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Delchet O, Nourredine M, González Serrano A, Morel-Journel N, Carnicelli D, Ruffion A, Neuville P. Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment. BJU Int 2024; 133:237-245. [PMID: 37501631 DOI: 10.1111/bju.16141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear. METHODS A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up. RESULTS The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%). CONCLUSION This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.
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Affiliation(s)
- Ophélie Delchet
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Mikaïl Nourredine
- Service de Biostatistiques, Hospices Civils de Lyon, Lyon, France
- UMR CNRS 558, Laboratoire de Biométrie et Biologie Évolutive, Lyon, France
| | | | | | - Damien Carnicelli
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | - Alain Ruffion
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
- Claude Bernard University Lyon 1, Lyon, France
| | - Paul Neuville
- Service d'Urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
- Claude Bernard University Lyon 1, Lyon, France
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2
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Lutz MA, Le QC, Müller M, Müller SC, Rosenbaum CM, Vetterlein MW, Kluth LA. [Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:34-42. [PMID: 38157068 DOI: 10.1007/s00120-023-02246-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.
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Affiliation(s)
- Malin A Lutz
- Klinik für Urologie, Universitätsklinikum der Goethe Universität in Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - Quynh Chi Le
- Klinik für Urologie, Universitätsklinikum der Goethe Universität in Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - Matthias Müller
- Klinik für Urologie, Universitätsklinikum der Goethe Universität in Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - Stefan C Müller
- Klinik für Urologie, Universitätsklinikum der Goethe Universität in Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | | | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Luis A Kluth
- Klinik für Urologie, Universitätsklinikum der Goethe Universität in Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
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3
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Uguzova S, Beisland C, Honoré A, Juliebø-Jones P. Refractory Bladder Neck Contracture (BNC) After Radical Prostatectomy: Prevalence, Impact and Management Challenges. Res Rep Urol 2023; 15:495-507. [PMID: 37954870 PMCID: PMC10638897 DOI: 10.2147/rru.s350777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/02/2023] [Indexed: 11/14/2023] Open
Abstract
Bladder neck contracture is a recognised complication associated with radical prostatectomy. The management can be challenging, especially when refractory to initial intervention strategies. For the patient, the burden of disease is high and continence status cannot be overlooked. This review serves to provide an overview of the management of this recognised clinical pathology. Consideration needs to be given to minimally invasive approaches such as endoscopic incision, injectables, implantable devices as well as major reconstructive surgery where the condition persists. For the latter, this can involve open and robotic surgery as well as use of grafts and artificial sphincter surgery. These elements underline the need for a tailored and a patient centred approach.
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Affiliation(s)
- Sabine Uguzova
- Department of Urology, Stepping Hill Hospital, Manchester, UK
| | - Christian Beisland
- Department of Urology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Alfred Honoré
- Department of Urology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Patrick Juliebø-Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Robotic Urethral Reconstruction Outcomes in Men with Posterior Urethral Stenosis. Urology 2021; 161:118-124. [PMID: 34968569 DOI: 10.1016/j.urology.2021.11.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction. METHODS A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed. RESULTS Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included BPH treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (BPH), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (p=0.52). Median length of stay after reconstruction was 2, 1, and 2 days (p=0.45). 30-day complications occurred in 0%, 20%, 40% (p =0.19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (p =0.004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (p=0.63), with functional success rates of 100%, 100%, 60% (p=0.035). Median postoperative pad/day usage was 0,0, 10.5 (p<0.001), and ultimately 0%, 30%, 80% (p=0.013) underwent artificial urinary sphincter placement. CONCLUSION Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence.
