Endoscopic Treatment of Vesicourethral Stenosis after Radical Prostatectomy: Outcomes and Predictors of Success

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.

Short- and intermediate-term outcome of robot-assisted inverted YV-plasty for recurrent bladder neck stenosis - a single centre study

OBJECTIVES

To report the technique and preliminary results for extraperitoneal robot-assisted laparoscopic YV-plasty (RAYV) for refractory bladder neck stenosis (BNS) and vesicourethral anastomosis stenosis (VUAS).

MATERIALS AND METHODS

Included were patients with recurrent BNS and VUAS who underwent RAYV at our institution. Primary outcome was short- and intermediate-term functional results measured with urinary peak flow (Qmax), post-void residual urine (PVR) as well as quality of life assessment with the international prostate symptom score (IPSS) and short form health survey (SF-8). Short- and intermediate-term follow-up periods were defined as 1 to 6 months and 6 to 24 months, respectively. Secondary, all patients were reviewed for etiology as well as perioperative data. Treatment success was defined by absence of further treatment and/or need for intermittent or permanent catheterization.

RESULTS

Between March 2016 and October 2020 a total of 30 patients with a median age of 70.8 (64 - 77) years underwent RAYV with a median follow-up of 27 months. Median operative time (skin-skin) was 131 (112 - 145) minutes. The transurethral indwelling catheter was removed after 10 (5 - 16) days. There were no intraoperative complications but two postoperative major complications Clavien-Dindo IIIa and IV, respectively. Short- and intermediate-term results revealed significant improvement of IPS symptom score from 17 (11-24) points to 11 (6-13) points and 6 (3-9) points, respectively. Further thePVR decreased from 90 (5-302) mL to 0 (0-30) mL and 0 (0-90) mL, respectively, and Qmax increased from 7.4 mL/s to 13 (8-16) mL/s and 17 (12-4) mL/s, respectively. Improvement of SF-8 did not reach significance. A total of 5/30 (16.7%) patients had a treatment failure after 24 months whereof 2 had a re-stricture.

CONCLUSION

RAVY-Plasty for recurrent bladder neck stenosis is a safe and effective procedure with good functional short- and median-term outcome.

Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy

OBJECTIVE

Vesicourethral anastomotic stenosis (VUAS) is frequently seen after prostate surgery because of various operative and postoperative factors. In this study, we aimed to present our results of perineoscopic bladder neck reconstruction, which is a new technique of the perineal approach in the treatment of patients with VUAS after prostate cancer surgery.

MATERIAL AND METHODS

Sixteen consecutive patients who underwent perineoscopic bladder neck reconstruction in our clinic between July 2017 and March 2019 were included in the study. Demographic characteristics, surgical history, postoperative continence status, and additional treatment requirements were recorded. Perineoscopic surgery is defined as the visualization of the surgical site with instruments used in laparoscopy and the surgeon performing the entire operative procedure through the screen.

RESULTS

The mean number of preoperative endoscopic bladder neck resections of the patients was 7±5.1, with a history of suprapubic cystostomy in 7 (43.7%) and radiotherapy in 5 (31.2%) patients before surgery. The mean surgical time was 126.2±13.1 min. The mean follow-up period was 13.2±6.8 months, and the success rate was 81.25%. During follow-up, two (12.5%) patients received perineoscopic re-do reconstruction because of stricture recurrence, and one (6.2%) patient was included in a urethral dilatation program.

CONCLUSION

Improving visualization and ergonomics with the perineoscopic approach can increase the success rate of bladder neck reconstruction in comparison with the standard approach. In addition, the lack of need for expanded dissection (corporal separation, inferior pubectomy) reduces postoperative complication rates.

Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy

OBJECTIVES

To investigate the outcomes of deep lateral incision for vesicourethral anastomotic stenosis after radical prostatectomy and its impact on postoperative urinary incontinence.

METHODS

We retrospectively investigated 43 men who underwent deep lateral incision for non-obliterated vesicourethral anastomotic stenosis after radical prostatectomy between 2011 and 2020. The bladder neck was deeply incised through its circular fibers into the surrounding perivesical fat at 3 and 9 o'clock through electrocautery incision using needle-type electrodes. Successful deep lateral incision was defined as the absence of additional treatment, including self-dilatation. The postoperative urinary incontinence status was evaluated based on the number of pads used daily.

