What's the next step in managing a 70-year-old male with parkinsonian tremors and a history of Myocardial Infarction (MI) who has a 7cm penile urethral stricture after a Transurethral Resection of the Prostate (TURP)?

Management of Penile Urethral Stricture After TURP

Urethroplasty with oral mucosa graft is the recommended treatment for this 70-year-old male with a 7cm penile urethral stricture following TURP. 1, 2

Rationale for Urethroplasty

The American Urological Association guidelines strongly recommend urethroplasty as the initial treatment for penile urethral strictures, particularly those ≥2 cm in length, due to the following factors:

• The patient's stricture is 7cm long, which significantly exceeds the 2cm threshold where minimally invasive approaches have acceptable success rates
• Endoscopic treatments like direct visual internal urethrotomy (DVIU) or dilation have extremely poor outcomes for strictures of this length 1
• Oral mucosa is the preferred graft material for urethroplasty with success rates exceeding 80% for long strictures 2

Special Considerations for This Patient

Several patient factors require careful consideration:

1. Age (70 years): While advanced age alone is not a contraindication for urethroplasty, it may influence surgical planning
2. Parkinsonian tremors: May affect post-operative care and catheter management
3. History of MI: Requires pre-operative cardiac clearance and optimization

Treatment Algorithm

1. Pre-operative Assessment:

   • Cardiac evaluation due to history of MI
   • Neurological assessment of Parkinsonian symptoms
   • Urine culture to rule out active UTI (must be treated before intervention) 1
   • Confirm stricture characteristics with retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) 1

2. Surgical Approach:

   • Urethroplasty using oral mucosa graft (buccal or lingual)
   • Avoid using hair-bearing skin or tubularized grafts due to high failure rates 2
   • Consider single-stage approach unless there are complicating factors like lichen sclerosus

3. Post-operative Management:

   • Urinary catheter placement for 2-3 weeks 2
   • Perform RUG or VCUG before catheter removal to confirm healing 1
   • Monitor for complications including transient erectile dysfunction and ejaculatory dysfunction 1

Alternative Options

If the patient is deemed too high-risk for urethroplasty due to his comorbidities:

1. Permanent perineal urethrostomy: A more conservative approach that doesn't restore normal urethral function but may be appropriate for patients with significant comorbidities 2

2. Temporary management with intermittent self-dilation: This should only be considered as a palliative approach if the patient is absolutely not a surgical candidate, as it has very poor long-term success for strictures of this length 2

Common Pitfalls to Avoid

• Attempting repeated endoscopic treatments: For a 7cm penile urethral stricture, DVIU or dilation will have extremely low success rates and may worsen subsequent reconstructive options 1, 2

• Using skin flaps instead of oral mucosa: Oral mucosa grafts have higher patient satisfaction with fewer complications like post-void dribbling and penile skin problems 2

• Inadequate follow-up: Post-operative monitoring should include assessment of urinary symptoms, peak flow rate (should exceed 15 ml/second), and post-void residual volume 1, 2

The management of this complex case requires balancing the need for definitive treatment with the patient's comorbidities. However, given the length of the stricture and its location, urethroplasty with oral mucosa graft offers the best chance for long-term success and improved quality of life.