An analysis of the causes of bladder neck contracture after open and robot‐assisted laparoscopic radical prostatectomy

Abstract

OBJECTIVES To evaluate the difference in outcome of bladder neck contracture (BNC) and its causes between large groups of patients undergoing open radical prostatectomy (ORP) and robot‐assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS We analysed 200 consecutive RPs performed by one surgeon for prostate cancer, 100 by ORP and 100 by RALP, between March 2003 and September 2007. The operative techniques of bladder neck repair and urethro‐vesical anastomosis were different. The ORP patients had a conventional stomatization and ‘racquet handle’ repair of the bladder if necessary, with mucosal eversion and a direct circular interrupted ‘end‐to‐end’ suture anastomosis between the bladder and urethra. The RALP patients had no bladder neck reconstruction or mucosal eversion and their anastomosis was by the continuous suture ‘parachute’ technique. RESULTS There was no BNC in the RALP group, whilst 9% of the ORP group developed a BNC (P < 0.005). Apart from surgical technique, other variables, including patient age, previous transurethral resection of the prostate, Gleason score, T stage, urine infection rate, urinary leakage, blood loss, drain tube removal, anastomotic suture material, catheter type and catheter removal times were statistically comparable in both groups. CONCLUSION This series suggests that the major factor involved in the cause of bladder neck contracture after ORP, relates to the stomatization or ‘racquet handle’ bladder neck repair, and the end‐to‐end anastomosis between the urethra and stomatized bladder. Mucosal eversion might also contribute. Normal postoperative urinary leakage when the anastomotic apposition is good seems unlikely to be a significant aetiological factor in the development of BNC. Prolonged urinary leakage results from an anastomotic gap, which heals by second intention, thereby causing scarring and BNC. The RALP ‘parachute’ technique, which expands the anastomosis towards the bladder, appears to protect against BNC. Mucosal eversion is not necessary in the parachute repair.

Unidirectional barbed suture versus standard monofilament for urethrovesical anastomosis during robotic assisted laparoscopic radical prostatectomy

“…In the contemporary literature, bladder neck contractures are reported in 0 to 7.4% of RALP patients and in 2.6 to 9% of patients after open radical prostatectomy (9,10,12,17,18). The exact cause of bladder neck contracture is not known although several theories exist.…”

“…These potential hypotheses include increased operative blood loss, poor mucosal approximation during UVA, ischemia of bladder neck tissue, extended length of urinary catheterization, urinary infection, and urinary extravasation. However, no study has demonstrated with significance any of these variables leading to a bladder neck contracture (18)(19)(20) (18). With excessive tension on the urethrovesical anastomosis, future tissue ischemia may develop with subsequent fibrosis and scarring, leading to bladder neck contracture.…”

Robot-Assisted Radical Prostatectomy vs. Open Retropubic Radical Prostatectomy for Prostate Cancer: A Systematic Review and Meta-analysis

“…Breyer et al [36] reported that the BNC rate was 1.4 % for RALP and 2.6 % for ORP. Webb et al [37] also reported that RALP was superior to ORP in the incidence of BNC. The incidence rate of inguinal hernia (IH) as a postoperative complication may have a difference due to surgical methods.…”

Risk factors and correction methods for postoperative vesicourethral anastomotic strictures: literature review

“…СВУА развился в 9 % случаев в группе РППЭ, в группе РА-РПЭ подобное осложнение не зарегистри-ровано. При анализе клинических данных пациентов и технических аспектов выполненных операций авто-ры пришли к выводу, что единственным значимым различием является методика формирования ВУА [18].…”

“…В результате ВУА представляет собой постепенно сужающуюся структуру, в отличие от ана-стомоза при РППЭ, где происходит резкий перепад между диаметрами просвета шейки мочевого пузыря и уретры, и можно выделить четкую границу между артифициальной шейкой мочевого пузыря и культей уретры. Диаметр просвета анастомоза превышает диа-метр просвета мембранозной уретры и после сокраще-ния рубца остается достаточным для адекватного мо-чеиспускания [18].…”