Is a prior Transurethral Resection of the Prostate (TURP) a contraindication to a permanent perineal urethrostomy?

Prior TURP is Not a Contraindication to Permanent Perineal Urethrostomy

A prior transurethral resection of the prostate (TURP) is not an absolute contraindication to a permanent perineal urethrostomy, but it may increase the risk of complications such as incontinence due to potential damage to the external sphincter mechanism.

Understanding Perineal Urethrostomy and TURP

• Perineal urethrostomy is a viable surgical option for complex anterior urethral strictures, creating a permanent opening in the perineum to allow for urination 1, 2
• TURP involves the surgical removal of the prostate's inner portion via an endoscopic approach through the urethra, which may affect the integrity of the urethral tissues and sphincter mechanism 1
• Perineal urethrostomy can be performed as a permanent solution or as part of a staged approach for urethral reconstruction 1, 2

Considerations for Patients with Prior TURP

Potential Challenges

• Patients with previous TURP have an increased risk of incontinence following additional urethral procedures due to potential compromise of the external sphincter mechanism 1
• The risk of bladder neck contractures after TURP (reported as 0.3-9.2%) may complicate subsequent urethral procedures 3
• Prior endoscopic procedures like TURP can make subsequent urethral surgery more technically challenging due to altered anatomy 1

Evidence Supporting Feasibility

• While the American Urological Association guidelines note that patients with previous TURP are not ideal candidates for brachytherapy (a different procedure), they do not specifically contraindicate perineal urethrostomy after TURP 1
• The 2017 AUA Male Urethral Stricture guideline states that perineal urethrostomy is an appropriate long-term treatment option for patients with complex anterior urethral strictures, without specifically excluding those with prior TURP 1
• The 2023 update to the Urethral Stricture Disease guideline recommends perineal urethrostomy as a viable option for "patient populations at high risk for failure of urethral reconstruction" 1

Outcomes and Considerations

• Perineal urethrostomy has shown success rates of approximately 90% in managing complex urethral strictures 2, 4
• In a study of 124 patients who underwent perineal urethrostomy, approximately 15% required secondary interventions, including stomal dilation and TURP 2
• Patient satisfaction rates after perineal urethrostomy are high, with 78% of patients in one study being satisfied with the results 4
• Urinary function typically improves after perineal urethrostomy with no significant negative impact on sexual function 5

Recommendations for Management

• Thorough preoperative evaluation is essential, including retrograde urethrography with voiding cystourethrogram to assess the urethral anatomy, particularly in patients with prior urethral procedures 1
• Surgeons should consider the potential for increased technical difficulty and higher complication rates in patients with prior TURP 1
• Patients should be counseled about the potential increased risk of incontinence and the possible need for secondary interventions 2, 4
• Referral to surgeons with expertise in urethral reconstruction is particularly important for complex cases such as those with prior TURP 1

Conclusion

While a prior TURP presents additional challenges for perineal urethrostomy, it is not an absolute contraindication. The decision should be based on careful preoperative assessment, patient factors, and surgical expertise. Patients should be informed about the potentially higher risk of complications, particularly incontinence, but can still achieve good outcomes with appropriate surgical technique and postoperative management.