Management of recurrent anastomotic stenosis following radical prostatectomy using holmium laser and steroid injection

Abstract

OBJECTIVE To present our experience with the management of recurrent and resistant anastomotic stenosis following radical prostatectomy (RP) using transurethral laser incision of the stenotic area and injection of steroids. PATIENTS AND METHODS Between January 1999 and April 2006, we evaluated 24 patients with anastomotic stenosis that would not allow the passage of the flexible cystoscope (17 F). Using the paediatric 7.5 F Olympus scope and a 550‐µm fibre holmium laser, deep incisions were cut at the 3 and 9 o’clock positions at the bladder neck, and then triamcinolone was injected at the incision sites. Another session was then scheduled for office cystoscopy 6 weeks later, and if that showed evidence of annularity, another incision was made, as described above. RESULTS All 24 patients had RP for localized disease, 21 were retropubic and two were perineal, and one laparoscopic. Five patients had adjuvant radiotherapy. The mean patient age was 64 years. Nineteen (79%) patients had previous attempts to open the bladder neck: eight patients had dilatation, eight patients had internal urethrotomy, five patients underwent transurethral resection of the bladder neck, and six patients had open surgical intervention. The procedure was done once in 17 patients, and twice in seven patients. After a mean (range) follow up of 24 (6–72) months, 19 patients (83%) had a well‐healed and widely patent bladder neck. Of the 24 patients, 17 had urinary incontinence (UI) associated with the bladder neck contracture. An artificial urinary sphincter was implanted in 11 patients, three of which had to be explanted for malfunction in two, and erosion in one. CONCLUSION Holmium laser bladder neck incision and steroid injection for anastomotic stenosis after RP had a success rate of 83% in this small series. It can be used safely as a primary treatment, or in some cases, for resistant and recurrent stenosis. It appears that insertion of an artificial sphincter can be done in patients with UI when the bladder neck remains patent for at least 8 weeks.

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures

“…52 In 2008, Eltahawy et al described a series of 24 patients with bladder neck contractures who underwent deep holmium laser incisions followed by injection of triamcinolone at the incision sites. 53 A mean follow up of 24 months revealed an 83% success rate with 70% requiring one treatment and the remainder requiring a second incision and injection at 6 weeks. Kravchick and colleagues also reported similar findings with an overall success rate of 93% with VUAS dilation followed by TRUS-guided injection of a longacting steroid.…”

Endoscopic Treatment of Vesicourethral Stenosis after Radical Prostatectomy: Outcomes and Predictors of Success

“…Despite advances in operative technique, such as the implementation of robotic assisted surgery, vesicourethral anastomotoic stenosis (VUS) remains a significant complication related to the procedure, with an incidence ranging between 1-30% [1][2][3][4][5] . Multiple patient and procedural factors have been attributed to the occurrence of VUS post-radical prostatectomy, including advanced patient age, radiotherapy, increased body mass index (BMI), surgeon technique/volume, postoperative hematoma or urinary leak, increased pathologic tumor stage or grade, prior transurethral resection of the prostate gland, and history of tobacco use [6][7][8][9][10] .…”

Management Strategies for Post-Prostatectomy Bladder Neck Contractures

“…Eltahawy et al performed holmium laser incision at the 3 and 9 o'clock positions followed by injection of steroids (triamcinolone, 2 mL, 40 mg/mL) in a cohort of 24 patients with recurrent BNC following RP procedures. They reported an 83 % success rate at 24 months after one (17/24) or two (7/24) treatment courses [21].…”