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Liu W, Shakir N, Zhao LC. Single-Port Robotic Posterior Urethroplasty Using Buccal Mucosa Grafts: Technique and Outcomes. Urology 2021; 159:214-221. [PMID: 34624362 DOI: 10.1016/j.urology.2021.07.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. METHODS We reviewed 9 patients who underwent single-port robotic posterior urethroplasty with buccal mucosa graft from May-December 2019. Variables included patient demographics, diagnosis/etiology, and intraoperative parameters. Intraabdominal or extraperitoneal transvesical approaches are used for the stricture via supraumbilical access, and if necessary, perineal dissection is performed. Cystoscopy identifies the extent of stenosis. Anastomosis is completed with buccal mucosal graft and rectus abdominis, omental or gracilis flaps as needed. RESULTS The mean age was 65.4 years. Robotic urethroplasty with buccal mucosa graft was performed for vesicourethral anastomotic strictures (n = 7), urethral strictures (n = 4), pubic fistula after robotic posterior urethroplasty (n = 1), and anastomotic distraction (n = 1). Strictures occurred after prostate cancer treatments (n = 8) and trauma (n = 1). All patients had prior failed endoscopic interventions: balloon dilatation, resection/incision of bladder neck, internal urethrotomy under direct vision, urethral stents, and posterior urethroplasty. Mean defect length was 3.9 cm. Five of 9 patients had ancillary procedures including rectus abdominis (n = 3), omental or gracilis (both n = 1) flap harvests. No intraoperative complications occurred. Median operative time was 377 minutes, blood loss was 200 mL, and length of stay was 2 days. Postoperative 30-day complications included urinary tract infection, epididymitis, anemia, recurrent stricture, and small bowel obstruction requiring surgery (all n = 1). Median follow-up was 11.7 months. CONCLUSION Buccal mucosa grafts with ancillary maneuvers such as flap interposition or adjacent tissue transfer in robotic lower tract reconstruction is durable, safe, and comparable to open approaches.
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Affiliation(s)
- Wen Liu
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY
| | - Nabeel Shakir
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY
| | - Lee Cheng Zhao
- Department of Urology, Grossman School of Medicine at New York University Langone Health, New York, NY.
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7
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[Urethro-vesical anastomosis reconstruction using extra-peritoneal robot-assisted laparoscopy for anastomotic stenosis after radical prostatectomy]. Prog Urol 2021; 31:591-597. [PMID: 33468413 DOI: 10.1016/j.purol.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Urethro-vesical anastomosis stenosis following radical prostatectomy is a rare complication but represents a challenging situation. While the first-line treatment is endoscopic, recurrences after urethrotomies require a radical approach. We present the updated results of our patient's cohort treated by pure robotic anastomosis refection. MATERIAL AND METHODS This is a retrospective, single-center study focusing on one surgeon's experience. Patients presented an urethro-vesical stricture following a radical prostatectomy. Each patient received at least one endoscopic treatment. The procedure consisted of a circumferential resection of the stenosis, followed by a re-anastomosis with well-vascularized tissue. We reviewed the outcomes in terms of symptomatic recurrences and continence after the reconstructive surgery. RESULTS From April 2013 to May 2020, 8 patients underwent this procedure. Half of the patients had previously been treated with salvage radio-hormonotherapy. The median age was 70 years (64-76). The mean operative time was 109minutes (60-180) and blood loss was 120cc (50-250). One patient had an early postoperative complication, with vesico-pubic fistula. The average length of stay was 4.6 days (3-8). Mean follow-up was 24.25 months (1-66). Half of the patients experienced a recurrence at a median time of 8.25 months (6-11) after surgery. Five patients experienced incontinence of which 3 required an artificial urinary sphincter implantation. CONCLUSION Extra-peritoneal robot-assisted urethro-vesical reconstruction is feasible and safe to manage bladder neck stricture after radical prostatectomy. The risk of postoperative incontinence is high, justifying preoperative information. LEVEL OF EVIDENCE III.
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Rosenbaum CM, Fisch M, Vetterlein MW. Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy. Front Surg 2020; 7:587271. [PMID: 33324673 PMCID: PMC7725760 DOI: 10.3389/fsurg.2020.587271] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022] Open
Abstract
Vesico-urethral anastomotic stenosis is a well-known sequela after radical prostatectomy for prostate cancer and has significant impact on quality of life. This review aims to summarize contemporary therapeutical approaches and to give an overview of the available evidence regarding endoscopic interventions and open reconstruction. Initial treatment may include dilation, incision or transurethral resection. In treatment-refractory stenoses, open reconstruction via an abdominal (retropubic), transperineal or combined abdominoperineal approach is a viable option with high success rates. All of the open surgical procedures are generally accompanied by a high risk of developing de novo incontinence and patients may need further interventions. In such cases, subsequent artificial urinary sphincter implantation is the most common treatment option with the best available evidence.
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Affiliation(s)
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]. Urologe A 2020; 59:398-407. [PMID: 32055934 DOI: 10.1007/s00120-020-01143-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bladder neck stenosis (BNS) after simple prostatectomy and vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy for prostate cancer are common sequelae. However, the two entities differ in their pathology, anatomy and their surgical results. VUAS has an incidence of 0.2-28%. Commonly, VUAS occurs within the first 2 years after surgery. Initial therapy should be performed endourologically: dilatation, (laser) incision or resection. After three unsuccessful treatment attempts, open reconstruction should be considered. Different surgical approaches (abdominal, perineal, abdominoperineal) have been described. All are associated with good success rates. However, they are accompanied by high rates of urinary incontinence. Incontinence can be treated safely by implantation of an artificial urinary sphincter. The incidence of BNS is around 5% for all types of surgery for benign prostate hyperplasia. It occurs within the first 2 years after surgery. Initial treatment should be performed endourologically. In case of recalcitrant BNS, open reconstruction is indicated. The YV-plasty is an established procedure, and the T‑plasty represents a modification. Success rates of both procedures are high. Robot-assisted reconstructive procedures have been described for both VUAS and BNS.
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10
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Vesicourethral Anastomotic Stenosis after Prostate Cancer Treatment. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00539-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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11
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Management of intractable bladder neck strictures following radical prostatectomy using the Memokath ®045 stent. J Robot Surg 2019; 14:621-625. [PMID: 31617064 PMCID: PMC7347512 DOI: 10.1007/s11701-019-01035-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 10/10/2019] [Indexed: 11/21/2022]
Abstract
The incidence of vesicourethral anastomotic stenosis (VUAS) post radical prostatectomy varies from 1 to 26%. Current treatment can be challenging and includes a variety of different procedures. These range from endoscopic dilations to bladder neck reconstruction to urinary diversion. We investigated a 2-stage endoscopic treatment, using the thermo-expandable Memokath®045 bladder neck stent to manage patients with VUAS post radical prostatectomy. We retrospectively reviewed 30 patients, between 2013 and 2017, who underwent a Memokath®045 stent insertion following failed primary treatment (dilation and clean intermittent catheterisation) for VUAS. The mean interval time between prostatectomy and Memokath®045 stent insertion was 13 months. The mean follow-up time was 3.6 years with all patients having a minimum of 12-month follow-up. All patients had two previous attempts at endoscopic dilatation with or without incision and a trial of clean intermittent catheterisation. During stage 1, the anastomotic stricture is dilated/incised to diameter of 30 Fr, the stricture length is measured, and a catheter is left in situ. One to 2 weeks later, post haemostasis and healing, an appropriately sized Memokath®045 stent is inserted. The stent is then removed 1-year post-op. Our series of patients had a median age of 62 (54–72). Most patients (26) had a robot-assisted radical prostatectomy (RARP) or salvage procedure. Results showed improvement in IPSS scores, IPSS quality of life scores, Qmax and PVR after the Memokath®045 stent was removed compared to pre-operation. With a minimum of 12 months post stent removal, 93% of patients were fully continent, whilst 7% of patients were socially continent. 2 (7%) patients had their stents removed and not replaced due to re-stricturing and stone formation. However, no urinary tract infections, stricture recurrence or urinary retention was observed in the rest of the cohort (93%). Overall, the Memokath®045 stent was successful in treating 93% of our patients with VUAS. Our series had minimal complications that were managed with conservative measures and in three patients’ re-operation was needed. In conclusion, the Memokath®045 stent is a minimally invasive technique with faster recovery time compared to other techniques such as bladder neck reconstruction or urinary diversion. Additionally, it provides superior patency results compared to other techniques such as bladder neck incision and injection of Mitomycin C. Therefore, this management option should be considered in the management of VUAS.
