Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

Abstract

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1–8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients’ quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

“…The literature for patients who have undergone both radical prostatectomy and radiation therapy is limited. 21 Rates of posterior urethral stenosis following salvage treatments range from 3% to 10% in patients receiving adjuvant/salvage radiation therapy to 11% to 40% in patients undergoing salvage prostatectomy. 3,6,[22][23][24] It is accepted that salvage prostatectomy has a measurable positive impact toward cancer-free survival but with added deleterious consequences such as posterior urethral stenosis and urinary incontinence.…”

AdVance™ male sling for stress urinary incontinence: Long‐term follow‐up and patient satisfaction

“…When conservative measures fail, further investigation may reveal sphincter insufficiency, bladder dysfunction or other complications after RP, including vesicourethral anastomosis stenosis (VUAS), or any combination of these. Radiation therapy may severely complicate the condition and exclude available surgical treatments 9 . Treatment needs to be directed to the exact underlying pathology.…”

Transperineal bulbovesical anastomosis for extensive posterior urethral stenoses after treatment of prostatic disease

“…Posterior urethral stenosis (PUS) represents a narrowing from the proximal bulbar urethra to the bladder neck and is classified as bladder neck stenosis (BNS), prostatic urethral stenosis, and bulbomembranous stenosis 1 . Treatments for prostate disease, that is, radical prostatectomy (RP), radiation therapy for localized prostate cancer, and transurethral surgery for benign prostatic hyperplasia (BPH), can cause PUS.…”

“…It is difficult to maintain the long‐term urethral patency in patients with recurrent stenosis and obliterated stenosis except by urethral reconstructive surgery. Since most PUSs are confined to either the bladder neck or the bulbomembranous urethra, they are managed by established and relatively straightforward reconstructive techniques (i.e., Y‐V plasty for BNS and excision and primary anastomosis for bulbomembranous stenosis) 1 . However, in the case of the PUS extending from bulbomembranous urethra to the bladder neck, bulbovesical anastomosis (BVA) is the only way of restoring urethral continuity, which is an unusual and difficult reconstructive technique 7 .…”