RESULTS

Deep lateral incision was successful in 35 (81.4%) patients, with a median follow-up period of 43 months (interquartile range 15-80 months). There was no significant association of age (P = 0.66), body mass index (P = 0.49) and history of diabetes mellitus (P = 0.39), radiation therapy (P = 0.89) or previous vesicourethral anastomotic stenosis treatment (P = 0.71) with the incision outcomes; however, there were significantly more unsuccessful cases in those with preoperative urinary retention (P = 0.04) or indwelling urinary catheters for >5 days post-incision (P = 0.01). A second incision was carried out in eight patients and a third incision in two patients, resulting in 42 (97.7%) successful incisions. A total of 37 (88.1%) patients had urinary incontinence and used at least one pad daily; seven (16.7%) underwent artificial urinary sphincter implantation after the last incision.

CONCLUSIONS

Deep lateral incision is highly effective for treating vesicourethral anastomotic stenosis after radical prostatectomy. Appropriate treatment is required for urinary incontinence, which occurs frequently after incision.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Management of Bladder Neck Contracture in the Age of Robotic Prostatectomy: An Evidence-based Guide

The incidence of bladder neck contracture (BNC), or postprostatectomy vesicourethral anastomosis, has declined since the advent of robotic surgery. However, men with peripheral vascular comorbidities, among other factors, still have a high risk of developing this complication after any surgery that involves manipulation of the prostate. The best strategy for BNC management remains uncertain because of inconsistency in success for different approaches across studies. We reviewed the available evidence on BNC, including the results for endoscopic treatments, scar modulation therapies, and open and robotic bladder neck reconstruction. On the basis of these data, we propose a management flowchart. Patient baseline status and subjective goals and preferences remain crucial in management choices. PATIENT SUMMARY: Contracture of the bladder neck can occur as a complication after surgery to the prostate. We reviewed the evidence for various treatment approaches and propose a flowchart for management of this condition.

The effect of proliferative hypertrophic scars on determining treatment options for preventing recurrence of vesicourethral anastomotic stenosis after radical prostatectomy: a single-center cross-sectional study

BACKGROUND

Vesicourethral anastomotic stenosis (VUAS) following retropubic radical prostatectomy (RRP) significantly worsens quality of life.

OBJECTIVES

To investigate the relationship between proliferative hypertrophic scar formation and VUAS, and predict more appropriate surgical intervention for preventing recurrent VUAS.

DESIGN AND SETTING

Retrospective cross-sectional single-center study on data covering January 2009 to December 2019.

METHODS

Among 573 male patients who underwent RRP due to prostate cancer, 80 with VUAS were included. They were divided into two groups according to VUAS treatment method: dilatation using Amplatz renal dilators (39 patients); or endoscopic bladder neck incision/resection (41 patients). The Vancouver scar scale (VSS) was used to evaluate the characteristics of scars that occurred for any reason before development of VUAS.

RESULTS

Over a median follow-up of 72 months (range 12-105) after RRP, 17 patients (21.3%) had recurrence of VUAS. Although the treatment success rates were similar (79.5% versus 78.0%; P = 0.875), receiver operating characteristic (ROC) curve analysis indicated that dilatation using Amplatz dilators rather than endoscopic bladder neck incision/resection in patients with VSS scores 4, 5 and 6 may significantly reduce VUAS recurrence. A strong positive relationship was observed between VSS and total number of VUAS occurrences (r: 0.689; P < 0.001). VSS score (odds ratio, OR: 5.380; P < 0.001) and time until occurrence of VUAS (OR: 1.628; P = 0.008) were the most significant predictors for VUAS recurrence.

CONCLUSIONS

VSS score can be used as a prediction tool for choosing more appropriate surgical intervention, for preventing recurrent VUAS.

Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy

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.

