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Martins FE, Lumen N, Holm HV. Management of the Devastated Bladder Outlet after Prostate CANCER Treatment. Curr Urol Rep 2024; 25:149-162. [PMID: 38750347 DOI: 10.1007/s11934-024-01206-8] [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] [Accepted: 04/23/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE OF REVIEW Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion. RECENT FINDINGS The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.
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Affiliation(s)
- Francisco E Martins
- Department of Urology, University of Lisbon, School of Medicine, Centro Hospitalar Universitário, Lisboa Norte (CHULN), Lisbon, Portugal
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000, Ghent, Belgium
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Horiguchi A, Shinchi M, Hirano Y, Asanuma H, Ishiura Y, Inoue K, Kanematsu A, Tabei T, Tamura Y, Nakajima Y, Moriya K, Yagihashi Y, Fukagai T, Fujii Y. Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures. Int J Urol 2024. [PMID: 38874432 DOI: 10.1111/iju.15512] [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: 04/18/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
- Division of Trauma Reconstruction, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masayuki Shinchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroshi Asanuma
- Department of Urology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | | | - Koji Inoue
- Department of Urology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Akihiro Kanematsu
- Department of Urology, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tadashi Tabei
- Department of Urology, Fujisawa Shonandai Hospital, Fujisawa, Kanagawa, Japan
| | - Yoshimi Tamura
- Department of Urology, Shibukawa Medical Center, Shibukawa, Gunma, Japan
| | | | - Kimihiko Moriya
- Department of Pediatric Urology, Jichi Children's Medical Center Tochigi, Shimotsuke, Tochigi, Japan
| | - Yusuke Yagihashi
- Department of Urology, Shizuoka City Shizuoka Hospital, Shizuoka City, Shizuoka, Japan
| | - Takashi Fukagai
- Department of Urology, Showa University, Shinagawa, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
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Takano S, Tomita N, Takaoka T, Niwa M, Torii A, Kita N, Okazaki D, Uchiyama K, Nakanishi-Imai M, Ayakawa S, Iida M, Tsuzuki Y, Otsuka S, Manabe Y, Nomura K, Ogawa Y, Miyakawa A, Miyamoto A, Takemoto S, Yasui T, Hiwatashi A. Late genitourinary toxicity in salvage radiotherapy for prostate cancer after radical prostatectomy: impact of daily fraction doses. Br J Radiol 2024; 97:1050-1056. [PMID: 38466928 DOI: 10.1093/bjr/tqae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/31/2023] [Accepted: 03/07/2024] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVE To evaluate the impact of daily fraction doses on late genitourinary (GU) toxicity after salvage radiotherapy (SRT) for prostate cancer. METHODS This multi-institutional retrospective study included 212 patients who underwent SRT between 2008 and 2018. All patients received image-guided intensity-modulated SRT at a median dose of 67.2 Gy in 1.8-2.3 Gy/fraction. The cumulative rates of late grade ≥2 GU and gastrointestinal (GI) toxicities were compared using Gray test, stratified by the ≤2.0 Gy/fraction (n = 137) and ≥2.1 Gy/fraction groups (n = 75), followed by multivariate analyses. The total dose was represented as an equivalent dose in 2-Gy fractions (EQD2) with α/β = 3 Gy. RESULTS After a median follow-up of 63 months, the cumulative rates of 5-year late grade ≥2 GU and GI toxicities were 14% and 2.5%, respectively. The cumulative rates of 5-year late grade ≥2 GU toxicity in the ≥2.1 Gy/fraction and ≤2.0 Gy/fraction groups were 22% and 10%, respectively (P = .020). In the multivariate analysis, ≥2.1 Gy/fraction was still associated with an increased risk of late grade ≥2 GU toxicity (hazard ratio, 2.37; 95% confidence interval, 1.12-4.99; P = .023), while the total dose was not significant. CONCLUSION The present results showed that ≥2.1 Gy/fraction resulted in a higher incidence of late grade ≥2 GU toxicity in SRT. ADVANCES IN KNOWLEDGE The impact of fraction doses on late GU toxicity after SRT remains unknown. The results suggest that higher fraction doses may increase the risk of late GU toxicity in SRT.
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Affiliation(s)
- Seiya Takano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Natsuo Tomita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Taiki Takaoka
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Masanari Niwa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Akira Torii
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Nozomi Kita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Dai Okazaki
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Kaoru Uchiyama
- Department of Radiology, Kariya Toyota General Hospital, Kariya, Aichi 448-8505, Japan
| | - Mikiko Nakanishi-Imai
- Department of Radiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi 466-8650, Japan
| | - Shiho Ayakawa
- Department of Radiology, Japan Community Health care Organization Chukyo Hospital, Nagoya, Aichi 457-8510, Japan
| | - Masato Iida
- Department of Radiation Oncology, Suzuka General Hospital, Suzuka, Mie 513-0818, Japan
| | - Yusuke Tsuzuki
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi 462-8508, Japan
| | - Shinya Otsuka
- Department of Radiology, Okazaki City Hospital, Okazaki, Aichi 444-8553, Japan
| | - Yoshihiko Manabe
- Department of Radiation Oncology, Nanbu Tokushukai General Hospital, Shimajiri, Okinawa 901-0493, Japan
| | - Kento Nomura
- Department of Radiotherapy, Nagoya City West Medical Center, Nagoya, Aichi 462-8508, Japan
| | - Yasutaka Ogawa
- Department of Radiation Oncology, Kasugai Municipal Hospital, Kasugai, Aichi 486-8510, Japan
| | - Akifumi Miyakawa
- Department of Radiation Oncology, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi 460-0001, Japan
| | - Akihiko Miyamoto
- Department of Radiation Oncology, Hokuto Hospital, Obihiro, Hokkaido 080-0833, Japan
| | - Shinya Takemoto
- Department of Radiation Oncology, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka 426-8662, Japan
| | - Takahiro Yasui
- Department of Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
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Zheng K, Sa Y, Hao C, Li C, Li W, Miao F, Gu C, Ding X, Huang J, Zhang Q, Huang J, Song L, Huang J, Si J, Zhang K, Fu Q, Hu X. Modified Y-V plasty based on MRU evaluation for iatrogenic bladder outlet obliteration: a multicentre experience in China. World J Urol 2024; 42:88. [PMID: 38372802 DOI: 10.1007/s00345-023-04765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/26/2023] [Indexed: 02/20/2024] Open
Abstract
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.
