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

A new approach to repair recurrent vescicourethral anastomotic strictures after radical prostatectomy: The use of prerectal access

BACKGROUND

Vesicourethral anastomosis stenosis (VUAS) is a well-known complication of prostate cancer treatments, observed in up to 26% of the cases after radical prostatectomy. Conservative management, with single or even repeated transurethral dilation or endoscopic incision of the stenosis, is successful in many cases, but up to 9% of patients are destined to fail after endoscopic treatment. In these cases, a revision of the vesicourethral anastomosis is necessary and can be realized with different surgical approaches. We aim to describe the technique and the outcomes of a new prerectal approach for VUAS repair.

METHODS

Twelve patients with recalcitrant VUAS following radical prostatectomy were enrolled between May 2014 and September 2018 for prerectal transperineal re-anastomosis. The evaluated outcomes were: the rate of successful anatomical repair at 3 months after surgery and at the last follow-up, postoperative incontinence and complications rate, and the need for further treatments.

RESULTS

No major intraoperative complications occurred. After a median follow-up of 46 months (IQR 36-55), 10 patients (83.3%) achieved a good anatomical repair even if one man required an endoscopic urethrotomy, while two patients (16.67%) with a history of pelvic radiotherapy developed a surgical site infection that required toilette and external urinary diversion. Among the others, nine (75%) developed severe stress urinary incontinence, with resolution of their condition. No patient reported significant postoperative pain or fecal incontinence.

CONCLUSIONS

The prerectal approach to VUAS repair allows direct access to the posterior urethra and the anastomosis, providing a better mobilization of the bladder neck for tension-free anastomosis. However, patients with a history of pelvic radiotherapy have a higher risk of complications. Postoperative incontinence is very common, but urinary continence could be restored with subsequent artificial urinary sphincter placement.

The efficacy of star-like mapping incision on vesicourethral anastomotic stenosis after radical prostatectomy and cystectomy

PURPOSE

To assess the efficacy of star-like internal urethrotomy on vesicourethral anastomotic stenosis (VUAS) and its impact on voiding and continence outcomes.

METHODS

This observational study was conducted in two tertiary referral hospitals. 31 patients confirmed with VUAS after radical prostatectomy or cystectomy were included. A novel Star-like Incision Urethrotomy procedure focused on a shallow incision on scar tissue all around the anastomotic site was performed. The primary outcome was the procedure's impact on urinary voiding and continence, assessed using the International Prostate Symptom Score (IPSS) and the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF).

RESULTS

Participants had a mean age of 68.32 years, 27 (87%) with a history of radical prostatectomy and 4 (13%) with a history of radical cystectomy, who presented to our clinic with urinary obstructive symptoms. We performed Star-like incision on the anastomotic site using a ureteral catheter as a guide. During patient follow-up, significant improvements were observed in urinary flow and continence. At one month postoperatively, the mean IPSS score decreased from 26.58 to 13.39, and the ICIQ-SF score initially increased from 4.48 to 6.87 at first and then reduced to about 4. These improvements were sustained throughout the six regular follow-ups, with an IPSS score of 12.8 and an ICIQ-SF score of 3.6. Besides these improvements, 5 (16%) patients required repeated urethrotomy due to recurrence of stenosis.

CONCLUSION

Endoscopic treatment with Star-like incision for VUAS has promising outcomes compared to other endoscopic treatments.

Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment

OBJECTIVE

To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear.

METHODS

A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up.

RESULTS

The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%).

CONCLUSION

This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

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.

Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease

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.

Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study

BACKGROUND

Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence.

OBJECTIVE

To demonstrate patency and continence outcomes of robotic-assisted VUAS repair.

DESIGN, SETTING AND PARTICIPANTS

Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo.

SURGICAL PROCEDURE

The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique.

MEASUREMENTS

Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention.

RESULTS AND LIMITATIONS

A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion.

CONCLUSIONS

Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates.

PATIENT SUMMARY

We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN AND SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy

Vesico-urethral anastomotic stenosis is a well-known sequela after radical prostatectomy for prostate cancer and has significant impact on quality of life. This review aims to summarize contemporary therapeutical approaches and to give an overview of the available evidence regarding endoscopic interventions and open reconstruction. Initial treatment may include dilation, incision or transurethral resection. In treatment-refractory stenoses, open reconstruction via an abdominal (retropubic), transperineal or combined abdominoperineal approach is a viable option with high success rates. All of the open surgical procedures are generally accompanied by a high risk of developing de novo incontinence and patients may need further interventions. In such cases, subsequent artificial urinary sphincter implantation is the most common treatment option with the best available evidence.