Treatment Of Bladder Neck Contracture Research Articles

El uso de la cirugía robótica para el tratamiento de estenosis uretrales y contracturas del cuello vesical: una revisión sistemática

ObjectiveThe aim of this systematic review is to offer a comprehensive view of the current use of robotic surgery for the treatment of urethral strictures and bladder neck contractures. MethodsA systematic review of the current literature was conducted through the Medline and NCBI PubMed, Embase databases in December 2023. Keywords used were ‘robotic’ and ‘robotic-assisted’ combined with ‘urethroplasty’, ‘urethral stricture’, and ‘bladder neck contracture’. All papers published after 2000, concerning studies conducted on humans for urethral strictures and bladder neck contractures managed with robotic surgery were considered for the review. Only procedures involving a direct approach to urethra/bladder neck and/or graft harvesting for urethroplasty have been included. ResultsA total of 275 articles were evaluated after the strategy search and only 11 articles were considered eligible for the final analysis. The studies included a series of between a minimum of 1 and a maximum of 104 patients, for a total of 203 patients. The robotic surgery was performed mainly for the treatment of bladder neck contracture and posterior urethra. In some reports, the robotic system was used for graft harvesting, subsequently used with an open perineal technique. The follow-up presented in the different studies is very heterogeneous. However, most studies have high success rates, with recurrence and redo surgery rates generally below 20%. Likewise, post-procedure incontinence rates are low. ConclusionsThe outcomes presented in the literature, combined with the minimally invasive nature, suggest a possible growing role for robotic surgery in the coming years in the treatment of these diseases.

Transurethral columnar balloon dilation of the prostate combined with holmium laser incision for bladder neck contracture in day-surgery mode.

The study aimed to investigate the clinical effect of transurethral columnar balloon dilation of the prostate combined with holmium laser in the treatment of bladder neck contracture (BNC). This retrospective study included 41 patients with BNC, who had been treated with transurethral columnar balloon dilation and holmium laser in our hospital from June 2020 to June 2022. Admission, operation, and discharge of all the patients were completed in 24h. The patients' satisfaction, postoperative complications, and chronic pain after operation were followed up. Clinical parameters, such as International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL), and post-void residual volume (PVR) in pre-operation, 1month and 6months after operation were recorded. All patients underwent the operations successfully. Six patients experienced urge incontinence and one patient experienced recurrence of BNC after 12months. At 1month and 6months after the operation, IPSS, QoL, PVR, and Qmax of the patients were significantly better than those before the operation (P < 0.05). Transurethral columnar balloon dilation of the prostate combined with holmium laser can effectively treat BNC with simple performance and satisfactory clinical effects. It is a minimally invasive treatment that can be conducted by simple day surgery.

Transurethral Vaporization of Bladder Neck Using Holmium Laser: First Experience in Manado

Abstract: Bladder neck contracture (BNC) is a potential complication after radical prostatectomy (RP). This may be a result of inadequate approximation at the time of surgery, urinary extravasation, or distraction of the bladder neck from a hematoma. Patients commonly complains of a poor urinary stream or prolonged unexplained incontinence. Treatment of BNC requires a tailored approach and can range from simple, office-based procedures to complex surgical reconstruction. We reported a case of 81-year-old male complaining urine retention for one month. The patient had previous open prostate procedure a year prior. On examination, neurogenic causes were excluded. Retrograde ureterocystography revealed bladder neck contracture. Patient was diagnosed as bladder neck contracture post open prostatectomy surgery. Transurethral holmium laser vaporization with 800 micrometre, 20 Hz frequency and 4,5 Joule of power. through a ureteroscope was performed. Two-way Folley catheter 18Fr was inserted without irrigation. Patient was discharged post-surgery two days after catheter removal and spontaneous micturition. Endoscopic balloon dilatation with incision appears to offers promising result in the management of BNC. The consideration of using transurethral vaporization with holmium laser modality was the first procedure ever done in Manado. In conclusion, TUVP is one of the alternatives, minimally invasive procedures to treat BNC. The use of holmium laser for the incision of bladder neck is another alternative to treat BNC with great outome proven by the length of stay (LOS) of two days after the procedure was done. Keywords: bladder neck contracture; transurethral vaporization; holmium laser; post prostatectomy

Synchronous Bladder Neck Contracture Dilation at the Time of Artificial Urinary Sphincter Placement Is Safe and Effective