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Affiliation(s)
- Kun Zheng
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Yinglong Sa
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Chuan Hao
- Department of Urology, Second Hospital of Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Chengyong Li
- Department of Urology, Second Hospital of Shanxi Medical University, Taiyuan, 030001, Shanxi, China
| | - Wei Li
- Department of Urology, People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, 530016, Guangxi, China
| | - Fachen Miao
- Department of Urology, Shanxian Central Hospital, Heze, 274399, Shandong, China
| | - Chaohui Gu
- Department of Urology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xiaoju Ding
- Department of Urology, Guilin Medical College Affiliated Hospital, Guilin, 541001, Guangxi, China
| | - Jiefu Huang
- Department of Urology, Guilin Medical College Affiliated Hospital, Guilin, 541001, Guangxi, China
| | - Qingbing Zhang
- Department of Urology, Dong E Hospital, Liaocheng, 252200, Shandong, China
| | - Jianbing Huang
- Department of Urology, Chinese Medicine Hospital of Mayang Autonomous County of Miao Nationality, Huaihua, 419400, Hunan, China
| | - Lujie Song
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Jianwen Huang
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Jiemin Si
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Kaile Zhang
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China
| | - Qiang Fu
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China.
| | - Xiaoyong Hu
- Department of Urology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China.
- Shanghai Eastern Institute of Urologic Reconstruction, Shanghai Jiao Tong University, Shanghai, 200233, China.
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Klemm J, Dahlem R, Kluth LA, Rosenbaum CM, Shariat SF, Fisch M, Vetterlein MW. [Evaluation and management of urethral strictures-guideline summary 2024 : Part 2-posterior urethra]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:15-24. [PMID: 38057615 DOI: 10.1007/s00120-023-02241-y] [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: 11/10/2023] [Indexed: 12/08/2023]
Abstract
In light of recently published international guidelines concerning the diagnosis, treatment, and aftercare of urethral strictures and stenoses, the objective of this study was to synthesize an overview of guideline recommendations provided by the American Urological Association (AUA, 2023), the Société Internationale d'Urologie (SIU, 2010), and the European Association of Urology (EAU, 2023). The recommendations offered by these three associations, as well as the guidelines addressing urethral trauma from the EAU, AUA, and the Urological Society of India (USI), were assessed in terms of their guidance on posterior urethral stenosis. On the whole, the recommendations from the various guidelines exhibit considerable alignment. However, SIU and EAU place a stronger emphasis on the role of repeated endoscopic treatment compared to AUA. The preferred approach for managing radiation-induced bulbomembranous stenosis remains a subject of debate. Furthermore, endoscopic treatments enhanced with intralesional therapies may potentially serve as a significant treatment modality for addressing even fully obliterated stenoses.
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Affiliation(s)
- Jakob Klemm
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Comprehensive Cancer Center, Medizinische Universität Wien, Universitätsklinik für Urologie, Wien, Österreich
| | - Roland Dahlem
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Luis A Kluth
- Klinik für Urologie, Universitätsklinikum Frankfurt am Main, Frankfurt am Main, Deutschland
| | | | - Shahrokh F Shariat
- Comprehensive Cancer Center, Medizinische Universität Wien, Universitätsklinik für Urologie, Wien, Österreich
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordanien
- Karl Landsteiner Institut für Urologie und Andrologie, Wien, Österreich
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prag, Tschechien
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Malte W Vetterlein
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Barnard J, Liaw A, Gelman J. Long-term follow-up suggests high satisfaction rates for bulbomembranous radiation-induced urethral stenoses treated with anastomotic urethroplasty. World J Urol 2023; 41:1905-1912. [PMID: 37314572 PMCID: PMC10352169 DOI: 10.1007/s00345-023-04429-5] [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] [Received: 02/16/2023] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To analyze patients who underwent anastomotic urethroplasty for radiationinduced bulbomembranous urethral stricture/stenosis (RIS) due to prostate cancer treatment with up to 19 years of follow-up and assess long-term patient reported outcomes (PROMs). Long-term follow-up with the inclusion of urethroplasty specific PROMs is lacking in the available research. METHODS Patients who underwent anastomotic urethroplasty for RIS were identified from 2002 to 2020. Inclusion criteria included completion of 4-month post-operative cystoscopy and PROMs including IPSS, SHIM, MSHQ-EF, 6Q-LUTS, and global satisfaction queries at 4 months. PROMs were assessed annually thereafter, and cystoscopy was performed for adverse change in PROMs or worsening uroflow/PVR parameters. PROMs were compared at pre-op, post-op, and most recent follow-up. RESULTS 23 patients met inclusion criteria. Short-term anatomic success was 95.7%. At a mean follow-up of 73.1 months (9.1-228.9), one late recurrence occurred for an overall success of 91.3%. Significant and sustained objective improvement was identified in voiding scores, quality of life, and urethroplasty specific PROMs. Satisfaction was 91.3% despite sexual side effects, and 95.7% of patients stated they would have surgery again knowing their outcome at a mean of over 6 years' follow up. CONCLUSIONS RIS are challenging problems, but durable symptomatic relief is achievable in well-selected patients. Patients with bulbomembranous RIS should be appropriately counseled regarding the risk of urinary incontinence and sexual side effects after anastomotic urethroplasty. However, long-term success is high, and overall QoL will have sustained subjective improvement in most cases.
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Affiliation(s)
- John Barnard
- West Virginia University School of Medicine, Morgantown, WV, USA.
| | - Aron Liaw
- University of California-Irvine, Irvine, CA, USA
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Sterling J, Rahman SN, Varghese A, Angulo JC, Nikolavsky D. Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease. J Clin Med 2023; 12:3950. [PMID: 37373644 DOI: 10.3390/jcm12123950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.
