The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction

Robotic YV plasty outcomes for bladder neck contracture vs. vesico-urethral anastomotic stricture

PURPOSE

To compare the outcomes of patients undergoing robotic YV plasty for bladder neck contracture (BNC) vs. vesico-urethral anastomotic stricture (VUAS).

METHODS

A retrospective study included male patients who underwent robotic YV plasty for BNC after endoscopic treatment of BPH or VUAS between August 2019 and March 2023 at a single academic center. The primary assessed was the patency rate at 1 month post-YV plasty and during the last follow-up visit.

RESULTS

A total of 21 patients were analyzed, comprising 6 in the VUAS group and 15 in the BNC group. Patients with VUAS had significantly longer operative times (277.5 vs. 146.7 min; p = 0.008) and hospital stay (3.2 vs. 1.7 days; p = 0.03). Postoperative complications were more common in the VUAS group (66.7% vs. 26.7%; p = 0.14). All patients resumed spontaneous voiding postoperatively. Five patients (23.8%) who developed de novo stress urinary incontinence had already an AUS (n = 1) or required concomitant AUS implantation (n = 3), all of whom were in the VUAS group (83.3% vs. 0%; p < 0.0001). The proportion of patients improved was similar in both groups (PGII = 1 or 2: 83.3% vs. 80%; p = 0.31). Stricture recurrence occurred in 9.5% of patients in the whole cohort, with no significant difference between the groups (p = 0.50). Long-term reoperation was required in three VUAS patients, showing a statistically significant difference between the groups (p = 0.05).

CONCLUSION

Robotic YV plasty is feasible for both VUAS and BNC. While functional outcomes and stricture-free survival may be similar for both conditions, the perioperative outcomes were less favorable for VUAS patients.

Modified Y-V plasty based on MRU evaluation for iatrogenic bladder outlet obliteration: a multicentre experience in China

PURPOSE

To compare the diagnostic ability of traditional radiographic urethrography and magnetic resonance urethrography (MRU) for iatrogenic bladder outlet obliteration (BOO), and explore the efficacy and complications of laparoscopic modified Y-V plasty for patients selected based on MRU evaluation.

METHODS

31 patients with obliteration segments ≤ 2 cm and no false passages or diverticula based on MRU evaluation from eight centers in China were included. Obliteration segments were measured preoperatively by MRU and conventional RUG/VCUG and compared with intra-operative measurements. Surgical effects were evaluated by uroflow rates, urethrography, or cystoscopy at 1, 3, 6, and 12 months post-operation and then every 12 months. Postoperative urinary continence was assessed by 24-h urine leakage (g/day).

RESULTS

The results showed that MRU measured the length of obliteration more accurately than RUG/VCUG (MRU 0.91 ± 0.23 cm, RUG/VCUG 1.72 ± 1.08 cm, Actual length 0.96 ± 0.36 cm, p < 0.001), and clearly detected false passages and diverticula. Laparoscopic Y-V plasty was modified by incisions at 5 and 7 o'clock positions and double-layer suture with barbed sutures. All operations were successfully completed within a median time of 75 (62-192) minutes and without any complications. Urethral patency and urinary continence rates were 90.3% (28/31) and 87.1% (27/31), respectively. Three recurrences were cured by direct visual internal urethrotomy. Four patients had stress urinary incontinence after catheter removal 14 days post-operation, with urine leakage of 80-120 g/day, not relieved during follow-up.

CONCLUSIONS

Laparoscopic modified Y-V plasty based on MRU evaluation is a promising approach for iatrogenic BOO, with a high patency rate and a low incontinence rate.

Refractory Bladder Neck Contracture (BNC) After Radical Prostatectomy: Prevalence, Impact and Management Challenges

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.

Risk factors for the postoperative bladder neck contracture in patients with small-volume prostatic hyperplasia

OBJECTIVE

This study was to explore the risk factors for postoperative bladder neck contracture (BNC) after transurethral operation of prostate in patients with small-volume prostatic obstruction.

