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Keywords:

  • radical prostatectomy;
  • stricture;
  • bladder neck;
  • dilatation

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45–76) who had open RRP by one surgeon between 1994 and 2003.

RESULTS

The mean (range) follow-up was 30 (2–89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment.

CONCLUSION

Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.


Abbreviations
(R)RP

(retropubic) radical prostatectomy

CISC

clean intermittent self-catheterization.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Contracture of the bladder neck at the level of the anastomosis between the bladder and membranous urethra is a well recognized complication after radical prostatectomy (RP), reportedly occurring in 0.4–32% of patients [1–4]. Bladder neck contracture is usually the result of scar tissue encircling and narrowing the reconfigured bladder neck. This narrowing may result in significant BOO, resulting in symptoms of urinary frequency, urgency, poor stream and incomplete emptying of the bladder. Eventually acute urinary retention (AUR) may develop.

The objective of the present study was to examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck and nerve-sparing open retropubic RP (RRP).

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

We retrospectively reviewed 510 consecutive patients (mean age 61 years, range 45–76) who had open RRP by one surgeon (R.S.K.) for clinically localized prostate cancer. A self-administered questionnaire, incorporating elements of the Short-Form-36 and ICS ‘male’ questionnaire was sent to every patient who had had RRP followed by either bladder neck dilatation or incision between 1994 and 2003. The operative technique of RRP was similar to that described by Walsh and Mostwin [5,6]. The prostate and seminal vesicles were removed through a transverse lower abdominal incision with as much bladder neck preserved as feasible, according to individual circumstances. The bladder neck was reconstructed with mucosal eversion, and a vesico-urethral anastomosis fashioned over an 18 F catheter using four to six absorbable anastomotic sutures (polyglactin 3/0).

Two suction drains were left in situ after RRP; the urethral catheter was left indwelling for 12–14 days. Patients were reviewed every 3 months for the first year by PSA assay and an enquiry about urinary symptoms. In addition, all patients were specifically advised to report if they developed restriction of their urinary flow or other urinary symptoms. Anastomotic strictures were generally managed by dilatation, using graduated Clutton's sounds, up to 26 F. A 16 F urethral catheter was left in situ for ≈ 12 h. Patients who reported impaired flow, incomplete emptying of the bladder, or had a high postvoid residual urine volume on ultrasonography, or developed recurrent AUR, had a second dilatation and, in the more severe cases, institution of temporary clean intermittent self-catheterization (CISC).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The mean (range) follow-up was 30 (2–89) months, during which 48 patients (9.4%) developed some degree of bladder neck contracture. The contracture occurred within 3 months of surgery in 36 patients (75%), at 4–12 months in nine (19%) and at >12 months in three (6%). In addition, nine men (19%) required more than one dilatation (usually two procedures) and five required CISC for 2–3 months. All patients eventually stabilized and voided well with a normal flow.

Most patients reported that their general health and quality of life was better or the same after RRP and bladder neck dilatation. At 1 year 95% of men were pad-free and only one reported that incontinence was a serious problem. After the second dilatation one patient had to use pads for 3 months during the day only; the remaining patients were completely dry.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The reported incidence of bladder neck contracture after open RRP (0.4–32%) probably depends on the surgical technique and patient-related factors, including the presence or absence of previous surgery of the prostate (Table 1) [1,3,4,7–13]. The cause of bladder neck contracture is probably multifactorial in most cases, and to date the fundamental mechanisms have not been well defined. Several factors have been proposed that might contribute to the development of bladder neck contracture, including the technique of bladder neck reconstruction, postoperative urinary extravasation, previous TURP and the duration of catheterization after RP [4,14,15]. Furthermore, overzealous diathermy for haemostasis of the bladder neck and previous radiotherapy treatment may also be significant contributing risk factors. In the present series, none of the patients developed a local recurrence that could have contributed to poor urinary flow. However, three patients had had early radiotherapy as part of the management for positive surgical margins. Also, two patients had had a previous TURP, which potentially could have made bladder neck contracture more likely because of fibrotic changes in the periprostatic tissue and bladder neck.

Table 1.  The incidence of bladder neck strictures in reported series of RRP since 1980
RefYear of publicationNo. of patients% stricture
[7]1980 36 6
[8]1981 50 6
[9]1983 75 3
[10]1987150 1.3
[11]1989100 9
[4]1990156 11.5
[12]1992620 0.5
[3]199613512.6
[13]1996 81 4.9
[1]199823915
Present2004510 9.4

One possible cause of bladder neck contracture is the failure of accurate apposition of the bladder neck to the urethral mucosa, especially posteriorly, where it may sometimes be technically difficult to achieve perfect urethro-vesical continuity. In this location there is a possibility of a gap remaining between epithelial surfaces, which eventually heals with fibrous tissue formation. A well-vascularized, watertight suture line is obviously ideal for optimal healing of the anastomosis. In addition, Walsh and Marschke [16] reported promising results for return of continence as early as 3 months after RRP, with intussusception of the reconstructed bladder neck using buttressing sutures to form a ‘tennis racquet’ closure. However, with this technique there is a risk of an ‘anterior hood’ at the bladder neck, with the potential to cause bladder neck contracture.

Excessive blood loss during the operation or haematoma formation soon after RRP might potentially compromise the vascular supply to the urethra and bladder neck. During RP the bladder neck is either preserved or reconstructed with mucosal eversion. The number and the location of the anastomotic sutures may also be important to prevent anastomotic leakage, which could lead to subsequent fibrosis and scarring [4]. However, an over-tight bladder neck reconstruction may increase the chance of subsequent BOO.

In the present patients, both drains were removed within 2–3 days of surgery in all cases, suggesting that extravasation was not a contributing risk factor for anastomotic stricture. We also used the technique of bladder-neck sparing, assuming that preserving the bladder neck might result in an earlier return of continence and reduce the number of anastomotic strictures without compromising surgical margins [17,18].

Reportedly, bladder neck contracture after RP can be effectively treated with dilatation, with a minimal risk of urinary incontinence [19]. The outcome after dilatation of the stricture probably depends on the length, thickness and location of the stricture, as well as on the interval between the original surgery and stricture development. Surya et al.[4] reported that cold-knife incision of the stricture alone was effective in only 62% of their patients. Moreover, incising the stricture resulted in urinary incontinence in all patients.

It is important to counsel patients before RP about the potential risk of bladder neck contracture. In our experience patients are willing to accept this risk as long as they have been well informed in advance, and trouble is taken to explain the necessity of dilatation if it is required. All the present patients were managed with a graduated dilatation without jeopardizing urinary continence. Dilatation (sounds, bougies, balloon catheter), stricture incision (over a guidewire) or resections have all been proposed for treatment, and should be effective. However, reconstructive surgery is very seldom required to resolve persistent bladder neck obstruction [20,21].

In conclusion, stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is not an infrequent complication, but can usually be successfully managed with one graduated dilatation under light sedation. A few patients required several dilatations or a period of CISC. Eventually all patients seemed to be stabilized satisfactorily without recourse to more extensive surgical procedures. Scrupulous surgical technique is required to minimize the incidence of this troublesome and inconvenient problem after RRP. Patients should be informed of the possibility of stricture before and after surgery.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES