Vesicourethral Anastomotic Stenosis Research Articles

Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis.

The treatment of urethral stenosis after a combination of prostatectomy and radiation therapy for prostate cancer is understudied. We evaluate the clinical and patient-related outcomes after dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) in men who underwent prostatectomy and radiation therapy. A multi-institutional, retrospective review of men with vesicourethral anastomotic stenosis or bulbomembranous urethral stricture disease after radical prostatectomy and radiation therapy from 8 institutions between 2013 to 2021 was performed. The primary outcomes were stenosis recurrence and development of de novo stress urinary incontinence. Secondary outcomes were surgical complications, changes in voiding, and patient-reported satisfaction. Forty-five men were treated with D-BMGU for stenosis following prostatectomy and radiation. There was a total of 7 recurrences. Median follow-up in patients without recurrence was 21 months (IQR 12-24). There were no incidents of de novo incontinence, 28 patients were incontinent pre- and postoperatively, and of the 6 patients managed with suprapubic catheter preoperatively, 4 were continent after repair. Following repair, men had significant improvement in postvoid residual, uroflow, International Prostate Symptom Score, and International Prostate Symptom Score quality-of-life domain. Overall satisfaction was +2 or better in 86.6% of men on the Global Response Assessment. D-BMGU is a safe, feasible, and effective technique in patients with urethral stenosis after a combination of prostatectomy and radiation therapy. Although our findings suggest this technique may result in lower rates of de novo urinary incontinence compared to conventional urethral transection and excision techniques, head-to-head comparisons are needed.

Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment.

To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear. A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up. The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%). This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.

Editorial Comment.

No AccessJournal of UrologyAdult Urology16 May 2023Editorial CommentThis article comments on the following:Vesicourethral Anastomotic Stenosis Following Radical Prostatectomy: Risk Factors, Natural History, and Treatment Outcomes Jaspreet S. Sandhu Jaspreet S. SandhuJaspreet S. Sandhu Department of Surgery/Urology, Memorial Sloan Kettering Cancer Center, New York, New York More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003488.03AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. REFERENCES 1. Vesicourethral anastomotic stenosis following radical prostatectomy: risk factors, natural history, and treatment outcomes. J Urol. 2023; 210(1):000. Google Scholar 2. Age, obesity, medical comorbidities and surgical technique are predictive of symptomatic anastomotic strictures after contemporary radical prostatectomy. J Urol. 2011; 185(6):2148-2152. Link, Google Scholar 3. Male urethral stricture: American Urological Association guideline. J Urol. 2017; 197(1):182-190. Link, Google Scholar 4. . Endoscopic treatment of vesicourethral stenosis after radical prostatectomy: outcomes and predictors of success. J Urol. 2016; 195(5):1495-1500. Link, Google Scholar Submitted July 21, 2022; accepted April 11, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology20 Apr 2023Vesicourethral Anastomotic Stenosis Following Radical Prostatectomy: Risk Factors, Natural History, and Treatment Outcomes Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaspreet S. Sandhu Department of Surgery/Urology, Memorial Sloan Kettering Cancer Center, New York, New York More articles by this author Expand All Submitted July 21, 2022; accepted April 11, 2023; published 000. Advertisement PDF downloadLoading ...

Management of male stress urinary incontinence in high-risk patients: a narrative review.

The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

Vesicourethral Anastomotic Stenosis Following Radical prostatectomy: Risk Factors, Natural History, and Treatment Outcomes.

Vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy (RP) is a complication with significant adverse quality of life implications. Herein, we identify groups at risk for VUAS and further characterize natural history and treatment patterns. Years 1987-2013 of a prospectively maintained RP registry were queried for patients with the diagnosis of VUAS, defined as symptomatic and inability to pass a 17Fr cystoscope. Patients with follow up less than 1-year, preoperative anterior urethral stricture, transurethral resection of prostate, prior pelvic radiotherapy, and metastatic disease were excluded. Logistic regression was performed to identify predictors of VUAS. Functional outcomes were characterized. Out of 17,904 men, 851 (4.8%) developed VUAS at a median 3.4 months. Multivariable logistic regression identified associations with VUAS including adjuvant radiation, BMI, prostate volume, urine leak, blood transfusion, and non-nerve sparing techniques. Robotic approach (OR 0.39, P < .01) and complete nerve sparing (OR 0.63, P < .01) were associated with reduced VUAS formation. VUAS was independently associated with 1 or more incontinence pads/day at 1 year (OR 1.76, P < .001). Of the patients treated for VUAS, 82% underwent endoscopic dilation. The 1- and 5-year VUAS retreatment rates were 34% and 42%, respectively. Patient related factors, surgical technique, and perioperative morbidity influence the risk of VUAS after RP. Ultimately, VUAS is independently associated with increased risk of urinary incontinence. Endoscopic management is temporizing for most men with a high rate of retreatment by 5 years.

