Recurrent Bladder Neck Contracture Research Articles

Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition.

Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique. The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire. A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2. Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

VE01 - Robotic YV plasty for recurrent bladder neck contracture

VE01 - Robotic YV plasty for recurrent bladder neck contracture

The First Known Documented Case of Ewingella Americana Urinary Tract Infection

We present a 73-year-old male with a history of end-stage renal disease (ESRD) on dialysis, type 2 diabetes mellitus, coronary artery disease status post stents, prostate carcinoma status post radiation, and prostatectomy, with recurrent bladder neck contracture requiring suprapubic catheter, left urethral stricture with nephrostomy tube placement, penile implant, and recurrent urinary tract infections, who presented to the emergency room complaining of constant bilateral groin pain for one day. Physical exam was significant for suprapubic tenderness and a chronic suprapubic catheter and left-sided nephrostomy tube. An initial examination of the patient's urine revealed turbid, yellow-colored fluid, positive for white blood cells, leukocyte esterase, and bacteria. A urine culture was obtained, which returned positive for E. americana, with>100,000colony-forming units (CFUs)as well as Enterococcus faecalis (E. faecalis) demonstrating low colony counts.The patient was treated with a seven-day course of meropenem 1 gm twice daily, whichimproved of his symptoms, and then completed a 10-day course of ertapenem 500 mg daily. The patient received a five-day course of vancomycin 1 gm on dialysis days for additional coverage of E. faecalis, despite low colony counts. This is the first documented case of a urinary tract infection caused by E. americana.The organism is primarily found in immunocompromised individuals, and a debate is still ongoing as to whether it is a true pathogen or exists primarily as an opportunistic infection.We suggest further inquiry and study of this resistant organism are paramount in establishing its role in both immunocompromised as well as immunocompetent individuals.E. americana is a multidrug-resistant organism, which to date has sparse documentation regarding its prevalence and potential for morbidity, especially in compromised individuals.In the era of increasing antibiotic resistance, we suggest that more research is needed to understand the pathogenicity of E. americana.

Bladder Neck Contractures Stabilize After Placement of the Artificial Urinary Sphincter.

For male cancer survivors, the combination of stress urinary incontinence and recurrent bladder neck contracture presents a management dilemma with poor consensus. Our objective was to assess the impact of artificial urinary sphincter placement on bladder neck contracture recurrence among prostate cancer survivors with stress urinary incontinence and bladder neck contracture. Men electing artificial urinary sphincter placement at our institution undergo synchronous bladder neck contracture treatment if indicated. An institutional database was queried for men with stress urinary incontinence and ≥1 intervention for bladder neck contracture. Records were divided according to whether an artificial urinary sphincter was ever placed. The impact of artificial urinary sphincter placement on bladder neck contracture recurrence was assessed using a multivariable conditional survival analysis, with survival defined as the recurrence-free interval following bladder neck contracture intervention. The proportional hazards assumption was assessed on the basis of Schoenfeld residuals. The analytic cohort consisted of 118 in the artificial urinary sphincter group and 88 in the non-artificial urinary sphincter group. Patients in both groups underwent a median of 2 (range 1-8) bladder neck contracture interventions over the entire course of their care, encompassing 445 total bladder neck contracture interventions. The artificial urinary sphincter group was on average 2.6 years younger (P = .02) and had a higher pack-year smoking history (P < .01). The presence of an artificial urinary sphincter was associated with a 61% lower bladder neck contracture re-intervention rate (HR 0.39, P < .01, CI 0.30-0.50) at any time when accounting for number of prior bladder neck contracture interventions and bladder neck contracture risk factors. Artificial urinary sphincter placement is associated with a lower rate of bladder neck contracture re-intervention. Artificial urinary sphincter placement should not be delayed or avoided due to the presence of bladder neck contracture.

