Complications after radical prostatectomy

Abstract

With the discovery of prostate-specific antigen and routine prostate cancer screening, came a renewed interest in the radical prostatectomy. As a result of early detection, the majority of prostate cancer is of low risk placing more emphasis on the social consequences of the surgery such as urinary incontinence, anastomotic contracture, erectile dysfunction and rectourethral fistula (RUF) formation. This review is specifically focused on the current approaches to anastomotic stricture and RUF following radical prostatectomy. A subset of anastomotic contractures following radical prostatectomy are recurrent and refractory to standard endoscopic therapy. Previous enthusiasm for permanent urethral stents has been dissipated by long-term results showing high revision and complication rates. In an attempt to avoid permanent urethral stents, new adjunctive agents are being used in combination with urethrotomy to achieve a stable, bladder neck anastomosis. There has been a major shift in the cause of RUF from primarily surgical to approximately 50% resulting from radiation/ablation therapy. Surgically induced RUF typically are small, located in bladder neck/trigonal region and can be primarily closed. Radiation/ablation induced fistula are large (>2 cm), involve the prostatic urethra and are fibrotic often requiring a combination of onlay grafting and interposition muscle flap for closure. The anterior, perineal sphincter-sparing approach is the optimal approach for closure of all RUF (simple or complex). Recent advancements in these two challenging patient populations have allowed reconstructive urologists to remain committed to rehabilitating the lower urinary tract avoiding palliative maneuvers and often-unnecessary urinary and fecal diversion.