Recurrent Bladder Neck Contracture Research Articles

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.

Visual Internal Urethrotomy With Intralesional Mitomycin C and Short-term Clean Intermittent Catheterization for the Management of Recurrent Urethral Strictures and Bladder Neck Contractures

To evaluate our longitudinal experience using visual internal urethrotomy (VIU) with intralesional mitomycin C (MMC) and short-term clean intermittent catheterization (CIC) for urethral strictures and bladder neck contractures (BNC) after failure of endoscopic management. This case series involved review of our prospectively developed database of all men who underwent VIU with MMC and CIC in a standardized fashion for urethral stricture or BNC between 2010 and 2013 at our tertiary care medical center. Etiology was identified as radiation-induced stricture (RIS) or non-RIS and analyzed by stricture location. Cold knife incisions were made in a tri or quadrant fashion followed by intralesional injection of MMC and 1 month of once daily CIC. All 37 patients previously underwent at least 1 intervention for urethral stricture or BNC before VIU with MMC and CIC. Mean stricture length was 2.0 cm (range, 1-6 cm; standard deviation, 1.0 cm). Over the median follow-up period of 23 months (range, 12-39 months), 75.7% of patients required no additional surgical intervention (RIS, 54.5%; non-RIS, 84.6%; P = .051). In those that did recur, median time to stricture recurrence was 8 months (range, 2-28 months). One patient with recurrence required urethroplasty. VIU with MMC followed by short-term CIC provides a minimally invasive and widely available tool to manage complex recurrent urethral strictures (<3 cm) and BNC without significant morbidity. This approach may be most attractive for patients who are poor candidates for open surgery.

Continence Outcomes After Treatment of Recalcitrant Postprostatectomy Bladder Neck Contracture and Review of the Literature

To present our experience with 2-stage management for recalcitrant refractory bladder neck contracture (BNC) after radical prostatectomy. A 15-year retrospective medical record review was performed for patients referred for BNC using current procedural terminology code or by International Classification of Diseases-Ninth Revision code for bladder neck incision (BNI). Treatment consisted of deep cold-knife BNI, followed by cystoscopy at 3-4 months. If stable and healed, an artificial urethral sphincter (AUS) or male sling was placed depending on continence level. Recurrent BNC at 3 months was treated with a second BNI. Sixty-three patients were referred with median (range) age of 66 (41-82) years, body mass index 30.1 (21.9-64.8) kg/m(2), and follow-up of 11 (1-144) months. Seventeen (27%) underwent adjuvant radiation therapy. Of the 46 who had successful management of the BNC, 91.3% were satisfied with level of continence after BNI alone or with a single additional operation. Of the 33 who underwent AUS or sling, only 2 failures occurred: 1 ultimately required cystectomy after multiple urethral erosions, and 1 with mild incontinence was satisfied with a secondary sling procedure. Four patients progressed to permanent urinary diversion. Together, either BNI (n = 4) or the secondary incontinence procedure (n = 1) was not successful in a total of 5 patients and required permanent urinary diversion. Nine had concurrent severe membranous strictures with no coaptation of the external urethral sphincter and were treated with direct vision internal urethrotomy and AUS and were continent. This represents the largest known experience with BNC after radical prostatectomy. Patients can be managed with cold-knife incision, followed by AUS or sling, with 66% achieving continence.

Deep Lateral Transurethral Incisions for Recurrent Bladder Neck Contracture: Promising 5-Year Experience Using a Standardized Approach

To evaluate our 5-year experience with deep lateral transurethral incisions of bladder neck contracture (TUIBNC), identify risk factors associated with failure of procedure, and assess outcomes of men subsequently treated for concomitant or de novo stress urinary incontinence (SUI). We reviewed 50 consecutive patients who underwent TUIBNC between June 2007 and January 2012. TUIBNC was standardized to include initial dilation followed by deep transurethral incisions. All patients were evaluated cystoscopically after a 2-month interval; those with recurrent bladder neck contracture (RBNC) underwent a second TUIBNC. For patients with concomitant SUI, we assessed the timing between TUIBNC and subsequent artificial urinary sphincter (AUS) placement and its outcome. Perioperative characteristics were reviewed to identify factors associated with failure. Of the 50 patients analyzed, most were refractory, 78% having failed previous TUIBNC. After TUIBNC, 72% required no further surgery for obstruction at a mean follow-up of 12.9 months. Of the 14 who failed initial TUIBNC, 7 underwent repeat TUIBNC with success, representing an overall success rate of 86% after 2 procedures. Significant factors associated with treatment failure were >10 pack/year smoking history (P = .039) and ≥ 2 previous endoscopic BNC procedures (P = .03). Of 39 men (78%) with concomitant SUI, two-thirds underwent AUS placement after an average of 2.9 months after TUIBNC. Only 2 of 26 (8%) patients required repeat transurethral procedures after AUS placement for RBNC. Deep lateral TUIBNC alone is a highly effective treatment modality for RBNC. Smokers and those having 2 or more previous transurethral procedures appear to have greater risk for failure. Subsequent AUS placement can be safely performed with >90% long-term urethral patency.