Transurethral Incisions for Bladder Neck Contracture: Comparable Results without Intralesional Injections

To present our 12-year experience using an endoscopic approach to manage bladder neck contracture (BNC) without adjunctive intralesional agents and compare it to published series not incorporating them, we retrospectively reviewed 123 patients treated for BNC from 2008 to 2020. All underwent 24 Fr balloon dilation followed by transurethral incision of BNC (TUIBNC) with deep incisions at 3 and 9 o’clock using a Collins knife without the use of intralesional injections. Success was defined as a patent bladder neck and 16 Fr cystoscope passage into the bladder two months later. Most with recurrent BNC underwent repeat TUIBNC. Success rates, demographics, and BNC characteristics were analyzed. The etiology of BNC in our cohort was most commonly radical prostatectomy with or without radiation (36/123, 29.3%, 40/123, 32.5%). Some had BNC treatment prior to referral (30/123, 24.4%). At 12-month follow-up, bladder neck patency was observed in 101/123 (82.1%) after one TUIBNC. An additional 15 patients (116/123, 94.3%) had success after two TUIBNCs. On univariate and multivariate analyses, ≥2 endoscopic treatments was the only factor associated with failure. TUIBNC via balloon dilation and deep bilateral incisions without the use of adjunctive intralesional injections has a high patency rate. History of two or more prior endoscopic procedures is associated with failure.

Extraperitoneal Laparoscopic Modified Y-V Plasty for the Treatment of Refractory Bladder Neck Contracture.

Bladder neck contracture (BNC) is a rare, late complication of transurethral resection of the prostate (TURP). Although the endoscopic procedure is the primary treatment for BNC, the recurrence rate remains high. Y-V plasty offers excellent surgical results for those individuals with refractory and recurrent BNC. Traditional open operations usually fail to provide satisfactory exposure to the operating field and lead to greater invasiveness. Interrupted sutures lead to prolonged operative time and increased anastomotic leakage. Laparoscopic modified Y-V plasty is performed through extraperitoneal access to the pelvis, which provides adequate exposure to the surgical view and avoids intra-abdominal injury. After incising the anterior bladder wall neck in a Y-shaped fashion, anastomosis is performed using two absorbable barbed sutures. The mucosa and submucosa layer of the bladder is closed to both sides with consecutive sutures in a V-shape before suturing serosa, and tunica muscularis are sutured to reinforce. The aforementioned procedures reduce leakage from the anastomosis and decrease operative time and patient trauma. Extraperitoneal laparoscopic modified Y-V plasty offers significant advantages over the open approach in terms of post-surgical recovery and invasiveness, making it a feasible and safe surgical option for patients with refractory BNC.

Assessment of the Balloon Dilation Efficiency in Bladder Neck Contracture after Transurethral Interventions on the Prostate

Purpose: The aim was to assess the results of balloon dilation in patients with bladder neck contracture (BNC) after endoscopic surgery for benign prostatic hyperplasia (BPH). Materials and Methods: The study involved 120 patients with recurrent BNC after transurethral interventions for BPH. All patients underwent transurethral resection (TUR) of the bladder neck and were divided into two groups: Group A (n = 45) included men who, after TUR, additionally underwent repeated balloon dilation, whereas the control group B (n = 75) included men who were treated with alpha-blockers alone. Results: In 9 months after TUR and 3 months after the 4th balloon dilation procedure in Group A, the mean international prostate symptom score (IPSS) decreased from 20.1 ± 8.4 to 17.2 ± 7.4, and the IPSS-quality of life was 4.2 ± 1.2 (P &gt; 0.05). In Group B, they were 21.7 ± 7.7 and 4.7 ± 1.1 (P &gt; 0.05), respectively. In addition, the mean flow rate in Group A was 13.2 ± 5.4 ml/s, whereas in Group B, it was 8.7 ± 4.9 ml/s (P &lt; 0.05). There was a significant decrease in the postvoid residual urine volume from 76.2 ± 96.1 ml to 37.6 ± 55.1 ml in Group A, whereas, in Group B, it increased from 63.0 ± 36.9 ml to 79.4 ± 71.6 ml (P &gt; 0.05). Furthermore, 28.0% of patients of Group B and 13.3% of patients of Group A underwent repeated TUR of the bladder neck in 9 months follow-up period (P &lt; 0.05). Conclusion: Balloon dilation is a safe less invasive procedure and can reduce the possibility of BNC recurrence and thus the rate of repeated transurethral interventions.

