On the final day of AUA2019, five experts reviewed treatment options for elderly men with severe urethral stricture disease.
Moderator Jessica DeLong, MD, assistant professor at Eastern Virginia Medical School, presented case studies of two men in their 80s with urethral stricture disease. The first was an 82-year-old with mild dementia and heart disease on anticoagulation medication with a 3 cm proximal bulbar urethral stricture. He had undergone transurethral resection of the prostate and two failed direct vision internal urethrotomies (DVIUs). The second patient was an 85-year-old hypertensive diabetic with a partially buried penis and a long anterior stricture from the meatus to the proximal bulb.
Tomas L. Griebling, MD, MPH, the John P. Wolf 33rd Degree Masonic Distinguished Professor of Urology at the University of Kansas School of Medicine, argued for suprapubic catheters for both patients.
“The first patient does have moderate comorbidity and dementia so this procedure can be done under local sedation, which will decrease his risk for cognitive decline,” Dr. Griebling said. “The second patient has more extensive comorbidity and also has a history of stones and a long urethral stricture. This will get access to his bladder in the future.”
Suprapubic catheters have some challenges, he noted, including the risk of bacterial colonization, mechanical issues, sequelae, structural injury and, in rare cases, vesicocutaneous fistula.
“However, it provides an increased level of independence and improved functional status. For many, it can be considered a palliative option, and by that I don’t mean sort of giving up, but rather as a form of therapy that really meets the patient’s goals and objectives,” Dr. Griebling said.
Sean P. Elliott, MD, MS, noted that many urologists favor endoscopic management for older patients.
“It’s easy to look at our national datasets and realize right away that most of the people in this room would prefer urethral dilation or other endoscopic management like DVIU for this type of a stricture,” said Dr. Elliot, the Cloverfields Professor, Vice Chair of Urology and Director of Reconstructive Urology at the University of Minnesota.
He noted that self-dilation after a DVIU can delay recurrence of the urethral stricture, but it’s not a cure. For the first patient with dementia, Dr. Elliott said self-dilation may not be optimal.
“He may be more suitable for in-office dilation. On the other hand, he’s older and he has a shorter stricture, so he may tolerate self-dilation better,” he said.
Dr. Elliott favored dilation for the second patient, who he said looks to have metabolic syndrome and is at high risk for recurrence.
Boyd R. Viers, MD, a urologist specializing in genitourinary reconstruction in the Department of Urology at the Mayo Clinic, discussed the benefits of perineal urethrostomy, including consistently high success rates in older patients, and those with longer strictures, failed prior urethroplasty and lichen sclerosus.
“Overall we’re seeing an increase in perineal urethrostomy utilization tenfold over 10 years in these patients with advanced urethral stricture disease, and it’s more likely to be in the elderly patients,” said Dr. Viers, adding that there’s also a maintenance of sexual function and better quality of life following perineal urethrostomy.
Joshua A. Broghammer, MD, FACS, associate professor of Urology at the University of Kansas Medical Center, discussed another treatment option, urethroplasty, although he said he would not advocate its use in every patient.
“I tend to tell my residents, ‘It’s not the age of the car, it’s the miles on the vehicle,’” said Dr. Broghammer, noting that it’s important to assess the overall health of each patient before deciding on a treatment approach. In the two cases considered in the session, he said health concerns such as dementia and other comorbidities were a serious consideration.
“We can all agree that urethroplasty is the gold standard in terms of long-term success rates. Looking at our first case, this is a 3 cm stricture. I think there’s a reasonable opportunity for cure and potentially doing that in a single operation,” Dr. Broghammer said.
“The second patient is more challenging because he’s older, has more comorbidities, exhibits a buried penis and may have lichen sclerosus. This is a difficult repair,” he said. “His risk factors are higher for serious complications, so I probably would not offer urethroplasty in this case.”