METHODS

Clinicopathologic data at our center from February 2016 to January 2020 were retrospectively collected and analyzed. Clinicopathological characteristics between patients with and without BNC were compared. Multivariate logistic regression was used to determine the risk factors for postoperative BNC.

RESULTS

There were a total of 39 patients (8.53%) with postoperative BNC. Multivariate logistic regression analysis demonstrated that preoperative bladder neck diameter (BND), intravesical prostatic protrusion (IPP), surgical methods (transurethral resection of prostate (TURP)/anatomical endoscopic enucleation of the prostate (AEEP)), and postoperative urinary tract infection (UTI) were independent risk factors for postoperative BNC in patients with small-volume prostatic obstruction (P < 0.05). The incidence of postoperative BNC in patients undergoing AEEP was significantly decreased compared with those undergoing TURP. The optimal cut-off value of preoperative IPP was 6.10 mm while the optimal cut-off value of preoperative BND was 2.52 cm.

CONCLUSIONS

Larger preoperative bladder neck and higher preoperative IPP lead to decreased incidence of postoperative BNC in patients with small-volume prostatic obstruction. Active management of postoperative UTI could effectively prevent the occurrence of postoperative BNC. Compared with TURP, complete AEEP would contribute to reduce BNC in patients with small-volume prostatic obstruction.

Transurethral Incision of the Bladder Neck at Three Points with a Needle-Type Electrode for Bladder Neck Contracture

Purpose

This study aims to evaluate the efficacy of transurethral incision of the bladder neck (TUIBN) at three points with a needle-type electrode for treatment of bladder neck contracture (BNC).

Materials and Methods

Between January 2016 and April 2021, the bladder necks of 53 patients with BNC after surgery were incised by the needle-type electrode at the 5, 7, and 12 O’clock positions. Patient’s preoperational characteristics, peri- and postsurgical outcomes, such as time of operation, postoperative bladder irrigation, and postoperative hospital stay, and data of the international prostate symptom score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) were recorded 3 and 6 months after surgery.

Results

All 53 cases of BNC were successfully treated in 35.00 (25.00, 45.00) min with 18.00 (14.00, 21.00) h for postoperative bladder irrigation with little intraoperative bleeding (less than 50 mL). The postoperative hospital stay ranged from 2 to 8 days, a mean of 3.50 (3.00, 5.00) days. No major intraoperative or postoperative complications were observed. All cases that underwent follow-up assessment at 3 and 6 months after the surgery showed significantly decreased IPSS and PVR and increased Qmax compared to preoperation ones (p ≤ 0.001). Of these 53 patients, there was no recurrence in severe BNC patients, but 5 of 53 (9.4%) BNC patients developed BNC again within 6 months and required repeated TUIBN. Thirty patients comprised five recurrent cases with a follow-up period of more than 1 year.

Conclusions

TUIBN at three points provides a safe, effective, and reliable option in treating patients with BNC.

Persistent storage symptoms following Y-V plasty reconstruction for the treatment of refractory bladder neck contracture

PURPOSE

Refractory bladder neck contracture (BNC) following transurethral prostatectomy is rare and difficult to manage. Success rate of endoscopic treatment decline considerably after repeated treatments. Bladder neck reconstruction are often the last resort to treat refractory BNC failing endoscopic treatments. In general, experience is limited with this type of bladder neck reconstruction, particularly in adult patients. This study aims to determine the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral prostatectomy. The study also aims to determine the rate, and potential predictors of persistent storage symptoms after Y-V plasty.

MATERIALS AND METHODS

Between January 2016 and February 2021, 18 consecutive patients with refractory BNC who underwent open Y-V plasty were included in this study. All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments followed by a 3-month period of outpatient serial dilation program. Clinicopathological data were extracted from medical records including baseline demographics, aetiology of BNC, previous endoscopic treatment, operative time, length of stay, complications, uroflow findings, International Prostate Symptom Score (IPSS) and OAB-V8. Primary outcome was the success of open YV plasty, defined as no need for further instrumentation such as indwelling catheterization, urethral dilatation, urethrotomy, or open surgery. Simple linear regression analysis was performed to determine predictor factors for postoperative OAB-V8. Variables that showed p < 0.25 were included in the multiple linear regression analysis.

