Radiation-induced Urethral Strictures Research Articles

Management of osteomyelitis of the pubic symphysis following urinary fistula in patients with radiation-induced urethral strictures after prostate cancer treatment.

Osteomyelitis of the pubic symphysis is a rare condition often occurring in patients with radiation therapy-related urethral strictures after prostate cancer treatment. We retrospectively reviewed patients who presented with osteomyelitis of the pubic symphysis from November 2016 to September 2021. We investigated the factors leading to urosymphyseal fistulas, clinical presentation, radiological assessment, treatments, and outcomes. A total 4 cases were collected. All patients underwent surgery and adjuvant or salvage radiotherapy for prostate cancer. Subsequently, they developed stricture of the vesicourethral anastomosis which was initially treated conservatively. Symptoms of pubic bone osteomyelitis included pain in the pubic area, fever, difficulty walking, and recurrent urinary tract infections. In all cases, computed tomography and magnetic resonance imaging showed a urinary fistula arising from the vesicourethral anastomosis with the involvement of the pubic bone, and severe osteomyelitis. Due to the failure of conservative treatment, debridement of the pubic bone with cystectomy and ileal conduit was performed in 3 patients. One patient refused surgery and bilateral percutaneous nephrostomies were placed. Patients regained their original performance status 1 to 6 months after surgery. General recommendations for the best diagnostic and therapeutic approach to osteomyelitis of the pubic symphysis due to urosymphyseal fistula still do not exist. Conservative treatment often fails and a surgical approach with definitive urinary diversion may be required.

Current Management of Membranous Urethral Strictures Due to Radiation.

Radiotherapy is a frequently used treatment for prostate cancer. It does not only causes the intended damage to cancer cells, but also affects healthy surrounding tissue. As a result radiation-induced urethral strictures occur in 2.2% of prostate cancer patients. Management of urethral strictures is challenging due to the presence of poor vascularized tissue for reconstruction and the proximity of the sphincter, which can impair the functional outcome. This review provides a literature overview of risk factors, diagnostics and management of radiation-induced urethral strictures.

Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM)

ObjectivesTo evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty.Patients and methodsMonocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan–Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM).ResultsOverall, 47 patients were available for final analyses. Median age was 70 (IQR 65–74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28–68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome.ConclusionThe success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.

Long-term outcomes of anastomotic urethroplasty for radiation-induced strictures.

To present our experience with excision and primary anastomosis (EPA) of radiation-induced urethral strictures (RUS) in men, including risk factors for stricture recurrence and long-term recurrence rates. A retrospective review was performed of patients who underwent EPA of RUS between 2007 and 2018 at a single tertiary referral center. Demographic information, stricture location and length, complications, and stricture recurrence were analyzed. Univariate and multivariate Cox regression analyses were performed to identify variables impacting recurrence. EPA was performed in 116 patients with RUS. The majority of patients (86.2%, 100/116) underwent at least one prior urologic intervention. Mean stricture length was 2.3cm. Stricture recurrence occurred in 19.0% (22/116) at a mean of 8.6months. For patients with at least 1year of postoperative follow-up (mean 30.7months), stricture recurrence significantly increased to 36.6% (15/41; p = 0.03). On univariate and multivariate analyses, postoperative complications were associated with stricture recurrence (p < 0.001). EPA remains a viable option for men with RUS. Nearly two-thirds of RUS patients remain recurrence-free with long-term follow-up following EPA.

Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-induced Posterior Urethral Strictures

To describe the inciting events leading to urosymphyseal fistulas (UFs) and pubic osteomyelitis (PO) in patients who had radiation-induced urethral strictures. We retrospectively reviewed patients who underwent simultaneous pubic debridement, simple cystectomy, and urinary diversion for refractory UF and PO from 2014 to 2016. We investigated inciting events leading to UF, as well as patient presenting symptoms, diagnosis, management, and outcomes. Five patients were identified over a 2-year period. All patients had a previous history of radiation for prostate cancer. The median age was 67 years. All patients developed UF and PO after endoscopic intervention for urethral stricture. The number of endoscopic interventions per patient for stricture ranged from 1 to 7, including serial dilation, balloon dilation, and urethrotomy. Sterile urine cultures were obtained before all endoscopic interventions. All patients had pelvic pain with ambulation and recurrent urinary tract infections at presentation. Patients were diagnosed using a combination of retrograde urethrography and magnetic resonance imaging. Simultaneous pubic debridement with simple cystectomy and diversion was used for management in all cases. One patient died postoperatively with the remainder recovering well without PO or fistula recurrence, with a median follow-up of 16 months. UF can occur as a complication of endoscopic treatment of posterior urethral stricture in patients with a history of radiation therapy for prostate cancer. This study demonstrates that UF and PO may develop even with minimally traumatic procedures and sterile urine. All patients treated for posterior stricture must be considered at risk of development of fistulas and osteomyelitis.