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Affiliation(s)
- Joshua Sterling
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Syed N Rahman
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Ajin Varghese
- New York College of Osteopathic Medicine, 8000 Old Westbury, Glen Head, NY 11545, USA
| | - Javier C Angulo
- Faculty of Biomedical Sciences, Universidad Europea, 28905 Madrid, Spain
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Yamada Y, Taguchi S, Kume H. Surgical Tolerability and Frailty in Elderly Patients Undergoing Robot-Assisted Radical Prostatectomy: A Narrative Review. Cancers (Basel) 2022; 14:cancers14205061. [PMID: 36291845 PMCID: PMC9599577 DOI: 10.3390/cancers14205061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/14/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Life expectancy in Western countries and East Asian countries has incremented over the past decades, resulting in a rapidly aging world, while in general, radical prostatectomy (RP) is not recommended in elderly men aged ≥75 years. Together with the evolving technique of robotic surgeries, surgical indications for RP should be reconsidered in ‘elderly’ and ‘frail’ men, since this procedure has now become one of the safest and most effective cancer treatments for prostate cancer. One important element to determine surgical indications is surgical tolerability. However, evidence is scarce regarding the surgical tolerability in elderly men undergoing robot-assisted radical prostatectomy (RARP). In this review, we focused on the surgical tolerability in ‘elderly’ and/or ‘frail’ men undergoing RARP, with the intent to provide up-to-date information on this matter and to support the decision making of therapeutic options in this spectrum of patients. Abstract Robot-assisted radical prostatectomy (RARP) has now become the gold standard treatment for localized prostate cancer. There are multiple elements in decision making for the treatment of prostate cancer. One of the important elements is life expectancy, which the current guidelines recommend as an indicator for choosing treatment options. However, determination of life expectancy can be complicated and difficult in some cases. In addition, surgical tolerability is also an important issue. Since frailty may be a major concern, it may be logical to use geriatric assessment tools to discriminate ‘surgically fit’ patients from unfit patients. Landmark studies show two valid models such as the phenotype model and the cumulative deficit model that allow for the diagnosis of frailty. Many studies have also developed geriatric screening tools such as VES-13 and G8. These tools may have the potential to directly sort out unfit patients for surgery preoperatively.
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Affiliation(s)
- Yuta Yamada
- Correspondence: ; Tel.: +81-3-5800-8662; Fax: +81-5800-8917
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Krughoff K, Shapiro J, Peterson AC. Pelvic Fracture Urethral Distraction Defect. Urol Clin North Am 2022; 49:383-391. [DOI: 10.1016/j.ucl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Sun X, Jin X, Leng K, Zhao Y, Zhang H. 180-W GreenLight laser photoselective vaporization with multiple triamcinolone acetonide injections for the treatment of bladder neck contractures. Lasers Med Sci 2022; 37:3115-3121. [DOI: 10.1007/s10103-022-03568-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
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11
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Kocjancic E, Chung E, Garzon JA, Haylen B, Iacovelli V, Jaunarena J, Locke J, Millman A, Nahon I, Ohlander S, Pang R, Plata M, Acar O. International Continence Society (ICS) report on the terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction. Neurourol Urodyn 2022; 41:140-165. [PMID: 34989425 DOI: 10.1002/nau.24846] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction has not been defined and organized into a clinically based consensus terminology report. The aim of this terminology report is to provide a definitional document within this context that will assist clinical practice and research. METHODS This report combines the input of the members of sexual health in men with LUT and PF Dysfunction working group of the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 18 rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). The Committee retained evidence-based definitions, identified gaps, and updated or discarded outdated definitions. Expert opinions were used when evidence was insufficient or absent. RESULTS A terminology report for sexual health in men with LUT and PF dysfunction, encompassing 198 (178 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different speciality groups involved. Conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 years) review is anticipated to keep the document updated. CONCLUSION A consensus-based terminology report for sexual health in men with LUT and PF dysfunction has been produced to aid clinical practice and research. The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions.
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Affiliation(s)
- Ervin Kocjancic
- Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Eric Chung
- Department of Urology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | | | - Bernard Haylen
- Department of Gynaecology, University of New South Wales, Sydney, New South Wales, Australia
| | - Valerio Iacovelli
- Department of Urology, San Carlo di Nancy General Hospital-GVM Care and Research, Tor Vergata University of Rome, Rome, Italy
| | - Jorge Jaunarena
- Division of Urology, Centro de Urologia CDU, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Jennifer Locke
- Department of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Alexandra Millman
- Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Irmina Nahon
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Samuel Ohlander
- Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ran Pang
- Department of Urology, Guang An Men Hospital, Beijing, China
| | - Mauricio Plata
- Department of Urology, Universidad de los Andes School of Medicine, Fundación Santa fe de Bogotá University, Bogotá, Colombia
| | - Omer Acar
- Department of Urology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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12
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Abbosov S, Sorokin N, Shomarufov A, Kadrev A, Nuriddinov KU, Mukhtarov S, Akilov F, Kamalov A. Bladder neck contracture as a complication of prostate surgery: Alternative treatment methods and prospects (literature review). UROLOGICAL SCIENCE 2022. [DOI: 10.4103/uros.uros_127_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Martins FE, Holm HV, Lumen N. Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life. J Clin Med 2021; 10:4920. [PMID: 34768438 PMCID: PMC8584541 DOI: 10.3390/jcm10214920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.
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Affiliation(s)
- Francisco E. Martins
- Department of Urology, School of Medicine, University of Lisbon, Hospital Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | | | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium;
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14
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Bozkurt O, Sen V, Demir O, Esen A. Subtrigonal Inlay Patch Technique with Buccal Mucosa Graft for Recurrent Bladder Neck Contractures. Urol Int 2021; 106:256-260. [PMID: 34610599 DOI: 10.1159/000517894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ozan Bozkurt
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Volkan Sen
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Omer Demir
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Adil Esen
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey
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15
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Hoeh B, Müller SC, Kluth LA, Wenzel M. Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review. Front Surg 2021; 8:688394. [PMID: 34434956 PMCID: PMC8381645 DOI: 10.3389/fsurg.2021.688394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Stefan C Müller
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
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16
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Shinchi M, Horiguchi A, Ojima K, Hirano Y, Takahashi E, Kimura F, Ito K. Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy. Int J Urol 2021; 28:1120-1126. [PMID: 34382239 DOI: 10.1111/iju.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Masayuki Shinchi
- Department of Urology, National Defense Medical College, Saitama, Japan.,Department of Urology, National Hospital Organization, Nishisaitama-Chuo Hospital, Saitama, Japan
| | - Akio Horiguchi
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Kenichiro Ojima
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Saitama, Japan
| | - Eiji Takahashi
- Department of Urology, National Hospital Organization, Nishisaitama-Chuo Hospital, Saitama, Japan
| | - Fumihiro Kimura
- Department of Urology, National Hospital Organization, Nishisaitama-Chuo Hospital, Saitama, Japan
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, Saitama, Japan
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17
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Albano D, Benenati M, Bruno A, Bruno F, Calandri M, Caruso D, Cozzi D, De Robertis R, Gentili F, Grazzini I, Micci G, Palmisano A, Pessina C, Scalise P, Vernuccio F, Barile A, Miele V, Grassi R, Messina C. Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe. Insights Imaging 2021; 12:76. [PMID: 34114094 PMCID: PMC8192650 DOI: 10.1186/s13244-021-01017-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023] Open
Abstract
Newer biologic drugs and immunomodulatory agents, as well as more tolerated and effective radiation therapy schemes, have reduced treatment toxicity in oncology patients. However, although imaging assessment of tumor response is adapting to atypical responses like tumor flare, expected changes and complications of chemo/radiotherapy are still routinely encountered in post-treatment imaging examinations. Radiologists must be aware of old and newer therapeutic options and related side effects or complications to avoid a misinterpretation of imaging findings. Further, advancements in oncology research have increased life expectancy of patients as well as the frequency of long-term therapy-related side effects that once could not be observed. This pictorial will help radiologists tasked to detect therapy-related complications and to differentiate expected changes of normal tissues from tumor relapse.