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Lavollé A, de la Taille A, Chahwan C, Champy CM, Grinholtz D, Hoznek A, Yiou R, Vordos D, Ingels A. Extraperitoneal Robot-Assisted Vesicourethral Reconstruction to Manage Anastomotic Stricture Following Radical Prostatectomy. Urology 2019; 133:129-134. [PMID: 31381896 DOI: 10.1016/j.urology.2019.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/22/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To demonstrate the feasibility of robot-assisted vesicourethral reconstruction. Vesicourethral anastomotic stricture following radical prostatectomy is a real challenge for reconstructive surgery when facing several endoscopic management failures. MATERIAL AND METHODS This is a case series of robot-assisted vesicourethral reconstruction for anastomotic stricture failing endoscopic management. The procedure was performed with an extraperitoneal approach. The fibrotic anastomotic region was resected and a new vesicourethral running suture was performed with well-vascularized tissue. Bladder catheter was removed after 7 days. RESULTS Six procedures were performed from April 2013 to May 2018 at our department. One patient had a robot-assisted radical prostatectomy at our department; the 5 others were referred from other institutions after receiving open prostatectomies. Three patients had salvage radiation therapy before reconstruction. Mean age was of 73.8 years (68-82). There was no peroperative complication. Mean operative time was of 108 minutes (60-180)], with a mean estimated blood loss of 130 mL (50-300). After surgery, 3 patients presented recurrences managed endoscopically without recurrence after 3, 5, and 11 months. Three patients presented incontinence treated with artificial sphincter implantation. One patient had no residual symptom after 5 years of follow-up. CONCLUSIONS Robot-assisted vesicourethral reconstruction is a safe procedure. It is an option to consider when facing recurring anastomotic stricture following radical prostatectomy. It is an alternative to the perineal approach and an option before urinary diversion. Patients should be informed of the risks of incontinence and recurrence before surgery especially if they had radiation therapy.
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Affiliation(s)
| | | | | | | | | | - Andras Hoznek
- Department of Urology, Mondor Hospital, Créteil, France
| | - Rene Yiou
- Department of Urology, Mondor Hospital, Créteil, France
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Kahokehr AA, Peterson AC, Lentz AC. Posterior urethral stenosis after prostate cancer treatment: contemporary options for definitive management. Transl Androl Urol 2018; 7:580-592. [PMID: 30211048 PMCID: PMC6127549 DOI: 10.21037/tau.2018.04.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Posterior urethral stenosis (PUS) is an uncommon but challenging problem following prostate cancer therapy. A review of the recent literature on the prevalence of PUS and treatment modalities used in the last decade was performed. A summative narrative of current accepted techniques in management of PUS is presented, and supplement with our own experience and algorithms.
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Affiliation(s)
- Arman A Kahokehr
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Andrew C Peterson
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Aaron C Lentz
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
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Kirshenbaum EJ, Zhao LC, Myers JB, Elliott SP, Vanni AJ, Baradaran N, Erickson BA, Buckley JC, Voelzke BB, Granieri MA, Summers SJ, Breyer BN, Dash A, Weinberg A, Alsikafi NF. Patency and Incontinence Rates After Robotic Bladder Neck Reconstruction for Vesicourethral Anastomotic Stenosis and Recalcitrant Bladder Neck Contractures: The Trauma and Urologic Reconstructive Network of Surgeons Experience. Urology 2018; 118:227-233. [PMID: 29777787 DOI: 10.1016/j.urology.2018.05.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates. MATERIALS AND METHODS Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence. RESULTS Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement. CONCLUSION RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.