To treat men with bladder neck contracture and stress urinary incontinence, neither long-term nor comparative data exist to support the superiority of simultaneous bladder neck contracture intervention at the time of artificial urinary sphincter placement (synchronous) or staged bladder neck contracture intervention followed by artificial urinary sphincter placement (asynchronous). This study aimed to compare outcomes of patients treated with synchronous and asynchronous protocols. Using a prospectively maintained quality improvement database, we identified all men between the years of 2001-2021 with a history of bladder neck contracture and artificial urinary sphincter placement. Baseline patient characteristics and outcome measures were collected. Categorical data was assessed with Pearson's Chi-square and continuous data was assessed using independent sample t-tests or Wilcoxon Rank-Sum test. In total, 112 men met inclusion criteria. Thirty-two patients were treated synchronously and 80 were treated asynchronously. There were no significant differences between groups across 15 relevant variables. Overall follow-up duration was 7.1 (2.8,13.1) years. Three (9.3%) in the synchronous group and 13 (16.2%) in the asynchronous group experienced an erosion. There were no significant differences in frequency of erosion, time to erosion, artificial sphincter revision, time to revision, or bladder neck contracture recurrence. Bladder neck contracture recurrences after artificial sphincter placement were treated with serial dilation with no early device failure or erosion. Similar outcomes are achieved following synchronous and asynchronous treatment of bladder neck contracture and stress urinary incontinence. Synchronous approaches should be considered safe and effective for men with stress urinary incontinence and bladder neck contracture.

MP78-17 SYNCHRONOUS BLADDER NECK CONTRACTURE DILATION AT THE TIME OF ARTIFICIAL URINARY SPHINCTER PLACEMENT IS SAFE AND EFFECTIVE

You have accessJournal of UrologyCME1 Apr 2023MP78-17 SYNCHRONOUS BLADDER NECK CONTRACTURE DILATION AT THE TIME OF ARTIFICIAL URINARY SPHINCTER PLACEMENT IS SAFE AND EFFECTIVE Austin J. Livingston, Kevin Krughoff, Jordan Foreman, and Andrew C. Peterson Austin J. LivingstonAustin J. Livingston More articles by this author , Kevin KrughoffKevin Krughoff More articles by this author , Jordan ForemanJordan Foreman More articles by this author , and Andrew C. PetersonAndrew C. Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For men with bladder neck contractures (BNC) and stress urinary incontinence (SUI), neither long-term nor comparative data exist to support the superiority of simultaneous BNC intervention at the time of artificial urinary sphincter (AUS) placement (synchronous) or staged BNC intervention followed by AUS placement (asynchronous). This study aimed to compare outcomes of patients treated with synchronous and asynchronous protocols. METHODS: Using a prospectively maintained quality improvement database, we identified all men between the years of 2001-2021 with a history of bladder neck contracture and artificial urinary sphincter placement. Baseline patient characteristics and outcome measures were collected. Categorical data was assessed with Pearson’s Chi-square and continuous data was assessed using independent sample t-tests or Wilcoxon Rank-Sum test. RESULTS: In total, 112 men met inclusion criteria. Thirty-two patients were treated synchronously and 80 were treated asynchronously. There were no significant differences between groups across 15 relevant clinical and surgical variables. Median overall follow-up duration was 7.1 (Interquartile range: 2.8-13.1) years. Three (9.3%) in the synchronous group and 13 (16.2%) in the asynchronous group experienced an erosion (p=0.35). There were no significant differences in the frequency of erosion, time to erosion (507 days vs. 826 days; p=0.54), AUS revision (43.8% vs. 62.5%; p=0.07), time to revision (1934 days vs. 2202 days, p=0.80), or BNC recurrence (15.0% vs. 18.8%, p=0.63). BNC recurrences after AUS placement were treated with serial dilation with no early device failure or erosion. CONCLUSIONS: Similar outcomes are achieved following synchronous and asynchronous treatment of bladder neck contracture and stress urinary incontinence. Synchronous approaches should be considered standard of care for men with SUI and BNC. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1138 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Austin J. Livingston More articles by this author Kevin Krughoff More articles by this author Jordan Foreman More articles by this author Andrew C. Peterson More articles by this author Expand All Advertisement PDF downloadLoading ...

Transurethral Incision of the Bladder Neck at Three Points with a Needle-Type Electrode for Bladder Neck Contracture.

