Managing bladder tumor with long-segment anterior urethral stricture: Perineal urethrostomy as a critical surgical solution

Bladder tumors complicated by anterior urethral strictures present unique management challenges, as strictures often prevent standard transurethral resection of bladder tumors (TURBT). While advances in endoscopic techniques have reduced the frequency of alternative approaches, perineal urethrostomy remains a valuable option in select cases. A 56-year-old male with a history of chronic tobacco use and recurrent, inadequately treated urethritis presented with clot-forming gross hematuria. Imaging revealed a large, vascularized bladder mass with invasion into perivesical fat and left-sided hydronephrosis. TURBT was initially planned, but a long-segment anterior urethral stricture prevented endoscopic access. Perineal urethrostomy was performed, allowing successful passage of the resectoscope and complete tumor resection. Histopathology confirmed high-grade urothelial carcinoma with a sarcomatoid component (pT2). The patient subsequently underwent nephrostomy drainage and was prepared for neoadjuvant chemotherapy prior to radical cystoprostatectomy. Although perineal urethrostomy is less common in modern practice, it remains essential for patients with complex urethral anatomy, such as long or recurrent strictures. This technique provides secure access for TURBT, reduces the risk of further urethral trauma, and minimizes the chance of tumor seeding compared to suprapubic approaches. Careful surgical technique is necessary to preserve vascular supply and optimize healing. Perineal urethrostomy can serve as a definitive or transitional solution before reconstructive surgery, provided oncological control is achieved. This case demonstrates that perineal urethrostomy remains a critical surgical option for managing bladder cancer complicated by anterior urethral stricture, highlighting the need for individualized, multidisciplinary approaches in complex urological oncology.