PHOENIX, AZ USA (UroToday.com) - This session was on the development of GU strictures in men following different urologic treatments.
This section began by discussing bladder neck contracture (BNC) nomenclature including:
- scarring that usually occurs after TURP (transurethral resection prostate),
- anastomotic stricture that occurs with surgical removal of the bladder neck that usually occurs after radical prostatectomy, and
- urethral stricture which is a true stricture of the urethra.
[refs: Breyer BN, Davis CB, Cowan JE, Kane CJ, Carroll PR. Incidence of bladder neck contracture after robot-assisted laparoscopic and open radical prostatectomy. BJU Int. 2010 Dec;106(11):1734.
Erickson BA, Meeks JJ, Roehl KA, Gonzalez CM, Catalona WJ. Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single-surgeon experience. BJU Int. 2009 Dec;104(11):1615-9.]
BNC risks after XRT (x-ray therapy) is 0.4 to 3%, but up to 36% in previous TURP patients compared to 3% in men who have not had previous TURP. Pretreatment TURP increases both BNC and urethral stricture from 6 to 15%.
BNC risk after brachytherapy and radiation therapy with no prior TURP is around 0.2% but the risk increases if the patient underwent a TURP before (75%), after (69%). The risks of the BNC can extend 33 months after treatment.
Urethral strictures in men who have undergone brachytherapy is a different entity, but they occur in 2 to 19% of cases and is caused by urethral overdosing (Merick reference).
[refs: Merrick GS, Butler WM, Tollenaar BG, Galbreath RW, Lief JH. The dosimetry of prostate brachytherapy-induced urethral strictures. Int J Radiat Oncol Biol Phys. 2002 52(2):461-8.
Mundy AR, Andrich DE. Urethral strictures. BJU Int. 2011 Jan;107(1):6-26.]
The mean for occurrence of a BNC after brachytherapy is twenty-six months and they generally always occur within forty-four months. The risk of BNC after IMRT (intensity modulated radiation therapy) is unknown but the risk of urethral stricture after IMRT is 0.5%. Risk of a urethral stricture in men who have undergone radical prostatectomy and then treatment by IMRT is 6%.
Anastomotic stricture after radical prostatectomy can occur in open procedures in up to 13% of men. After expert robotic radical prostatectomy the risk of an anastomotic stricture is only 0.5%, but open radical retropubic risk is 5.5% when compared to a 3.8% from perineal approach. In salvage prostatectomy, the risk of an anastomotic stricture is higher at 11%.
[refs: Abraham NE, Makarov DV, Laze J, Stefanovics E, Desai R, Lepor H. Patient centered outcomes in prostate cancer treatment: predictors of satisfaction up to 2 years after open radical retropubic prostatectomy. J Urol. 2010. 184(5):1977-81
Gillitzer R, Thomas C, Wiesner C, Jones J, Schmidt F, Hampel C, Brenner W, Thüroff JW, Melchior SW. Single center comparison of anastomotic strictures after radical perineal and radical retropubic prostatectomy. Urology. 2010 Aug;76(2):417-22
Tan G, Srivastava A, Grover S, Peters D, Dorsey P Jr, Scott A, Jhaveri J, Tilki D, Te A, Tewari A. Optimizing vesicourethral anastomosis healing after robot-assisted laparoscopic radical prostatectomy: lessons learned from three techniques in 1900 patients. J Endourol. 2010. 24(12):1975-83]
There are several theories about the causes of anastomotic strictures, including predisposing factors such as Gleason Score, previous TURP, extracapsular extension, obesity (more difficult surgery), patient age > 70 years, and cigarette use. Surgical technique may play a factor in the cause of anastomotic stricture if there is intra-operative blood loss as this increases the risk. Acute treatment of anastomotic strictures include cold knife or Holmium incisions.
Presented by Richard A Santucci, Charles L. Secrest, and Sender Herschorn at the Society for Urodynamics and Female Urology (SUFU) 2011 Winter Meeting - March 1 - 5, 2011 - Arizona Biltmore, Phoenix, Arizona, USA
Reported for UroToday by Diane K. Newman, RNC, MSN, CRNP, FAAN and Continence Nurse Practitioner Specialist - University of Pennsylvania Medical Center.