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Affiliation(s)
- Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università Degli Studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy. .,Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy.
| | - Massimo Benenati
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy.,Dipartimento di Diagnostica per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Bruno
- Diagnostic and Interventional Radiology Unit, Maggiore Hospital "C. A. Pizzardi", 40133, Bologna, Italy
| | - Federico Bruno
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy.,Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - Marco Calandri
- Radiology Unit, A.O.U. San Luigi Gonzaga di Orbassano, Department of Oncology, University of Torino, 10043, Turin, Italy
| | - Damiano Caruso
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome - Sant'Andrea University Hospital, Via di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Diletta Cozzi
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy.,Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50123, Florence, Italy
| | - Riccardo De Robertis
- U.O.C. Radiologia BT, Ospedale Civile Maggiore - Azienda Ospedaliera Universitaria Integrata Verona, Piazzale A. Stefani 1, 37126, Verona, Italy
| | - Francesco Gentili
- Unit of Diagnostic Imaging, Department of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Irene Grazzini
- Department of Radiology, Section of Neuroradiology, San Donato Hospital, Arezzo, Italy
| | - Giuseppe Micci
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università Degli Studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy.,Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy
| | - Anna Palmisano
- Experimental Imaging Centre, Radiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, via Olgettina 58, 20132, Milan, Italy
| | - Carlotta Pessina
- Department of Radiology, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Paola Scalise
- Department of Diagnostic Imaging, Pisa University Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Federica Vernuccio
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università Degli Studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Antonio Barile
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50123, Florence, Italy
| | - Roberto Grassi
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122, Milan, Italy.,Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
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18
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Chen YZ, Lin WR, Chow YC, Tsai WK, Chen M, Chiu AW. Analysis of risk factors of bladder neck contracture following transurethral surgery of prostate. BMC Urol 2021; 21:59. [PMID: 33840387 PMCID: PMC8037916 DOI: 10.1186/s12894-021-00831-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUNDS The aim of the present study was to investigate the perioperative parameters associated with bladder neck contracture (BNC) after transurethral surgery of the prostate and to compare the incidence of BNC after transurethral resection of the prostate (TURP) or Thulium vaporesection (resection group) versus Thulium vapoenucleation or enucleation of the prostate (enucleation group). METHODS Between March 2008 and March 2020, 2363 patients received TURP and 1656 patients received transurethral surgery of the prostate with Thulium laser (ThuP) at Mackay Memorial Hospital. A total of 62 patients developed BNC. These BNC patients were age-and operation-matched to 124 randomly sampled TURP/ThuP controls without BNC. A 1:1 propensity score matching model was used to evaluate the difference in incidence of BNC. RESULTS Our study demonstrated that a greater proportion of BNC patients had history of cerebrovascular accidents (11/62 vs. 7/124, p = 0.009), coronary artery disease (14/48 vs. 16/108, p = 0.03), chronic kidney disease (14/62 vs. 11/124, p = 0.01), and two or more comorbidities (29/62 vs. 27/124, p = 0.001) compared with NBNC patients. Multivariate analysis showed that smaller prostate volume (OR 0.96 (0.94-0.99), p = 0.008) and recatherization (OR 5.6 (1.02-30.6), p = 0.047) were significantly associated with BNC. A ROC curve predicted that a prostate volume < 42.9 cm3 was associated with a notably higher rate of BNC. The propensity score matching model reported there was no difference in incidence between resection and enucleation groups. CONCLUSION This study demonstrated that incidence of BNC was the same in different surgical techniques and that low prostate volume, recatherization and ≥ 2 comorbidities were positively correlated with the development of BNC after TURP or ThuP.
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Affiliation(s)
- Yi-Zhong Chen
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan
| | - Wun-Rong Lin
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan.,School of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yung-Chiong Chow
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan.,School of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Wei-Kung Tsai
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan.,School of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Marcelo Chen
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan. .,School of Medicine, MacKay Medical College, New Taipei City, Taiwan. .,Department of Cosmetic Applications and Management, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.
| | - Allen W Chiu
- Department of Urology, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Zhongshan Dist., Taipei, 104, Taiwan.,School of Medicine, MacKay Medical College, New Taipei City, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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19
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Waterloos M, Martins F, Verla W, Kluth LA, Lumen N. Current Management of Membranous Urethral Strictures Due to Radiation. Front Surg 2021; 8:635060. [PMID: 33748181 PMCID: PMC7969877 DOI: 10.3389/fsurg.2021.635060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/01/2021] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy is a frequently used treatment for prostate cancer. It does not only causes the intended damage to cancer cells, but also affects healthy surrounding tissue. As a result radiation-induced urethral strictures occur in 2.2% of prostate cancer patients. Management of urethral strictures is challenging due to the presence of poor vascularized tissue for reconstruction and the proximity of the sphincter, which can impair the functional outcome. This review provides a literature overview of risk factors, diagnostics and management of radiation-induced urethral strictures.
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Affiliation(s)
- Marjan Waterloos
- Department of Urology, AZ Maria Middelares Ghent, Ghent, Belgium
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Francisco Martins
- Department of Urology, University of Lisbon School of Medicine, Lisbon, Portugal
| | - Wesley Verla
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Luis Alex Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nicolaas Lumen
- Department of Urology, University Hospital Ghent, Ghent, Belgium
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20
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Voelzke BB, Leddy LS, Myers JB, Breyer BN, Alsikafi NF, Broghammer JA, Elliott SP, Vanni AJ, Erickson BA, Buckley JC, Zhao LC, Wright T, Rourke KF. Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment. Urology 2021; 152:117-122. [PMID: 33556448 DOI: 10.1016/j.urology.2020.11.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.
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Affiliation(s)
- B B Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - L S Leddy
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - J B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | - B N Breyer
- Department of Urology, University of California-San Francisco Medical Center, San Francisco, CA
| | | | - J A Broghammer
- Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | - S P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - A J Vanni
- Department of Urology, Lahey Clinic, Burlington, MA
| | - B A Erickson
- Department of Urology, University of Iowa, Iowa City, IA
| | - J C Buckley
- Department of Urology, University of California-San Diego, San Diego, CA
| | - L C Zhao
- Department of Urology, New York University Langone Health, New York City, NY
| | - T Wright
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - K F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada.