Incidence of Stress Urinary Incontinence After Posterior Urethroplasty for Radiation-induced Urethral Strictures

To identify the frequency of de novo stress urinary incontinence (SUI) after posterior excision and primary anastomotic (EPA) urethroplasty in patients with radiation-induced urethral strictures (RIUS) and compare with patients with pelvic fracture urethral injuries (PFUIs). A retrospective review was conducted among patients who underwent successful posterior EPA urethroplasty between 2008 and 2016 for RIUS from prostate cancer or PFUI from blunt trauma. Only patients with an intact bladder neck on imaging were included. SUI was defined by patient-reported outcomes and daily pad use. Inclusion criteria were met by 36 patients with RIUS and 33 patients with PFUI. Among the RIUS cohort, mean follow-up was 18 months, mean stricture length was 2.5 cm, and surgical dissection extended to the prostatic urethra in 67% (n = 24). The overall frequency of de novo SUI among patients with RIUS was 33% (n = 12), of which 75% (9 of 12) had prostatic urethral involvement. Two patients with RIUS (17%, n = 12) proceeded with artificial urinary sphincter (AUS) placement, whereas the remaining 10 patients required pads. SUI after urethroplasty in patients with PFUI was less common (12%, n = 4) and the prostatic urethra was involved in only 3% (n = 1) of all patients with PFUI. One patient with PFUI underwent AUS placement, whereas the remaining 3 patients did not require pads. Among RIUS patients with an intact bladder neck, SUI impacts one-third of patients. Subsequent AUS placement is uncommon. Prostatic urethral involvement increases risk of SUI. SUI is less common among patients with PFUI, likely related to a more limited involvement of the proximal bulbomembranous urethra and lack of radiation.

Re: Improving Outcomes of Bulbomembranous Urethroplasty for Radiation-Induced Urethral Strictures in Post-UroLume Era.

Objective To evaluate contemporary outcomes of excision and primary anastomosis (EPA) for the treatment of radiation-induced urethral strictures (RUS). Patients and Methods A retrospective review of 72 patients undergoing EPA for RUS from 2007 to 2015 by a single surgeon was performed. We analyzed overall and long-term success rates of EPA urethroplasty and compared patient cohorts from two groups, 2007-2012 vs 2013-2015 (post-Urolume). Results During the course of the study, we noted a near doubling of patient volume from the earlier (6.2 patients/year) to later (11.7 patients/year) cohorts. Among the 37 men treated from 2007 to 2012, we identified an EPA success rate of 70% compared with the improved 86% success rate in the subsequent cohort of 35 men treated from 2013 to 2015 ( P = .07). Single dilation was successful in 50% of initial and 40% of subsequent cohort patients in the treatment of recurrence. Initial and subsequent cohorts varied only in regard to stricture length (mean 2.0 cm vs 3.0 cm in initial and subsequent cohorts, P = .001) and number treated with Urolume stent (initial 5 vs none in the later cohort, P = .03). Length of follow-up (median 50 [17-97] months for the initial and 22 [6-34] months for the later cohort) was not associated with recurrence. Conclusion Increasing numbers of RUS patients are presenting for urethral reconstruction in the post-Urolume era. With increasing experience, we improved success rates of EPA urethroplasty to over 85% despite increased stricture length.

Improving Outcomes of Bulbomembranous Urethroplasty for Radiation-induced Urethral Strictures in Post-Urolume Era

To evaluate contemporary outcomes of excision and primary anastomosis (EPA) for the treatment of radiation-induced urethral strictures (RUS). A retrospective review of 72 patients undergoing EPA for RUS from 2007 to 2015 by a single surgeon was performed. We analyzed overall and long-term success rates of EPA urethroplasty and compared patient cohorts from two groups, 2007-2012 vs 2013-2015 (post-Urolume). During the course of the study, we noted a near doubling of patient volume from the earlier (6.2 patients/year) to later (11.7 patients/year) cohorts. Among the 37 men treated from 2007 to 2012, we identified an EPA success rate of 70% compared with the improved 86% success rate in the subsequent cohort of 35 men treated from 2013 to 2015 (P = .07). Single dilation was successful in 50% of initial and 40% of subsequent cohort patients in the treatment of recurrence. Initial and subsequent cohorts varied only in regard to stricture length (mean 2.0 cm vs 3.0 cm in initial and subsequent cohorts, P = .001) and number treated with Urolume stent (initial 5 vs none in the later cohort, P = .03). Length of follow-up (median 50 [17-97] months for the initial and 22 [6-34] months for the later cohort) was not associated with recurrence. Increasing numbers of RUS patients are presenting for urethral reconstruction in the post-Urolume era. With increasing experience, we improved success rates of EPA urethroplasty to over 85% despite increased stricture length.

