Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy

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.

[Evaluation and management of urethral strictures-guideline summary 2024 : Part 2-posterior urethra]

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.

[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.

Multiple bladder calculi after radical prostatectomy due to bladder neck stenosis in a patient with hypertrophic scar: A case report

INTRODUCTION AND IMPORTANCE

Bladder calculi after radical prostatectomy is rare and usually associated with migrated clips into the bladder forming a nidus. We present a patient with multiple bladder calculi resulting from bladder neck stenosis after radical prostatectomy causing bothersome lower urinary tract symptoms. He had an associated hypertrophic scar.

CASE PRESENTATION

A 60-year-old man of African ancestry presented with recent onset of irritative urinary symptoms three years after radical prostatectomy. Abdomen pelvic ultrasound and pelvic X-ray revealed a urinary bladder calculus. Examination of the previous radical prostatectomy scar found him to have a hypertrophic scar. He had urethroscopy with bladder neck incision for bladder neck stenosis and cystolithotomy with resolution of the symptoms.

CLINICAL DISCUSSION

The presentation was that of dysuria and frequency three years after radical prostatectomy. The cause of the symptoms was diagnosed after an abdomen pelvic ultrasound and pelvic X-ray as multiple bladder calculi. This is a rare finding with the few reported cases associated with clips that migrated to the urinary bladder forming a nidus for the calculi. This was of consideration in the case presented, however, the findings at urethroscopy revealed bladder neck stenosis suggesting stasis as possible cause of the bladder calculi. The symptoms resolved after bladder neck incision and cystolithotomy.

CONCLUSION

In addition to clips forming a nidus for calculi in the urinary bladder after radical prostatectomy, bladder neck stenosis being the cause of urinary bladder calculi should be considered in a patient with hypertrophic scar.

Use of the Allium Round Posterior Stent for the Treatment of Recurrent Vesicourethral Anastomosis Stricture

OBJECTIVE

To compare outcomes of monopolar incision and Allium Round Posterior Stent (RPS) insertion for the treatment of recurrent vesicourethral anastomosis stricture.

METHODS

Having a suprapubic catheter and an obstructed pattern with a peak flow rate (PFR) ≤12 mL/s on uroflowmetry were the indications for the surgery. Once the fibrotic vesicourethral anastomosis was incised, RPS was inserted at the level of vesicourethral anastomosis under fluoroscopic guidance. All the stents were removed at postoperative first year. Patients were evaluated 3months after stent removal. Objective cure was defined as no need to further treatments and PFR ≥12 mL/s while subjective cure was defined as having points <4 on Patient Global Impression of Improvements scale.

RESULTS

Of the 30 patients with a median age 66 (52-74) enrolled in the study, 18 had a suprapubic catheter, remaining 12 had median PFR 5.2 (2-10) mL/s. Stent migration was noted in two patients, these stents were replaced by new ones. Stone formation was diagnosed in one patient, a pneumatic-lithotripsy was performed. The median follow-up time was 28 (4-60) months following stent removal. Six cases needed further treatment after removal. The median PFR of remaining 24 patients was 20 (16-30) mL/s (P = .001). The objective cure rate was 24/30(80%), the Patient Global Impression of Improvements scores varied from 1 to 2, meaning subjective cure rate was 24/30(80%). For the six failed cases, according to patient preferences a lifetime RPS insertion was planned.

CONCLUSION

With its minimally invasive nature, reversibility, and acceptable success and complication rates, incision of anastomosis and insertion of the RPS for a 1-year duration is a promising option for the treatment of recurrent vesicourethral anastomosis stricture.

Robotic Simultaneous Repair of Rectovesical Fistula With Vesicourethral Anastomotic Stricture after Radical Prostatectomy: Step-by-Step Technique and Outcomes

OBJECTIVE

To report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with vesicourethral anastomotic stricture (VUAS) after radical prostatectomy (RP).

METHODS

Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent VUAS after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complications Panel Assessment and Recommendations.

RESULTS

Four cases with a median age of 68.5 (63.3-72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3-453) minutes, 255 (175-262.5) mL, and 2.5 (2-3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6-10), 38 (32-43), and 30 (27-41) days, respectively. No postoperative complications were reported. The median follow-up time was 16.25 (12-26) months, and no fistula recurrence was shown.

CONCLUSION

Robotic-assisted laparoscopic repair could represent an effective approach for the simultaneous repair of RVF with concomitant VUAS. More studies and management standardization are needed to assess the role of the robotic platform in the simultaneous repair of RVF with VUAS after radical prostatectomy.

Acute, Subchronic, and Chronic Complications of Radical Prostatectomy Versus Radiotherapy With Hormone Therapy in Older Adults With High-Risk Prostate Adenocarcinoma

Purpose

To compare acute, subchronic, and chronic complications between older patients with high-risk localized prostate cancer (HR-LPC) receiving radical prostatectomy (RP) and high-dose intensity-modulated radiotherapy (IMRT) combined with long-term hormone therapy (HT).

Patients and Methods

We recruited older patients (≥80 years) with HR-LPC from the Taiwan Cancer Registry database. After propensity score matching, logistic regression analysis was used to compare the acute, subchronic, and chronic complication rates between patients who underwent RP (the RP group) and high-dose IMRT combined with long-term HT (the IMRT+HT group).

Results

Benign prostatic hyperplasia (BPH) symptoms and urinary incontinence (UI) were the most common complications over 5 years (BPH symptoms: RP, 17.69%; IMRT+HT, 29.58%; UI: RP, 10.47%; IMRT+HT, 5.50%). Compared with the RP group, the IMRT+HT group had higher odds of BPH symptoms and lower odds of UI and hernia after the 5-year follow-up period. The impotence rates were significantly higher in the IMRT+HT group than in the RP group at 3 months and 1 year after treatment and became nonsignificant after 2 years. At 5 years after treatment, the IMRT+HT group had lower risks of UI (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.28–0.88) and hernia (aOR, 0.21; 95% CI, 0.11–0.82) and a higher risk of BPH symptoms (aOR, 4.15; 95% CI, 2.82–7.37) than the RP group.

Conclusion

IMRT+HT was associated with lower UI and hernia risks than RP. By contrast, RP was associated with fewer complications of BPH over the follow-up period and less impotence during the first year after treatment. Our findings provide important and valuable references for shared decision-making for optimal therapy selection among older men with HR-LPC.

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

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.