95 DEEP TRANSURETHRAL INCISION ALONE FOR REFRACTORY BLADDER NECK CONTRACTURE WITH OR WITHOUT STRESS URINARY INCONTINENCE: IS INJECTION THERAPY NECESSARY?

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery (II)1 Apr 201395 DEEP TRANSURETHRAL INCISION ALONE FOR REFRACTORY BLADDER NECK CONTRACTURE WITH OR WITHOUT STRESS URINARY INCONTINENCE: IS INJECTION THERAPY NECESSARY? Daniel Ramirez, Aditya Bagrodia, Steven J. Hudak, Lee C. Zhao, and Allen F. Morey Daniel RamirezDaniel Ramirez Dallas, TX More articles by this author , Aditya BagrodiaAditya Bagrodia Dallas, TX More articles by this author , Steven J. HudakSteven J. Hudak Dallas, TX More articles by this author , Lee C. ZhaoLee C. Zhao Dallas, TX More articles by this author , and Allen F. MoreyAllen F. Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1473AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Injection of mitomycin C during transurethral incision of recurrent bladder neck contracture (RBNC) has been reported to produce a 72% success rate after one treatment (J Urol 186; 156-160, 2011). We evaluated results of deep transurethral incision of bladder neck contracture (TUIBNC) alone and identified risk factors associated with RBNC. For patients with concomitant stress urinary incontinence (SUI), we assessed timing between TUIBNC and placement of a subsequent artificial urinary sphincter (AUS). METHODS We reviewed 50 consecutive men undergoing standardized deep TUIBNC from 2007 to 2012. TUIBNC involved dilation with a 4 cm X 24 Fr balloon followed by deep transurethral incisions at 3 and 9 o'clock with a Collings knife. No urethral injections of any kind were performed. We examined patient records for smoking history, radiation, diabetes, previous TUIBNC, and prostate surgery. We reviewed failure rates, time to AUS placement, need for AUS revision, and recurrence of BNC after AUS. Univariate analysis was performed to identify risk factors for RBNC. RESULTS Of the 50 patients studied, 80% had failed previous BNC procedures. After deep TUIBNC, 72% required no further surgery for obstruction at a mean follow-up of 12.9 months. Of the 14 patients who failed initial TUIBNC, 7 underwent repeat TUIBNC with success. Patients most likely to fail initial deep TUIBNC were those having two or more prior BNC procedures or ≥10 pack/year smoking history [failure rates 40.7% (P = 0.03) and 71.4% (P = 0.04), respectively]. A total of 39 men (78%) presented with concomitant SUI; two-thirds of these underwent AUS placement after an average of 2.9 months following TUIBNC. SUI occurred de novo after TUIBNC in 1 /11 (9%) patients. Only 2/26 patients required repeat transurethral procedures after AUS placement for recurrent BNC. CONCLUSIONS Deep lateral TUIBNC alone is a highly effective treatment modality for RBNC, and produces results comparable to those reported after mitomycin C injection. The majority of men with RBNC can be stabilized with deep lateral TUIBNC alone, although smokers and those having 2 or more prior RBNC procedures are at greater risk for failure. Subsequent AUS placement can be safely performed after a 3-month rest period with > 90% urethral patency rate. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e38-e39 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Ramirez Dallas, TX More articles by this author Aditya Bagrodia Dallas, TX More articles by this author Steven J. Hudak Dallas, TX More articles by this author Lee C. Zhao Dallas, TX More articles by this author Allen F. Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