PurposeThis study aims to evaluate the efficacy of transurethral incision of the bladder neck (TUIBN) at three points with a needle-type electrode for treatment of bladder neck contracture (BNC).Materials and MethodsBetween January 2016 and April 2021, the bladder necks of 53 patients with BNC after surgery were incised by the needle-type electrode at the 5, 7, and 12 O’clock positions. Patient’s preoperational characteristics, peri- and postsurgical outcomes, such as time of operation, postoperative bladder irrigation, and postoperative hospital stay, and data of the international prostate symptom score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR) were recorded 3 and 6 months after surgery.ResultsAll 53 cases of BNC were successfully treated in 35.00 (25.00, 45.00) min with 18.00 (14.00, 21.00) h for postoperative bladder irrigation with little intraoperative bleeding (less than 50 mL). The postoperative hospital stay ranged from 2 to 8 days, a mean of 3.50 (3.00, 5.00) days. No major intraoperative or postoperative complications were observed. All cases that underwent follow-up assessment at 3 and 6 months after the surgery showed significantly decreased IPSS and PVR and increased Qmax compared to preoperation ones (p ≤ 0.001). Of these 53 patients, there was no recurrence in severe BNC patients, but 5 of 53 (9.4%) BNC patients developed BNC again within 6 months and required repeated TUIBN. Thirty patients comprised five recurrent cases with a follow-up period of more than 1 year.ConclusionsTUIBN at three points provides a safe, effective, and reliable option in treating patients with BNC.

180-W GreenLight laser photoselective vaporization with multiple triamcinolone acetonide injections for the treatment of bladder neck contractures.

Bladder neck contracture (BNC), one of the most challenging complications after transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP), lacks effective treatment. In the present study, our experience in treating BNC using GreenLight laser vaporization with triamcinolone acetonide (TA) injections was shared. This is a retrospective cohort study that included 46 patients with BNC after TURP and PVP in our center. GreenLight laser surgeries (180W) were carried out and TA was administrated simultaneously. TA injections were repeated every week for three times after surgeries. The perioperative and postoperative parameters were reviewed and compared. Bladder neck tissues were examined by immunohistochemical staining to explore the expressions of collagen I, matrix metalloproteinase-3 (MMP-3), and transforming growth factor-β (TGF-β) after treatments. The chief complaint symptoms of all patients were significantly relieved after our treatments. None of them showed BNC recurrence during the follow-up. Complications were rare and mild. Postoperative assessments including maximal urinary flow rate (P < 0.01), International Prostate Symptom Score (P < 0.01), quality of life index (P < 0.01), and post-void residual volume (P < 0.001) were significantly better than baseline values, respectively. Immunohistochemical staining showed significantly lower expressions of collagen I (P < 0.001), MMP-3 (P < 0.001), and TGF-β (P < 0.001) after treatments. In conclusion, 180-W GreenLight laser with repeated TA injections demonstrated the safety and long-term efficacy in treating BNC, by inhibiting the expressions of fibrotic factors. Our procedure was a promising treatment for BNC after PVP and TURP.

Incorporating intra-lesional injection of mitomycin C in the management algorithm for bladder neck contractures and vesicourethral anastomotic strictures

Objective: This study aims to describe the experience of a single-surgeon series with the use of intra-lesional mitomycin C (MMC) in the treatment of bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). Patients and methods: From July 2014 to January 2019, patients who underwent bladder neck incision (BNI) and intra-lesional MMC injection performed by a single surgeon were included in this retrospective study. Clinico-pathological data were extracted from medical records. The primary outcome was recurrence rate following BNI and MMC injection. Results: Ten patients were included in the study. The median age was 68 years. The cause of BNC or VUAS was secondary to radical prostatectomy in eight patients and to endoscopic prostatectomy in two patients. The median follow-up was 16.4 months. The success rate was 70% after first treatment with BNI and MMC injection, and 80% after repeated treatment. There were no serious adverse events or complications related to the MMC injection. Conclusion: BNI and intra-lesional MMC injection is a minimally invasive treatment for refractory bladder neck contractures with a good success rate and minimal risk of side effects when a low dose of MMC is used. Further prospective multicentre study is warranted. Level of evidence: Level 4.