Bladder Neck Contracture as a Complication of Prostate Surgery

Bladder neck contracture (BNC) is one of the most common complications of surgical treatment of prostate diseases. The rate of postoperative BNC varies depending on the type of surgical treatment used. The options for treatment techniques for BNC can vary from endoscopic interventions to complex (abdominal) surgical interventions. This review evaluates various alternative surgical methods of BNC treatment. The search and analysis of publications in the databases PubMed (MEDLINE), Scopus, Cochrane Library, according to the keywords, “bladder neck sclerosis,” “benign prostatic hyperplasia,” “BNC,” “bladder neck stenosis,” “balloon dilation,” “treatment.” As a result, 71 publications were selected and included in this review. In addition to the standard treatment methods in the form of transurethral resection and incision of the bladder neck using electricity and laser energy, the urologist also has alternative methods of treatment, such as balloon dilation, placement of urethral stents, instillation of the bladder or intraoperative injection of cytostatic drugs, hormones, hyaluronic acid derivatives, and biomedical cell products into the bladder neck area. Although transurethral resection is currently the main treatment option for BNC, the recurrence rate after this procedure can reach up to 38%. According to the literature, balloon dilation can be a promising and minimally invasive method of treatment for recurrent BNC. This method can be used as the first stage in the treatment of recurrent contracture deformity. Furthermore, intravesical instillation of various anti-inflammatory drugs and cytostatics can be promising directions in the treatment and prevention of BNC.

Subtrigonal Inlay Patch Technique with Buccal Mucosa Graft for Recurrent Bladder Neck Contractures

Introduction: We aimed to present a novel subtrigonal inlay patch (SIP) technique with buccal mucosa graft (BMG) for recurrent bladder neck contracture (BNC) via open approach. Materials and Methods: Surgical approach for SIP technique is described in detail and outcomes of patients who have been operated with this technique for recurrent BNC were given. Briefly, bladder neck incision is performed after vertical cystotomy, fibrotic scar tissue is excised completely, and a BMG is patched at the end. Results: All 3 patients were able to void in their first attempt after catheter removal. Follow-up durations were 14, 11, and 5 months for the patients and all 3 patients reported satisfactory voiding. No de novo urinary incontinence was reported by patients after catheter removal, and all were continent with no pad need on their last follow-up visit. None of the operated patients needed any intervention such as catheterization, dilatation, or internal urethrotomy for BNC on follow-up. Conclusion: The present study demonstrates the feasibility and promising results of SIP technique with open surgical approach. Further experience is mandatory with larger patient cohorts and longer follow-up.

Successful treatment of recurrent recalcitrant bladder neck contracture with transurethral bladder neck injection of triamcinolone acetonide

Successful treatment of recurrent recalcitrant bladder neck contracture with transurethral bladder neck injection of triamcinolone acetonide

Minimal invasive management of bladder neck contracture using Allium round posterior stent: the long-term results.

BackgroundThe purpose of this study was to assess the long-term clinical efficacy of temporary, Allium round posterior stent (RPS) used for treatment of recurrent bladder neck contracture (BNC).MethodsRecords of 42 patients with recurrent BNC who underwent Allium RPS placement after bladder neck incision, between 2009 and 2019, were analyzed. After stent removal, the success criteria for Allium RPS treatment were defined as: no evidence of stricture on urethrogram or endoscopy; more than 12 ml/sec of urinary peak flow; and no recurrent urinary tract infections. Based on clinical success, patients were divided into two groups and compared. Clinical success was evaluated with particular regard to stent indwelling time and contracture etiology.ResultsThe mean ± standard deviation age, stricture length, and indwelling time were 66.7 ± 9 years, 2.4 ± 1.4 cm, and 7.7 ± 2.2 months, respectively. Median (range) follow-up was 59 (8–73) months. The etiologies of BNC in this cohort were 57.1% retropubic radical prostatectomy; and 42.9% transurethral resection of prostate. Overall clinical success was achieved in 64.3% and the success rates did not differ by etiology. The success rates were 54.2% and 77.8% (P = 0.118) for retropubic radical prostatectomy and transurethral resection of prostate, respectively. Longer indwelling time (8–14 vs 3–7, months) was significantly associated with clinical success (78.3% vs 47.4%, P = 0.040).ConclusionOur data suggest that better clinical success was associated with longer indwelling time for stent in BNC treatment. In BNC management, Allium RPS treatment may be considered since its clinical efficacy is acceptable and tolerable.