97 MODIFIED Y/V-PLASTY FOR THE TREATMENT OF RECURRENT BLADDER NECK CONTRACTURE: OUTCOME AND PATIENT SATISFACTION

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery (II)1 Apr 201397 MODIFIED Y/V-PLASTY FOR THE TREATMENT OF RECURRENT BLADDER NECK CONTRACTURE: OUTCOME AND PATIENT SATISFACTION Philip Reiss, Philipp Schriefer, Werner Struss, Brigitte Schwaiger, Hendrik Isbarn, Oliver Engel, Silke Riechardt, Margit Fisch, Sascha Ahyai, and Roland Dahlem Philip ReissPhilip Reiss Hamburg, Germany More articles by this author , Philipp SchrieferPhilipp Schriefer Hamburg, Germany More articles by this author , Werner StrussWerner Struss Hamburg, Germany More articles by this author , Brigitte SchwaigerBrigitte Schwaiger Hamburg, Germany More articles by this author , Hendrik IsbarnHendrik Isbarn Hamburg, Germany More articles by this author , Oliver EngelOliver Engel Hamburg, Germany More articles by this author , Silke RiechardtSilke Riechardt Hamburg, Germany More articles by this author , Margit FischMargit Fisch Hamburg, Germany More articles by this author , Sascha AhyaiSascha Ahyai Hamburg, Germany More articles by this author , and Roland DahlemRoland Dahlem Hamburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1475AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent bladder neck contractures after surgery for benign prostatic hyperplasia are a rare but a troublesome complication. In these cases, open surgery can be the last therapeutic option before urinary diversion. The study was conducted to assess the outcome, satisfaction and the improvement on quality of life (QoL) for Y/V-plasty in a modified technique in patients with highly recurrent bladder neck contracture (BNC). METHODS Comprehensive retrospective analysis by pts chart review and standardized questionnaire including validated questionnaires (IPSS, SF-8, ICIQ-SF) of 10 pts treated by modified Y/V-plasty for highly recurrent BNC after surgery for benign prostatic hyperplasia in 2009-2012. Previous surgeries, recurrence rate, complications, micturition status, incontinence, satisfaction and quality of life were assessed. Difference to the standard Y/V-plasty was a T-shaped incision of the anterior bladder wall. By this technique two well vascularized flaps were created, which offer the possibility to reconstruct a wide bladder neck and anterior prostatic urethra. RESULTS Mean age was 69.2 yrs. (range 61-79), mean follow up was 26 months (3-46). All pts. had had multiple previous (trans) urethral surgeries (mean 3.5, range 2-5). Etiology was transurethral resection of the prostate in 70%, holmium enucleation of the prostate in 20% and HiFU of the prostate in 10%. Success rate was 100%. No complications were reported. No de novo stress incontinence occurred. 1 pt. noted a pre- and postoperative urge incontinence due to overactive bladder. 50% of pts. reported a strong or very strong, 20% a moderate and 20% a weak urinary stream. Mean postoperative IPSS-score was 11.3 (range 4-29), postoperative IPSS-QoL was delighted or pleased in 70%, mixed in 10% and due to urodynamic hypocontractile detrusor in one pt. mostly dissatisfied. Pts. satisfaction was very high in 70%, high in 20%, 10% were undecided. Quality of life improved in 90%, 10% report no change. CONCLUSIONS The technique of modified Y/V-plasty for the repair of highly recurrent bladder neck contractures seems to represents a successful and safe method and improves quality of life with good satisfaction rates. No complications were seen. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e39 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Philip Reiss Hamburg, Germany More articles by this author Philipp Schriefer Hamburg, Germany More articles by this author Werner Struss Hamburg, Germany More articles by this author Brigitte Schwaiger Hamburg, Germany More articles by this author Hendrik Isbarn Hamburg, Germany More articles by this author Oliver Engel Hamburg, Germany More articles by this author Silke Riechardt Hamburg, Germany More articles by this author Margit Fisch Hamburg, Germany More articles by this author Sascha Ahyai Hamburg, Germany More articles by this author Roland Dahlem Hamburg, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2178 SAFETY AND EFFECTIVENESS OF THULIUM VAPOENUCLEATION OF THE PROSTATE IN PATIENTS WITH ONGOING ORAL ANTICOAGULATION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy and New Technology (III)1 Apr 20132178 SAFETY AND EFFECTIVENESS OF THULIUM VAPOENUCLEATION OF THE PROSTATE IN PATIENTS WITH ONGOING ORAL ANTICOAGULATION Christopher Netsch, Michael Stöhrer, Sophie Knipper, Thorsten Bach, Thomas Herrmann, and Andreas Gross Christopher NetschChristopher Netsch Hamburg, Germany More articles by this author , Michael StöhrerMichael Stöhrer Hannover, Germany More articles by this author , Sophie KnipperSophie Knipper Hamburg, Germany More articles by this author , Thorsten BachThorsten Bach Hamburg, Germany More articles by this author , Thomas HerrmannThomas Herrmann Hannover, Germany More articles by this author , and Andreas GrossAndreas Gross Hamburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2087AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the safety and efficacy of Thulium VapoEnucleation of the prostate (ThuVEP) in patients with ongoing oral anticoagulation (OA) and symptomatic benign prostatic obstruction (BPO). METHODS Fifty-six patients, undergoing ThuVEP at two institutions, were evaluated prospectively from May 2009 until June 2011. All patients were at high cardiopulmonary risk and presented with a mean American Society of Anesthesiology score of 2.7±0.5. Thirty-two patients were on aspirin, 8 were on clopidogrel or clopidogrel and aspirin, and 16 on phenprocoumon at the time of surgery. Patient demographic, perioperative, and 12-month follow-up data were analyzed. The complications were assessed. RESULTS Mean prostate volume was 57.15±30.75 cc and resected tissue weight was 37.72±22.91 gm. The mean operative time was 74.92±46.81 minutes and the catheter time 2.14±0.36 days, respectively. The mean postoperative haemoglobin decrease was 1.4±1.18 g/dL. There were no perioperative thromboembolic events. Five (8.9%) patients required a second-look operation in the immediate postoperative course (haemorrhage n=4, residual adenoma n=1) and four (7.1%) patients received blood transfusions. Complications within 30 days included urinary tract infection (n=1, 1.7%), acute urinary retention (n=2, 3.6%), and delayed bleeding (n=4, 7.1%). These complications were managed conservatively. At 12-month follow-up, Quality of Life (4.38±0.93 vs. 1.47±0.95), international prostate symptom score (20.25±5.25 vs. 5.29±3.28), maximum urinary flow rate (8.22±3.15 vs. 29.4±11.08 ml/s), and post-void residual urine (123.6±98.67 vs. 22.4±25.35 ml) improved significantly (p<0.002). None of the patients were re-treated during follow-up for recurrent prostatic tissue, urethral strictures or bladder neck contractures. CONCLUSIONS ThuVEP is a safe and efficacious procedure for the treatment of symptomatic BPO in patients at high cardiopulmonary risk with ongoing OA. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e893 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Netsch Hamburg, Germany More articles by this author Michael Stöhrer Hannover, Germany More articles by this author Sophie Knipper Hamburg, Germany More articles by this author Thorsten Bach Hamburg, Germany More articles by this author Thomas Herrmann Hannover, Germany More articles by this author Andreas Gross Hamburg, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