RESULTS

Most common aetiology of BNC was transurethral resection of prostate gland (n = 18, 100%). Mean age at surgery age (SD) was 65.5 (7.3) years. Mean follow-up was 14.8 (7) months. Success rate was 100%. Postoperative Qmax improved significantly [pre-OP 6.7 (8.1) ml/s vs. post-OP was 14.8 (7.3) ml/s, p < 0.001]. Mean postvoid residual decreased significantly [pre-OP 223.3 (254.3) ml vs. post-OP 45.1 (71.0) ml, p < 0.01)]. Persistent storage symptoms were reported in 61% of patients. BMI and baseline IPSS score are significant predictors for the postoperative OAB V8 change (adjusted b (95% confidence interval) = 1.037 (0.2-1.9), 0.64 (0.28-0.99), respectively, R²  = 0.59).

CONCLUSION

Y-V plasty reconstruction for refractory BNC represents a feasible and successful option with high success rate and favorable outcomes. While functional and patient-reported outcomes had significantly improved post-operatively, persistent storage symptoms after this procedure still exist. BMI and baseline IPSS score are significant predictors for persistent storage symptoms after bladder neck reconstruction.

Minimal invasive management of bladder neck contracture using Allium round posterior stent: the long-term results

Background

The purpose of this study was to assess the long-term clinical efficacy of temporary, Allium round posterior stent (RPS) used for treatment of recurrent bladder neck contracture (BNC).

Methods

Records of 42 patients with recurrent BNC who underwent Allium RPS placement after bladder neck incision, between 2009 and 2019, were analyzed. After stent removal, the success criteria for Allium RPS treatment were defined as: no evidence of stricture on urethrogram or endoscopy; more than 12 ml/sec of urinary peak flow; and no recurrent urinary tract infections. Based on clinical success, patients were divided into two groups and compared. Clinical success was evaluated with particular regard to stent indwelling time and contracture etiology.

Results

The mean ± standard deviation age, stricture length, and indwelling time were 66.7 ± 9 years, 2.4 ± 1.4 cm, and 7.7 ± 2.2 months, respectively. Median (range) follow-up was 59 (8–73) months. The etiologies of BNC in this cohort were 57.1% retropubic radical prostatectomy; and 42.9% transurethral resection of prostate. Overall clinical success was achieved in 64.3% and the success rates did not differ by etiology. The success rates were 54.2% and 77.8% (P = 0.118) for retropubic radical prostatectomy and transurethral resection of prostate, respectively. Longer indwelling time (8–14 vs 3–7, months) was significantly associated with clinical success (78.3% vs 47.4%, P = 0.040).

Conclusion

Our data suggest that better clinical success was associated with longer indwelling time for stent in BNC treatment. In BNC management, Allium RPS treatment may be considered since its clinical efficacy is acceptable and tolerable.

Lower Urinary Tract Stenosis Following Surgery for Benign Prostatic Hyperplasia

PURPOSE OF REVIEW

This article reviews the mechanisms, risk factors, evaluation and current management options for iatrogenic lower urinary tract stenosis, including urethral stricture and bladder neck contracture, caused by surgery for benign prostatic hyperplasia (BPH).

RECENT FINDINGS

The incidence of iatrogenic stenosis following endoscopic BPH surgery ranges from 0 to 9.7%. New endoscopic techniques and technologies for treating BPH do not appear to substantially mitigate this risk. However, new advances in our understanding of urethral sphincter anatomy combined with both innovative open urethroplasty techniques and utilization of robotic surgery for bladder neck reconstruction, offer promise in improving treatment outcomes for this patient population. Treating patient with stenosis following BPH-related surgery can be challenging, especially in patients with recurrent disease. Optimizing outcomes and patient satisfaction relies on performing a thorough work-up and openly discussing treatment choices, risks and postoperative expectations with patients. Future research and emerging technology in both endoscopic BPH treatment surgical options and management of postoperative stenosis is critical to continuing to improve patient care.

