, endoscopic management has very low success rates (only 20% for strictures >4 cm) 1
- Penile urethral strictures have particularly high recurrence rates with endoscopic treatments 1
Step 2: Consider Treatment Options Based on Guidelines
Urethral dilation/DVIU: Not recommended for this patient
Daily self-dilation: Not appropriate as definitive treatment
- Only recommended as temporary measure for patients who are not candidates for urethroplasty 1
- High failure rate for long strictures
Perineal urethrostomy: Possible option but not optimal
- Can be considered for patients with complex strictures, advanced age, or significant comorbidities 1
- However, this is a more conservative approach that doesn't restore normal urethral function
Two-stage urethral plasty: Unnecessarily complex
- Typically reserved for cases with lichen sclerosus, failed prior urethroplasty, or extremely complex strictures 1
Augmentation urethroplasty with oral mucosal graft: Optimal choice
Step 3: Consider Patient-Specific Factors
- Parkinson's tremors: May affect self-catheterization ability, making daily self-dilation challenging
- History of MI: Requires careful perioperative management but is not an absolute contraindication to urethroplasty
- Age: While advanced age is a consideration, the patient's overall functional status is more important than chronological age
Evidence-Based Recommendation
The American Urological Association guidelines strongly recommend:
- Urethroplasty as the initial treatment for patients with long (≥2 cm) urethral strictures 1
- Oral mucosa as the first choice when using grafts for urethroplasty 1
- Avoiding repeated endoscopic treatments for penile urethral strictures 1
Potential Complications and Management
- Erectile dysfunction: May occur transiently after urethroplasty but typically resolves within six months 1
- Ejaculatory dysfunction: Reported in up to 21% of men following bulbar urethroplasty 1
- Recurrence risk: Lower with proper technique, but requires monitoring
Follow-Up Protocol
- Retrograde urethrogram or voiding cystourethrogram 2-3 weeks postoperatively 1
- Subsequent monitoring for:
- Lower urinary tract symptoms
- Peak urine flow (should be >15 ml/second)
- Post-void residual volume
- Flexible cystoscopy may be performed to confirm absence of recurrence 1
Pitfalls to Avoid
Repeated endoscopic treatments: These have very low success rates for long strictures and may compromise the success of subsequent urethroplasty 1
Using penile skin for reconstruction: This should be avoided if there's any suspicion of lichen sclerosus 1
Tubularized urethroplasty: Single-stage tubularized urethroplasty has a high risk of restenosis and should be avoided 1
Delaying definitive treatment: Post-TURP strictures typically present within 6 months of surgery 2 and should be addressed promptly to prevent complications