762 ENDOSCOPIC MANAGEMENT OF RECURRENT POSTERIOR URETHRAL STRICTURES (PUS) WITH VISUAL INTERNAL URETHROTOMY (VIU) AND INJECTION OF MITOMYCIN C (MMC)

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease (II)1 Apr 2013762 ENDOSCOPIC MANAGEMENT OF RECURRENT POSTERIOR URETHRAL STRICTURES (PUS) WITH VISUAL INTERNAL URETHROTOMY (VIU) AND INJECTION OF MITOMYCIN C (MMC) James Rybak and Laurence Levine James RybakJames Rybak Chicago, IL More articles by this author and Laurence LevineLaurence Levine Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.325AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent posterior urethral strictures pose a challenging therapeutic dilemma. Surgery is complex and difficult. MMC has been shown to reduce fibroblast and scar proliferation. It has been previously studied to be a safe minimally invasive approach for recurrent bladder neck contractures (BNC) following radical prostatectomy. This study assessed patient outcomes following VIU and injection with MMC in a patient population with a variety of complex and radiation induced PUS. METHODS Retrospective chart review from our database of reconstructive surgery with PUS between 2010 and 2012 that had failed previous intervention with at least 1 prior VIU. Quadrant cold knife incisions of the scar were performed followed by 0.3-0.5mg/ml injections of MMC at each incision site; a total of 10 mL was used in each scar. Postoperative flexible cystoscopy and post void residual (PVR) assessed urethral patency postoperatively at 1,3,6,12 months. RESULTS 14 patients were treated with VIU and injection of MMC. All pt's had failed a mean of 2.5 prior procedures (1-4) Mean follow-up was at 8 months (1-14). Average scar length was 1.5cm (1-2.5cm). 42% (6/14) had post brachytherapy induced strictures. 2 patients had strictures from previous RALP, 1 had postoperative external beam radiation s/p RRP. 2 patients had a BNC after holmium laser ablation of the prostate, 1 after TUNA, 2 had strictures from prior failed urethroplasties. Complications were seen in 2/14 patients, 1 needed surgical intervention for a urethral false passage after self catheterization, 1 experienced gross hematuria necessitating clot evacuation. 11/14 patients were continent at baseline and 11/14 remained continent post procedure. 14/14 pt's had patent posterior urethral stricture confirmed by flexible cystoscopy at follow up. Average PVR improved from mean 148ml to 31.25ml post procedure. 3/14 (21%) needed repeat procedure for stricture recurrence. 2/14 patients had successful placement of artificial urinary sphincter with a patent urethra seen intraoperatively. CONCLUSIONS Management of recurrent proximal urethral strictures is one of the most challenging reconstructive problems. In our series it appears that VIU or resection of PUS with injection of MMC can provide a minimally invasive tool to manage these strictures without significant morbidity, even in patients with radiation-induced disease. In those men who have urinary incontinence, successful sphincter placement is offered when there is no stricture recurrence or > 6 months. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e313 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Rybak Chicago, IL More articles by this author Laurence Levine Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

