BERKELEY, CA (UroToday.com) - We have recently published an article describing our experience treating patients referred to our center for GU reconstruction for postprostatectomy bladder neck contractures (BNCs). The article serves both to describe our technique, as well as the success rate, with a large patient cohort with recalcitrant BNCs.
BNCs after prostatectomy are routinely treated with office dilations or bladder neck incision (BNI). However, a small percentage of these become densely scarred or refractory to dilation and must be treated more aggressively to preserve urinary function. For this, we treat with a two-stage approach consisting of deep BNI through to the perivesicle fat followed by artificial urinary sphincter (AUS) implantation 3-4 months later. Before AUS, we perform office cystoscopy to ensure the stricture remains patent. For recurrent strictures, the BNI is repeated along with follow-up cystoscopy.
We found that 66% of patients referred to us were continent after this approach. Of those patients, 30% of them were able to be managed with the BNI alone. This approach was based on our experience that some patients could be managed with incision alone, and is, thus, why we do not perform both procedures at the same time, as others have proposed.[1]
Obviously there are cohorts of patients who fit into the most severe cases of BNC after radical prostatectomy, including radiation cases, those with concomitant membranous strictures, urethral obliterations, and those referred who have had previous procedures. We did, however, include these patients in our study. Radiated patients had a 53% success rate of urinary continence with the two-stage approach. Patients with membranous stricture were also successfully treated and had no increased risk of BNI failure. The most severe cases had to be diverted, and in our group, there were 5 patients. Four of these patients had urethral obliterations. One patient was previously treated with radiation therapy and then with an AUS, which eroded through. We reconstructed his urethra and then later placed an AUS. This also eventually eroded through and he had to be diverted.
Our cohort represents a heterogenous practice referral pattern to a reconstructive urologist. The information helps provide counseling on treatment success, to patients, at the time of initial office visit as well as proves to be a consistent and useful treatment approach. Perhaps further modification of the treatment approach will be developed with larger studies of injectable agents such as mitomycin C or steroids.[2]
References:
- Mark S., Perez L.M., Webster G.D.: Synchronous management of anastomotic contracture and stress urinary incontinence following radical prostatectomy. J Urol 151. 1202-1204.1994.
- Vanni A.J., Zinman L.N., Buckley J.C.: Radial Urethrotomy and intralesional mitomycin C for the management of recurrent bladder neck contractures. J Urol 186. 156-160.2011.
Written by:
Chris Brede and Hadley Wood as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Cleveland Clinic Foundation, Cleveland, Ohio USA
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