From the Guidelines
The next step for this 70-year-old man with a 7 cm penile urethral stricture after TURP, complicated by Parkinson's tremors and previous myocardial infarction, should be urethroplasty. This surgical reconstruction of the urethra is the preferred approach for long strictures (>2 cm) as it offers the best long-term success rates, with success rates of greater than 80% for buccal mucosa graft urethroplasty for strictures of this length 1. Given the significant length of the stricture (7 cm), endoscopic management like direct vision internal urethrotomy or dilation would likely have poor outcomes with high recurrence rates, as longer strictures are less responsive to endoscopic treatment, with success rates of only 20% for strictures longer than 4cm in the bulbar urethra 1.
The procedure would involve either excision and primary anastomosis or, more likely given the length, substitution urethroplasty using buccal mucosa grafts. Prior to surgery, the patient should undergo comprehensive cardiovascular evaluation due to his cardiac history, and his Parkinson's medication regimen should be optimized to minimize tremors during the perioperative period. Antiplatelet or anticoagulant medications may need temporary adjustment in consultation with cardiology. Key considerations for the patient's management include:
- Comprehensive preoperative evaluation to assess cardiac risk and optimize Parkinson's disease management
- Potential need for temporary adjustment of antiplatelet or anticoagulant medications
- Urethroplasty procedure details, including the likely use of buccal mucosa grafts for substitution urethroplasty
- Postoperative care, including hospital stay, catheterization duration, and follow-up
The surgery typically requires 2-3 hours under general anesthesia, with a hospital stay of 1-3 days and catheterization for 2-3 weeks postoperatively. Urethroplasty provides superior outcomes compared to repeated endoscopic procedures for extensive strictures, with success rates that significantly outweigh the potential benefits of less invasive but less effective treatments 1.
From the Research
Treatment Options for Urethral Stricture
The patient has a 7 cm penile urethral stricture after a Transurethral Resection of the Prostate (TURP) and has a history of myocardial infarction and Parkinson's tremors. Considering the length of the stricture, the following treatment options are available:
- Urethral dilatation: This is a minimally invasive procedure, but it has a high failure rate, with stricture-free rates ranging from 10 to 90% at 12 months 2.
- Direct Visual Internal Urethrotomy (DVIU): This procedure has a poor long-term cure rate, with success rates ranging from 6% to 28% 3. Repeated urethrotomies are associated with poor results.
- Urethroplasty: This is a more invasive procedure, but it has a higher success rate, with 64% of men being stricture-free after two years compared to 24% of men treated with urethrotomy 4, 5.
Considerations for the Patient
Given the patient's age and medical history, a less invasive procedure may be preferred to minimize the risk of complications. However, the length of the stricture and the patient's history of TURP may require a more invasive procedure like urethroplasty.
- The patient's Parkinson's tremors may affect the outcome of the procedure, and the patient's history of myocardial infarction may increase the risk of complications during surgery.
- The patient's quality of life and ability to perform self-catheterization should be considered when choosing a treatment option.
Next Steps
Based on the available evidence, the next step for the patient would be to consult with a urologist to discuss the treatment options and determine the best course of action. The urologist will consider the patient's medical history, the length and location of the stricture, and the patient's overall health to recommend a treatment plan. The patient should be informed about the potential risks and benefits of each treatment option, including the success rates and potential complications 2, 4, 5, 3, 6.