Efficacy of Needle Electrode Three-Point Method on Bladder Neck Contracture After Transurethral Resection of the Prostate

Introduction: Benign prostate hyperplasia (BPH) is a common disease among the elderly, which is the major cause of lower urinary tract symptoms. Transurethral resection of the prostate (TURP) is widely used for the treatment of BPH. However, complications of urethral stricture and bladder neck contracture (BNC) occur postoperation that causes poor quality of life in patients. Reported incidence of BNC ranges from 0.3% to 9.6%.1,2 Bladder neck incision, laser vaporization, and balloon dilatation are applied for the treatment of BNC with overall high recurrence rates. In recent years, new techniques such as T-plasty, a modified YV-plasty, and robot-assisted laparoscopic Y-V plasty were performed in the treatment of BNC and achieved satisfactory outcomes with success rate of 83.3%–90%.3,4 However, these techniques are complicated and difficult for the primary urologists to master. This video shows a transurethral approach by using a needle electrode to incise the pathway from the bladder outlet to the proximal verumontanum at 5, 7, and 12 o'clock positions, respectively, the depth of the incision should reach the adipose layer. Materials and Methods: From February 2015 to August 2019, the bladder necks from 48 patients with BNC after TURP were incised by the needle electrode at the 5, 7, and 12 o'clock positions, which extended the incision from the bladder outlet to the proximal verumontanum until exposure of the adipose layer. During the whole procedure in the treatment of BNC including cut of the residual prostate scar tissue, three-point incision by the needle electrode was the most important for the treatment of BNC, which could be against the formation of fibrous rings and prevent the recurrence of BNC. Patient's preoperation properties, peri- and postsurgical data, such as time of operative, postsurgical bladder irrigation, catheter duration, and hospital stay, as well as data of the international prostate symptom score (IPSS), maximum flow rate (Qmax), and postvoid residual (PVR), were recorded 1 and 6 months after surgery. Results: All 48 cases of BNC were effectively treated in (49.6 ± 14.4) minutes with (15.1 ± 4.6) hours for postoperative bladder irrigation. The urethral catheter was withdrawn at (5.6 ± 2.4) days post-treatment. Only one case had dysuria after postoperative catheter removal, the other 47 cases on re-examination after 1 and 6 months showed that IPSS and PVR were significantly decreased, but Qmax was increased when compared with preoperation (p < 0.001). Importantly, there were no significantly different outcomes between 1 and 6 months postoperation (p > 0.05). Strikingly, 20 cases followed up 6–24 months, mean of 12 months, had no urinary incontinence, retrograde ejaculation, and recurrence of BNC. Conclusions: Transurethral incision of bladder neck by the three-point method using the needle electrode for the treatment of BNC is mini-invasive, safe, effective, and reliable and may be implemented in the clinical setting. No competing financial interests exist. Runtime of video: 6 mins 53 secs

Bladder Neck Contracture After Endoscopic Surgery for Benign Prostatic Obstruction: Incidence, Treatment, and Outcomes.

In recent years, new endoscopic techniques have been developed to reduce the morbidity of transurethral resection of the prostate. Nonetheless, complications are still frequently encountered and bladder neck contracture (BNC) is a well-described complication after endoscopic surgery for benign prostatic obstruction (BPO). Our aim is to review and discuss the contemporary incidence, the relevant treatment strategies, and their outcomes. Findings suggest that BNC is a common complication with an acceptably low incidence but can range in complexity. Most contractures were usually managed successfully with conservative measures; nevertheless, in patients with refractory BNC, various valuable management strategies were employed with different kinds of success and re-treatment rates. In consideration of these challenging possibilities, the treatment of BNC requires a tailored approach with patient-specific management that can range from simple procedures to complex surgical reconstruction.

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.

Fistulation into the Pubic Symphysis after Treatment of Prostate Cancer: An Important and Surgically Correctable Complication

