What is the best management approach for a 70-year-old man with a history of myocardial infarction (MI) and Parkinsonian tremors who has developed a 7 cm penile urethral stricture after Transurethral Resection of the Prostate (TURP)?

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

Augmentation urethroplasty with oral mucosa graft is the optimal treatment for this 70-year-old man with a 7 cm penile urethral stricture after TURP, considering his medical history and the length of the stricture. 1, 2

Rationale for Oral Mucosa Graft Urethroplasty

• For penile urethral strictures, especially those ≥2 cm in length, urethroplasty is strongly recommended as the initial treatment due to the high recurrence rates with endoscopic treatments 1, 2
• Oral mucosa should be used as the first choice when using grafts for urethroplasty (Expert Opinion) 1
• Success rates for buccal mucosa graft urethroplasty for long strictures exceed 80%, significantly better than the 20% success rate for endoscopic treatment of strictures >4 cm 1, 3

Why Other Options Are Less Suitable

1. Daily urethral self-dilation (Option A):

   • Not recommended for long strictures (7 cm) due to very low success rates 2
   • Particularly inappropriate for a patient with Parkinsonian tremors, which would make self-dilation technically difficult and potentially dangerous

2. Permanent perineal urethrostomy (Option B):

   • While this can be considered for patients with advanced age and medical comorbidities 1
   • It's a more conservative approach that doesn't restore normal urethral function 2
   • Should be reserved for cases where reconstruction has failed or when patient factors make longer surgeries too risky

3. Augmentation urethroplasty with penile skin flap (Option C):

   • Patient satisfaction is higher for oral mucosa urethroplasty compared to skin flaps due to less post-void dribbling and fewer penile skin problems 1
   • Hair-bearing skin should not be used for substitution urethroplasty 1

4. Two-stage urethroplasty (Option E):

   • Typically reserved for cases with lichen sclerosus, failed prior urethroplasty, or extremely complex strictures 2
   • Not necessary as first-line treatment for this case where a single-stage procedure is feasible

Special Considerations for This Patient

• Age and comorbidities: While the patient is 70 years old with cardiac history, oral mucosa graft urethroplasty can still be performed with appropriate perioperative management
• Parkinsonian tremors: These don't contraindicate urethroplasty but may make self-dilation (Option A) particularly challenging
• Post-TURP stricture: These strictures can occur anywhere in the urethra and have been successfully treated with buccal mucosa graft urethroplasty with success rates of 82.43% 4

Surgical Approach

• For a 7 cm penile urethral stricture, dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one-sided urethral dissection (Kulkarni technique) are appropriate one-stage procedures 5
• Ventral onlay may be considered for proximal strictures close to the membranous urethra 4
• Tubularized urethroplasty should be avoided due to high risk of restenosis 1

Postoperative Care

• Urinary catheter placement for 2-3 weeks with retrograde urethrogram or voiding cystourethrogram before removal 1
• Monitor for potential complications including transient erectile dysfunction (typically resolves within 6 months) and ejaculatory dysfunction (reported in up to 21% of men) 1, 2

In conclusion, based on the American Urological Association guidelines and current evidence, augmentation urethroplasty with oral mucosa graft (Option D) is the most appropriate management for this patient with a long penile urethral stricture.