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Krughoff K, Livingston AJ, Peterson AC. Synchronous Bladder Neck Contracture Dilation at the Time of Artificial Urinary Sphincter Placement Is Safe and Effective. Urology 2023; 178:155-161. [PMID: 37100178 DOI: 10.1016/j.urology.2023.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To treat men with bladder neck contracture (BNC) and stress urinary incontinence, neither long-term nor comparative data exist to support the superiority of simultaneous BNC intervention at the time of artificial urinary sphincter placement (synchronous) or staged BNC intervention followed by artificial urinary sphincter placement (asynchronous). This study aimed to compare the outcomes of patients treated with synchronous and asynchronous protocols. METHODS Using a prospectively maintained quality improvement database, we identified all men between the years of 2001-2021 with a history of BNC and artificial urinary sphincter placement. Baseline patient characteristics and outcome measures were collected. Categorical data were assessed with Pearson's Chi-square, and continuous data were assessed using independent sample t tests or the Wilcoxon Rank-Sum test. RESULTS In total, 112 men met the inclusion criteria. Thirty-two patients were treated synchronously, and 80 were treated asynchronously. There were no significant differences between groups across 15 relevant variables. Overall follow-up duration was 7.1 (2.8, 13.1) years. Three (9.3%) in the synchronous group and 13 (16.2%) in the asynchronous group experienced an erosion. There were no significant differences in frequency of erosion, time to erosion, artificial sphincter revision, time to revision, or BNC recurrence. BNC recurrences after artificial sphincter placement were treated with serial dilation with no early device failure or erosion. CONCLUSION Similar outcomes are achieved following synchronous and asynchronous treatment of BNC and stress urinary incontinence. Synchronous approaches should be considered safe and effective for men with stress urinary incontinence and BNC.
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Affiliation(s)
- Kevin Krughoff
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC.
| | - Austin J Livingston
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew C Peterson
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC
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Queissert F, Huesch T, Kretschmer A, Kirschner-Hermanns R, Pottek T, Olianas R, Friedl A, Homberg R, Pfitzenmaier J, Naumann CM, Nyarangi-Dix J, Hofmann T, Rose A, Weidemann C, Wotzka C, Hübner W, Loertzer H, Abdunnur R, Grabbert M, Anding R, Bauer RM, Haferkamp A, Schrader AJ. Is the Standard Artificial Urinary Sphincter AMS 800 Still a Treatment Option for the Irradiated Male Patient Presenting with a Devastated Bladder Outlet? J Clin Med 2023; 12:4002. [PMID: 37373698 DOI: 10.3390/jcm12124002] [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: 02/20/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Circular urethral compression with an artificial sphincter allows control of voiding, even in patients with severe stress urinary incontinence, but it heightens the risk of urethral atrophy and erosion. This study of one of the largest populations of patients treated with radiotherapy investigates the additive effect of the post-radiogenic stricture of the membranous urethra/bladder neck on AMS 800 artificial urinary sphincter outcomes. METHODS In a retrospective multicenter cohort study, we analyzed patients fitted with an AMS 800, comparing those who had received radiotherapy with patients presenting a devastated bladder outlet (stricture of the membranous urethra/bladder neck). We determined the correlation between these groups of patients using both univariate and stepwise adjusted multivariate regression. The revision-free interval was estimated by a Kaplan-Meier plot and compared by applying the log-rank test. A p value below 0.05 was considered statistically significant. RESULTS Of the 123 irradiated patients we identified, 62 (50.4%) had undergone at least one prior desobstruction for bladder-neck/urethra stenosis. After a mean follow-up of 21 months, the latter tended to achieve social continence less frequently (25.7% vs. 35%; p = 0.08). Revision was required significantly more often for this group (43.1% vs. 26.3%; p = 0.05) due to urethral erosion in 18 of 25 cases. A stenosis recurred in five cases; desobstruction was performed in two cases, leading to erosion in both. Multivariate analysis revealed a significantly higher risk of revision when recurrent stenosis necessitated at least two prior desobstructions (HR 2.8; p = 0.003). CONCLUSIONS A devastated bladder outlet is associated with a lower proportion of men with social continence and a significantly higher need for revision compared with irradiated patients without a history of urethral stenosis. Alternative surgical procedures should be discussed beforehand, especially in cases of recurrent urethral stenosis.
