Recurrent vesicourethral anastomotic stenosis following treatment for prostate cancer: an effective endoscopic treatment using bipolar plasma button and triamcinolone

Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition

PURPOSE

Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique.

MATERIALS & METHODS

The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire.

RESULTS

A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2.

CONCLUSIONS

Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment

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.

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.

Use of the Allium Round Posterior Stent for the Treatment of Recurrent Vesicourethral Anastomosis Stricture

OBJECTIVE

To compare outcomes of monopolar incision and Allium Round Posterior Stent (RPS) insertion for the treatment of recurrent vesicourethral anastomosis stricture.

METHODS

Having a suprapubic catheter and an obstructed pattern with a peak flow rate (PFR) ≤12 mL/s on uroflowmetry were the indications for the surgery. Once the fibrotic vesicourethral anastomosis was incised, RPS was inserted at the level of vesicourethral anastomosis under fluoroscopic guidance. All the stents were removed at postoperative first year. Patients were evaluated 3months after stent removal. Objective cure was defined as no need to further treatments and PFR ≥12 mL/s while subjective cure was defined as having points <4 on Patient Global Impression of Improvements scale.

RESULTS

Of the 30 patients with a median age 66 (52-74) enrolled in the study, 18 had a suprapubic catheter, remaining 12 had median PFR 5.2 (2-10) mL/s. Stent migration was noted in two patients, these stents were replaced by new ones. Stone formation was diagnosed in one patient, a pneumatic-lithotripsy was performed. The median follow-up time was 28 (4-60) months following stent removal. Six cases needed further treatment after removal. The median PFR of remaining 24 patients was 20 (16-30) mL/s (P = .001). The objective cure rate was 24/30(80%), the Patient Global Impression of Improvements scores varied from 1 to 2, meaning subjective cure rate was 24/30(80%). For the six failed cases, according to patient preferences a lifetime RPS insertion was planned.

CONCLUSION

With its minimally invasive nature, reversibility, and acceptable success and complication rates, incision of anastomosis and insertion of the RPS for a 1-year duration is a promising option for the treatment of recurrent vesicourethral anastomosis stricture.