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21
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Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present. Int Neurourol J 2021; 25:119-127. [PMID: 33504132 PMCID: PMC8255820 DOI: 10.5213/inj.2040202.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.
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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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Groom N, Tsang Y, Lowe G, Hoskin P. Risk factors for urethral stricture following external beam radiotherapy and HDR brachytherapy for prostate cancer. Brachytherapy 2020; 20:302-306. [PMID: 33234408 DOI: 10.1016/j.brachy.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE A potential late side effect of high-dose-rate (HDR) prostate brachytherapy combined with external beam radiotherapy (EBRT) is urethral stricture. The purpose of this study was to evaluate dosimetric parameters possibly contributing to stricture development, including dose to bladder base and D2cc(Gy) within 10 mm of prostatic urethra (D2cc 10 mm), which has, so far, not been reported in the literature. METHODS AND MATERIALS Patients developing urethral stricture, and matched controls, were identified from a prospective database of those receiving 46 Gy in 23 fractions of EBRT, followed by a single 15 Gy HDR brachytherapy dose. Patients had locally advanced, high- and intermediate-risk prostate cancer. Brachytherapy treatment planning parameters (planning target volume (PTV) size (cm 3), V110(%) bladder base, D2cc 10mm, number of HDR catheters, number of source dwell positions, and total source dwell time within 10 mm of the prostatic urethra) were analyzed to determine potential risk factors for urethral stricture. RESULTS Seventy-two patients were treated, 22 of whom developed a urethral stricture. Univariate logistic regression performed on the planning parameters identified increased PTV size and D2cc 10 mm, with decreased V110(%) bladder base as risk factors for stricture formation. CONCLUSIONS It is suggested that PTV size, V110(%) bladder base, and D2cc 10mm are predictive of urethral stricture formation following EBRT and brachytherapy to the prostate. This study demonstrates the importance of minimizing high dwell times and hot spots close to organs at risk and also the correction of any craniocaudal movement of catheters to avoid potential hot spots in the bulbomembranous urethra where there may be increased dose sensitivity.
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Affiliation(s)
| | | | - Gerry Lowe
- Mount Vernon Cancer Centre, Northwood, UK
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Neu S, Vigil H, Locke JA, Herschorn S. Triamcinolone acetonide injections for the treatment of recalcitrant post-radical prostatectomy vesicourethral anastomotic stenosis: A retrospective look at efficacy and safety. Can Urol Assoc J 2020; 15:E175-E179. [PMID: 32807289 DOI: 10.5489/cuaj.6644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Sarah Neu
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Humberto Vigil
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Locke
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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25
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Doiron RC, Witten J, Rourke KF. The scope, presentation, and management of genitourinary complications in patients presenting with high-grade urethral complications after radiotherapy for prostate cancer. Can Urol Assoc J 2020; 15:E6-E10. [PMID: 32701436 DOI: 10.5489/cuaj.6599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The scope of complications arising after radiotherapy (RT) treatment for prostate cancer is under-recognized and not well-described. The objective of this study is to describe the presentation, scope, and management of genitourinary (GU) complications in patients referred for high-grade urethral complications or sphincter weakness incontinence after prostate RT. METHODS A retrospective review was performed of patients referred to a reconstructive urologist for management of grade 4 urethral complications and sphincter weakness incontinence after prostate RT from December 2004 to December 2015. Patients' signs, symptoms, complications, and treatments are described. RESULTS A total of 120 patients were identified, with a mean age of 67.8 years; 55.8% (n=67) received external beam radiotherapy (EBRT), 38.3% (n=46) brachytherapy (BT), and 5.8% (n=7) combination RT. The mean time to first complication after RT was 57.7 months (1-219) and number of complications per patient was 5.1±2.2. The most common associated complications were urethral stenosis (n=106, 88.3%), sphincter weakness urinary incontinence (n=55, 45.8%), radiation cystitis (n=61, 50.8%), refractory storage lower urinary tract symptoms (n=106, 88.3%), GU pain (n=28, 23.3%), and prostate necrosis/abscess (n=17, 14.2%). Patients required a mean of 7.4±4.4 treatments over a 33-month period, including urethral dilation/urethrotomy (n= 93, 77.5%), urethroplasty (n=53, 44.2%), transurethral resection (n=52, 43.3%), cystolithopaxy (n=14, 11.7%), artificial urinary sphincter (n=8, 6.7%), and urinary diversion (n=8, 6.7%). Patients with RT combined with other modalities had more complications (6.2 vs. 4.2, p=0.001), higher rates of incontinence (93.8% vs. 29.5%, p=0.001), necrosis (31.3% vs. 8.0%, p=0.003), erectile dysfunction (84.4% vs. 51.1%, p=0.001), and hematuria (59.4% vs. 36.4%, p=0.04). CONCLUSIONS Urethral complications related to prostate RT are seldom an isolated problem and require a substantial amount of urological resources and interventions.
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Affiliation(s)
- R Christopher Doiron
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jon Witten
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Her EJ, Haworth A, Reynolds HM, Sun Y, Kennedy A, Panettieri V, Bangert M, Williams S, Ebert MA. Voxel-level biological optimisation of prostate IMRT using patient-specific tumour location and clonogen density derived from mpMRI. Radiat Oncol 2020; 15:172. [PMID: 32660504 PMCID: PMC7805066 DOI: 10.1186/s13014-020-01568-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/13/2020] [Indexed: 12/24/2022] Open
Abstract
AIMS This study aimed to develop a framework for optimising prostate intensity-modulated radiotherapy (IMRT) based on patient-specific tumour biology, derived from multiparametric MRI (mpMRI). The framework included a probabilistic treatment planning technique in the effort to yield dose distributions with an improved expected treatment outcome compared with uniform-dose planning approaches. METHODS IMRT plans were generated for five prostate cancer patients using two inverse planning methods: uniform-dose to the planning target volume and probabilistic biological optimisation for clinical target volume tumour control probability (TCP) maximisation. Patient-specific tumour location and clonogen density information were derived from mpMRI and geometric uncertainties were incorporated in the TCP calculation. Potential reduction in dose to sensitive structures was assessed by comparing dose metrics of uniform-dose plans with biologically-optimised plans of an equivalent level of expected tumour control. RESULTS The planning study demonstrated biological optimisation has the potential to reduce expected normal tissue toxicity without sacrificing local control by shaping the dose distribution to the spatial distribution of tumour characteristics. On average, biologically-optimised plans achieved 38.6% (p-value: < 0.01) and 51.2% (p-value: < 0.01) reduction in expected rectum and bladder equivalent uniform dose, respectively, when compared with uniform-dose planning. CONCLUSIONS It was concluded that varying the dose distribution within the prostate to take account for each patient's clonogen distribution was feasible. Lower doses to normal structures compared to uniform-dose plans was possible whilst providing robust plans against geometric uncertainties. Further validation in a larger cohort is warranted along with considerations for adaptive therapy and limiting urethral dose.