Subtrigonal Inlay Patch Technique with Buccal Mucosa Graft for Recurrent Bladder Neck Contractures

INTRODUCTION

We aimed to present a novel subtrigonal inlay patch (SIP) technique with buccal mucosa graft (BMG) for recurrent bladder neck contracture (BNC) via open approach.

MATERIALS AND METHODS

Surgical approach for SIP technique is described in detail and outcomes of patients who have been operated with this technique for recurrent BNC were given. Briefly, bladder neck incision is performed after vertical cystotomy, fibrotic scar tissue is excised completely, and a BMG is patched at the end.

RESULTS

All 3 patients were able to void in their first attempt after catheter removal. Follow-up durations were 14, 11, and 5 months for the patients and all 3 patients reported satisfactory voiding. No de novo urinary incontinence was reported by patients after catheter removal, and all were continent with no pad need on their last follow-up visit. None of the operated patients needed any intervention such as catheterization, dilatation, or internal urethrotomy for BNC on follow-up.

CONCLUSION

The present study demonstrates the feasibility and promising results of SIP technique with open surgical approach. Further experience is mandatory with larger patient cohorts and longer follow-up.

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months; IQR 4–10) and those without BNC recurrence (10 months; IQR 6–20; p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months; IQR 6–9) compared to those treated successfully (median 12 months; IQR 9–25; p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months; IQR 2–12) and those without a recurrence (6 months; IQR 6–10; p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%; p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis

PURPOSE

Bladder neck stenosis (BNS) is a long-term complication of surgical procedures for benign prostatic hyperplasia (BPH). We performed a systematic literature review and a meta-analysis of the incidence of BNS after transurethral procedures for BPH.

METHODS

We performed a systemic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We accepted only randomized trials comparing transurethral resection of the prostate (TURP) vs. other transurethral surgery for BPH that were grouped in Ablation vs. Enucleation modalities. The incidences of BNS were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios, 95% Confidence Intervals, and p values. Study heterogeneity was assessed utilizing the I² value.

RESULTS

72 studies were identified for meta-analysis, 46 comparing TURP vs. Ablation and 26 TURP vs. Enucleation. The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation and 1.2% after Ablation. The incidence of BNS was higher after TURP than after Enucleation but the difference was not statistically significant (RR 1.75 95% CI 0.81-3.79, p = 0.16). There was no significant heterogeneity among the studies (I² 0%, Chi² 4.11, p = 0.90). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR 1.31, 95% CI 0.82-2.11, p = 0.26) with no significant heterogeneity (I² 0%, Chi² 21.1, p = 0.51).

CONCLUSION

Our study showed no difference in the rate of BNS incidence among randomized trials comparing TURP vs. Ablation vs. Enucleation and can be used as a reference to counsel patients undergoing BPH surgery.

Transurethral Incision with Transverse Mucosal Realignment for the Management of Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis

OBJECTIVE

To assess efficacy and safety of a novel cystoscopic technique for definitive repair of bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS).

METHODS

A retrospective review of patients who underwent a transurethral incision with transverse mucosal realignment between July 2019 and December 2020 by a single surgeon was completed. This is novel procedure of incising a scar cystoscopically and using a laparoscopic suturing device transurethrally to bring healthy bladder mucosa across the defect, like a YV plasty. Patients were only included if they had ≥4 months follow-up. Surgical success was defined as ability to pass a 17 French flexible cystoscope through the previously stenotic segment at 4 month follow up.

RESULTS

Nineteen patients with a median follow-up of 6 months were included in this analysis. Etiology of posterior urethral stenosis was 53% from VUAS and 47% from BNC, with 32% of patients having prior pelvic radiation. Success was achieved in 89% of patients after 1 procedure and 100% of patients achieved success after a second procedure. There was no de novo incontinence or major complications.

CONCLUSION

Transurethral incision with transverse mucosal realignment  for VUAS and BNC has a high success rate after only 1 procedure. This is the first reported series of an endoscopic Y-V plasty type repair for BNC and VUAS. Longer term follow up to ensure durability and reporting from other institutions will be needed to establish reproducibility.

