Vesicourethral anastomotic stenosis – after radical prostatectomy
- Rates reported 3 – 6 % – probably less now with robotic surgery
- Much higher rates after salvage prostatectomy (20 – 40 %)
- Risk factors – higher grade and advanced stage cancer, larger prostate, obesity, diabetes, previous TURP/surgery, older age, non nerve sparing, anastomotic leak, catheter misadventure, increased operative time, increased EBL, low volume surgeons, Hem-o-loks, post-operative radiation
Bladder neck stenosis – i.e, after TURP
- More common in smaller prostates
- No evidence type of energy source affects contracture rates
- Overall about 5 % rate of bladder neck stenosis
Radiation induced bulbomembranous stricture
- Urethral strictures occur in 1.5 % EBRT patients, 1.9 % brachy, and 4.9 % combination brachy-EBRT.
- Increases with time from radiation.
- Use of radiation as salvage treatment, or focal therapy after radiation, increases risk.
- Probably increased risk with TURP prior to radiation also.
- Methods to prevent – delayed salvage radiation after prostatectomy, reduction of brachytherapy doses in the “hot spot” at the apex, more careful brachy needle placement, fiducial markers, improved radiation techniques (3D conformation)
Management options:
Endoscopic incision or resection
- Avoid aggressive incision or resection at 12 o’clock (urosymphyseal fistula, particularly post radiation) and 6 o’clock (rectal injury)
- May exacerbate or unmask stress urinary incontinence
- Hot knife, cold knife and laser all reported
- First line is resection or hot knife post TURP
- 50 – 80 % success for first endoscopic treatment
- Endoscopic treatments can be repeated which may be successful in stabilising the stenosis (consider adjuvant triamcinolone injection)
- Self-dilation afterwards may also aid in stabilising the stenosis
Reconstruction
Indicated for complete obliteration, or failure of dilation/endoscopic treatment
EAU:
Re-do VUA after RP VUAS
- Less successful after radiation
- May need flaps to support vascularity
- Ensure bladder function is adequate
- Ensure distal urethra is adequate
- Tissue must be healthy – no calcification, fistulation
- Open (abdominal, perineal, combined) or robotic
- High rates of exacerbating or causing de novo incontinence
Bladder neck reconstruction for BNC
- Advancement of local bladder flaps with or without resection of scar tissue (e.g. V-Y plasty)
- Robotic assisted
- High patency and success rates reported
Bulbomembranous strictures after TURP or simple prostatectomy
- Manage as bulbar stricture – EPA or graft urethroplasty depending on length and calibre
- As reconstruction is close to sphincter, and bladder neck has also been compromised, risk of incontinence of up to 25 %
Bulbomembranous strictures after radiation or other energy
- Difficult to manage due to tissue damage, impaired healing and vascularity involving not only the stricture but surrounding proximal and distal tissues
- Proximity to the sphincter also complicates surgery
- Long been treated as poor surgical candidates and mainly managed with diversion if endoscopic treatments failed
- EPA an option – over 30 % incontinence rates
- Longer strictures will need graft – but because of poor quality ischaemic tissue bed the failure rates are higher and issues with incontinence persist
- Urethroplasty patency rates reported 50 – 80 % after radiation
Extirpation and diversion
- In complex or recurrent cases – reconstruction is not possible or contraindicated due to severe necrosis, calcification and morbidity.
- Other reasons to “abandon the urethra” are intractable pain, haematuria, fistulation or a bladder not worth saving.
- Urinary diversion with or without cystectomy improves quality of life in patients with a “devastated lower urinary tract”. Cystectomy should be done if painful bladder, spasms and haematuria.
- Consider long term SPC for radiation induced strictures in frailer men (or any posterior urethral stenosis not willing or suitable for palliative management with dilations).