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Affiliation(s)
- E J Her
- School of Physics, Mathematics and Computing, University of Western Australia, Perth, Australia.
| | - A Haworth
- Institute of Medical Physics, University of Sydney, Sydney, Australia
| | - H M Reynolds
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Y Sun
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Australia
| | - V Panettieri
- Alfred Health Radiation Oncology, Melbourne, Australia
| | - M Bangert
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Medical Physics in Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - S Williams
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - M A Ebert
- School of Physics, Mathematics and Computing, University of Western Australia, Perth, Australia.,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Australia.,5D Clinics, Perth, Australia
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Liu Z, Huang G, Zhou N, Man L. Modified cystoscopy-assisted laparoscopic Y-V plasty for recalcitrant bladder neck contracture. MINIM INVASIV THER 2020; 31:185-190. [PMID: 32628075 DOI: 10.1080/13645706.2020.1786705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Zhenhua Liu
- Department of Urology, Beijing Jishuitan Hospital, The 4th Medical College of Peking University, Beijing, China
| | - Guanglin Huang
- Department of Urology, Beijing Jishuitan Hospital, The 4th Medical College of Peking University, Beijing, China
| | - Ning Zhou
- Department of Urology, Beijing Jishuitan Hospital, The 4th Medical College of Peking University, Beijing, China
| | - Libo Man
- Department of Urology, Beijing Jishuitan Hospital, The 4th Medical College of Peking University, Beijing, China
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Rourke KF, Welk B, Kodama R, Bailly G, Davies T, Santesso N, Violette PD. Canadian Urological Association guideline on male urethral stricture. Can Urol Assoc J 2020; 14:305-316. [PMID: 33275550 DOI: 10.5489/cuaj.6792] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Keith F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada
| | - Blayne Welk
- Division of Urology, Western University, London, ON, Canada
| | - Ron Kodama
- Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Greg Bailly
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Tim Davies
- McMaster University, Hamilton, ON, Canada
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Mutelica L, DeCian M, Tricard T, Severac F, Saussine C. [Influence of urethral self-dilatation on the morbidity of the artificial urinary sphincter after endoscopic treatment of recurrent stenosis of the vesicourethral anastomosis]. Prog Urol 2020; 30:304-311. [PMID: 32386679 DOI: 10.1016/j.purol.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the morbidity of the practice of daily self-dilatation (SD) in patients undergoing total prostatectomy, who have had artificial urinary sphincter (AUS) for urinary incontinence (UI) and who have had a recurrence of endoscopically treated vesicourethral anastomosis (VUS) stenosis. MATERIALS AND METHOD One hundred and thirty-eight patients with SUA for urinary incontinence (UI) fitted between 1998 and 2007 were divided into two groups. Thirty-five patients have had used self-dilatation (SD) for recurrent anastomotic stenosis (SD group) and 103 patients did not perform SD (non-SD group). These two groups were compared for explantation rate (erosion-infection), revision rate (urethral atrophy and mechanical failure) and 2-year functional results. The uni- and multivariate statistical analysis taken into consideration confounding factors such as age and radiotherapy history. The functional assessment was done by the validated IQoL, Ditrovie and MHU tests. RESULTS Patients in both groups were comparable except for the importance of urinary incontinence assessed by PAD test and questionnaires. The explantation rate was significantly higher in the "SD" group (28.5% vs 7.77%) and (OR=4.68, 95% CI [1.490-15.257], P=0.006). There was no significant difference between the two groups in the surgical revision rate (32% vs 20%, OR=0.44, P=0.09). The functional results at two years did not show any significant difference. CONCLUSIONS The use of self-dilation for recurrence of stenosis of vesicourethral anastomosis after prostatectomy exposes patients fitted with an SUA to a higher explantation rate. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- L Mutelica
- Service d'urologie, Nouvel hôpital civil, CHU de Strasbourg, Strasbourg, France.
| | - M DeCian
- Service d'urologie, Nouvel hôpital civil, CHU de Strasbourg, Strasbourg, France
| | - T Tricard
- Service d'urologie, Nouvel hôpital civil, CHU de Strasbourg, Strasbourg, France
| | - F Severac
- Groupe méthodes en recherche clinique, service santé publique, nouvel hôpital civil, CHU de Strasbourg, Strasbourg, France
| | - C Saussine
- Service d'urologie, Nouvel hôpital civil, CHU de Strasbourg, Strasbourg, France
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30
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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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Pfalzgraf D, Worst T, Kranz J, Steffens J, Salomon G, Fisch M, Reiß CP, Vetterlein MW, Rosenbaum CM. 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. World J Urol 2020; 39:89-95. [PMID: 32236662 DOI: 10.1007/s00345-020-03157-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/03/2020] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- D Pfalzgraf
- Heilig-Geist-Hospital, Bensheim, Germany. .,University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany.
| | - T Worst
- University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - J Kranz
- St.-Antonius-Hospital, Eschweiler, Germany.,University Medical Centre Halle, Halle, Germany
| | - J Steffens
- St.-Antonius-Hospital, Eschweiler, Germany
| | - G Salomon
- Martini-Clinic, Prostate Cancer Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - M Fisch
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - C P Reiß
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - M W Vetterlein
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - C M Rosenbaum
- University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany.,Asklepios Clinic Hamburg Barmbek, Barmbek, Germany
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Impact of advanced radiotherapy techniques and dose intensification on toxicity of salvage radiotherapy after radical prostatectomy. Sci Rep 2020; 10:114. [PMID: 31924839 PMCID: PMC6954263 DOI: 10.1038/s41598-019-57056-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 12/20/2019] [Indexed: 12/16/2022] Open
Abstract
The safety and efficacy of dose-escalated radiotherapy with intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT) remain unclear in salvage radiotherapy (SRT) after radical prostatectomy. We examined the impact of these advanced radiotherapy techniques and dose intensification on the toxicity of SRT. This multi-institutional retrospective study included 421 patients who underwent SRT at the median dose of 66 Gy in 2-Gy fractions. IMRT and IGRT were used for 225 (53%) and 321 (76%) patients, respectively. At the median follow-up of 50 months, the cumulative incidence of late grade 2 or higher gastrointestinal (GI) and genitourinary (GU) toxicities was 4.8% and 24%, respectively. Multivariate analysis revealed that the non-use of either IMRT or IGRT, or both (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.8-5.4, p < 0.001) and use of whole-pelvic radiotherapy (HR 7.6, CI 1.0-56, p = 0.048) were associated with late GI toxicity, whereas a higher dose ≥68 Gy was the only factor associated with GU toxicities (HR 3.1, CI 1.3-7.4, p = 0.012). This study suggested that the incidence of GI toxicities can be reduced by IMRT and IGRT in SRT, whereas dose intensification may increase GU toxicity even with these advanced techniques.