Bladder Neck Resection Combined with Ten Point Intralesional Mitomycin C Injection in Management of Refractory Bladder Neck Contracture in Post TURP Status: A Single-Center, 2-Year Experience

Purpose

Bladder neck contracture is an annoying problem for patients as well as urologists. Recurrence still remains a common problem associated with significant morbidity. This study evaluated the efficacy and side effects of mitomycin C (MMC) which has anti-fibroblast as well as anti-collagen properties in the deterrence of bladder neck contracture (BNC) recurrence after transurethral bladder neck resection (TUBNR).

Materials and Methods

Ten patients between March 2017 and April 2018 with extremely persistent BNCs who underwent multiple failed endoscopic procedures (≥3 times) were evaluated by using International Prostate Symptom Score (IPPS), uroflowmetry, quality of life (QOL) and post void residual urine (PVR) preoperatively. All patients underwent transurethral bladder neck resection (TUBNR) followed by ten-point intraoperative MMC injection, not exceeding a total dose of 2 mg (0.2 mg/mL), which was given circumferentially at the resected site, using Williams cystoscopic needle. Patients were reviewed at 3 months, 6 months, 1 year and 2 years postoperatively.

Results

The procedure was done on a day care basis. The recurrence period prior to our treatment was 3.2 ± 1.3 months. The follow-up was for 24 months. Overall 80% (8 of 10) of patients demonstrated resolution of BNCs as well as sufficient flow rate which was evaluated by uroflowmetry, PVR, IPPS and QoL postoperatively. One patient had detrusor underactivity. Relapse was seen in two patients. None of the patients experienced any significant adverse effects related to MMC.

Conclusion

Intraoperative ten-site injection of MMC after TUBNR can be regarded as a safe and efficient technique with no serious adverse event.

Laparoscopic T-Plasty for the Treatment of Refractory Bladder Neck Stenosis

Preliminary results of a case series on refractory bladder neck stenosis treated with laparoscopic T-plasty are presented in this article. This study retrospectively identified nine patients with refractory bladder neck stenosis aged 60 to 80 years between May 2016 and December 2017, who had undergone laparoscopic T-plasty. All patients presented voiding difficulty and failed after two or more prior endoscopic treatments. Laparoscopic T-plasty was performed by incising the anterior wall of the bladder neck in a T-shaped manner and creating two well-vascularized and tension-free flaps, which offer the possibility to reconstruct a wide bladder neck. After a mean follow-up of 14.7 months (ranging 3–22 months), a successful outcome was achieved in eight patients without incontinence secondary to surgery. Recurrent voiding difficulty developed in one patient, which was cured after a following endoscopic treatment. Through these nine patients, a preliminary conclusion can be drawn that a wider bladder neck can be obtained through modified YV-reconstruction of the bladder neck, while avoiding external urethral sphincter injury. And laparoscopic T-plasty has clear advantages compared with an open approach. It is an available and effective option for refractory bladder neck stenosis.

Modified cystoscopy-assisted laparoscopic Y-V plasty for recalcitrant bladder neck contracture

Background and aim: Recalcitrant bladder neck contracture (BNC) is a common complication after transurethral resection of the prostate. Our aim was to show the outcomes of a modified cystoscopy-assisted laparoscopic Y-V plasty for BNC treatments.Material and methods: We retrospectively evaluated a series of 27 patients who underwent a modified cystoscopy-assisted laparoscopic Y-V plasty for recalcitrant BNC from January 2017 to September 2019. Urinary flow rate, international prostate symptom score (IPSS), international index of erectile function-5 (IIEF-5) and bladder urethral examination by cystoscopy were performed preoperatively and postoperatively, respectively.Results: All patients underwent the procedure successfully and no serious complication occurred. The median surgery time was 68.6 min without massive bleeding. The median follow-up time was 14.2 months and no patients had urinary incontinence. The maximum urine flow rate 3 months after surgery was significantly higher than prior to surgery (17.7 ± 2.1 ml/s vs. 8.2 ± 1.2 ml/s, p < 0.05). The IPSS was significantly decreased compared with the preoperative score (5.7 ± 2.3 vs. 19.2 ± 1.4, p < 0.05). The cystoscopy showed a wide bladder neck and the survival bladder flap in prostate urethral 3 months postoperatively in 92.6% (25/27) patients.Conclusions: The modified cystoscopy-assisted laparoscopic Y-V plasty is a feasible and effective technique for recalcitrant BNC treatment.