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Affiliation(s)
| | - Lee C Zhao
- Department of Urology, New York University, New York, NY
| | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA
| | - Nima Baradaran
- Department of Urology, University of California San Francisco, San Francisco, CA
| | | | - Jill C Buckley
- Department of Urology, UC San Diego Health System, San Diego, CA
| | - Bryan B Voelzke
- Department of Urology, University of Washington, Seattle, WA
| | | | | | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Atreya Dash
- Department of Urology, University of Washington, Seattle, WA
| | - Aaron Weinberg
- Department of Urology, New York University, New York, NY
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Beck V, Apfelbeck M, Chaloupka M, Kretschmer A, Strittmatter F, Tritschler S. [Stricture of the vesicourethral anastomosis after radical prostatectomy]. Urologe A 2017; 57:29-33. [PMID: 29209754 DOI: 10.1007/s00120-017-0550-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5-8% of patients after radical prostatectomy. SYMPTOMS Usually the clinical symptoms include an irritative and obstructive component similar to benign prostatic hyperplasia. In rare cases, patients suffer from partial or complete stress incontinence as a result of the anastomotic stricture. DIAGNOSTICS The diagnostic workup is similar to the procedure for urethral strictures. In addition to uroflowmetry, a cystourethrogram (CUG) or, if necessary, a micturating cystourethrogram (MCU) can be performed. A urethrocystoscopy can be performed to ensure the diagnosis. THERAPY In most cases, endoscopic procedures were performed for treatment. Beside a transurethral dilation of the stricture or the Sachse urethrotomy, the most common procedure is transurethral resection to treat the stricture. However, all procedures are associated with a high recurrence rate. In recurrent strictures, open surgical procedures, usually a perineal reanastomosis, should performed early. CONCLUSION Endourological procedures like transurethral resection are a good treatment option, but due to the high recurrence rates, open surgical procedures should be discussed and if necessary should be performed early.
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Affiliation(s)
- V Beck
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland.
| | - M Apfelbeck
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - M Chaloupka
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - A Kretschmer
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - F Strittmatter
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik, Campus Großhadern, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
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Rocco NR, Zuckerman JM. An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures. Ther Adv Urol 2017; 9:99-110. [PMID: 28588647 PMCID: PMC5444622 DOI: 10.1177/1756287217701391] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/06/2017] [Indexed: 12/30/2022] Open
Abstract
Postprostatectomy vesicourethral anastomotic stenosis (VUAS) remains a challenging problem for both patient and urologist. Improved surgical techniques and perioperative identification and treatment of risk factors has led to a decline over the last several decades. High-level evidence to guide management is lacking, primarily relying on small retrospective studies and expert opinion. Endourologic therapies, including dilation and transurethral incision or resection with or without adjunct injection of scar modulators is considered first-line management. Recalcitrant VUAS requires surgical reconstruction of the vesicourethral anastomosis, and in poor surgical candidates, a chronic indwelling catheter or urinary diversion may be the only option. This review provides an update in the diagnosis and management of postprostatectomy VUAS.
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Affiliation(s)
| | - Jack M Zuckerman
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
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Dinerman BF, Hauser NJ, Hu JC, Purohit RS. Robotic-Assisted Abdomino-perineal Vesicourethral Anastomotic Reconstruction for 4.5 Centimeter Post-prostatectomy Stricture. Urol Case Rep 2017; 14:1-2. [PMID: 28607874 PMCID: PMC5458053 DOI: 10.1016/j.eucr.2017.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/04/2017] [Accepted: 05/10/2017] [Indexed: 12/02/2022] Open
Abstract
We report surgical management of a disrupted radical prostatectomy vesicourethral anastomosis after bleeding from undiagnosed hemophilia that required re-exploration, pudendal artery embolization, and urinary diversion with nephrostomy and surgical drains. After referral, the 4.5 cm vesicourethral anastomotic defect was reconstructed with a robotic-assisted abdomino-perineal approach. Intra-abdominal robotic-assisted mobilization of the bladder and perineal mobilization of the urethra permitted a tension-free vesicourethral anastomosis while avoiding a pubectomy. Side docking of the Da Vinci Xi robot allows for simultaneous access to the perineum during pelvic minimally invasive surgery, enabling a novel approach to complex bladder neck reconstruction.