866 Modified Y/V-plasty for the treatment of recurrent bladder neck contracture: Outcome and patient satisfaction

866 Modified Y/V-plasty for the treatment of recurrent bladder neck contracture: Outcome and patient satisfaction

91 THE SURGICAL CORRECTION OF BLADDER NECK CONTRACTURE (BNC) FOLLOWING THE TREATMENT OF PROSTATE CANCER

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201291 THE SURGICAL CORRECTION OF BLADDER NECK CONTRACTURE (BNC) FOLLOWING THE TREATMENT OF PROSTATE CANCER Anthony Mundy and Daniela Andrich Anthony MundyAnthony Mundy London, United Kingdom More articles by this author and Daniela AndrichDaniela Andrich London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.138AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The majority of patients with BNC following surgery or radiotherapy for prostate cancer can be treated endoscopically but this is not always successful. On the other hand surgical correction is rarely reported, indeed only 24 cases have been described in the English literature. Herein we describe our experience with 32 patients and distinguish between BNC due to surgery and BNC due to radiotherapy. METHODS Group 1: 17 patients with BNC following radical retropubic prostatectomy (RRP). Group 2: 6 patients with BNC following RRP plus salvage external beam radiotherapy (EBRT). Group 3: 9 patients with BNC following EBRT with or without other salvage treatment with either brachytherapy or HIFU. All patients had failed to respond to several attempts at urethrotomy, bladder neck incision and/or bladder neck resection. Patients in group 1 and 2 were treated by transperineal excision of their BNC and re-do vesico-urethral anastomosis (VUA). Patients in Group 3 underwent salvage RRP. RESULTS Two of the 17 patients in Group 1 developed a recurrent BNC which was successfully dealt with by a further redo-VUA so that ultimately all 17 were cured of their BNC. Two of the 6 patients in Group 2 developed a recurrent BNC and were managed with a long term suprapubic catheter (SPC). Of the 21/23 success in Groups 1 and 2, all 21 needed implantation of an AUS to restore continence. Six of the 9 patients in Group 3 had successful correction of their BNC one of whom needed an AUS to restore continence. The 3 failures in Group 3 were managed by a long-term SPC. In the patients who had had EBRT, surgery was technically more challenging, the post-operative recovery was more protracted and the outcome was less satisfactory. CONCLUSIONS Re-do VUA is a very successful management of patients with refractory post-surgical BNC but all patients require an AUS so treatment is a two-stage process. After irradiation, surgery is significantly more complicated and the outcome less satisfactory but nonetheless successful in the majority. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e38 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anthony Mundy London, United Kingdom More articles by this author Daniela Andrich London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radial Urethrotomy and Intralesional Mitomycin C for the Management of Recurrent Bladder Neck Contractures

