Urethral Stricture/Stenosis as a Complication of High Intensity Focused Ultrasound of the Prostate (HIFU): What is the Overall Patient Experience? - Beyond the Abstract

For the past 20+ years, we have treated men with urethral stenosis following radiation therapy for prostate cancer including external beam radiation, brachytherapy, or both. When they were evaluated, the stenosis was often limited to the membranous urethra. In these cases, posterior anastomotic urethroplasty was an option, and we have had excellent long-term. In contrast, we noted that men who came to us with stenosis after HIFU had stenosis that overwhelmingly involved the prostatic urethra which was not amenable to urethroplasty. Removing the area of stenosis would require a robotic or open prostatectomy, and this becomes especially problematic if the damage extended into the membranous urethra. Over time, it became clear that these were serious life-changing complications.

To better appreciate the patient experience, we followed patients with HIFU urethral stenosis-strictures longitudinally even when they did not have a specific treatment at our Center. It became very apparent that when posterior urethral stenosis developed as a complication of HIFU, there was a severe impact on the patient’s quality of life long-term as this represented a chronic condition to be managed rather than a problem highly amenable to curative treatment.

As we reviewed the HIFU literature, we were disappointed to observe that those who perform HIFU and report stenosis as a complication never really provide much detail. Was the patient evaluated with a retrograde urethrogram and voiding cystourethrogram and antegrade cystoscopy when there was a suprapubic tube before endoscopic treatment? It may be mentioned that certain patients “required dilation or internal urethrotomy” for treatment, but then what? Was the patient cured (unlikely), or did the patient have to self catheterize with increasing difficulty and then come to the Emergency Room in retention repeatedly and ultimately undergo suprapubic tube placement? These details matter, yet the HIFU literature does not include these details.

Our study does not address the incidence of these complications with whole gland or focal HIFU as we do not treat prostate cancer. The objective was to create awareness that when there is stenosis stricture, it is not an insignificant complication. It is, in general, a more severe complication than stenosis after radiation therapy. It is our hope that those who public HIFU outcomes will provide more specific information about these complications than what has been reported to date.

Written by: David W. Barham, MD, & Joel Gelman, MD, Department of Urology, University of California, Irvine

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