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Affiliation(s)
- Brian F Dinerman
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | | | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
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Kranz J, Reiss PC, Salomon G, Steffens J, Fisch M, Rosenbaum CM. Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis. Front Surg 2017; 4:44. [PMID: 28848735 PMCID: PMC5554361 DOI: 10.3389/fsurg.2017.00044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
Objectives The objective of this study was to compare the recurrence rate and de novo incontinence after endoscopic treatment of vesicourethral stenosis (VUS) after radical prostatectomy (RP) and for bladder neck stenosis (BNS) after transurethral resection of the prostate (TURP). Methods Retrospective analysis of patients treated endoscopically for VUS after RP or for BNS after TURP at three German tertiary care centers between March 2009 and June 2016. Investigated endpoints were recurrence rate and de novo incontinence. Chi-squared tests and t-tests were used to model the differences between groups. Results A total of 147 patients underwent endoscopic therapy for VUS (59.2%) or BNS (40.8%). Mean age was 68.3 years (range 44–86), mean follow-up 27.1 months (1–98). Mean time to recurrence after initial therapy was 23.9 months (1–156), mean time to recurrence after prior endoscopic therapy for VUS or BNS was 12.0 months (1–159). Patients treated for VUS underwent significantly more often radiotherapy prior to endoscopic treatment (33.3 vs. 13.3%; p = 0.006) and the recurrence rate was significantly higher (59.8 vs. 41.7%; p = 0.031). The overall success rate of TUR for VUS was 40.2%, success rate of TUR for BNS was 58.3%. TUR for BNS is significantly more successful (p = 0.031). The mean number of TUR for BNS vs. TUR for VUS in successful cases was 1.5 vs. 1.8, which was not significantly different. The rate of de novo incontinence was significantly higher in patients treated for VUS (13.8 vs. 1.7%; p = 0.011). After excluding those patients with radiotherapy prior to endoscopic treatment, the recurrence rate did not differ significantly between both groups (60.3% for VUS vs. 44.2% for BNS; p = 0.091), whereas the rate of de novo incontinence (13.8 for VUS vs. 0% for BNS; p = 0.005) stayed significantly higher in patients treated for VUS. Conclusion Most patients with BNS are successfully treated endoscopically. In patients with VUS, the success rate is lower. Both stenoses differ with respect to de novo incontinence. Patients must be counseled regarding the increased risk of de novo incontinence after endoscopic treatment of VUS, independent of prior radiotherapy. Longer follow-up is warranted to address long-term outcomes.
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Affiliation(s)
- Jennifer Kranz
- Department for Urology and Pediatric Urology, St. Antonius Hospital, Eschweiler, Germany
| | - Philipp C Reiss
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Georg Salomon
- Martini Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Steffens
- Department for Urology and Pediatric Urology, St. Antonius Hospital, Eschweiler, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens M Rosenbaum
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Schuettfort VM, Dahlem R, Kluth L, Pfalzgraf D, Rosenbaum C, Ludwig T, Fisch M, Reiss CP. Transperineal reanastomosis for treatment of highly recurrent anastomotic strictures after radical retropubic prostatectomy: extended follow-up. World J Urol 2017; 35:1885-1890. [DOI: 10.1007/s00345-017-2067-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022] Open
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Pfalzgraf D, Siegel FP, Kriegmair MC, Wagener N. Bladder Neck Contracture After Radical Prostatectomy: What Is the Reality of Care? J Endourol 2017; 31:50-56. [DOI: 10.1089/end.2016.0509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel Pfalzgraf
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian P. Siegel
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian C. Kriegmair
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Nina Wagener
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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