How can post-Transurethral Resection of the Prostate (TURP) urethral strictures be prevented in patients with a history of urethral trauma, previous urethral strictures, or conditions like diabetes?

Prevention of Post-TURP Urethral Strictures

To prevent urethral strictures after TURP, limit operative time to under 60 minutes, use appropriate catheter size and duration, consider prophylactic internal urethrotomy in high-risk patients, and optimize perioperative management of diabetes and urinary tract infections.

Risk Factor Modification

Operative Technique Factors

• Minimize resection time to less than 60 minutes, as prolonged operative duration significantly increases stricture risk (75.8% of stricture patients had procedures >60 minutes vs. 25% without strictures) 1

• Limit prostate resection volume, particularly when prostate size exceeds 70 cm³, as larger glands requiring more extensive resection correlate with higher stricture rates (mean 80 cm³ in stricture patients vs. 60 cm³ in those without) 1

• Use bipolar TURP when possible, as it has a more favorable perioperative safety profile than monopolar TURP with potentially lower complication rates 2

Preoperative Urethral Preparation

• Consider prophylactic internal urethrotomy (Otis urethrotomy) immediately before TURP, which reduced stricture incidence from 7.3% to 4.4% in comparative studies, though this difference did not reach statistical significance 3

• Avoid prolonged preoperative urethral catheterization when possible, as counterintuitively, the presence of a transurethral catheter before TURP was protective against stricture formation (OR 0.16,95% CI 0.064-0.442) 4

Medical Comorbidity Management

• Aggressively control diabetes mellitus preoperatively, as diabetic patients have significantly higher stricture rates (30% in stricture group vs. 12.5% in non-stricture group) 1

• Screen for and treat asymptomatic bacteriuria before TURP, as preoperative infection increases postoperative complications including stricture formation 5

• Treat chronic prostatitis before surgery when identified, as chronic prostatic inflammation was present in 66.6% of patients who developed strictures compared to 32.5% without strictures 1

• Optimize blood pressure control in hypertensive patients, as hypertension was more prevalent in the stricture group (60.6% vs. 37.5%) 1

Postoperative Catheter Management

Catheter Selection and Duration

• Place an appropriately sized urethral catheter (20-24 Fr) following TURP to divert urine from the surgical site and prevent urinary extravasation 6

• Maintain short-duration catheterization as prolonged catheter use may increase stricture risk, though specific optimal duration varies by procedure extent 6

• Consider urethral catheter over suprapubic tube as urethral catheterization is thought to be optimal for standard TURP 6

Infection Prevention

• Administer appropriate prophylactic antibiotics based on preoperative urine culture to reduce surgical site infections 6

• Initiate antimicrobial therapy 30-60 minutes before the procedure with short-course therapy as recommended 5

• Treat active UTIs completely before proceeding with urethral stricture intervention if subsequent procedures are needed 6

Special Population Considerations

Patients with Prior Urethral Trauma or Strictures

• Exercise extreme caution in patients with previous urethral pathology, as they represent the highest-risk group for recurrent stricture formation 6

• Consider alternative surgical approaches (such as open prostatectomy or laser procedures) in patients with significant prior urethral scarring 6

Patients with Previous TURP

• Recognize that repeat TURP carries higher stricture risk, particularly in the proximal bulbar urethra near the membranous urethra 7, 8

• Ensure adequate healing time (at least 3 months) if prior urethral procedures were performed before proceeding with TURP 6

Surveillance and Early Detection

Follow-up Protocol

• Monitor patients for at least one year following TURP using uroflowmetry, symptom assessment, and post-void residual measurements 6

• Maintain high clinical suspicion for stricture in patients presenting with decreased urinary stream, incomplete emptying, or recurrent UTIs within 6 months post-TURP, as most strictures present during this timeframe 7

• Define treatment success as peak urine flow >15 ml/second, absence of lower urinary tract symptoms, and low post-void residual 6

Common Pitfalls to Avoid

• Avoid repeated attempts at catheter placement during or after TURP, as this increases injury extent and stricture risk 6

• Do not ignore chronic inflammation on pathology reports, as this finding should trigger more intensive follow-up 1

• Avoid aggressive resection in patients with multiple risk factors (diabetes, large prostate, hypertension, chronic prostatitis), as cumulative risk substantially increases stricture probability 1

• Do not delay treatment of symptomatic strictures, as early intervention with appropriate techniques (urethroplasty rather than repeated dilation) provides better long-term outcomes 7, 8