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Long-term outcomes of anastomotic urethroplasty for radiation-induced strictures. World J Urol 2019; 38:3055-3060. [DOI: 10.1007/s00345-019-03028-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 11/18/2019] [Indexed: 01/10/2023] Open
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A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9046430. [PMID: 31139658 PMCID: PMC6500724 DOI: 10.1155/2019/9046430] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/31/2019] [Indexed: 12/21/2022]
Abstract
To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.
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Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, Koontz BF, Murphy DG, Nguyen PL, Nam RK. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol 2018; 75:464-476. [PMID: 30573316 DOI: 10.1016/j.eururo.2018.12.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/04/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. OBJECTIVE To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. EVIDENCE ACQUISITION A collaborative narrative review of the literature from 2010 to present was conducted. EVIDENCE SYNTHESIS Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3-9% and 0-4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4-14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. CONCLUSIONS There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. PATIENT SUMMARY In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.
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Affiliation(s)
- Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Prostate and Urologic Cancers Center, Duke University Medical Center, Durham, NC, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique? BIOMED RESEARCH INTERNATIONAL 2018; 2018:3050537. [PMID: 30515389 PMCID: PMC6236655 DOI: 10.1155/2018/3050537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/19/2018] [Indexed: 11/17/2022]
Abstract
Objective To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. Materials and Methods Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. Results Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. Conclusions Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.
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MODERN METHODS OF TREATING DISEASES OF THE BULBO-MEMBRANOUS PART OF URETHRA. ACTA BIOMEDICA SCIENTIFICA 2018. [DOI: 10.29413/abs.2018-3.5.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Strictures of the bulbous-membranous urethra are a common cause of obstructive urination disorder. Modern trends in the development of medicine lead to a wider application of endoscopic method, a more frequent cause of iatrogenic injury of the urethra. At present, conservative, endourologic and reconstructive methods of care are used to treat urethral strictures. There are several conservative, endourological and reconstructive methods for treating patients with urethral stricture. Conservative methods include interventions that do not involve the destruction of urethral stricture or its reconstruction, such as stenting, blind dilatation, and recanalization of the urethra. Performing blind dilatation strictures of the bulbo-membranous urethra is not recommended because of the high risk of false path formation and low efficiency. Endourological operations refer to surgical methods of care and suggest the natural restoration of urethral tissues after the destruction of stricture. Because of the low effectiveness of correction of strictures of the posterior urethra (more than 90 % of relapses in five years), this method is a variant of temporary or palliative care. Currently, two approaches to the reconstruction of the bulbo-membranous urethra are used: anastomotic and replacement operations. Anastomotic surgery involves excision of the affected area and juxtaposition of healthy urethral tissues without tension. Replacement plastic allows to restore patency of the urethra by increasing the diameter of the lumen due to the implantation of various grafts. The article shows that, based on international clinical studies, the most effective method of reconstructing the bulbomembranous urethra is reconstructive surgical methods.
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Campos-Juanatey F, Portillo Martín JA. [Management of vesicourethral anastomotic stenosis after radical prostatectomy]. Rev Int Androl 2018; 17:110-118. [PMID: 30237067 DOI: 10.1016/j.androl.2018.05.003] [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: 01/15/2018] [Revised: 05/13/2018] [Accepted: 05/20/2018] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Félix Campos-Juanatey
- Servicio de Urología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | - José Antonio Portillo Martín
- Servicio de Urología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España; Facultad de Medicina, Universidad de Cantabria, Santander, Cantabria, España
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Abstract
PURPOSE OF REVIEW Due to the proximity of the rhabdosphincter and cavernous nerves to the membranous urethra, reconstruction of membranous urethral stricture implies a risk of urinary incontinence and erectile dysfunction. To avoid these complications, endoscopic management of membranous urethral strictures is traditionally favored, and bulboprostatic anastomosis is reserved as the main classical approach for open reconstruction of recalcitrant membranous urethral stricture. The preference for the anastomotic urethroplasty among reconstructive urologists is likely influenced by the familiarity and experience with trauma-related injuries. We review the literature focusing on the anatomy of membranous urethra and on the evolution of treatments for membranous urethral strictures. RECENT FINDINGS Non-traumatic strictures affecting bulbomembranous urethra are typically sequelae of instrumentation, transurethral resection of the prostate, prostate cancer treatment, and pelvic irradiation. Being a different entity from trauma-related injuries where urethra is not in continuity, a new understanding of membranous urethral anatomy is necessary for the development of novel reconstruction techniques. Although efficacious and durable to achieve urethral patency, classical bulboprostatic anastomosis carries a risk of de-novo incontinence and impotence. Newer and relatively less invasive reconstructive alternatives include bulbar vessel-sparing intra-sphincteric bulboprostatic anastomosis and buccal mucosa graft augmented membranous urethroplasty techniques. The accumulated experience with these techniques is relatively scarce, but several published series present promising results. These approaches are especially indicated in patients with previous transurethral resection of the prostate in which sparing of rhabdosphincter and the cavernous nerves is important in attempt to preserve continence and potency. Additionally, introduction of buccal mucosa onlay grafts could be especially beneficial in radiation-induced strictures to avoid transection of the sphincter in continent patients, and to preserve the blood supply to the urethra for incontinent patients who will require artificial urinary sphincter placement. The evidence regarding erectile functional outcomes is less solid and this item should be furtherly investigated.
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Affiliation(s)
- Javier C Angulo
- Departamento Clínico, Facultad de Ciencias Biomédicas, Hospital Universitario de Getafe, Universidad Europea de Madrid, Carretera de Toledo Km 12.5, 28905, Getafe, Madrid, Spain.
| | - Reynaldo G Gómez
- Hospital del Trabajador, Universidad Andrés Bello, Vicuña Mackenna, 185, Santiago, Chile
| | - Dmitriy Nikolavsky
- Department of Urology, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
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Browne BM, Vanni AJ. Management of Urethral Stricture and Bladder Neck Contracture Following Primary and Salvage Treatment of Prostate Cancer. Curr Urol Rep 2018; 18:76. [PMID: 28776126 DOI: 10.1007/s11934-017-0729-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Brendan Michael Browne
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA
| | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA.