[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]

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.

Management of highly recurrent bladder neck contractures via transurethral resection combined with intra- and post-operative triamcinolone acetonide injections

PURPOSE

To present our preliminary experience in managing patients with highly recurrent bladder neck contractures (BNCs) after transurethral resection of the prostate (TURP).

METHODS

Between February 2015 and March 2018, 28 patients with highly recurrent BNCs who had failed multiple prior to endoscopic treatments were managed with transurethral resection and intra- and post-operative triamcinolone acetonide injections. The scar tissue was resected to the circular fiber at the bladder neck, and triamcinolone acetonide (2 mL, 40 mg/mL) was injected at the incision sites (8 points) using a cystoscopic injection needle. The cystoscopy-guided injections were repeated every four weeks for total three times after surgery. The patients were followed up at 3, 6, 12 months after surgery, and in July-August 2019.

RESULTS

The recurrent interval before the treatments was 2.2 ± 1.2 months, without any BNC recurrence in the first 12 weeks after transurethral resection. The urinary flow rate increased significantly and was maintained during the follow-up period. Adequate voiding function was reported in 25 of 28 patients at a median follow-up of 2.8 (1.7, 3.9) years. One of the three patients with decreased urinary flow rate had underactive detrusor and no BNC recurrence. The complications were mild and tolerable.

CONCLUSION

Transurethral resection of the scar tissue combined with intra- and post-operative triamcinolone acetonide injections resulted in a success rate of 92.9% in patients with highly recurrent BNC following TURP. It is a simple, safe, and effective treatment for highly recurrent BNCs.

The outcome of Y-V plasty as a final option in patients with recurrent bladder neck sclerosis following failed endoscopic treatment

INTRODUCTION

Bladder neck sclerosis is a rare late complication of transurethral resection of the prostate (TURP). Endoscopic resection or incision of the bladder neck is usually successful in the management of such cases. In some cases, even repeated endoscopic management always followed with recurrent sclerosis. In these cases, the Y-V plasty of the bladder neck provides a final option of treatment.

MATERIAL AND METHODS

Retrospective evaluation of 24 patients who underwent Y-V plasty of the bladder neck from 2007 to 2014 was performed. All patients had TURP once and presented after at least 2 failed attempts of endoscopic management. The principle of this technique is to insert a V-shaped part of the bladder wall into the fibrosed bladder neck. The patient evaluation included measuring Q max, residual urine volume and asking about their satisfaction. All patients were operated in the same center by the same surgeon.

RESULTS

The mean age of patients at surgery was 66.8 years (range 56-74 years). All patients presented preoperatively with obstructive micturition with mean Qmax 2.2 ml/s (SD ±1.9) and mean residual urine volume of 381 ±169 ml. After a mean follow-up of 46 months (SD ±22), the mean Qmax reached 16.4 ml/s (SD 3.3) while the mean residual urine volume was 18 ml (SD ±6). Recurrent sclerosis occurred in three patients (12.5%). A total of 94.1% of patients reported satisfactory micturition with significant improvement in the quality of life.

CONCLUSIONS

The Y-V plasty can provide a final option with a high success rate for patients with bladder neck sclerosis after failed endoscopic treatment.

Posterior urethral stenosis after prostate cancer treatment: contemporary options for definitive management

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.

