Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

Abstract

Purpose: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. Materials and Methods: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. Results: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 – 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 – 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. Conclusion: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Bladder Neck Contractures Stabilize After Placement of the Artificial Urinary Sphincter

“…Reconstructive approaches in the setting of prior radiation are notoriously difficult and most reports describe recurrence rates of 30% or higher. 17-23 The most recent data at the time of this report come from the Trauma and Reconstructive Urology Working Party of the European Association of Urology, who report a recurrence-free rate of 67% for 47 patients after a median of 44 months of follow-up. 24 We have not found that bladder neck reconstruction with the use of buccal mucosa grafts or muscle flaps offers a reliable, long-term solution in this population and do not routinely offer this, making it difficult to draw comparisons between these approaches and the use of up-front AUS placement in the present study.…”

Urethral Stricture Disease Guideline Amendment (2023)

“…40 Open VUAS or bladder neck reconstruction can be performed retropubically or perineally with patency rates ranging from 70-100%. [42][43][44] In patients continent of urine preoperatively who had a retropubic approach, 10% were incontinent post-operatively, while those who had a perineal reconstruction had an 83.3% incontinence rate post-operatively. 42,43 Special Circumstances 30.…”

“…[42][43][44] In patients continent of urine preoperatively who had a retropubic approach, 10% were incontinent post-operatively, while those who had a perineal reconstruction had an 83.3% incontinence rate post-operatively. 42,43 Special Circumstances 30. In men who require chronic selfcatheterization (eg, neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent selfcatheterization.…”

“…42-44 In patients continent of urine pre-operatively who had a retropubic approach, 10% were incontinent post-operatively, while those who had a perineal reconstruction had an 83.3% incontinence rate post-operatively. 42,43…”

Refractory Bladder Neck Contracture (BNC) After Radical Prostatectomy: Prevalence, Impact and Management Challenges

“…Reported definitions range between failure after one to >3 procedures. [19][20][21][22][23][24] The treatment carries an economic burden. It is estimated that in the UK, an elective bladder neck incision (BNI) procedure costs £1204-2987 in the elective setting and this cost rises threefold if it is performed in the emergency setting.…”