MP52-18 CHRONIC SUPRAPUBIC TUBE URINARY DIVERSION AS A MINIMALLY INVASIVE STRATEGY FOR RESOLUTION OF INCONTINENCE FOR COMPLEX RADIATION-INDUCED STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2016MP52-18 CHRONIC SUPRAPUBIC TUBE URINARY DIVERSION AS A MINIMALLY INVASIVE STRATEGY FOR RESOLUTION OF INCONTINENCE FOR COMPLEX RADIATION-INDUCED STRICTURES Kunj R. Sheth, Matthias D. Hofer, Nicholas L. Kavoussi, Billy H. Cordon, Jeremy M. Scott, and Allen F. Morey Kunj R. ShethKunj R. Sheth More articles by this author , Matthias D. HoferMatthias D. Hofer More articles by this author , Nicholas L. KavoussiNicholas L. Kavoussi More articles by this author , Billy H. CordonBilly H. Cordon More articles by this author , Jeremy M. ScottJeremy M. Scott More articles by this author , and Allen F. MoreyAllen F. Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.494AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radiation-induced urethral strictures can be complex and reconstruction challenging with the potential to become subsequently incontinent. We report on our experience treating patients with chronic suprapubic tubes (SPT) as an alternative to urethral reconstruction for men with radiation-induced urethral strictures. METHODS We retrospectively reviewed all patients that underwent SPT placement at our institution from 2008-2015. We identified 68 patients that received SPTs for radiation-induced urethral strictures and had a minimum of 6 months follow-up. Patient and stricture characteristics were recorded. RESULTS Among 68 patients with radiation-induced urethral strictures who underwent SPT placement at our institution, 31/68 (46%) chose to continue with a chronic SPT whereas 37/68 (54%) elected to subsequently undergo urethral reconstruction. Patients electing a chronic SPT were slightly older than those undergoing reconstruction (72.9 years versus 70.1 years, p = 0.16), but otherwise shared similar characteristics. Stress urinary incontinence (SUI) at time of initial presentation was reported by 22/31 (71%) patients and resolved after SPT placement in 9/22 (41%) patients. The majority of patients (16/31 (51.2%)) managed with a chronic SPT reported no side effects. Development of bladder stones occurred in 7/31 (22.6%) patients and 12/31 (38.7%) patients reported irritative bladder symptoms, the majority of whom (7/12 (58.3%)) had radiation-induced cystitis. Five patients with refractory radiation cystitis ultimately underwent ileal conduit urinary diversion for their symptoms. CONCLUSIONS Chronic SPT can be a successful initial management strategy for refractory radiation-induced urethral strictures in patients unwilling to undergo open urethral reconstruction. SPT is overall well tolerated and can resolve incontinence in nearly half of patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e695-e696 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Kunj R. Sheth More articles by this author Matthias D. Hofer More articles by this author Nicholas L. Kavoussi More articles by this author Billy H. Cordon More articles by this author Jeremy M. Scott More articles by this author Allen F. Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of radiation-induced urethral strictures.

Radiation as a treatment option for prostate cancer has been chosen by many patients. One of the side effects encountered are radiation-induced urethral strictures which occur in up to 11% of patients. Radiation damage has often left the irradiated field fibrotic and with poor vascularization which make these strictures a challenging entity to treat. The mainstay of urologic management remains an urethroplasty procedure for which several approaches exist with variable optimal indication. Excision and primary anastomoses are ideal for shorter bulbar strictures that comprise the majority of radiation-induced urethral strictures. One advantage of this technique is that it does not require tissue transfers and success rates of 70-95% have consistently been reported. Substitution urethroplasty using remote graft tissue such as buccal mucosa are indicated if the length of the stricture precludes a tension-free primary anastomosis. Despite the challenge of graft survival in radiation-damaged and poorly vascularized recipient tissue, up to 83% of patients have been treated successfully although the numbers described in the literature are small. The most extensive repairs involve the use of tissue flaps, for example gracilis muscle, which may be required if the involved periurethral tissue is unable to provide sufficient vascular support for a post-operative urethral healing process. In summary, radiation-induced urethral strictures are a challenging entity. Most strictures are amenable to excision and primary anastomosis (EPA) with encouraging success rates but substitution urethroplasty may be indicated when extensive repair is needed.