Management of restenosis after urethral stent placement

Urethral reconstruction in patients previously treated with Memokath™ urethral endoprosthesis

PURPOSE

To evaluate the role and success rate of urethral reconstruction in patients with urethral stricture previously treated with thermos-expandable Memokath™ urethral endoprosthesis.

MATERIALS AND METHOD

A case series of patients with urethral stricture and Memokath™ endoprosthesis treated with urethroplasty is presented. Reconstruction was decided due to stricture progression or complications derived from primary stent treatment. Age, stricture and stent length, time between stent placement and urethroplasty, mode of stent retrieval, type of urethroplasty, complications and voiding parameters before and after urethroplasty were evaluated. Successful outcome was defined as standard voiding, without need of any postoperative procedure.

RESULTS

Eight cases with bulbar urethra stricture were included. Memokath™ was endoscopically retrieved before urethroplasty in 6 (75%) and by open urethrotomy at the time of urethroplasty in 2 (25%). Technique of urethroplasty was dorso-lateral onlay buccal mucosa graft in 5 (62.5%) cases and excision and primary anastomosis, anastomotic urethroplasty, and dorsal onlay buccal mucosa graft in one (12.5%) case each. There was no failure at 26±21.5 months median follow-up. Total IPSS, QoL, Qmax and postvoid residual significantly improved (P<.05). The only complication presented was epididymitis and penile shortening in one patient (12.5%).

CONCLUSIONS

Urethroplasty after re-stricture or other complications in patients with temporary Memokath™ urethral stent is a viable and definite option of reconstruction with excellent results in the short term and few complications. One-side dorsolateral onlay buccal mucosa graft augmentation is the optimal technique for this indication.

[Management of vesicourethral anastomotic stenosis after radical prostatectomy]

Vesicourethral anastomotic stenosis is a relatively uncommon problem after radical prostatectomy, but it could become recurrent and difficult to treat. Risk factors are known, and they can help to decrease the incidence. When discussing the therapeutic plan, we must consider the stenosis risk, and also the urinary continence after the prostatectomy. Many treatment schedules are proposed, some of them with low available evidence, limited to case series with different number of patient and follow-up length, or reviews on the subject. Endoscopic options are the commonest, obtaining different success rates depending on the incision, resection or vaporization of the tissue. They could also benefit from the use of adjuvant local injections of drugs regulating tissue growth. Recurrent or obliterated cases could require surgical reconstruction using perineal, abdominal or combined approaches, or even suprapubic urinary diversions.

Urethroplasty After Urethral Urolume Stent: An International Multicenter Experience

OBJECTIVE

To evaluate the outcomes and factors affecting success of urethroplasty in patients with stricture recurrence after Urolume urethral stent.

MATERIAL AND METHODS

This is a retrospective international multicenter study on patients treated with urethral reconstruction after Urolume stent. Stricture and stent length, time between urethral stent insertion and urethroplasty, age, mode of stent retrieval, type of urethroplasty, complications and baseline, and posturethroplasty voiding parameters were analyzed. Successful outcome was defined as standard voiding, without need of any postoperative adjunctive procedure.

RESULTS

Sixty-three patients were included. Stent was removed at urethroplasty in 61 patients. Reconstruction technique was excision and primary anastomosis in 14 (22.2%), dorsal onlay buccal mucosa graft (BMG) in 9 (14.3%), ventral onlay BMG in 6 (9.5%), dorsolateral onlay BMG in 9 (14.3%), ventral onlay plus dorsal inlay BMG in 3 (4.8%), augmented anastomosis in 5 (7.9%), pedicled flap urethroplasty in 6 (9.5%), 2-stage procedure in 4 (6.4%), and perineal urethrostomy in 7(11.1%). Success rate was 81% at a mean 59.7 ± 63.4 months. Dilatation or internal urethrotomy was performed in 10 (15.9%) and redo-urethroplasty in 5 (7.9%). Total International Prostate Symptom Score, quality of life, urine maximum flow, and postvoid residual significantly improved (P <.0001). Complications occurred in 8 (12.7%), all Clavien-Dindo ≤2. Disease-free survival rate after reconstruction was 88.1%, 79.5%, and 76.7% at 1, 3, and 5 years, respectively. Explant of individual strands followed by onlay BMG is the most common approach and was significantly advantageous over the other techniques (P = .018).

CONCLUSION

Urethroplasty in patients with Urolume urethral stents is a viable option of reconstruction with a high success rate and very acceptable complication rate. Numerous techniques are viable; however, urethral preservation, tine-by-tine stent extraction, and use of BMG augmentation produced significantly better outcomes.

Drug-eluting metallic stents in urology

Drugeluting metal stents (DESs) have been extensively used in coronary and vascular disease. This type of stents has been proven to provide significantly lower restenosis rates due to the reduction of neo-intimal hyperplasia in comparison to the traditionally used bare metal stents (BMSs). The latter stents have been evaluated for more than a decade in urological practice in an attempt to provide permanent relief of urethral or ureteral obstruction. Although the initial results were promising, long-term experience revealed significant complications, which are mainly attributed to stent-related hyperplastic reaction compromising stent patency. The favorable experience of vascular DESs led to the application of DESs in both the urethra and ureter of animal models. These experimental results demonstrated a reduction of hyperplastic reaction of DESs in comparison to BMSs. Nevertheless, clinical data are currently not available. Considering the fact that DESs are under continuous development, the use of DESs in urology holds promise for the future and seems to be an intriguing field.

Management for prostate cancer treatment related posterior urethral and bladder neck stenosis with stents

PURPOSE

Prostate cancer treatment has the potential to lead to posterior urethral stricture. These strictures are sometimes recalcitrant to dilation and urethrotomy alone. We present our experience with the Urolume® stent for prostate cancer treatment related stricture.

MATERIALS AND METHODS

A total of 38 men with posterior urethral stricture secondary to prostate cancer treatment were treated with Urolume stenting. Stents were placed in all men after aggressive urethrotomy over the entire stricture. A successfully managed stricture was defined as open and stable for greater than 6 months after any necessary secondary procedures.

RESULTS

The initial success rate was 47%. After a total of 31 secondary procedures in 19 men, including additional stent placement in 8 (18%), the final success rate was 89% at a mean ± SD followup of 2.3 ± 2.5 years. Four cases (11%) in which treatment failed ultimately requiring urinary diversion (3) or salvage prostatectomy (1). Incontinence was noted in 30 men (82%), of whom 19 (63%) received an artificial urinary sphincter a mean of 7.2 ± 2.4 months after the stent. Subanalysis revealed that irradiated men had longer strictures (3.6 vs 2.0 cm, p = 0.003) and a higher post-stent incontinence rate (96% vs 50%, p < 0.001) than men who underwent prostatectomy alone but the initial failure rate was similar (54% vs 50%, p = 0.4).

CONCLUSIONS

Urolume stenting is a reasonable option for severe post-prostate cancer treatment stricture when patients are unwilling or unable to undergo open reconstructive surgery. Incontinence should be expected. The need for additional procedures is common and in some men may be required periodically for the lifetime of the stent.

Management of urethral stent failure for recurrent anterior urethral strictures

BACKGROUND

Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications.

OBJECTIVE

To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures.

DESIGN, SETTING, AND PARTICIPANTS

We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures.

SURGICAL PROCEDURE

The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section.

MEASUREMENTS

Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications.

RESULTS AND LIMITATIONS

Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases.

CONCLUSIONS

The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion.