Post-radical-prostatectomy urinary incontinence: the management of concomitant bladder neck contracture

Can we define reliable risk factors for anastomotic strictures following radical prostatectomy?

BACKGROUND

To identify risk factors for anastomotic strictures in patients after radical prostatectomy.

METHODS

In all, 140 prostate cancer patients with one or more postoperative anastomotic strictures after radical prostatectomy were included. All patients underwent transurethral anastomotic resection at the University Hospital of Munich between January 2009 and May 2016. Clinical data and follow-up information were retrieved from patients' records. Statistical analysis was done using Kaplan-Meier curves and log rank-test with time to first transurethral anastomotic resection as endpoint, Chi-square-test, and Mann-Whitney-U test.

RESULTS

In all, 140 patients with a median age of 67 years (IQR: 61-71 years) underwent radical prostatectomy. Median age at time of transurethral anastomotic resection was 68 years (IQR: 62-72). Patients needed 2 surgical interventions in median (range: 1-15). Median time from radical prostatectomy to transurethral anastomotic resection was 6 months (IQR: 3.9-17.4). Median duration of catheterization after radical prostatectomy was 10 days (IQR: 8-13). In all, 26% (36/140) received additional radiotherapy. Regarding time to first transurethral anastomotic resection, age and longer duration of catheterization after radical prostatectomy with a cutoff of 7 days showed no statistically significant differences (p = 0.392 and p = 0.141, respectively). Tumor stage was no predictor for development of anastomotic strictures (p = 0.892), and neither was prior adjuvant radiation (p = 0.162). Potential risk factors were compared between patients with up to 2 strictures (low-risk) and patients developing > 2 strictures (high-risk): high-risk patients had more often injection of cortisone during surgery (14% vs 0%, p < 0.001) and more frequently advanced tumor stage pT > 2 (54% vs 38%, p = 0.055), respectively. Other risk factors did not show any significant difference compared to number of prior transurethral anastomotic strictures.

CONCLUSIONS

We could not identify a reliable risk factor to predict development of anastomotic strictures following radical prostatectomy.

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

Purpose:

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

Materials and Methods:

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

Results:

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

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

Conclusion:

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

Post Prostatectomy Vesicourethral Stenosis or Bladder Neck Contracture with Concomitant Urinary Incontinence: Our Experience and Recommendations

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.

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.

Management of the incontinent patient with a sphincteric stricture following radical prostatectomy

PURPOSE OF REVIEW

The 5-year and 15-year life expectancy following the treatment of localized prostate cancer is excellent. Patients may develop rare but devastating complications following the surgery for prostate cancer. The purpose of this review is to summarize the available literature to date surrounding the management of the incontinent patient with a concomitant bladder neck contracture (BNC), or sphincteric stricture, following radical prostatectomy.

RECENT FINDINGS

The literature consists of several case series, but no clinical trials exist to provide an evidence-based approach to the incontinent patient with concomitant BNC. Fortunately, this is a relatively rare clinical scenario and most cases are successfully managed with urethral dilatation or endoscopic techniques. Multiple endoscopic techniques are available. In addition, some authors include injectable agents in their armamentarium for the treatment of BNC. Open reconstructive techniques or permanent urinary diversion may be necessary in rare cases. Both male slings and artificial urinary sphincter may be considered for the management of concomitant urinary incontinence. Some authors suggest it is safe to proceed with simultaneous artificial urinary sphincter implantation at the time of endoscopic management of the BNC.

SUMMARY

Management of the incontinent patient with concomitant BNC represents a challenging situation for the urologist. Several techniques are available to stabilize the BNC before safely proceeding with surgery for urinary incontinence. For the rare, complex case that has failed endoscopic management, referral to a surgeon experienced in reconstructive techniques is warranted.

A report of a regional service for post-prostatectomy urinary incontinence: a model for best practice?

INTRODUCTION

Post-prostatectomy incontinence (PPI) is a potentially highly significant complication of a common urological procedure. Pathophysiology may be multifactorial but most commonly involves urinary sphincter weakness. The gold standard treatment for severe incontinence is artificial urinary sphincter but multiple alternatives exist. The growing incidence of PPI has led to the development of a specialized regional service dedicated to management.

PATIENTS AND METHODS

In 2004 a regional referral protocol for PPI was established with a dedicated clinic at a single centre for assessment and management including videourodynamics, pelvic floor rehabilitation, biofeedback and a consultant with a specialist interest in PPI surgery. Data regarding all in-house and tertiary referrals to this clinic between 2004 and 2011 were analysed with patients categorized by symptom severity.

RESULTS

A total of 267 patients were referred to the post-prostatectomy service (mean age 66.6, range 49-83 years) with numbers increasing year on year. Two-thirds of these were tertiary referrals: 27.7% of referrals were for mild symptoms, 35.2% moderate and 33.3% severe. One-third of referrals were made within 2 years of the primary procedure. Just over half of referred patients underwent invasive treatment including 24.3 artificial sphincter (24.3%) and male slings (22.8%). 7.5% patients were managed with medication, 14.6% were managed conservatively with containment therapy only. One-fifth remain under assessment or have deferred treatment.

CONCLUSION

PPI is of increasing personal and societal impact which should be identified early and supported. Investigation and management can be standardized and intervention at a high volume centre achieved by early specialist referral.

Management of anastomotic stricture after artificial urinary sphincter placement in patients who underwent salvage prostatectomy

OBJECTIVE

To report on a safe endoscopic management technique for the treatment of an anastomotic stricture (AS) in patients with an artificial urinary sphincter (AUS).

METHODS

Five patients with a history of salvage prostatectomy after radiation therapy that developed an AS after AUS placement were treated with a rigid ureteroscope and a Holmium YAG (Ho: YAG) laser to incise the AS. The AUS was opened and deactivated but not decoupled or removed during the procedure. The rigid ureteroscope allowed complete control of the laser fiber to incise the stricture at the 3 and 9 o' clock positions and then circumferentially.

RESULTS

There were no intraoperative complications and the mean operative time was 42.6 minutes. Of the 5 patients who underwent holmium laser incision of an AS after AUS placement, none developed AUS malfunction or required device replacement. No patients reported worsening of urinary incontinence after treatment. Two patients required repeat holmium laser incision for AS recurrence.

CONCLUSION

Using a rigid ureteroscope and a holmium laser to incise an AS after AUS placement seems to be a safe management option that does not damage the AUS or result in worsening incontinence. This treatment strategy provides an endoscopic alternative to using open surgical technique to uncouple or remove the AUS while treating the AS.