Antegrade endourethroplasty with free skin graft for recurrent vesicourethral anastomotic strictures after radical prostatectomy

Substitution Urethroplasty With Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-institution Long-term Experience With Perineal Approach and Endourethroplasty

OBJECTIVE

To present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP).

MATERIALS AND METHODS

A single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an "auxiliary" DVIU. The primary outcome was 3-year stricture recurrence-free survival (SRFS).

RESULTS

BMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The 3-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, 3-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients.

CONCLUSION

We present 2 techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach.

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

Bladder neck contracture is a recognised complication associated with radical prostatectomy. The management can be challenging, especially when refractory to initial intervention strategies. For the patient, the burden of disease is high and continence status cannot be overlooked. This review serves to provide an overview of the management of this recognised clinical pathology. Consideration needs to be given to minimally invasive approaches such as endoscopic incision, injectables, implantable devices as well as major reconstructive surgery where the condition persists. For the latter, this can involve open and robotic surgery as well as use of grafts and artificial sphincter surgery. These elements underline the need for a tailored and a patient centred approach.

MODERN METHODS OF TREATING DISEASES OF THE BULBO-MEMBRANOUS PART OF URETHRA

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.

[Management of vesicourethral anastomotic stenosis after radical prostatectomy]

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

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

Posterior urethral stenosis (PUS) is an uncommon but challenging problem following prostate cancer therapy. A review of the recent literature on the prevalence of PUS and treatment modalities used in the last decade was performed. A summative narrative of current accepted techniques in management of PUS is presented, and supplement with our own experience and algorithms.

Urethral Strictures and Stenoses Caused by Prostate Therapy

The number of patients with prostate cancer and benign prostatic hyperplasia is on the rise. As a result, the volume of prostate treatment and treatment-related complications is also increasing. Urethral strictures and stenoses are relatively common complications that require individualized management based on the length and location of the obstruction, and the patient's overall health, and goals of care. In general, less invasive options such as dilation and urethrotomy are preferred as first-line therapy, followed by more invasive substitution, flap, and anastomotic urethroplasty.

Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: surgical technique and preliminary results

OBJECTIVES

To introduce a novel surgical technique for the reconstruction of distal urethral strictures using buccal mucosal graft (BMG) through a transurethral approach.

METHODS

A retrospective institution chart review was conducted of all the patients who underwent a transurethral ventral BMG inlay urethroplasty from March 2014 to March 2016. Patients with greater than one-year follow-up were included. Steps of the procedure: transurethral ventral wedge resection of the stenosed segment and transurethral delivery and spread fixation of appropriate BMG inlay into the resultant urethrotomy. The patients were followed for post-operative complications and stricture recurrence with uroflow, PVR, cystoscopy and outcome questionnaires.

RESULTS

Three patients with a minimum of 12-month follow-up are included in this case series. The mean age of the patients was 42 years (35-53); mean stricture length was 2.1 cm (1-4). All patients had at least 2 previous failed procedures. Mean follow-up was 18 months (12-24). There were no stricture recurrences or fistula. Mean pre- and post-operative uroflow values were 4.3 (0-8) and 19 (16-26), respectively. Neither penile chordee nor changes in sexual function were noted in patients on follow-up.

CONCLUSION

Transurethral ventral BMG inlay urethroplasty is a feasible option for treatment of fossa navicularis strictures. This single-stage technique allows for avoiding skin incision or urethral mobilization. It helps to prevent glans dehiscence, fistula formation and avoids the use of genital skin flaps in all patients, especially those affected with LS. This novel surgical technique is an effective treatment alternative for men with distal urethral strictures.

Postprostatectomy Anastomosis Stenosis: A Systematic Review

Anastomotic strictures (AS) are uncommon but a vexing problem after radical prostatectomy. We reviewed the literature for AS treatment modalities to summarize the best management strategies for AS, as supported by current evidence. Twenty studies fit the inclusion and exclusion criteria. Weighted success rates and incontinence rates were calculated and used to create a treatment algorithm. Repeat attempts of minimally invasive methods seem to improve the success rate. Repeat procedures and more invasive techniques, however, may lead to higher incontinence rates.

SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer

Posterior urethral stenosis can result from radical prostatectomy in approximately 5%-10% of patients (range 1.4%-29%). Similarly, 4%-9% of men after brachytherapy and 1%-13% after external beam radiotherapy will develop stenosis. The rate will be greater after combination therapy and can exceed 40% after salvage radical prostatectomy. Although postradical prostatectomy stenoses mostly develop within 2 years, postradiotherapy stenoses take longer to appear. Many result in storage and voiding symptoms and can be associated with incontinence. The evaluation consists of a workup similar to that for lower urinary tract symptoms, with additional testing to rule out recurrent or persistent prostate cancer. Treatment is usually initiated with an endoscopic approach commonly involving dilation, visual urethrotomy with or without laser treatment, and, possibly, UroLume stent placement. Open surgical urethroplasty has been reported, as well as urinary diversion for recalcitrant stenosis. A proposed algorithm illustrating a graded approach has been provided.