WITHDRAWN: Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy

Abstract Vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy is a narrowing of the vesicourethral anastomosis after radical prostatectomy. We aim to describe a safe re-anastomotic procedure for recurrent bladder neck contracture following radical prostatectomy (RP). This technique allows an easier access to the stenotic vesico-urethral anastomosis, a better mobilization of the bladder neck and a tension free re-anastomosis. Twelve patients suffering from VUAS after radical prostatectomy were enrolled between May 2014 and September 2018. We describe our approach to the disease. The evaluated outcomes were intra- and post-operative complications, stricture recurrence, and postoperative stress incontinence. Average operative time was 3 h. No major intraoperative complications or bleeding occurred. Patients were discharged after 72 h. At the time of catheter removal, 3 weeks after surgery, 9 out of twelve patients developed stress urinary incontinence, requiring 4 pads/day. Two patients with history of pelvic radiotherapy developed a surgical site abscess that required toilette and external urinary diversion. One recurrence occurred and was treated with internal urethrotomy before sphincter placement. No patient reported significant postoperative pain or fecal incontinence. Our approach allows direct access to the posterior urethra, and we demonstrate the advantages for treatment of VUAS to achieve a tension free anastomosis. All patients need to be informed of subsequent urinary incontinence to be treated with artificial sphincter placement. Patients with a history of pelvic radiotherapy show very poor preoperative conditions of the tissues and must be informed about the possibility of an external urinary diversion.

The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience

To assess the efficacy, effect of radiotherapy, and complications of direct visual internal urethrotomy (DVIU) and intralesional mitomycin C (MMC) for recurrent bladder neck contracture/vesicourethral anastomotic stenosis (BNC/VUAS). Patients who underwent DVIU with intralesional MMC for recurrent BNC/VUAS between 2007 and 2019 at 2 institutions were included. Cold knife incisions were performed in a reproducible fashion followed by injection of 0.3-0.4 mg/mL MMC at each incision site. Those with evidence of complete urethral obliteration, stenosis of the entire posterior urethra, or <3 months follow-up were excluded. Success was defined as the ability to pass a 17-French cystoscope postoperatively without the need for catheterization or additional procedures. Eighty-six patients were analyzed over a median follow-up of 21.1 months. Around 91% had at least 1 prior DVIU, 56% had at least 1 prior dilation, and 44% presented with an indwelling catheter or performed intermittent catheterization. Success was achieved in 65% after 1 procedure, an additional 18% after 2 procedures, and another 7% after 3 or more procedures (90% overall success rate). Nonradiated patients showed a higher overall success rate compared to radiated patients (94% vs 76%, P=0.04). Of the 9 cystoscopic failures, 5 were asymptomatic and pursued observation. Only 2 (5%) patients with a history of catheterization required this postoperatively. Two patients underwent subsequent urinary diversion surgery. No long-term complications were seen. DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in >90% of nonradiated patients and >75% of radiated patients.

Intralesional steroid injection combined with bladder neck incision is efficacious in the treatment of recurrent bladder neck contracture.

Bladder neck contracture (BNC) is a well-recognized complication following radical prostatectomy (RP). This problem may recur after failing initial endoscopic management. This study evaluated the efficacy of intralesional steroid injection combined with bladder neck incision (BNI) for recurrent BNC following RP. Between November 2011 and March 2018, data from all men who underwent BNI and intralesional steroid injection for recurrent BNC from a single regional center were collected. BNC was diagnosed endoscopically and identified as recurrent if having previously failed endoscopic management with BNI alone. Follow up was initially performed at 3 months with an International Prostate Symptom Score and urinary flow rate. Patients were noted to be recurrence-free when discharged from follow up or after having undergone a continence procedure indicating stability of the contracture. Thirty patients underwent BNI and intralesional steroid injection for recurrent BNC over the study period. All patients had received prior endoscopic incision of BNC without lasting success. Seventy percent (21/30) of patients were recurrence-free post-procedure, and this increased to 83.3% (25/30) after a repeat procedure in four patients. All five patients who had previous salvage radiotherapy had their recurrent BNC successfully managed with one BNI and intralesional steroid injection. The mean follow up was 33.4 months (range 7-75). There were no adverse events recorded. BNI combined with injection of intralesional steroids is a simple, cost-effective intervention which requires no specialist equipment/skills outside the realm of a general urologist. It is safe and has an excellent success rate.

Management of highly recurrent bladder neck contractures via transurethral resection combined with intra- and post-operative triamcinolone acetonide injections.