MP78-11 DORSAL BUCCAL MUCOSAL GRAFT URETHROPLASTY FOR VESICO-URETHRAL ANASTOMOTIC STENOSIS: LONG TERM FOLLOW UP

You have accessJournal of UrologyCME1 Apr 2023MP78-11 DORSAL BUCCAL MUCOSAL GRAFT URETHROPLASTY FOR VESICO-URETHRAL ANASTOMOTIC STENOSIS: LONG TERM FOLLOW UP Waleed Shabana, Vahid Mehrnoush, Hazem Elmansy, Ahmed Kotb, Ahmed S. Zakaria, and Walid Shahrour Waleed ShabanaWaleed Shabana More articles by this author , Vahid MehrnoushVahid Mehrnoush More articles by this author , Hazem ElmansyHazem Elmansy More articles by this author , Ahmed KotbAhmed Kotb More articles by this author , Ahmed S. ZakariaAhmed S. Zakaria More articles by this author , and Walid ShahrourWalid Shahrour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess long term outcomes of dorsal buccal mucosal graft (BMG) urethroplasty for the repair of refractory vesico-urethral anastomotic stenosis (VUAS) post open radical prostatectomy. METHODS: We retrospectively reviewed collected data of patients underwent buccal mucosa graft urethroplasty following at least 3 interventions for VUAS. Patients were included if they completed 24 months after surgery. Patients’ demographics, preoperative continence status, number of dilations, and urine flow preoperatively and postoperatively were collected. Trial of void and retrograde urethrogram were done after 1-3 weeks. Patients were followed every 6 months up to 4 years by flowrate, postvoiding residual urine volume, cystourethroscopy and GRA questionnaire. RESULTS: Twelve patients underwent dorsal BMG urethroplasty between Jan 2018-Jan 2022. Eleven out 12 patients (91%) received adjuvant radiotherapy. Strictures were in the anastomotic site and median stricture length was 3 cm (2-4). All patients were incontinent preoperatively with median preoperative flow of 4.5 mL/s (2-7 mL/s). Mean operative time and blood loss were 182 minutes and 250 mL respectively. We did not record any case of intraoperative rectal injuries. No change in erectile function was noted. Median follow up was 24 months (range 9-48 months). The median flow at 24 months was 23 ml/sec. success rate at 24 months was 91% with one patient that failed immediately post operatively. Three out of 12 patients had artificial urinary sphincter post urethroplasty. GRA score of 4-5 was found in 100% of patients CONCLUSIONS: Dorsal BMG urethroplasty post VUAS has a solid promising urinary functional outcome. Dorsally placed BMG eliminate risk of rectal injuries associated with other approaches although incontinence persisted post repair. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1136 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Waleed Shabana More articles by this author Vahid Mehrnoush More articles by this author Hazem Elmansy More articles by this author Ahmed Kotb More articles by this author Ahmed S. Zakaria More articles by this author Walid Shahrour More articles by this author Expand All Advertisement PDF downloadLoading ...

