Complex urethral strictures affecting multiple segments and presenting with severe fibrosis pose a therapeutic challenge in reconstructive urology. In these cases, it may be necessary to combine open and endoscopic surgical techniques to achieve anatomical and functional resolution.

We present the case of a 72-year-old man referred for severe lower urinary tract symptoms (LUTS) despite medical treatment. Due to the impossibility of catheterization, a suprapubic cystostomy was placed. Cystoscopy and voiding cystourethrectomy (VCUG) revealed an impassable stricture 2 cm from the urethral meatus and a second stricture at the penobulbar level. A urethroplasty was performed using a preputial flap, and the penobulbar urethra was dilated with a paclitaxel-coated balloon (Optilume).

Given the absence of a healthy urethral plate in the distal stricture and the completely impassable stricture, a preputial flap was used for tubing, and a histopathological sample was taken. Additionally, the proximal stricture was dilated under direct vision. The procedure was performed without incident. The patient was discharged after 48 hours with an open urethral catheter and suprapubic cystostomy. The sample result was squamous metaplasia. At the first follow-up visit one month later, a urethrocutaneous fistula was observed at the level of the ventral balanopreputial sulcus. The catheter and suprapubic cystostomy were removed. At three months, the patient was asymptomatic, urinating from both orifices. The fistula in the balanopreputial sulcus was consolidated. Fistula repair was proposed, but the patient declined further surgery due to good voiding quality. Uroflowmetry was performed at three months: 10.2/180/60.

A combined open and endoscopic approach is possible and a valid option in patients with multiple urethral strictures. Urethrocutaneous fistulas occur in 3–10% of cases according to the literature, favored by multifactorial causes. Surgical correction of fistulas depends on the patient's wishes, the functional outcome, the size, location, and symptoms of the fistula.