We evaluated urethrotomy combined with intralesional injection of the antiproliferative agent mitomycin C for the treatment of severe, recurrent bladder neck contractures after traditional endoscopic management failed. We report our experience with radial urethrotomy and intralesional mitomycin C in patients with recurrent bladder neck contractures. A retrospective review was performed of patients evaluated for severe, recurrent bladder neck contractures between January 2007 and April 2010. All patients had at least 1 prior failed incision of a bladder neck contracture. Tri or quadrant 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. A total of 18 patients were treated with bladder neck incision and mitomycin C injection. Preoperatively 4 (22%) patients presented with indwelling Foley catheters while 7 (39%) required a dilation schedule. At a median followup of 12 months (range 4 to 26) 13 patients (72%) had a patent bladder neck after 1 procedure, as did 3 (17%) after 2 procedures and 1 after 4 procedures. All of the patients presenting with a prior indwelling urethral catheter or requiring a dilation schedule had a stable, patent bladder neck. Management of recurrent bladder neck contractures with radial urethrotomy combined with intralesional mitomycin C resulted in bladder neck patency in 72% of the patients after 1 procedure and in 89% after 2 procedures. Although early results are promising, longer followup and randomized, prospective studies are required to validate these findings.

MP-02.16: Preliminary results of mitomycin on recurrent bladder neck contracture after radical prostatectomy

MP-02.16: Preliminary results of mitomycin on recurrent bladder neck contracture after radical prostatectomy

1224 MANAGEMENT OF INTRACTABLE BLADDER NECK CONTRACTURE AND URINARY INCONTINENCE: LONG TERM EVALUATION

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery IV1 Apr 20101224 MANAGEMENT OF INTRACTABLE BLADDER NECK CONTRACTURE AND URINARY INCONTINENCE: LONG TERM EVALUATION Polina Reyblat, Priyanka Kadam, David A. Ginsberg, and Stuart D. Boyd Polina ReyblatPolina Reyblat More articles by this author , Priyanka KadamPriyanka Kadam More articles by this author , David A. GinsbergDavid A. Ginsberg More articles by this author , and Stuart D. BoydStuart D. Boyd More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.747AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary incontinence combined with intractable posterior urethra/ bladder neck contractures after radical prostatectomy or following radiation therapy for prostate cancer presents a very difficult management problem. Urinary incontinence is routinely managed with Artificial Urinary Sphincter (AUS), however, instrumentation required to perform multiple incisions, resections and/or dilations for treatment of recurrent bladder neck contracture is a contraindication for AUS placement. Placement of an Urolume stent across the posterior urethra/ bladder neck allows it to stay open while AUS provides continence. METHODS We retrospectively evaluated medical records of 16 men who underwent Urolume stent placement with subsequent implantation of the AUS between 2004 and 2009 (follow up ranging 5 to 61 months, mean 20.4 mo) RESULTS 16 men with a mean age of 76 (range 67-88) underwent combined Urolume stent placement with AUS implantation. Etiology of bladder neck contracture and incontinence was radiation therapy alone for prostate cancer in 6, radical prostatectomy alone in 5, radical prostatectomy with radiation therapy in 3, proton beam therapy in one, and radical cystoprostatectomy with orthotopic neobladder in one. Time from initial treatment to AUS/Urolume ranged from 5 months to 27 years. Number of prior incisions/dilations ranged from 3 to 18. Two patients required subsequent addition of a second Urolume stent for further stricture management. Out of 16 patients, 9 (56%) are completely dry, 6 (37%) report minimal leak upon exertion and use 1 pad a day. The AUS mechanism is turned off in one patient secondary to the development of dementia. Four patients require periodic CIC to maintain patency of the stent. Three patients required AUS revision. Four patients developed tissue growth into the Urolume stent requiring transurethral intervention. Of the 16 patients, 14 (88%) are satisfied with the results. These patients are older, more debilitated, or have longer strictures (>2.5cm) than patients receiving urethral reconstruction. CONCLUSIONS Combination of Urolume stent and artificial urinary sphincter can be effective in management of complicated bladder neck contractures with urinary incontinence in patients suffering consequences of prostate cancer treatment. This can be accomplished with minimal morbidity and significantly less invasiveness than the alternative of urinary diversion. Los Angeles, CA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e474 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Polina Reyblat More articles by this author Priyanka Kadam More articles by this author David A. Ginsberg More articles by this author Stuart D. Boyd More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcome Analysis of Urethral Wall Stent Insertion With Artificial Urinary Sphincter Placement for Severe Recurrent Bladder Neck Contracture Following Radical Prostatectomy