To present our preliminary experience in managing patients with highly recurrent bladder neck contractures (BNCs) after transurethral resection of the prostate (TURP). Between February 2015 and March 2018, 28 patients with highly recurrent BNCs who had failed multiple prior to endoscopic treatments were managed with transurethral resection and intra- and post-operative triamcinolone acetonide injections. The scar tissue was resected to the circular fiber at the bladder neck, and triamcinolone acetonide (2mL, 40mg/mL) was injected at the incision sites (8 points) using a cystoscopic injection needle. The cystoscopy-guided injections were repeated every four weeks for total three times after surgery. The patients were followed up at 3, 6, 12months after surgery, and in July-August 2019. The recurrent interval before the treatments was 2.2 ± 1.2months, without any BNC recurrence in the first 12weeks after transurethral resection. The urinary flow rate increased significantly and was maintained during the follow-up period. Adequate voiding function was reported in 25 of 28 patients at a median follow-up of 2.8 (1.7, 3.9) years. One of the three patients with decreased urinary flow rate had underactive detrusor and no BNC recurrence. The complications were mild and tolerable. Transurethral resection of the scar tissue combined with intra- and post-operative triamcinolone acetonide injections resulted in a success rate of 92.9% in patients with highly recurrent BNC following TURP. It is a simple, safe, and effective treatment for highly recurrent BNCs.

257 Use of a Suprapubic Tube at the Time of Artificial Urinary Sphincter Placement: A Strategy to Avoid Urethral Catheterization in the “at risk” Patient

Prolonged urethral catheterization in a patient with an artificial urinary sphincter (AUS) is problematic. In this situation, cuff erosion is not unusual. Also, though most men will have no difficulty voiding in the first 24 hours after AUS placement, the patient who does presents the surgeon with a dilemma: place a urethral catheter with it’s inherent risks, or place a surprapubic tube (SPT). In an effort to avoid this scenario, those patients who seemed most at risk for urinary retention or cuff erosion following AUS placement had a SPT placed while under anesthesia. We report a single center experience with placement of a SPT at the time of AUS surgery. From July 1, 2017 to July 1, 2018 fifty-eight (58) men underwent surgery to place an AUS. Three (3) of those patients were felt to be at increased risk of post-surgical urinary retention or cuff erosion: 1 patient had had a prior AUS and experienced cuff erosion; 1 patient had a prior transobturator sling and the dissection to place the occlusive cuff was more difficult raising the concern of a post-operative cuff site hematoma; 1 patient has prior episodes of urinary retention related to recurrent bladder neck contractures. While still under anesthesia, these 3 men had a 10Fr SPT placed via percutaneous punch using flexible cystoscopy to fill the bladder and confirm correct tube placement. The SPTs were capped, to be opened if the patient experienced symptoms of urinary retention. All patients were discharged from the hospital on the day of surgery.

Bladder Neck Contracture After Radical Prostatectomy: What Is the Reality of Care?

To evaluate the therapeutic methods and algorithms currently used in the treatment of bladder neck contracture (BNC) after radical prostatectomy (RP). Heads of 170 urologic departments in Germany, listed at the German Society of Urology (DGU), were invited to participate in an Internet-based customized survey. The questions consisted of an epidemiologic part (kind of hospital, state of practice) and questions inquiring used surgical techniques with their respective incidence and given algorithms for therapy. Of 170 contacted heads of urologic departments in Germany, 84 responded to the questionnaire (return rate 49.41%). The most common treatment modalities are transurethral resection, cold knife incision, hot knife incision, and dilation in descending order. For those institutions using several treatment modalities, 56 (66.67%) follow a therapeutic algorithm, while 28 (33.33%) follow no set order of treatment. However, among the 56 institutions with a set algorithm, 33 different approaches were identified. Of 84 institutions, 29 (34.52%) perform open reanastomosis in case of recurrent BNC, the remaining 55 (65.48%) do not. Despite several published guidelines on urethral strictures, numerous self-employed treatment algorithms are used to treat BNC. Although treatment results of these algorithms and the underlying treatment modalities cannot be determined with this work, it highlights the necessity for further studies comparing the different surgeries to allow for a more evidence-based approach.

The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction.