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Affiliation(s)
- Fabian Queissert
- Department of Urology and Pediatric Urology, University Hospital Münster, 48149 Münster, Germany
| | - Tanja Huesch
- Department of Urology, University Medical Center of Johannes Gutenberg University, 55131 Mainz, Germany
| | - Alexander Kretschmer
- Department of Urology, Ludwig-Maximilians University, Campus Großhadern, 80539 Munich, Germany
| | | | - Tobias Pottek
- Department of Urology, Vivantes Hospital Am Urban, 10117 Berlin, Germany
| | - Roberto Olianas
- Department of Urology, Hospital Lüneburg, 21339 Lüneburg, Germany
| | - Alexander Friedl
- Department of Urology, Göttlicher Heiland Vienna, 1170 Vienna, Austria
| | - Roland Homberg
- Department of Urology and Pediatric Urology, St. Barbara Hospital Hamm, 59075 Hamm, Germany
| | - Jesco Pfitzenmaier
- Department of Urology, Evangelic Hospital Bethel, 42240 Bielefeld, Germany
| | - Carsten M Naumann
- Department of Urology and Pediatric Urology, St. Elisabeth Hospital, 56564 Neuwied, Germany
| | - Joanne Nyarangi-Dix
- Department of Urology and Pediatric Urology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Torben Hofmann
- Department of Urology, Diakonie Hospital Schwaebisch Hall, 74523 Schwaebisch Hall, Germany
| | - Achim Rose
- Department of Urology and Pediatric Urology, Helios Hospital Duisburg, 47166 Duisburg, Germany
| | - Christian Weidemann
- Department of Urology and Pediatric Urology, Catholic Hospital St. Johann Nepomuk, 99097 Erfurt, Germany
| | - Carola Wotzka
- Department of Urology, Diakonie Hospital Stuttgart, 70176 Stuttgart, Germany
| | - Wilhelm Hübner
- Department of Urology, Hospital Weinviertel Korneuburg, 2100 Korneuburg, Austria
| | - Hagen Loertzer
- Department of Urology and Pediatric Urology, Westpfalz Medical Center, 67655 Kaiserslautern, Germany
| | - Rudi Abdunnur
- Department of Urology, Helios Hospital Schwelm, 58332 Schwelm, Germany
| | - Markus Grabbert
- Department of Urology, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Ralf Anding
- Department of Urology, University Hospital Basel, 4031 Basel, Switzerland
| | - Ricarda M Bauer
- Department of Urology, Ludwig-Maximilians University, Campus Großhadern, 80539 Munich, Germany
| | - Axel Haferkamp
- Department of Urology, University Medical Center of Johannes Gutenberg University, 55131 Mainz, Germany
| | - Andres J Schrader
- Department of Urology and Pediatric Urology, University Hospital Münster, 48149 Münster, Germany
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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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Pfalzgraf D, Siegel FP, Kriegmair MC, Wagener N. Bladder Neck Contracture After Radical Prostatectomy: What Is the Reality of Care? J Endourol 2017; 31:50-56. [DOI: 10.1089/end.2016.0509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel Pfalzgraf
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian P. Siegel
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian C. Kriegmair
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Nina Wagener
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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Abstract
Bladder neck contracture (BNC) is a well-described complication of the surgical treatment of benign and malignant prostate conditions. Nevertheless, etiologies of BNC development are highly dependent on the primary treatment modality undertaken with BNC also occurring after pelvic radiation. The treatment options for BNC can range from simple, office-based dilation procedures to more invasive, complex abdomino-perineal reconstructive surgery. Although numerous strategies have been described, a patient-specific approach is usually necessary in the management of these complex patients. In this review, we highlight various therapeutic maneuvers described for the management of BNC and further delineate a tailored approach utilized at our institution in these complicated patients.
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Affiliation(s)
- Jay Simhan
- 1 Department of Urology, UT Southwestern, Dallas, TX, USA ; 2 Urology Section, Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
| | - Daniel Ramirez
- 1 Department of Urology, UT Southwestern, Dallas, TX, USA ; 2 Urology Section, Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
| | - Steven J Hudak
- 1 Department of Urology, UT Southwestern, Dallas, TX, USA ; 2 Urology Section, Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
| | - Allen F Morey
- 1 Department of Urology, UT Southwestern, Dallas, TX, USA ; 2 Urology Section, Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
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Management of the incontinent patient with a sphincteric stricture following radical prostatectomy. Curr Opin Urol 2015; 24:578-85. [PMID: 25203243 DOI: 10.1097/mou.0000000000000116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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