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Murray KS, Akin O, Coleman JA. Irreversible Electroporation for Prostate Cancer as Salvage Treatment Following Prior Radiation and Cryotherapy. Rev Urol 2018; 19:268-272. [PMID: 29472832 DOI: 10.3909/riu0755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Salvage treatment options after localized primary treatment failure of prostate cancer are limited and associated with risk for serious complications. We report on the management details of a 57-year-old African American man treated with partial-gland ablation using irreversible electroporation following local recurrence after brachytherapy and prior salvage cryoablation. Therapeutic and functional outcomes were assessed by conventional means, including serum prostate-specific antigen values and prostate biopsy results.
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Affiliation(s)
- Katie S Murray
- Division of Urology, Department of Surgery, University of Missouri Columbia, MO
| | - Oguz Akin
- Body Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center New York, NY
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center New York, NY
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Mitomycin-C and urethral dilatation: A safe, effective, and minimally invasive procedure for recurrent vesicourethral anastomotic stenoses. Urol Oncol 2017; 35:672.e15-672.e19. [DOI: 10.1016/j.urolonc.2017.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/30/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
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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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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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Bladder Neck Contracture After Endoscopic Surgery for Benign Prostatic Obstruction: Incidence, Treatment, and Outcomes. Curr Urol Rep 2017; 18:79. [PMID: 28795367 DOI: 10.1007/s11934-017-0723-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Chung ASJ, McCammon KA. Incidence and Management of Lower Urinary Tract Symptoms After Urethral Stricture Repair. Curr Urol Rep 2017; 18:70. [DOI: 10.1007/s11934-017-0716-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Nicholson HL, Al-Hakeem Y, Maldonado JJ, Tse V. Management of bladder neck stenosis and urethral stricture and stenosis following treatment for prostate cancer. Transl Androl Urol 2017; 6:S92-S102. [PMID: 28791228 PMCID: PMC5522805 DOI: 10.21037/tau.2017.04.33] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/26/2017] [Indexed: 12/03/2022] Open
Abstract
The aim of this review is to examine all urethral strictures and stenoses subsequent to treatment for prostate cancer, including radical prostatectomy (RP), radiotherapy, high intensity focused ultrasound (HIFU) and cryotherapy. The overall majority respond to endoscopic treatment, including dilatation, direct visual internal urethrotomy (DVIU) or bladder neck incision (BNI). There are adjunct treatments to endoscopic management, including injections of corticosteroids and mitomycin C (MMC) and urethral stents, which remain controversial and are not currently mainstay of treatment. Recalcitrant strictures are most commonly managed with urethroplasty, while recalcitrant stenosis is relatively rare yet almost always associated with bothersome urinary incontinence, requiring bladder neck reconstruction and subsequent artificial urinary sphincter (AUS) implantation, or urinary diversion for the devastated outlet.
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Affiliation(s)
- Helen L. Nicholson
- Department of Urology, Concord Repatriation General Hospital, Concord, University of Sydney, Australia
| | - Yasser Al-Hakeem
- Department of Urology, Macquarie University Hospital, Sydney, Australia
| | | | - Vincent Tse
- Department of Urology, Concord Repatriation General Hospital, Concord, University of Sydney, Australia
- Department of Urology, Macquarie University Hospital, Sydney, Australia
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Overactive bladder syndrome and lower urinary tract symptoms after prostate cancer treatment. Curr Opin Urol 2017; 27:307-313. [DOI: 10.1097/mou.0000000000000391] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bang SL, Yallappa S, Dalal F, Almallah YZ. Post Prostatectomy Vesicourethral Stenosis or Bladder Neck Contracture with Concomitant Urinary Incontinence: Our Experience and Recommendations. Curr Urol 2017; 10:32-39. [PMID: 28559775 DOI: 10.1159/000447148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/06/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To present our experience in the management of bladder neck contracture with concomitant post prostatectomy incontinence and to provide our recommendations based on the updated literature. MATERIALS AND METHODS Between Jan 2010 and June 2015, 37 patients from our cohort of 341 patients with post prostatectomy incontinence were evaluated. Patient data were retrospectively collected. Patients with bladder neck contracture confirmed on flexible cystoscopy underwent subsequent rigid cystoscopy and deep endoscopic bladder neck incision (BNI). A follow up flexible cystoscopy would be performed 3 months later. If there was no recurrence of the bladder neck contracture, an artificial urethral sphincter (AUS) or a male sling was recommended. RESULTS The mean age of patients was 68 years (range 59-77) and the mean BMI was 31 (range 21-41) kg/m2. Twenty-five (67.7%) patients had open prostatectomy and 12 (32.4%) patients had laparoscopic prostatectomy. Fourteen patients (37.8%) underwent adjuvant radiotherapy. Twenty-four (64.8%) patients had one BNI procedure, 8 (21.6%) patients had two procedures and 5 (13.5%) patients had more than 2 procedures. Twenty-one (91.3%) patients had AUS implantation and 2 (8.7%) patients had male sling placement. Besides, 85.7% of AUS and 50% of male sling patients managed to achieve successful outcomes with a mean follow up period of 13.1 months (range 2-33 months). CONCLUSION Initial management with aggressive BNI followed by implantation of an AUS or male sling when bladder neck is stable is essential to achieve a satisfactory urinary continence outcome.
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Affiliation(s)
- Shieh L Bang
- Department of Urology, The Queen Elizabeth Hospital, University Hospital Birmingham, Birmingham, UK
| | - Sachin Yallappa
- Department of Urology, The Queen Elizabeth Hospital, University Hospital Birmingham, Birmingham, UK
| | - Fatima Dalal
- Department of Urology, The Queen Elizabeth Hospital, University Hospital Birmingham, Birmingham, UK
| | - Yahia Z Almallah
- University Hospital Birmingham, NHS Foundation Trust, Birmingham, UK
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Abstract
Radiation therapy may result in urethral strictures from vascular damage. Most radiation-induced urethral strictures occur in the bulbomembranous junction, and urinary incontinence may result as a consequence of treatment. Radiation therapy may compromise reconstruction due to poor tissue healing and radionecrosis. Excision and primary anastomosis is the preferred urethroplasty technique for radiation-induced urethral stricture. Principles of posterior urethroplasty for trauma may be applied to the treatment of radiation-induced urethral strictures. Chronic management with suprapubic tube is an option based on patient comorbidities and preference.
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Affiliation(s)
- Matthias D Hofer
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Joceline S Liu
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
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