PD35-04 OPEN VS. ROBOTIC-ASSISTED RECONSTRUCTION IN VESICOURETHRAL ANASTOMOTIC STENOSIS

You have accessJournal of UrologyCME1 Apr 2023PD35-04 OPEN VS. ROBOTIC-ASSISTED RECONSTRUCTION IN VESICOURETHRAL ANASTOMOTIC STENOSIS Metin Savun, Harun Ozdemir, Emin Taha Keskin, Yunus Colakoglu, Halil Lutfi Canat, and Abdulmuttalip Simsek Metin SavunMetin Savun More articles by this author , Harun OzdemirHarun Ozdemir More articles by this author , Emin Taha KeskinEmin Taha Keskin More articles by this author , Yunus ColakogluYunus Colakoglu More articles by this author , Halil Lutfi CanatHalil Lutfi Canat More articles by this author , and Abdulmuttalip SimsekAbdulmuttalip Simsek More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vesicourethral anastomotic stenosis (VUAS) that is unresponsive to endoscopic treatment after radical prostatectomy can be treated with open or robot-assisted reconstruction. In this study, we aimed to compare the patency and complications of these two methods. METHODS: Eighteen patients who underwent open perineal reconstruction surgery and ten patients who underwent robot-assisted (Da Vinci XI) transabdominal reconstruction surgery for VUAS between July 2017 and August 2022 were included in this study. Demographic, operative, and postoperative patient data were examined. The two methods were compared in terms of patency, complications, recurrence, and incontinence. Patency was defined as either the passage of a 16 French cystoscope or a maximum flow on uroflowmetry of >15 ml/s. Incontinence was defined as use of more than one pad per day. RESULTS: The median age was 67 years, and the number of previous endoscopic interventions was seven in both groups. The median operation time was 120 and 150 minutes (p:0.175), median bleeding amount was 200 and 100 ml (p:0,001), and median hospitalization time was four and three days (0,001) in the open and robotic-asisted groups, respectively. Wound infection (Clavien grade 2) developed in one patient and puborectal fistula (Clavien grade 3b) developed in one patient in the open group. Wound infection (Clavien grade 2) developed in one patient and ileus (Clavien grade 2) developed in one patient in the robotic-asisted group (p:0,724). Patency rate is 77.8% and 80.0% (p:0,944) in the open and robotic-asisted groups, respectively. All patients (%100) in the open group experienced incontinence during the follow-up period. Of the six patients without pre-existing incontinence, five (16,6%) remained continent at the last follow-up in the robotic-asisted groups. CONCLUSIONS: Compared to open perineal reconstruction, robot-assisted transabdominal VUAS reconstruction has less bleeding and a shorter hospitalization time. Although the patency and complication rates of both methods are similar, robot-assisted reconstruction is superior in terms of continence rates. Source of Funding: There is no source of fundings © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e975 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Metin Savun More articles by this author Harun Ozdemir More articles by this author Emin Taha Keskin More articles by this author Yunus Colakoglu More articles by this author Halil Lutfi Canat More articles by this author Abdulmuttalip Simsek More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA

You have accessJournal of UrologyCME1 Apr 2023MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA Syed M. Alam, Jordan Stiverson, and Hadley Wyre Syed M. AlamSyed M. Alam More articles by this author , Jordan StiversonJordan Stiverson More articles by this author , and Hadley WyreHadley Wyre More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-radiation puboprostatic and pubourethral fistulae are devastating conditions, and surgical intervention remains highly morbid. Here, we describe a novel technique using a mesh buttress and vertical rectus abdominis muscle flap (VRAM) to restore pelvic integrity during cystectomy for anterior urinary fistulae. METHODS: Patients having undergone cystectomy with ileal conduit were identified in a prospectively maintained database. Those having undergone VRAM harvest with placement of a mesh buttress for anterior urinary fistula were selected for analysis. Following supratrigonal cystectomy, all patients underwent a left-sided VRAM harvest. After the bladder plate was fulgurated, a biologic mesh was tailored to the pelvic defect and sutured to the posterior trigone. It was then incorporated circumferentially around the levator muscles and anteriorly to the pubic bone and underside of rectus fascia. Prior to circumferential closure of the underlying space, a VRAM flap was secured in the pelvis. The remainder of the mesh was then secured, creating a tunnel for the flap pedicle. Surgical metrics and post-operative outcomes were evaluated using descriptive statistics. RESULTS: Between 2019-2021, eleven patients underwent this technique, of which five carried a diagnosis of post-radiation anterior urinary fistula with pubic osteomyelitis. The median age was 73 years, and all patients were male. Three patients previously underwent radical prostatectomy, all of whom underwent subsequent endoscopic intervention for vesicourethral anastomotic stenosis. One patient underwent transurethral resection of the prostate after radiation. One patient had no prior surgical history. Median operative time was 387 minutes and median blood loss was 500cc. Average length of stay was five days. No patients developed an immediate post-operative complication. All patients had positive intra-operative bone cultures. No patients reported persistent pubic, groin, or thigh pain after surgery. No fistula recurrence occurred at a median follow-up of 264 days. CONCLUSIONS: The use of a mesh buttress in conjunction with pelvic VRAM flap is a novel technique designed to restore pelvic integrity for patients undergoing cystectomy for an anterior urinary fistula. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e573 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Syed M. Alam More articles by this author Jordan Stiverson More articles by this author Hadley Wyre More articles by this author Expand All Advertisement PDF downloadLoading ...

Editorial Comment.

No AccessJournal of UrologyAdult Urology23 Feb 2023Editorial CommentThis article comments on the following:Bladder Neck Contractures Stabilize After Placement of the Artificial Urinary Sphincter Lee C. Zhao, Ashley V. Alford, and Tenny R. Zhang Lee C. ZhaoLee C. Zhao Department of Urology, NYU Langone Medical Center, New York, New York More articles by this author , Ashley V. AlfordAshley V. Alford Department of Urology, NYU Langone Medical Center, New York, New York More articles by this author , and Tenny R. ZhangTenny R. Zhang Department of Urology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003194.03AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. – REFERENCES 1. . Bladder neck contractures stabilize after placement of the artificial urinary sphincter. J Urol.2023; 209(5):000-000. Google Scholar 2. Durable treatment of refractory vesicourethral anastomotic stenosis via robotic-assisted reconstruction: a Trauma and Urologic Reconstructive Network of Surgeons study. Eur Urol. 2022; 81:176. Crossref, Medline, Google Scholar Submitted July 22, 2022; accepted January 18, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology30 Jan 2023Bladder Neck Contractures Stabilize After Placement of the Artificial Urinary Sphincter Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lee C. Zhao Department of Urology, NYU Langone Medical Center, New York, New York More articles by this author Ashley V. Alford Department of Urology, NYU Langone Medical Center, New York, New York More articles by this author Tenny R. Zhang Department of Urology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York More articles by this author Expand All Submitted July 22, 2022; accepted January 18, 2023; published 000. Advertisement PDF downloadLoading ...

Recurrent vesicourethral anastomotic stenosis following treatment for prostate cancer: an effective endoscopic treatment using bipolar plasma button and triamcinolone.

To evaluate the efficacy of deep bladder neck incision plus adjuvant Triamcinolone in the treatment of recurrent vesicourethral anastomotic stenosis following surgical treatment for prostate cancer. A retrospective review of patients undergoing bladder neck incision from 2013 to 2019 was conducted. Patients who had previously undergone surgical treatment for prostate cancer and had failed treatment for bladder neck contracture were included. Twentypatients underwent deep bladder neck incision (BNI) with plasma button and adjuvant injection with a patency rate of 85%. Complete obliteration portended worst prognosis with 100% recurrence. Deep BNI with triamcinolone is a minimally morbid alternative for treatment of refractory vesicourethral anastomotic contractures.

EDITORIAL COMMENT

Reconstruction of the posterior urethra following prostate cancer therapies such as radical prostatectomy or radiotherapy has traditionally been discouraged due to difficulties achieving an anastomosis, significant morbidity, including hemorrhage, rectal injury, ureteral injury and low success rates. However, there has been a growing experience of successful reconstruction of the posterior urethra using open, perineal, and abdominal perineal techniques.1 More recently the Trauma and Urologic Reconstructive Network of Surgeons reported encouraging results with the use of the robotic platform for reconstruction for vesicourethral anastomotic stenosis (VUAS) and recalcitrant bladder neck stenosis (BNS).