Triamcinolone acetonide injections for the treatment of recalcitrant post-radical prostatectomy vesicourethral anastomotic stenosis: A retrospective look at efficacy and safety

INTRODUCTION

We aimed to evaluate the success of bladder neck injections of triamcinolone at the time of transurethral bladder neck incision (BNI) for prevention of recurrent vesicourethral anastomotic stenosis (VUAS) following prostate cancer treatment.

METHODS

This is a retrospective cohort study examining patients with recurrent VUAS post-radical prostatectomy (RP) ± radiation treated with triamcinolone injections at the time of BNI. VUAS was diagnosed by symptoms followed by cystoscopy or urethrography. The outpatient procedures were done under general anesthesia. Cold knife incisions were made at the three, nine, and 12 o'clock BN positions, followed by triamcinolone injections (4 mg/mL) into the three and nine o'clock incision sites. Treatment outcomes were determined with cystoscopy.

RESULTS

Eighteen men underwent 25 procedures over a four-year period. Median age at diagnosis of VUAS was 65 (interquartile range [IQR] 61-68); median time to VUAS from RP was eight months (IQR 5-12). Fourteen patients (78%) had radiation treatment. The cohort had 128 unsuccessful VUAS treatments, with a median of five failed treatments per patient (IQR 3-10). Failed treatments included BN dilation, BNI, BN injection of mitomycin C, and urethral stent placement. Success rate after a mean of 16.3 months (standard deviation [SD] 8.1) from the time of triamcinolone injection was 83% (15/18). Six patients went on to have successful incontinence surgery. Five patients (28%) had treatment complications (bleeding, urinary tract infection, pain, and urinary extravasation). The three non-responders are stable and awaiting re-treatment with triamcinolone injection.

CONCLUSIONS

Triamcinolone bladder neck injections for post-RP VUAS are a useful and safe treatment for recurrent stenosis.

Canadian Urological Association guideline on male urethral stricture

Urethral stricture is fundamentally a fibrosis of the urethral epithelial and associated corpus spongiosum, which in turn, causes obstruction of the urethral lumen. Patients with urethral stricture most commonly present with lower urinary tract symptoms, urinary retention or urinary tract infection but may also experience a broad spectrum of other signs and symptoms, including genitourinary pain, hematuria, abscess, ejaculatory dysfunction, or renal failure. When urethral stricture is initially suspected based on clinical assessment, cystoscopy is suggested as the modality that most accurately establishes the diagnosis. This recommendation is based on several factors, including the accuracy of cystoscopy, as well as its wide availability, lesser overall cost, and comfort of urologists with this technique. When recurrent urethral stricture is suspected, we suggest performing retrograde urethrography to further stage the length and location of the stricture or referring the patient to a physician with expertise in reconstructive urology. Ultimately, the treatment decision depends on several factors, including the type and acuity of patient symptoms, the presence of complications, prior interventions, and the overall impact of the urethral stricture on the patient's quality of life. Endoscopic treatment, either as dilation or internal urethrotomy, is suggested rather than urethroplasty for the initial treatment of urethral stricture. This recommendation applies to men with undifferentiated urethral stricture and does not apply to trauma-related urethral injuries, penile urethral strictures (hypospadias, lichen sclerosus), or suspected urethral malignancy. In the setting of recurrent urethral stricture, urethroplasty is suggested rather than repeat endoscopic management but this may vary depending on patient preference and impact of the symptoms on the patient.The purpose of this guideline is to provide a practical summary outlining the diagnosis and treatment of urethral stricture in the Canadian setting.

[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.

Vesico-urethral anastomotic stenosis following radical prostatectomy: a multi-institutional outcome analysis with a focus on endoscopic approach, surgical sequence, and the impact of radiation therapy

OBJECTIVES

To investigate the predictors of recurrence and of de novo incontinence in patients treated by transurethral incision or resection for vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy.

MATERIAL AND METHODS

All patients undergoing endoscopic treatment for VUAS between March 2009 and October 2016 were identified in our multi-institutional database. Digital chart reviews were performed and patients contacted for follow-up. Recurrence was defined as any need for further instrumentation or surgery, and de-novo-incontinence as patient-reported outcome.