We present outcome and quality of life analyses for the treatment of post-radical prostatectomy bladder neck contracture with urethral wall stent insertion and subsequent artificial urinary sphincter placement. A retrospective analysis from June 2001 to September 2007 identified 25 consecutive men who underwent urethral wall stent placement for severe, recurrent bladder neck contracture despite aggressive transurethral resection after radical prostatectomy. Assessment of symptoms and quality of life impact from urinary incontinence was conducted with a self-administered, standardized questionnaire. Nonparametric testing was used for comparing covariates among groups. Univariate Cox proportional hazards modeling was used to assess predictors of treatment failure. P values are double-sided and are considered statistically significant if </=0.05. Etiology of recurrent bladder neck contracture was radical prostatectomy in all patients. Concurrent severe stress incontinence before treatment of bladder neck contracture was noted in 23 of 25 patients (92%). Before urethral wall stent insertion a median of 3 (IQR 2 to 5) failed endoscopic treatments were performed. Bladder neck contracture stabilization with insertion of 1 urethral wall stent was noted in 13 of 25 (52%) patients with a median followup of 2.9 years from last urethral wall stent insertion. Multiple urethral wall stent insertions (range 2 to 4) salvaged an additional 6 of 25 (24%) patients and failure to obtain patency was observed in 6 of 25 (24%). All patients responded to the questionnaire and quality of life improvement was noted in 23 of 25 patients (92%). Urethral wall stent and delayed artificial urinary sphincter placement for treatment of severe, recurrent bladder neck contracture and incontinence after radical prostatectomy is associated with improvement in quality of life. Long-term followup is required to further delineate the efficacy of this treatment approach.

Salvage surgery for bladder outlet obstruction after prostatectomy or cystectomy

Obstruction of the outlet secondary to a recurrent bladder neck contracture postprostatectomy or cystectomy presents a reconstructive challenge combined with the goal of restoring normal lower urinary tract function. The majority of bladder neck contractures are responsive to urethral dilation or cold knife direct visual internal urethrotomy. Urethral stents and anastomotic urethroplasty have been used with increasing frequency to regain urethral continuity. In the postcystectomy patient, obstruction due to stricture must be differentiated from dysfunctional voiding - unfavorable pouch voiding mechanics, insufficient pouch pressure generation or failure of external sphincter relaxation. Aggressive electrocautery resection with urethral stent placement and anastomotic urethroplasty are viable options for achieving patency after bladder neck obstruction. For those desirous of achieving a continent endpoint, artificial urinary sphincter should be planned as a second stage procedure after stabilization of the bladder neck. Creation of a catheterizable limb remains an option for the unreconstructable urethra. If augmentation cystoplasty is necessary due to storage pressure abnormalities, an appendicovesicostomy or reconfigured ileum segment is a reasonable method to achieve continence. The incidence of recurrent obstruction due to tissue in-growth or stricture is similar between urethral stent placement and anastomotic urethroplasty, respectively. The high incontinence rate after either initial treatment should be expected and factored into the overall treatment plan.

MP-11.05: Management of recurrent bladder neck contracture following radical prostatectomy using Ho:YAG laser and steroid injection

MP-11.05: Management of recurrent bladder neck contracture following radical prostatectomy using Ho:YAG laser and steroid injection

Management of Severe Urethral Complications of Prostate Cancer Therapy

We present our management of urethral stenosis and rectourinary fistula resulting from prostate cancer therapy. We concentrated on cases refractory to minimally invasive treatment, such as dilation, urethrotomy, and urinary and/or fecal diversion. In our prospectively collected urethral reconstruction database we identified patients who underwent reconstruction of urethral stenosis or rectourinary fistula who also received prior treatment for prostate cancer. We documented demographics, prostate cancer pretreatment characteristics, prostate cancer therapy type, urethral reconstruction type and success. A total of 48 patients met the inclusion criteria, including 16 with rectourinary fistula and 32 with urethral stenosis. Urethral complications followed prior radical prostatectomy, brachytherapy, external beam radiotherapy, cryotherapy, thermal ablation and any combination of these procedures. Stenosis repair was successful in 23 of 32 cases (73%) and it differed little between anterior and posterior urethral stenosis. Repair was accomplished by anastomotic urethroplasty in 19 cases, flap urethroplasty in 2, perineal urethrostomy in 2 and a urethral stent in 9. Prior external beam radiotherapy was a risk factor for urethral reconstruction failure. Fistula repair was successful in 14 of 15 patients (93%), excluding 1 who died postoperatively. The complexity of fistula management was dictated by fistula size and the presence or absence of coincident urethral stenosis. Urethral stenosis or rectourethral fistula following prostate cancer therapy can be managed by urethral reconstruction, such that normal voiding via the urethra is maintained, rather than abandoning the urethral outlet and performing heterotopic diversion. This can be accomplished with an acceptable rate of failure, given the complexity of the cases.

