Urethral Stricture Following Endoscopic Prostate Surgery: A Systematic Review and Meta‑analysis of Prospective, Randomized Trials - Beyond the Abstract

Background: In 2021 when we did the literature review for our Meta-analysis on incidence of Bladder neck stenosis (BNS) after transurethral prostate surgery1 we realised that along with BNS the other complication following transurethral prostate intervention which is very not well understood in its incidence and etiopathology is Urethral stricture (US).

US often recurs after trans-urethral intervention and requires individualized management based on the length and location of the narrowing, patient’s overall health, and goals of care. Treatment varies from less invasive options (i.e. dilation and internal urethrotomy) to more invasive (anastomotic urethroplasty and graft).2 With a multitude of options nowadays available for BPH treatments as per EAU3 and AUA4 guidelines, it's very relevant to establish the incidence of US in direct relation to the type of intervention as this may help to counsel patients. Transurethral resection of the prostate (TURP) has been the time tested surgical treatment for BPH with Monopolar TURP (M-TURP) as the gold-standard treatment for prostates with volume up to 80 ml.5 Hence, with that as a baseline comparison we systematically reviewed the literature to assess if there was a difference in the incidence of US in studies comparing TURP vs Ablation and TURP vs Enucleation.

Methodology: This formed the basis of the Meta-analysis done as per PRISMA framework guidelines wherein patients were assigned in two groups according to the type of surgery and regardless of energy used: Ablation group and Enucleation group.

The Enucleation group included Thulium (ThuLEP), Holmium (HoLEP), Diode (DiLEP), Bipolar (BTUEP), and monopolar (MTUEP) techniques. The Ablation group included any laser vaporization and bipolar/monopolar vaporization. The transurethral resection group consisted of M-TURP and bipolar TUIRP (B-TURP).

Findings: 3315 papers were screened and 80 studies were finally included. Many important take home messages (THM) that are practically useful for patient counseling were deduced.

In summary, the THM are:

  • Overall US incidence after endoscopic surgery for BPH is low
  • This is likely to occur earlier on in postoperative period as our MA with follow-up longer than 12 months didn’t show significant differences between each technique whereas studies with shorter follow-up highlight a higher incidence of US.
  • TURP especially M-TURP compared to enucleation had a higher risk in studies with less than 12-month follow-up and this is probably related to the influence of monopolar electrocautery.
  • Surgical duration does not appear to have an influence on the incidence of US.
  • Data suggests that instrument calibre and duration of postoperative catheterization could contribute to US development.

The summary displayed in Figure A represents the pooled incidence of Urethral stricture rate after different interventions

Figure A:
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We invite and encourage our colleagues to read and share the paper as we have highlighted what mechanisms might contribute to and hence be useful to prevent US development in different surgeries.

We would like to thank all our co-authors for their contribution in this MA which we think adds useful clinical information to the armamentarium in counselling patients undergoing BPH surgery

Written by: Vineet Gauhar,1 Giacomo Maria Pirola,2 Jeremy Yuen-Chun Teoh,3 Emanuele Rubilotta,4 Daniele Castellani5

  1. Department of Urology, Ng Teng Fong General Hospital, National University Health System, Singapore. ()
  2. Department of Urology, San Giuseppe Hospital, Multimedica Group, Milano, Italy
  3. S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
  4. Department of Urology, A.O.U.I. Verona University, Verona, Italy
  5. Department of Urology, University Hospital “Ospedali Riuniti di Ancona” and Polytechnic University of Marche Region, Ancona, Italy

References:

  1. Castellani D, Wroclawski ML, Pirola GM, Gauhar V, Rubilotta E, Chan VW, Cheng BK, Gubbiotti M, Galosi AB, Herrmann TRW, Teoh JY. Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis. World J Urol. 2021 Nov;39(11):4073-4083. doi: 10.1007/s00345-021-03718-1. Epub 2021 May 11. PMID: 33974100
  2. Chen ML, Correa AF, Santucci RA (2016) Urethral strictures and stenosis caused by prostate therapy. Rev Urol 18(2):90–102
  3. https://uroweb.org/guideline.
  4. Lerner LB, McVary, KT, Barry MJ et al: Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline part I, initial work-up and medical management. J Urol 2021; 206: 806
  5. Oelke M, Bachmann A, Descazeaud A et al (2013) EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 64(1):118–140

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