RESULTS

Of 103 patients undergoing endoscopic VUAS treatment, 67 (65%) underwent transurethral resection (TR) and 36 (35%) transurethral incision (TI). TI was performed more frequently as primary treatment compared to TR (58% vs. 37%; p = 0.041). Primary and repeated treatment was performed in 46 (45%) and 57 patients (55%), respectively. Overall, 38 patients (37%) had a history of radiation therapy. There was no difference in time to recurrence for primary vs repeat VUAS treatment, previous vs no radiation, TR compared to TI (all p > 0.08). Regarding treatment success, no difference was found for primary vs. repeat VUAS treatment (50% vs. 37%), previous radiation vs. no radiation (42% vs. 43%), and TR vs. TI (37% vs. 53%; all p ≥ 0.1). Postoperative de novo incontinence was more common after TI vs. TR (31% vs. 12%; p = 0.032), no difference was observed for previous radiation therapy vs. no radiation therapy (18% vs. 18%; p > 0.9) or primary vs. repeat VUAS treatment (22% vs. 16%; p = 0.5).

CONCLUSION

VUAS recurrence after endoscopic treatment is not predictable. Endoscopic treatment with TI showed a higher risk for de novo incontinence than TR, and previous irradiation and the number of treatments do not influence incontinence.

Treatment outcomes of bladder neck contractures from surgical clip erosion: a matched cohort comparison

Vesicourethral anastomotic stenosis (VUS) from surgical clip erosion after radical prostatectomy (RP) is a rare scenario with potentially significant quality of life implications. The literature is limited to case series, and the impact of clip erosion on VUS prognosis is not known. Years 2001 to 2012 of our institutional RP registry were queried for patients with symptomatic VUS without prior strictures or radiotherapy. Patients with clip-associated VUS (caVUS) were identified and compared to a 1:3 matched cohort (based on age, Gleason score, and year of surgery) of non-caVUS patients using descriptive statistics and time to event analyses. At a median follow-up of 54 months after RP, 243 men with symptomatic VUS were identified of which 21 (8.6%) were caVUS. Robotic RPs had a higher rate of caVUS (0.5%) vs. open RPs (0.06%), P<0.01. Patients with caVUS had longer time to diagnosis after RP compared to a matched cohort of 63 non-caVUS patients (median 9.2 vs. 3.7 months after RP, P<0.01). Although patients with caVUS had a higher VUS recurrence rate after endoscopic treatment compared to patients with non-caVUS, the difference was not statistically significant on log-rank comparison (3-year VUS recurrence rate 56.4% vs. 39.4%, P=0.23). Majority of VUS recurrences were within 18 months of initial treatment. Clip erosion is responsible for 8.6% of VUS after RP, takes longer to present than non-caVUS, and was seen more commonly after a robotic RP. VUS recurrence rates are similar for caVUS and non-caVUS.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

Purpose:

To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence.

Materials and Methods:

Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope.

Results:

Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 – 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 – 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels.

Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up.

Conclusion:

Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Management of Urethral Stricture and Bladder Neck Contracture Following Primary and Salvage Treatment of Prostate Cancer

PURPOSE OF REVIEW

This article discusses the incidence, evaluation, and treatment of bladder outlet obstruction from urethral stricture, vesicourethral anastomotic stricture, and bladder neck contracture following primary and salvage treatment of prostate cancer.

RECENT FINDINGS

Rates of stenosis after prostate cancer treatment appear similar across all primary treatment modalities including radical prostatectomy, radiation therapy, cryoablation, and high-intensity focused ultrasound in contemporary series. Urethral dilation and urethrotomy continue to report moderate patency rates. Urethroplasty achieves high patency rates even for long strictures, but more extensive reconstruction increases the risk of postoperative urinary incontinence. Recent AUA guidelines on urethral strictures provide new recommendations for management of these patients. All treatment options for prostate cancer carry a risk for bladder outlet obstruction, and intervention is often necessary to relieve long-lasting morbidity. Careful preoperative evaluation should be completed to assess location and extent of the stricture in order to choose optimal therapy. Endoscopic treatments, open reconstruction, and urinary diversion all play a role in relief of stenosis depending on stricture length, location, characteristics, and patient comorbidities.

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures

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.

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.