Chronic pubic pain after the treatment of prostate cancer is often attributed to osteitis pubis. We have become aware of another complication, namely fistulation into the pubic symphysis, which is more serious and more common than previously thought. A total of 16 patients were treated for urosymphyseal fistulas after the treatment of prostate cancer between January 2011 and April 2014. Clinical presentation was characterized by chronic, debilitating pubic/pelvic/groin pain in all patients. Diagnosis was confirmed by magnetic resonance imaging. Conservative management was successful in only 1 patient. The remaining patients were treated surgically with excision of the fistulous track and involved symphyseal bone and omentoplasty, followed by reconstruction when feasible. All 16 patients had had radiotherapy as primary treatment (8) or after prostatectomy (8). There were 5 patients (31.3%) who underwent various combinations of brachytherapy, external beam radiotherapy and cryotherapy. Bladder neck contractures developed in 13 patients (81.3%), whose treatment (endoscopic or open reconstruction) resulted in urinary leak leading to urosymphyseal fistulas. Reconstruction was possible in 7 of 15 patients (46.7%) with salvage radical prostatectomy and substitution/augmentation cystoplasty. The other 8 patients (53.3%) underwent cystectomy and ileal conduit diversion. Allpatients experienced resolution of symptoms, most significantly the almost immediate resolution of pain. A high index of suspicion must be maintained in irradiated patients presenting with symptoms suggestive of urosymphyseal fistulas, especially after having undergone treatment of bladder neck contractures or prostatic urethral stenoses. Although extensive, surgery for urosymphyseal fistulas, with a high risk of morbidity and mortality and a protracted recovery, leads to immediateand dramatic improvement in symptoms.

Outcomes of the Endoscopic Treatment of Bladder Neck Contractures in the Orthotopic Neobladder

To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthotopic neobladder (ONB) after radical cystectomy focusing on success rates for patients who require multiple treatments. Patients who underwent treatment for cystoscopically confirmed BNC in an ONB from 2007 to 2014 were studied. Treatment information included procedure type, use of adjuvant clean intermittent catheterization (CIC), and follow-up procedures. Procedures followed by additional interventions were categorized as failures. Success was defined as no additional surgical procedure with at least 1 year of follow-up. Procedures were classified by a number of prior endoscopic treatments. Seventy-one patients underwent 155 individual endoscopic procedures (146 urethrotomy, 3 dilation, and 6 transurethral resection of bladder neck). All patients were male without prior radiation. Median follow-up after initial endoscopic treatment was 26.8 months (interquartile range: 16.6-51.7), and time to recurrence was 3.5 months (1.6-6.3). Success was experienced for 50 of 136 individual procedures (37%) after excluding 19 procedures for inadequate follow-up. Success rates remained 25%-43% even after multiple prior interventions. Adjuvant CIC was associated with a higher success rate (14/24 or 58%) compared to procedures without CIC (36/112 or 32%, P = .02). Successful outcomes were seen in 50 of 71 patients (73%) with 2 patients requiring ONB removal. Individual endoscopic treatments of BNC in the ONB were met with 37% success. The rate did not decrease with subsequent procedures. Adjuvant CIC improved the outcomes. Overall, a successful outcome was achieved for most patients, but the majority required more than one procedure.

Management of the incontinent patient with a sphincteric stricture following radical prostatectomy.

The 5-year and 15-year life expectancy following the treatment of localized prostate cancer is excellent. Patients may develop rare but devastating complications following the surgery for prostate cancer. The purpose of this review is to summarize the available literature to date surrounding the management of the incontinent patient with a concomitant bladder neck contracture (BNC), or sphincteric stricture, following radical prostatectomy. The literature consists of several case series, but no clinical trials exist to provide an evidence-based approach to the incontinent patient with concomitant BNC. Fortunately, this is a relatively rare clinical scenario and most cases are successfully managed with urethral dilatation or endoscopic techniques. Multiple endoscopic techniques are available. In addition, some authors include injectable agents in their armamentarium for the treatment of BNC. Open reconstructive techniques or permanent urinary diversion may be necessary in rare cases. Both male slings and artificial urinary sphincter may be considered for the management of concomitant urinary incontinence. Some authors suggest it is safe to proceed with simultaneous artificial urinary sphincter implantation at the time of endoscopic management of the BNC. Management of the incontinent patient with concomitant BNC represents a challenging situation for the urologist. Several techniques are available to stabilize the BNC before safely proceeding with surgery for urinary incontinence. For the rare, complex case that has failed endoscopic management, referral to a surgeon experienced in reconstructive techniques is warranted.