Bladder Neck Contracture after Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Treated with a Thermo-Expandable Metal Stent (Memokath® 045)

Bladder neck contracture following transurethral resection of the prostate is a rare but feared complication. Treatment is often challenging with significant recurrence rates. In this report, we present a complicated case treated with a simple procedure. A 75-year-old male developed urinary retention due to bladder neck contracture after transurethral resection of the prostate. He was initially treated with several transurethral incisions, but the obstruction recurred few months after each incision. At urethroscopy, the bladder neck was completely obstructed. Using both retrograde and antegrade endoscopy, it was possible to place a through-and-through guidewire, after which the length of the stricture could be measured. Subsequently, the stricture was slightly dilated, and a double-cone thermo-expandable metal stent (Memokath 045) could be placed. The correct position was monitored with antegrade and retrograde endoscopy, securing the proximal cone expanded above the stricture and the distal cone above the sphincter. The patient was discharged the same day with spontaneous voiding and minimal residual urine. Twenty-one months after stent placement, the patient still had no complaints of his urination. Thus, the double-cone thermo-expandable metal stent, Memokath 045, may be a durable option for treatment of complicated bladder neck contracture after TURP for benign prostatic hyperplasia.

Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis

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.

Bladder Neck Contracture After Endoscopic Surgery for Benign Prostatic Obstruction: Incidence, Treatment, and Outcomes

PURPOSE OF REVIEW

In recent years, new endoscopic techniques have been developed to reduce the morbidity of transurethral resection of the prostate. Nonetheless, complications are still frequently encountered and bladder neck contracture (BNC) is a well-described complication after endoscopic surgery for benign prostatic obstruction (BPO). Our aim is to review and discuss the contemporary incidence, the relevant treatment strategies, and their outcomes.

RECENT FINDINGS

Findings suggest that BNC is a common complication with an acceptably low incidence but can range in complexity. Most contractures were usually managed successfully with conservative measures; nevertheless, in patients with refractory BNC, various valuable management strategies were employed with different kinds of success and re-treatment rates. In consideration of these challenging possibilities, the treatment of BNC requires a tailored approach with patient-specific management that can range from simple procedures to complex surgical reconstruction.

[Bladder neck sclerosis following prostate surgery : Which therapy when?]

Secondary bladder neck sclerosis represents one of the more frequent complications following endoscopic, open, and other forms of minimally invasive prostate surgery. Therapeutic decisions depend on the type of previous intervention (e.g., radical prostatectomy, TURP, HoLEP, radiotherapy, HIFU) and on associated complications (e.g., incontinence, fistula). Primary treatment in most cases represents an endoscopic bilateral incision. No specific advantages of any type of the applied energy (i.e., mono-/bipolar HF current, cold incision, holmium/thulium YAG laser) could be documented. Adjuvant measures such as injection of corticosteroids or mitomycin C have not been helpful in clinical routine. In case of first recurrence, a transurethral monopolar or bipolar resection can usually be performed. Recently, the ablation of the scared tissue using bipolar vaporization has been recommended providing slightly better long-term results. Thereafter, surgical reconstruction is strongly recommended using an open, laparoscopic, or robot-assisted approach. Depending on the extent of the bladder neck sclerosis and the underlying prostate surgery, a Y-V/T-plasty, urethral reanastomosis, or even a radical prostatectomy with new urethravesical anastomosis should be performed. Stent implantation should be reserved for patients who are not suitable for surgery. The final palliative measure is a cystectomy with urinary diversion or a (continent) cystostomy.

Reconstructive Management Options of Delayed Complications Following Bladder Outlet Surgery

PURPOSE OF REVIEW

Technological advancements in urologic endoscopy within the last decades have improved outcomes following bladder outlet reduction surgery while minimizing risks of short- and intermediate-term complications. This review aims to examine late complications of endoscopic reduction of the prostate and the various treatment options available.

RECENT FINDINGS

Urinary incontinence, ejaculatory dysfunction, urethral strictures, bladder neck contractures, and fistula formations are the most common delayed complications following bladder outlet reduction surgery. Evaluation of these complications typically involves a combination of endoscopic examination, urodynamic findings, pelvic imaging, and review of pre-existing symptoms. Treatment options range from conservative measures such as pelvic floor muscle therapy to complex reconstructive procedures including anti-incontinence surgery, urethral reconstruction, and permanent urinary diversion. Although rare, late complications of bladder outlet reduction surgery are important to recognize in order to manage appropriately. Careful evaluation involving multiple diagnostic modalities with consideration for referral to a dedicated reconstructive urologist may be warranted in complex cases.