COMBINED STENT AND ARTIFICIAL URINARY SPHINCTER FOR MANAGEMENT OF SEVERE RECURRENT BLADDER NECK CONTRACTURE AND STRESS INCONTINENCE AFTER PROSTATECTOMY: : A LONG-TERM EVALUATION

Concurrent incontinence and severe recurrent bladder neck contracture following radical prostatectomy are difficult to manage. Recurrent anastomotic strictures following repeat transurethral incisions and resections, and the need for frequent instrumentation are contraindications for artificial urinary sphincter placement. Usually treatment alternatives for these patients consist of some form of urinary diversion or chronic catheter drainage. We evaluated our results using a UroLume stent across the bladder neck contracture followed by placement of an artificial urinary sphincter. After failed multiple (mean incisions 4.4) attempts at conservative management of anastomotic stricture 9 men were treated with a UroLume urethral stent across the contracture followed by artificial urinary sphincter placement after appropriate epithelialization of the stent was confirmed. All patients were followed for a mean of 17.5 months. Mean pad use per day decreased from 6.5 to 0.7 before and after artificial urinary sphincter placement, respectively. Two patients reported mild persistent perineal discomfort and 1 had a recurrent contracture after stent placement, which was successfully managed with placement of a second overlapping stent. Overall, 89% of the patients were satisfied with the results. UroLume stent placement followed by artificial urinary sphincter can be a successful method for treating recurrent severe bladder neck contracture and incontinence. There is minimal morbidity with the procedures, and the combination offers a much more attractive treatment alternative compared to urinary diversion or chronic catheter drainage.

Gossypiboma (Retained Surgical Sponge) and Recurrent Bladder Neck Contracture After Radical Retropubic Prostatectomy and Bilateral Pelvic Lymph Node Dissection

Retained foreign bodies after abdominal or pelvic surgery are rarely reported despite an estimated incidence of 1/1,500 cases.' While surgical removal is typically required, potential difficulties may not be appreciated and published guidelines are limited. We report on a patient with retained gauze sponges discovered incidentally 18 months after radical prostatectomy. CASE REPORT A 65-year-old white man presented with recurrent bladder neck contracture 18 months after radical retropubic prostatectomy and bilateral pelvic lymph node dissection performed elsewhere for pathological stage T2cNOMO Gleason grade 3+2 adenocarcinoma. Bladder neck dilation was required 1 and 3 months postoperatively followed by cold knife incision of the bladder neck 13 months after surgery. Prostate specific antigen remained undetectable and biopsy of the bladder neck demonstrated only fibrosis. The patient was instructed to perform clean intermittent self-catheterization on a tapering schedule. A total of 18 months after prostatectomy the patient reported recurrent obstructive symptoms. Following urethral dilation to 20F with filiforms and followers, an 18F Foley catheter was inserted. A pelvic radiograph performed to screen for surgical clips near the bladder neck revealed radiopaque thread consistent with retained surgical sponges in the obturator fossae bilaterally (fig. 1). Radiopaque contrast material was instilled via the indwelling urethral catheter, and pelvic computerized tomography showed encapsulated masses of variable attenuation lateral to the bladder base bilaterally and extending proximally along the psoas muscles (fig. 2). Attenuation values were consistent with fluid filled cavities surrounding the foreign material, suggesting possible lymphoceles or sterile abscesses. Cystoscopy with the patient under anesthesia demonstrated moderately dense fibrosis at the bladder neck and a polypoid mass adjacent to the bladder neck that acted as a ball valve. Excisional biopsy revealed proliferative cystitis, including nephrogenic adenoma and xanthogranulomatous inflammation with foreign body material. Exploratory laparotomy was performed via a midline infraumbilical incision. Moderately dense adhesions were noted in the space of Retzius and dissection was extended to the obturator fossae bilaterally with care taken to preserve

Gossypiboma (Retained Surgical Sponge) and Recurrent Bladder Neck Contracture After Radical Retropubic Prostatectomy and Bilateral Pelvic Lymph Node Dissection

Gossypiboma (Retained Surgical Sponge) and Recurrent Bladder Neck Contracture After Radical Retropubic Prostatectomy and Bilateral Pelvic Lymph Node Dissection