Bladder neck contracture after radical retropubic prostatectomy

OBJECTIVE: To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45-76) who had open RRP by one surgeon between 1994 and 2003. RESULTS: The mean (range) follow-up was 30 (2-89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment. CONCLUSION: Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.     

Bladder neck contracture

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.     

经尿道低温双极等离子技术治疗前列腺增生术后膀胱颈挛缩

目的 探讨经尿道低温双极等离子技术治疗前列腺增生术后膀胱颈挛缩的疗效.方法 前列腺增生术后膀胱颈挛缩患者共35例,采用等离子探针式电极和等离子袢状电切环两种设备经尿道分别置入后切除膀胱颈后唇瘢痕组织,扩大膀胱颈口.结果 所有患者术后症状均得到改善,最大尿流率(18.1±3.3)ml/s和平均尿流率(8.4±1.3)ml/s,均高于术前,差异具统计学意义(P＜0.05);随访9至30个月,除2例复发经再次手术治愈外,其余均一次治愈.结论 经尿道低温双极等离子技术治疗前列腺增生术后膀胱颈挛缩,是一种安全、疗效确切的微创手术方法.     

Neodymium:YAG laser treatment of bladder neck contracture following prostatectomy.

A total of 21 patients with postprostatectomy bladder neck contracture underwent treatment with Nd:YAG laser irradiation. A new 800-microns hemispherical optical quarz fiber was used in contact technique to produce linear incisions in the scarred tissue. Within 11.2 months, median of follow-up, there was improvement in the obstructive voiding symptoms in all the patients. Two patients who had still mild contracture in the first follow-up cystoscopy were managed successfully with a second treatment. Endoscopic application of laser energy in the contact mode enables the immediate vaporization and disintegration of the fibrous area and secondary reepithelization of the bladder neck without scarring.     

Post-operative drain output as a predictor of bladder neck contracture following radical prostatectomy

Background Bladder neck contracture (BNC) following prostatectomy has been reported in 0.5–32% of cases. While the etiology of a BNC is unclear, several factors have been associated with this complication, including blood loss, devascularization of bladder neck tissue, poor mucosal apposition and urinary extravasation. To study the impact of urinary extravasation on BNC formation, we used post-operative drain output as a surrogate measure for anastomotic leakage. Methods All patients undergoing a radical retropubic prostatectomy (RRP) or a robotic assisted radical prostatectomy (RARP) from January 2000 to April 2006 have been entered into a prospective review board-approved database. All RRP patients had their anastomosis performed in an interrupted fashion using six monofilament 2-0 sutures. All robotic-assisted radical prostatectomy anastomoses were performed in a running fashion using 2-0 monofilament sutures. A single, closed suction Jackson Pratt drain was placed over the surgical bed at the conclusion of the case. Post-operative drain outputs were recorded. All patients were evaluated at 3, 6, 9, 12 and 24 months post-operatively. All patients who reported a diminished urinary stream or incontinence were evaluated by office cystoscopy. The inability to navigate an 18 French cystoscope through the bladder neck was defined as a bladder neck contracture. Results A total of 576 patients underwent a radical prostatectomy over this time span. Complete records were available for 535 (93%) of these patients. There were 21 bladder neck contractures (3.9%) overall. The post-operative drain output ranged from 5–5,465 ml (median 119 ml). Eight patients who had drain outputs less than 119 ml developed a BNC while 13 BNC developed in patients with Jackson Pratt drain output >119 ml (P = 0.343). In patients who underwent an open RRP, 19/424 (4.5%) developed contractures while 2/108 (1.9%) RARP patients developed a BNC (P = 0.105). Conclusion The amount of post-operative drain output is not statistically associated with the development of a bladder neck contracture.     

Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function

PURPOSE: Bladder neck contracture (BNC) after radical prostatectomy has been reported to occur in 5% to 32% of men after open radical retropubic prostatectomy (RRP) and 0% to 3% after laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized, mucosal apposition and correct realignment of the urethra. The cause of BNC is poorly understood; however, it is likely related to multiple factors, including excessive luminal narrowing at the site of reconstruction, local tissue ischemia, failed mucosal apposition, and urinary leakage. In this large series of patients who underwent robot-assisted laparoscopic radical prostatectomy (RLRP), we report the incidence of BNC, evaluate the influence of age, body mass index (BMI), estimated blood loss (EBL), surgical time, and prostate weight on its development and assess follow-up urinary function. MATERIALS AND METHODS: Between February 2003 and July 2006, 650 consecutive men underwent RLRP at our institution. Patients with aborted or open conversion procedures were excluded from analysis. The mean overall follow-up for the remaining 634 patients was 19.5 months. Patients presenting with symptoms of outlet obstruction were evaluated with cystoscopy to confirm a BNC. Comparisons of age, BMI, EBL, operative time, and prostate weight were performed using the Student t-test and chi-square analysis. RESULTS: BNC was the diagnosis in seven patients (1.1%), with a mean time of presentation of 4.8 (3-12) months postoperatively. The BNC patients had comparable mean age, BMI, prostate weight, and EBL to the non-BNC cohort. Their operative time, however, was significantly longer (283 v 225 min, P = 0.04). CONCLUSIONS: The incidence of BNC after radical prostatectomy is 1.1% in a large series of men undergoing RLRP. The diagnosis was made within 1 year. No significant impact on urinary continence or quality-of-life urinary function was observed after BNC management. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.     

Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single‐surgeon experience

OBJECTIVE

To examine a large, single‐surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs).

PATIENTS AND METHODS

From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development.

RESULTS

Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow‐up was 44 (12–233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ‐confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate‐specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non‐nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18‐month follow‐up.

CONCLUSIONS

BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non‐nerve‐sparing surgery and early in a surgeon’s experience.     

Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function

BACKGROUND AND PURPOSE: Bladder neck contracture (BNC) after radical prostatectomy has been reported to occur in 5% to 32% of men after open retropubic prostatectomy (RRP) and in 0% to 3% after laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized, mucosal apposition and correct realignment of the urethra. The cause of BNC is poorly understood; however, it is likely related to multiple factors, including excessive luminal narrowing at the site of reconstruction, local tissue ischemia, failed mucosal apposition, and urinary leakage. In this large series of patients who underwent robot-assisted laparoscopic radical prostatectomy (RLRP), we report the incidence of BNC, evaluate the influence of age, body mass index (BMI), estimated blood loss (EBL), surgical time, and prostate weight on its development and assess follow-up urinary function. METHODS: Between February 2003 and July 2006, 650 consecutive men underwent RLRP at our institution. Patients with aborted or open conversion procedures were excluded from analysis. The mean overall follow-up for the remaining 634 patients was 19.5 months. Patients presenting with symptoms of outlet obstruction were evaluated with cystoscopy to confirm a BNC. Comparisons of age, BMI, EBL, operative time, and prostate weight were performed using the Student t-test and chi-square analysis. RESULTS: BNC was the diagnosis in seven patients (1.1%) with a mean time of presentation of 4.8 (3-12) months postoperatively. The BNC patients had comparable mean age, BMI, prostate weight, and EBL to the non-BNC cohort. Their operative time, however, was significantly longer (283 v 225 min., P = 0.04). CONCLUSIONS: The incidence of BNC after radical prostatectomy is 2.2% in a large series of men undergoing RLRP. The diagnosis was made within 1 year. No significant impact on urinary continence or quality-of-life urinary function was observed after BNC management. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.     

Bladder neck contraction after radical prostatectomy: morbidity and risk factors

We retrospectively analyzed the morbidity and risk factors of bladder neck contraction (BNC) after retropubic prostatectomy. Of 99 consecutive patients who underwent radical retropubic prostatectomy between 1995 and 2001, 10 (10%) developed anastomotic stricture after surgery. BNC was diagnosed 7 months on average after the surgery. Nine patients were successfully treated by cold-knife incision, but 5 required additional incision against the recurrence of BNC. None of them revealed newly diagnosed stricture or incontinence. Thirteen potential risk factors including age, stage, PSA, neoadjuvant treatment, pathology, intraoperative blood loss, operation time, operator, nerve sparing, extravasation of urine, marginal status, the year of operation, and the method of ureterovesical anastomosis were evaluated using univariate and multivariate analysis. The BNC rate was increased in patients with longer (more than 4 hrs) operations and excessive bleeding (more than 1,000 ml) (p=0.0027, respectively). The year of operation (before 1998, p=0.0015), the method of ureterovesical anastomosis (p=0.0017), operator experience (less than 5 cases, p=0.0056), and neoadjuvant treatment (p=0.09) were also risk factors. In multivariate analysis, the year of operation (p=0.03) and operator experience(p=0.04) were strong predictors of BNC. The skill levels of surgeons and institutes are expected to decrease BNC.     