Intralesional Injection of Mitomycin C at Transurethral Incision of Bladder Neck Contracture May Offer Limited Benefit: TURNS Study Group

Injection of mitomycin C may increase the success of transurethral incision of the bladder neck for the treatment of bladder neck contracture. We evaluated the efficacy of mitomycin C injection across multiple institutions. Data on all patients who underwent transurethral incision of the bladder neck with mitomycin C from 2009 to 2014 were retrospectively reviewed from 6 centers in the TURNS. Patients with at least 3 months of cystoscopic followup were included in the analysis. A total of 66 patients underwent transurethral incision of the bladder neck with mitomycin C and 55 meeting the study inclusion criteria were analyzed. Mean ± SD patient age was 64 ± 7.6 years. Dilation or prior transurethral incision of the bladder neck failed in 80% (44 of 55) of patients. Overall 58% (32 of 55) of patients achieved resolution of bladder neck contracture after 1 transurethral incision of the bladder neck with mitomycin C at a median followup of 9.2 months (IQR 11.7). There were 23 patients who had recurrence at a median of 3.7 months (IQR 4.2), 15 who underwent repeat transurethral incision of the bladder neck with mitomycin C and 9 of 15 (60%) who were free of another recurrence at a median of 8.6 months (IQR 8.8), for an overall success rate of 75% (41 of 55). Incision with electrocautery (Collins knife) was predictive of success compared with cold knife incision (63% vs 50%, p=0.03). Four patients experienced serious adverse events related to mitomycin C and 3 needed or are planning cystectomy. The efficacy of intralesional injection of mitomycin C at transurethral incision of the bladder neck was lower than previously reported and was associated with a 7% rate of serious adverse events.

Management of Bladder Neck Contractures in the Elderly

Prostate surgery for benign and malignant disease is common in the male patient greater than 60 years of age. Bladder neck contracture (BNC), a well-known complication following surgical treatment of the prostate, can range from simple lesions to complex, recalcitrant contractures that are refractory to multiple treatment modalities. The treatment of BNCs can thus vary from straightforward, office-based interventions to complex surgical reconstructions. Although numerous treatments have been described as an initial management strategy for patients with this condition, management of refractory cases requires a highly tailored approach. We review here the various therapeutic maneuvers used for the management of BNC in elderly patients.

Treatment of bladder neck contractures with multiple immunologic modulators

Treatment of bladder neck contractures with multiple immunologic modulators

Pubovesical Fistula: A Rare Complication After Treatment of Prostate Cancer

To characterize the clinicopathologic features of patients who developed pubovesical fistula (PVF) after treatment of prostate cancer and to identify some possible methods of reducing the incidence of this rare complication for which no well-established guidelines exist. We identified men at 2 centers who presented with PVF after prostate cancer treatment from January 2000 to December 2010. Prostate cancer was treated with radiotherapy (RT) or radical prostatectomy, or both. Patients with bladder neck contracture (BNC) received endoscopic treatment. The demographic and clinical data were collected. Of the 12 patients who presented with PVF, the treatment of prostate cancer was external beam RT in 8 (5 of whom underwent subsequent salvage radical prostatectomy) and radical prostatectomy (followed by salvage RT) in 4. All patients developed BNC requiring endoscopic treatment. The median interval between primary endoscopic treatment of BNC and the development of PVF was 35.9 months (range 0.6 to 97). The most common presenting symptom was suprapubic or groin pain. Of the 12 patients, 10 ultimately required cystectomy with urinary diversion. The treatment of prostate cancer with RT followed by the development of BNC requiring endoscopic intervention appears to be associated with PVF development Despite conservative measures, patients who developed PVF often required cystectomy with urinary diversion. To avoid PVF, care should be taken during endoscopic intervention for BNC in patients who have received RT for prostate cancer. PVF should be on the differential diagnosis of patients with a history of RT and BNC who develop pubic pain or recurrent urinary tract infection.

Ho:YAG-laser: treatment of vesicourethral strictures after radical prostatectomy

To review the indication, feasibility and treatment outcome of Ho:YAG laser application for definitive endoscopic treatment of anastomotic stricture formation after radical prostatectomy. Currently, no universally accepted regime for managing post-prostatectomy anastomotic strictures exists. Cold knife incision is the most commonly utilized invasive technique for the treatment of bladder neck contractures. The Ho:YAG laser with its shallow tissue absorption of <0.5 mm offers favorable cutting properties including low blood loss and less induction of scar tissue formation and could be a valid alternative to endoscopic knife incision. PubMed and Medline were searched for reports on Ho:YAG laser therapy in strictures from 1980 to 2009 with particular focus on the operating techniques using the Ho:YAG laser system. Ho:YAG laser endourethrotomy tends to be a safe and at least minimally invasive therapeutic modality for the treatment of bladder neck contractures after radical prostatectomy. No cohort study that evaluates the use of laser for this modality is available in literature. Due to the lack of comparable randomized multicentre trials, the indications for a laser-related endoscopic treatment option has to be defined based on the operators expertise and the patient's individual situation.

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.