To describe a modified surgical technique for treatment of highly recurrent bladder neck contracture (BNC) after transurethral surgery for benign hyperplasia and to evaluate success rate and patient satisfaction of this novel technique. Ten patients with highly recurrent BNC and multiple prior attempts of endoscopic treatment underwent the T-plasty. Perioperative complications were recorded and classified according to the Clavien classification. Patient reported functional outcomes were retrospectively analysed using a standardized questionnaire assessing recurrence of stenosis, incontinence, satisfaction and changes in quality of life (QoL). The questionnaires included validated IPSS and SF-8-health survey items. Mean age at the time of surgery was 69.2 years (range 61-79), and the mean follow-up was 26months (range 3-46). No complications grade 3 or higher according to the Clavien classification occurred. Success rate was 100%. No de novo stress incontinence occurred. Urinary stream was described as very strong to moderate by 80% of the patients, mean post-operative IPSS-score was 11.3 (range 4-29), and mean post-operative IPSS-QoL was 2.4 (range 1-5). Patients satisfaction was very high or high in 90%, and QoL improved in 90%. The SF-8-health survey showed values comparable to the reference population. The T-plasty represents a safe and valuable option in treating highly recurrent BNC after surgery for benign hyperplasia. It offers multiple advantages compared to other techniques such as a single-staged approach and the opportunity for reconstruction of a reliable wide bladder neck by usage of two well-vascularized flaps. Success rate, low rate of complications and preservation of continence are highly encouraging.

The devastated bladder outlet: treatment options.

The purpose of this study is to review and discuss recently published studies of therapeutic options in cases with the combination of severe sphincteric damage and recurrent stricture of the bladder neck or anastomosis in patients with postradical prostatectomy. Recent focus has been on successful management of recurrent bladder neck contracture with urethral dilatation or endoscopic techniques even in patients with prior history of additional radiation therapy. In addition, some authors include injectable agents in their armamentarium for the treatment of recurrent bladder neck stricture. Failure of all attempts to restore the bladder outlet and urethral patency results in a devastated bladder outlet with persistence of urinary incontinence, sometimes worsened when combined with recurrent obstruction. For this small subgroup of patients with severe damage of the lower urinary tract, treatment options are rare. In the current literature, several case series can be found, but no clinical trials exist to provide an evidence-based approach to this severe disorder. Open reconstructive techniques or urinary diversion with reservoirs made from bowel are necessary in these patients. In recent studies, laparoscopic and robot-assisted approaches have also been described. In case of a 'nonreconstructible' devastated bladder outlet treatment, options are limited. These devastating conditions require a definitive surgical solution. Bladder neck closure, continent vesicostomy in most cases combined with augmentation or urinary diversion with or without cystectomy are last resort techniques for this problem.

Durable Results of Mitomycin C Injection with Internal Urethrotomy for Refractory Bladder Neck Contractures: Multi-institutional Experience

IntroductionWe evaluated our intermediate term experience with radial urethrotomy and intralesional mitomycin C injection in patients with recurrent bladder neck contractures. Recurrent bladder neck contractures in which previous endoscopic treatment failed pose a difficult management dilemma. MethodsProspectively collected data were reviewed in a retrospective manner of patients presenting with recurrent bladder neck contractures from January 2007 to June 2014. All patients had at least 1 prior failed incision of a bladder neck contracture and many had additional dilations or catheter dependence. Radial cold knife incisions of the bladder neck were performed followed by injection of 0.3 to 0.4 mg/ml mitomycin C at each incision site. All surgeons performed the incision technique and injection in a reproducible fashion. ResultsA total of 40 patients underwent urethrotomy with mitomycin C injection. At a median followup of 20.5 months 30 patients (75.0%) had a stable bladder neck after 1 procedure. An additional 5 patients required 2 procedures to obtain a stable patent bladder neck (87.5%). Of the 40 patients 14 (35.0%) presented in retention on catheter drainage and all had a stable, patent bladder neck. No recurrence was detected in the original 18 patients in the pilot study with patent bladder necks. Rigorous followup revealed no long-term complications. ConclusionsUrethrotomy with mitomycin C injection for the management of recurrent bladder neck contractures is safe and efficacious. The addition of an antifibrotic agent in conjunction with internal urethrotomy offers a definitive solution to a problem that would otherwise be managed with repeat urethral incision/dilation, catheter dependence or open bladder neck reconstruction.