膀胱颈部电切结合曲安奈德注射治疗良性前列腺增生术后膀胱颈部挛缩的疗效观察

目的研究应用膀胱颈部电切结合术中及术后曲安奈德注射,治疗前列腺增生术后膀胱颈部挛缩(BNC)的有效性和安全性。方法通过电话随访方式收集2015年8月至2018年6月在西安交通大学第一附属医院泌尿外科接受治疗的92例BNC患者的相关资料,包括BNC复发情况、患者排尿情况以及并发症。结果 92例患者中8例(8.7%)患者存在排尿困难,其中4例证实为BNC复发,并发症包括短暂性尿失禁4例(4.3%)、血尿28例(30.4%)及附睾炎16例(17.4%),治疗后均缓解。结论膀胱颈部电切结合术中及术后曲安奈德注射治疗前列腺增生术后BNC操作简单、安全有效。     

Incidence of bladder neck contracture after robot‐assisted laparoscopic and open radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot‐assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well‐described complication of ORP and may be partially attributable to technique.

PATIENTS AND METHODS

The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer‐specific information, surgical data, and follow‐up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan–Meier methods.

RESULTS

From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow‐up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean (sd ) age was 59.3 (6.80) years and 91% of men were Caucasian. D’Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP (P= 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1–15) months after surgery. At 18 months after surgery, the BNC‐free rate was 97% for ORP and 99% for RALP (log‐rank P= 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC.

CONCLUSIONS

The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group.     

Bladder contracture following intravesical BCG immunotherapy treated by hydrodistention: a case report

A 35-year-old man had undergone retroperitoneoscopic radical nephrouretectomy in May 2002 (pTisNxM0). He later developed carcinoma in situ (CIS) of the bladder, and underwent intravesical instillation of 80 mg of Bacillus-Calmette-Guerin (BCG) once a week for 6 weeks in January 2004. After the treatment, irritative symptoms (frequency and dysuria) developed, and he was diagnosed with bladder contracture. Conventional treatment with anti-cholinergics, analgesics, anti-tuberculous drugs, and steroids was ineffecsive, but hydrodistention improved the subjective symptoms. Hydrodistention seems to be useful for bladder contracture following intravesical BCG immunotherapy.     

Bladder neck contracture after radical retropubic prostatectomy using an intussuscepted vesico‐urethral anastomosis: incidence with long‐term follow‐up

OBJECTIVE

To evaluate the incidence of bladder neck contracture (BNC), a known complication of radical retropubic prostatectomy (RRP), after a 9‐year experience by one surgeon using a novel approach to lower urinary tract reconstruction, the intussuscepted vesico‐urethral anastomosis (IVUA).

PATIENTS AND METHODS

After institutional review board approval, the charts of 406 patients who had RRP for clinically localized prostate cancer from March 1998 to July 2007 were reviewed retrospectively. All patients had lower urinary tract reconstruction using the IVUA technique, which involves a looped urethral suture using six double‐armed sutures that are drawn ‘inside‐to‐out’ from staggered points on the urethral stump through the bladder neck opening. When the sutures are tied down, the urethra is intussuscepted into the bladder neck opening.

RESULTS

At a median follow‐up of 48 months, three patients developed BNC: one was at increased risk secondary to a previous TURP; one had his catheter removed on the second day after RRP in the presence of a suprapubic tube and developed a BNC at his ‘dry’ anastomosis; and one with no risk factors developed a BNC. Balloon dilatation, laser incision and self obturation were successful in stabilizing the strictures while preserving continence. Overall, the incidence of BNC in this series was three of 406 (0.74%).

CONCLUSIONS

IVUA gives a lower incidence of BNC over a long‐term follow‐up than rates cited in previous reports. IVUA is a valuable technique for lower urinary tract reconstruction in patients undergoing RRP.