The risk of strictures of the vesicourethral anastomosis following radical prostatectomy is roughly 4-7%; risk factors for stricture include radiation therapy, urinary extravasation, and postoperative hematoma. The risk of urethral stricture following radical prostatectomy is higher at 8-12% and risk factors include mainly radiation therapy, urinary tract infection, and previous transurethral resection of the prostate.
Treatment options for recurrent strictures include either endoscopic or open reconstructive surgery. Endoscopy may include bladder neck incision/resection or internal urethrotomy and/or urethral dilation. Open reconstructive procedures may include a Y-V reconstruction of the bladder neck, a bladder neck closure with continent vesicostomy, or an open urethral reconstruction with buccal mucosa.
Dr. Heidenreich notes that endoscopic bladder neck incision/resection has a high frequency of recurrence and often leads to a subsequent open reconstructive procedure. For patients with recurrent bladder neck/anastomotic strictures, Dr. Heidenreich prefers a perineal approach and preparation of the bulbomembranous urethra; the bulbar urethra is then closed in 2-3 layers. Another option for these patients is to isolate the appendix with the mesenteric vessels, including the vermicularis artery, performing submucosal tunneling of the appendix to the bladder, and then building a catheterizable stoma in the lower right quadrant of the abdomen. In patients who have previously had an appendectomy, another option is to identify a ~10-15 cm segment of ileum and make an antimesenteric incision. This is followed by a side-to-side anastomosis using a 14-16Fr catheter and anastomosing this segment to the bladder (ie. Monti reconstruction).
At his institution, with a sample size of 35 patients, Dr. Heidenreich reports a mean OR time of 125 min, mean hospitalization of 12.5 days, and no Clavien grade IIIB-V complications. Three patients had significant urinary tract infections, two patients were managed conservatively for paralytic ileus, and after a mean follow-up of 37 months, two patients developed stomal stenosis, which was corrected surgically.
For patients with urethral strictures, Dr. Heidenreich notes that it is important to have essential imaging in the form of a retrograde urethrogram. At his institution, they often also use an ultrasound of the urethra to define the stricture location. Patients may be a candidate for internal urethrotomy if they have short strictures, have not had radiation therapy and are not amenable to open reconstructive surgery. When open reconstructive procedures are required, he favors a buccal mucosal graft grown by tissue engineering (MukoCell). Several weeks before the open procedure, a 0.5 cm biopsy of the buccal mucosa is obtained under local anesthesia, and these cells are cultivated for 3 weeks in cell culture. These grafts are grown to 2.8 x 3.8 cm in size and allow an autologous buccal mucosal patch. Their group’s initial experience included 40 patients, with a median stricture length of 4.9 cm (range 2-15cm), of which 50% were bulbar strictures. At a median follow-up of 15.3 months, the success rate was 87.5%; 91.5% of patients had a ventral onlay procedure.
Dr. Heidenreich concluded with several take-home messages for his presentation:
- Complex and disaster situations need complex reconstructive surgeries
- Recurrent strictures of the vesicourethral anastomosis are best treated by open surgery
- Bladder neck closure and continent vesicostomy is straightforward, has a low rate of complications, with a high rate of success
- Recurrent urethral strictures are best treated with open surgery using buccal mucosa – either native buccal mucosa or tissue engineered buccal mucosa
Presented by: Axel Heidenreich, Professor of Urology, Chairman, and Director of the Department of Urology, Uro-Oncology, Robot-Assisted, and Specialized Urologic Surgery at the University Hospital in Cologne Germany
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
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