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Bladder Neck Contractures after Radical Prostatectomy
STEVEN B BRANDES, MD, FACS
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Incidence of BN Contracture and Urethral Stricture After Prostate Cancer Therapy
• Elliott et al: J Urol 2007
• CAPSure Database
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*
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Lower BNC Incidence w RALP
• RALP: 0.2%-1.4%
• Running suture (Rocco, Van velhovan)
• Magnified visualization
• Lower EBL
• Mucosal eversion
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Risk Factors for Post CAP TX.BN Contracture & Urethral Stricture
Elliott et al: J Urol 2007
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Other Risk factors for BNC
• Prolonged urinary leak
• Postop pelvic bleed/ hematoma
• Cigarette smoking
• CAD
• Hi Intra-op EBL
• Surgical clip migration (Lapra-Ty, Weck)
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Time from Prostate Cancer Therapy till Stenosis
RP
BT+EBRT HT EBRT
RTWW
CaPSURE data; Elliott et al: J Urol 2007
Mean time from RRP till BNC = 5 mo. (1-15mo.)
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BNC Stenosis Characteristics
• Not a urethral stricture
• Akin to a PFUI
– Distraction of urethral- vesico anastomosis
• Length
• Location
• Etiology
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Literature weaknesses:
• All retrospective and Oxford LOE 4 series
• No details as to stenosis length or lumen size
• No details as to flowrate, IPSS, or PVR
• No uniform accepted grading scale
• No uniform definition of success
594 papers identified; 22 met criteria for review
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Dilation
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TUIBN
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TUIBN
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Deep TUIBN
De novo incontinence = 100%
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TUIBN + biologic modifiers
• MMC
– Promising results
– Jury still out
• Steroids
– Longer time to recurrence
– Restenosis rates unchanged
• AmnioFix
(amnion- chorion = rich in GF)
– (?)
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TUR-BN
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BN Stent (Wall stent)
De novo incontinence = 100%
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Urethral Stents for Refractory BNC Management?
• Permanent
• Retrievable
• Bio-absorable
• Drug eluting
Uro-coil Allium
MemokathWall stent
PLAAllium
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Urolume and Recurrent BNC
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BNC
Dilation + CIC
BNC Recurrence
BNC Resolution
53%
47%
TUIBN -or- TURS
BNC Recurrence
7%
BNC Recurrence
26%
BNC Resolution
74% BNC Resolution
93%
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BNC Recurrence
Stent -or-
Deep TUIBN BNC
Resolution
91%BNC Resolution
65%
Open Repair
BNC Recurrence
26%
BNC Resolution
74%
BNC Recurrence
9%
BNC Recurrence
35%
Urinary Diversion
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Open BN Reconstruction
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Open Repair
• Potentially morbid
• Needs a highly motivated and well informed patient
• Challenging surgery – requires being facile with multiple reconstructive techniques
• Requires a staged AUS
• Less then ideal overall success
• Supravesical diversion may ultimately be needed
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Vesico-urethroplasty
• Perineal approach
– May require inferior pubectomy
• Abdominoperineal approach
– Usually requires superior pubectomy vs total pubectomy and omental flap
– 2 team approach preferred
• Cystoscopy at 3 and 6 months post op
• Planned AUS at 6-12 mo – if BN open
– Consider transcorporal cuff
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Perineal Approach
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AP Approach + Pubectomy
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Bipedal Blood Supply
cp
Normal Urethral-vesical EPA
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Urethral-Vesical EPA
• “Urethral advancement flap surgery” that relies on bipedal corpus spongiosal circulation
• Detached from its proximal vascular supply the urethra is dependent on distal retrograde blood flow
– Perforators and circumflex penile arteries
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Surgical Method Goals
• Tension-free anastomosis
• Spatulated urethra
• Mucosa to mucosa apposition
– Urethra to bladder
• Liberal excision of “scar”
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Methods to Bridge the Gap in Anastomotic Urethroplasty
• Natural elasticity of the mobilized corpus spongiosum
• Shorten the distance between the distal and proximal ends of the urethra
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Bladder Flaps
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DEVASTATED OUTLET
• Bladder Neck Stenosis beyond repair
• Failed multiple endoscopic methods
• Obliterative stenosis
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Options for Supravesical Diversion
• Incontinent
– SP tube
– Ileal Conduit
– Transverse colo-conduit
– Cutaneous Ureterostomy
• Continent
– Catherizable stoma
– Cath Stoma + augmentation cystoplasty
– Continent Cath Urinary Diversion (i.e. Indiana)
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Catherizable Stomas for the Devastated Outlet
• Options:
– Mitrofanoff(Appendix)
– Monti
– Ileal Cecal Valve (Indiana, Florida etc.)
– Ileal Intussusception (Mainz, Kock etc.)
• Surgical Decision Making:
– Bladder Capacity
– Performance Status
– Manual Dexterity
– Pt. desire
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MITROFANOFFPRINCIPLE
*
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MONTICATHETERIZABLE CHANNEL
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Spiral Monti and Bladder Augment
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SPIRAL MONTI
Casale, J Urol, 162:1743, 1999
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SPIRAL MONTI
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Cecal augment and ilealcatherizable stoma
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STOMA ConstructionVQZ and V Flaps
VQZ
V
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STOMA COMPLICATIONS
• Stomal stenosis
– 30 - 55%
– with V-flap and VQZ-flap
– Pain + difficult cath
• Continence
– 95- 99 % (peds)
– 75-95% (adults)
– Durable results
• Gowda et al: BJU 2008
• Van der Aa et al: Neurou UroD 2009
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BNC Treatment Conclusions
• Endoscopic treatments have variable success
• The more aggressive the TX
the more expected de novo ISD-SUI
• Deep TUIBN or Open BN reconstruction assumes severe post op ISD-SUI.
Staged AUS for ISD-SUI ( > 6 to 12mo.)
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BNC Treatment Conclusions
• Open BN reconstructions can be technically difficult and have moderate success
• For obliterative and refractory BNC Consider supra-vesical diversion
• BNC literature is poorly detailed, retrospective and overly heterogeneous
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Thank you.