Outcomes of Vesicourethral Anastomotic Stenosis and Bladder Neck Contracture With Direct Visual Internal Urethrotomy With Mitomycin-C After Prostate Cancer Treatment

ObjectiveTo examine the use of Direct Visual Internal Urethrotomy with Mitomycin-C (DVIU-MMC) for bladder neck contracture and vesicourethral anastomotic stenosis in men who have undergone treatment for prostate cancer with radical prostatectomy and/or radiation therapy. MethodsRetrospective chart review of patients at a tertiary care center who underwent DVIU-MMC for recurrent bladder neck contracture/vesicourethral anastomotic stenosis between 2012 and 2020. Patients with complete urethral obliteration, prior bladder neck reconstruction, or less than 3 months of follow-up were excluded. Patients were sorted into three groups based on prostate cancer treatment history: radical prostatectomy (RP), RP with subsequent external beam radiation therapy (RP-EBRT), and radiation therapy (RT). ResultsFifty-one patients with a median follow up of 32 months were included. Twenty-nine percent had pre-operative suprapubic tube (SPT), Foley, or required clean intermittent catheterization. Overall success after initial DVIU-MMC was 45%. In all patients with up to four procedures, cumulative overall success was 84%. There was no significant difference in relative success rates between groups. However, the interval to recurrence after initial DVIU-MMC was shortest for RP-EBRT group (P = .018). Three patients required SPT, all were in the RP-EBRT group. There was no statistical difference in recurrence after any number of procedures between patients in radiation (RP-EBRT and RT) and non-radiation (RP) groups. ConclusionThere was no significant difference in success rates between patients who had undergone RP-EBRT, RT, or RP. However, our data suggests that RP-EBRT patients experience poorer outcomes given that their interval to recurrence was more rapid and all patients requiring SPT placement were in this group.

EDITORIAL COMMENT

Robotic assisted reconstruction for recalcitrant posterior urethral obstruction has now enabled the surgeon to preserve the pelvic floor and often avoid the need and morbidity associated with a perineal dissection. Aside from pelvic fracture related urethral injuries, posterior urethral obstruction typically presents in several scenarios: (1) bladder neck contracture after transurethral prostate resection, which is associated with excellent results utilizing a Y-V technique, (2) vesicourethral anastomotic stenosis after radical prostatectomy with a dense and often obliterative scar at the anastomosis amenable to transabdominal excision and redo of the anastomosis, and (3) post-prostatectomy post-radiation outlet obstruction.

Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study

BackgroundRefractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. ObjectiveTo demonstrate patency and continence outcomes of robotic-assisted VUAS repair. Design, setting and participantsPatients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. Surgical procedureThe space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MeasurementsPatency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. Results and limitationsA total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. ConclusionsRobotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. Patient SummaryWe studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy.

To investigate the outcomes of deep lateral incision for vesicourethral anastomotic stenosis after radical prostatectomy and its impact on postoperative urinary incontinence. We retrospectively investigated 43 men who underwent deep lateral incision for non-obliterated vesicourethral anastomotic stenosis after radical prostatectomy between 2011 and 2020. The bladder neck was deeply incised through its circular fibers into the surrounding perivesical fat at 3 and 9o'clock through electrocautery incision using needle-type electrodes. Successful deep lateral incision was defined as the absence of additional treatment, including self-dilatation. The postoperative urinary incontinence status was evaluated based on the number of pads used daily. Deep lateral incision was successful in 35 (81.4%) patients, with a median follow-up period of 43months (interquartile range 15-80months). There was no significant association of age (P=0.66), body mass index (P=0.49) and history of diabetes mellitus (P=0.39), radiation therapy (P=0.89) or previous vesicourethral anastomotic stenosis treatment (P=0.71) with the incision outcomes; however, there were significantly more unsuccessful cases in those with preoperative urinary retention (P=0.04) or indwelling urinary catheters for >5days post-incision (P=0.01). A second incision was carried out in eight patients and a third incision in two patients, resulting in 42 (97.7%) successful incisions. A total of 37 (88.1%) patients had urinary incontinence and used at least one pad daily; seven (16.7%) underwent artificial urinary sphincter implantation after the last incision. Deep lateral incision is highly effective for treating vesicourethral anastomotic stenosis after radical prostatectomy. Appropriate treatment is required for urinary incontinence, which occurs frequently after incision.

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia.

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months; IQR 4–10) and those without BNC recurrence (10 months; IQR 6–20; p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months; IQR 6–9) compared to those treated successfully (median 12 months; IQR 9–25; p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months; IQR 2–12) and those without a recurrence (6 months; IQR 6–10; p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%; p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

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 proliferative hypertrophic scars on determining treatment options for preventing recurrence of vesicourethral anastomotic stenosis after radical prostatectomy: a single-center cross-sectional study.

Vesicourethral anastomotic stenosis (VUAS) following retropubic radical prostatectomy (RRP) significantly worsens quality of life. To investigate the relationship between proliferative hypertrophic scar formation and VUAS, and predict more appropriate surgical intervention for preventing recurrent VUAS. Retrospective cross-sectional single-center study on data covering January 2009 to December 2019. Among 573 male patients who underwent RRP due to prostate cancer, 80 with VUAS were included. They were divided into two groups according to VUAS treatment method: dilatation using Amplatz renal dilators (39 patients); or endoscopic bladder neck incision/resection (41 patients). The Vancouver scar scale (VSS) was used to evaluate the characteristics of scars that occurred for any reason before development of VUAS. Over a median follow-up of 72 months (range 12-105) after RRP, 17 patients (21.3%) had recurrence of VUAS. Although the treatment success rates were similar (79.5% versus 78.0%; P = 0.875), receiver operating characteristic (ROC) curve analysis indicated that dilatation using Amplatz dilators rather than endoscopic bladder neck incision/resection in patients with VSS scores 4, 5 and 6 may significantly reduce VUAS recurrence. A strong positive relationship was observed between VSS and total number of VUAS occurrences (r: 0.689; P < 0.001). VSS score (odds ratio, OR: 5.380; P < 0.001) and time until occurrence of VUAS (OR: 1.628; P = 0.008) were the most significant predictors for VUAS recurrence. VSS score can be used as a prediction tool for choosing more appropriate surgical intervention, for preventing recurrent VUAS.

Transurethral Incision with Transverse Mucosal Realignment for the Management of Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis

ObjectiveTo assess efficacy and safety of a novel cystoscopic technique for definitive repair of bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). MethodsA retrospective review of patients who underwent a transurethral incision with transverse mucosal realignment between July 2019 and December 2020 by a single surgeon was completed. This is novel procedure of incising a scar cystoscopically and using a laparoscopic suturing device transurethrally to bring healthy bladder mucosa across the defect, like a YV plasty. Patients were only included if they had ≥4 months follow-up. Surgical success was defined as ability to pass a 17 French flexible cystoscope through the previously stenotic segment at 4 month follow up. ResultsNineteen patients with a median follow-up of 6 months were included in this analysis. Etiology of posterior urethral stenosis was 53% from VUAS and 47% from BNC, with 32% of patients having prior pelvic radiation. Success was achieved in 89% of patients after 1 procedure and 100% of patients achieved success after a second procedure. There was no de novo incontinence or major complications. ConclusionTransurethral incision with transverse mucosal realignment for VUAS and BNC has a high success rate after only 1 procedure. This is the first reported series of an endoscopic Y-V plasty type repair for BNC and VUAS. Longer term follow up to ensure durability and reporting from other institutions will be needed to establish reproducibility.

Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy.

Vesicourethral anastomotic stenosis (VUAS) is frequently seen after prostate surgery because of various operative and postoperative factors. In this study, we aimed to present our results of perineoscopic bladder neck reconstruction, which is a new technique of the perineal approach in the treatment of patients with VUAS after prostate cancer surgery. Sixteen consecutive patients who underwent perineoscopic bladder neck reconstruction in our clinic between July 2017 and March 2019 were included in the study. Demographic characteristics, surgical history, postoperative continence status, and additional treatment requirements were recorded. Perineoscopic surgery is defined as the visualization of the surgical site with instruments used in laparoscopy and the surgeon performing the entire operative procedure through the screen. The mean number of preoperative endoscopic bladder neck resections of the patients was 7±5.1, with a history of suprapubic cystostomy in 7 (43.7%) and radiotherapy in 5 (31.2%) patients before surgery. The mean surgical time was 126.2±13.1 min. The mean follow-up period was 13.2±6.8 months, and the success rate was 81.25%. During follow-up, two (12.5%) patients received perineoscopic re-do reconstruction because of stricture recurrence, and one (6.2%) patient was included in a urethral dilatation program. Improving visualization and ergonomics with the perineoscopic approach can increase the success rate of bladder neck reconstruction in comparison with the standard approach. In addition, the lack of need for expanded dissection (corporal separation, inferior pubectomy) reduces postoperative complication rates.