Posterior urethral complications of the treatment of prostate cancer

Abstract

What's known on the subject? and What does the study add? Urethral strictures, bladder neck and posterior urethral contractures, and urorectal fistulation are three well‐recognised complications of the treatment of prostate cancer, whether by surgery or non‐surgical treatment. Because these are relatively rare problems the treatment is uncertain. There is a heavy reliance on endoscopic or instrumental management of urethral strictures and of bladder neck and posterior urethral contractures, and there is little discrimination in any of these conditions between those that are the result of surgery and those that are the result of radiotherapy and other treatment methods using external energy sources. This review aims to clarify out current understanding of these three clinical problems and draws attention to the role of reconstructive surgery, particularly when dealing with bladder neck contractures, prostatic urethral stenoses and urorectal fistula. This also shows that the nature of the problem, the recovery time after treatment and the degree of functional recovery is radically different in the surgical as against the non‐surgical group, to a degree that the authors believe is not sufficiently stressed when patients are counselled and consented before their primary treatment. To review the less common and not widely discussed, but much more serious complications of prostate cancer treatment of: urethral stricture, bladder neck contracture and urorectal fistula. The treatment options for patients with organ‐confirmed prostate cancer include: radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy (EBRT), high‐intensity focussed ultrasound (HIFU) and cryotherapy; with each method or combination of methods having associated complications. Complications resulting from RP are relatively easy to manage, with rapid recovery and return to normal activities, and usually a return to normal bodily functions. However, after non‐surgical treatments, i.e. BT, EBRT, HIFU and cryotherapy, these same problems are more difficult to treat with a much slower return to a much lower level of function. When counselling patients about the primary treatment of prostate cancer they should be advised that although the same type of complication may occur after surgical or non‐surgical treatment, the scope and scale of that complication, the ease with which it is treated and the degree of restoration of normality after treatment, is altogether in favour of surgery in those for whom surgery is appropriate and who are fit for surgery.

Management of iatrogenic urorectal fistulae in men with pelvic cancer

“…On the other hand, in our opinion, access to the urinary tract is more difficult in the York-Mason procedure: 1) it cannot be used in large and complex fistulae; 2) it should be avoided in patients with severe radiation proctitis; 3) the operation is generally performed by general/colorectal surgeons; 4) the interposition of a vascularized flap requires a second incision; 5) the incidence of recto-cutaneous fistulation is higher; and 6) we do not see a reason for a risky and unnecessary division of the anal sphincter complex (both internal and external anal sphincters) with subsequent flatus incontinence and fecal soiling, although not true fecal incontinence. 1,[13][14][15][16] This issue has been described superficially, insufficiently, or even ignored, in most York-Mason literature. 6,11,17,18 Although popular between the 1960s and 1980s for the surgical treat- iatrogenic urorectal fistulae in men with pelvic cancer ment of small rectal cancers and adenomas, especially in an era where endoscopic excision of these lesions was nonexistent, 6,18-20 its popularity has recently been replaced by the transperineal approach by reconstructive surgeons, especially in high-volume centres.…”

“…The transperineal approach is usually favoured by urologists, who perform these operations themselves, as they feel more familiar with the perineal anatomy and with this "classical" urological approach to treat urological and other pelvic cancer complications involving the urinary tract. 1 We think the transperineal approach is currently the most commonly used method for URF repair. On the other hand, in our opinion, access to the urinary tract is more difficult in the York-Mason procedure: 1) it cannot be used in large and complex fistulae; 2) it should be avoided in patients with severe radiation proctitis; 3) the operation is generally performed by general/colorectal surgeons; 4) the interposition of a vascularized flap requires a second incision; 5) the incidence of recto-cutaneous fistulation is higher; and 6) we do not see a reason for a risky and unnecessary division of the anal sphincter complex (both internal and external anal sphincters) with subsequent flatus incontinence and fecal soiling, although not true fecal incontinence.…”

“…3,4 Therefore, failure of conservative treatment mandates surgical intervention. Several techniques have been employed for decades to treat URF, including transperineal, abdominoperineal, trans-ano-rectal Francisco E. Martins, MD 1,2 ; Natália M. Martins (Parks), posterior transsacral (Kraske), and variants; 1,[5][6][7][8] however, despite all these reported surgical possibilities, the single "best" procedure is still a topic of intense debate.…”

“…In contrast, URF patients following non-surgical treatments are more problematic and have a much slower return to a more compromised level of daily activities and overall recovery. 1 Management of URF is challenging and often frustrating for the reconstructive surgeon. Spontaneous closure may rarely occur in very small fistulae not caused by irradiation and after fecal and urinary diversion.…”

Rectourethral Fistulas Secondary to Prostate Cancer Treatment: Management and Outcomes from a Multi-Institutional Combined Experience

“…1 Small surgical fistulas diagnosed early after RP may heal spontaneously with urinary and The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number.…”