Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management

PURPOSE: We present a heterogeneous group of men presenting with varying degrees of anastomotic contracture (AC) and associated stress urinary incontinence (SUI) following radical prostatectomy. It is particularly important that AC should be resolved before artificial urinary sphincter (AUS) implantation, because instrumentation through the AUS can risk erosion. MATERIALS AND METHODS: The records of 54 consecutive men who were referred for the management of AC and associated SUI were reviewed. Patient treatment and outcomes were stratified according to their unique characteristics. RESULTS: A total of 54 patients underwent radical prostatectomy alone (48), or in combination with radiation therapy (7) or cryotherapy (1). In group 1, 35 patients had previously undiscovered AC, or 1 or more prior contracture incisions (CIs) with SUI. CI and AUS were performed simultaneously in 33 patients and sequentially in 2. In group 2, 7 patients with intractable AC following multiple CIs/dilations and self-calibration, or an indwelling urethral or suprapubic catheter underwent simultaneous (3) or sequential (2) CI/AUS or CI only (2). Five patients required temporary self-calibration. In group 3, in 12 patients with total outlet obliteration recanalization was accomplished with combined antegrade/retrograde endoscopy and CI. Ten patients had re-obliteration, of whom 1 underwent suprapubic diversion and 9 underwent repeat recanalization with placement of a UroLume stent (American Medical Systems, Minnetonka, Minnesota) across the anastomosis. Eight patients underwent artificial urinary sphincter (AUS) placement 4 to 6 weeks later and 1 awaits an AUS. Of those implanted with an AUS 2 required repeat endoscopic procedures because of recurrent but manageable stent ingrowth. CONCLUSIONS: Most ACs are treated successfully with simultaneous, aggressive CI/AUS. A history of many CIs or long, dense contractures suggest the need for staged management. In those with obliterated outlets we prefer to reestablish patency and if rapid recurrence develops, we place a UroLume stent. Regardless of a history of radiation therapy, continence is restored with an AUS.