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Streamlined Surgical Approach for Coexistent Urethral Stricture and Benign Prostatic Enlargement: Feasibility, Safety and Patency Results - Beyond the Abstract

In some patients, Benign Prostatic Enlargement (BPE) and significant Urethral Structure (US) coexist, presenting unique diagnostic and therapeutic challenges. This coexistence may be identified in various ways:

  1. Patients with low urinary tract symptoms due to BPE, who have previously undergone urethroplasty and are free of strictures, but whose repaired urethral segment cannot accommodate even a mini-resectoscope (18.5 - 22 Fr).
  2. Cases of critical urethral re-stricture in patients with a history of urethroplasty where an intravesical prostatic protrusion or a high prostate volume is also detected.
  3. The unexpected discovery of a critical US in patients undergoing endoscopic BPE surgery, where the resectoscope cannot be easily passed.
  4. Patients with LUTS due to BPE who are managed pharmacologically but develop a US during follow-up.
Managing these cases can be challenging due to a lack of established guidelines and limited - if not almost nonexistent - evidence. Furthermore, each case is unique, with differences in US length, location, etiology, prostate volume, and previous surgical interventions.

Traditionally, significant US is managed surgically, followed by prompt pharmacological treatment for BPE. However, we must recognize that medical management will eventually fail in patients with intravesical prostatic protrusion or high-volume prostates. If surgery is warranted, transurethral access may be complicated by the reconstructed urethra, as repaired segments rarely accommodate a resectoscope (and in some cases, even a flexible cystoscope).

Although simple prostatectomy remains a feasible option, HoLEP has gained prominence as a safer alternative with either open or minimally invasive approaches.1,2 Moreover, novel minimally invasive technologies, such as Urolift, may not be appropriate in all cases. In experienced hands, the complication rate of laser enucleation is comparable to that of urethroplasty. Given that both procedures have low associated risks and our team has mastered both reconstructive and endoscopic techniques, why not explore the potential of combining the two?

Extraordinary situations often call for extraordinary measures. This study demonstrates that treating both obstructive factors simultaneously is feasible without compromising urethroplasty outcomes in a carefully selected group of patients. While not intended as a standard recommendation, this combined approach offers urologists working in high-volume centers an additional strategy for managing such complex cases, laying a foundation for future validation in subsequent studies.

Ultimately, treatment selection should be individualized, considering comorbidities, patient expectations, and the goal of a swift return to daily activities.

Written by: Jordán Scherñuk, MD; Federico Ignacio Tirapegui, MD; and Gabriel Andrés Favre, MD

Genitourinary Reconstructive Surgery Division, Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina

References:

  1. Benzouak T, Addar A, Prudencio-Brunello MA, Aldien AS, Amougou SE, AlShammari A, et al. Comparative Analysis of Holmium Laser Enucleation of the Prostate (HoLEP) and Robotic-Assisted Simple Prostatectomy (RASP) in BPH Management: A Systematic Review and Meta-Analysis. The Journal of Urology [Internet]. 2024 Oct 18 [cited 2024 Nov 13]
  2. Titus RS, Bhatia A, Porto JG, Shah K, Lopategui DM, Herrmann TRW, et al. Open simple prostatectomy in the last three decades: results of a meta-analysis. World Journal of urology [Internet]. 2024 Nov 5 [cited 2024 Nov 13];42(1)
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