Date Published: April 24, 2012
Publisher: Hindawi Publishing Corporation
Author(s): A. Simonato, M. Ennas, A. Benelli, A. Gregori, F. Oneto, E. Daglio, P. Traverso, G. Carmignani.
Introduction. The recurrence of urethral/bladder neck stricture after multiple endoscopic procedures is a rare complication that can follow prostatic surgery and its treatment is still controversial. Material and Methods. We retrospectively analyzed our data on 17 patients, operated between September 2001 and January 2010, who presented severe urinary incontinence and urethral/bladder neck stricture after prostatic surgery and failure of at least four conservative endoscopic treatments. Six patients underwent a transperineal urethrovesical anastomosis and 11 patients a combined transperineal suprapubical (endoscopic) urethrovesical anastomosis. After six months the patients that presented complete incontinence and no urethral stricture underwent the implantation of an artificial urethral sphincter (AUS). Results. After six months 16 patients were completely incontinent and presented a patent, stable lumen, so that they underwent an AUS implantation. With a mean followup of 50.5 months, 14 patients are perfectly continent with no postvoid residual urine. Conclusions. Two-stage procedures are safe techniques to treat these challenging cases. In our opinion, these cases could be managed with a transperineal approach in patients who present a perfect operative field; on the contrary, in more difficult cases, it would be preferable to use the other technique, with a combined transperineal suprapubical access, to perform a pull-through procedure.
Referring to prostate surgery, urinary incontinence and iatrogenic bladder neck/urethral strictures are devastating complications that strongly impair a patient’s quality of life (QoL).
We did not observe intraoperative or early postoperative complications in either of the approaches, for any patient. Six months after the first step of the treatment 16 patients (94%) were completely incontinent with no urethral strictures and complete anastomotic healing. One patient was retentive after the urethroplasty but he showed a pervious urethra lumen and continues to drain his bladder with self-catheterization.
For both the anastomotic posterior urethroplasty techniques we achieved excellent results, with a specific success rate of 100% in group A and 91% in group B, similar to contemporary reported experiences concerning the trans-perineal approach . Regarding AUS implantation, currently it seems to be the most effective treatment for severe urinary incontinence . Having said this, in our opinion, in patients affected by recurrent urethral stricture caused by prostatic surgery, it is a reasonable approach to perform preliminary surgery to obtain a patent and stable lumen. The aim of this first step is to create a clinical and functional context of urinary incontinence which can be managed by the implantation of an AUS.
To treat patients that present urethral stricture or bladder neck contracture after prostatic surgery and failure of several endoscopic treatment, we advise performing a first-step surgery with a pure trans-perineal urethroplasty which is less invasive, easier to perform and has a lower operative time. If difficulties are encountered during the procedure, this may be switched to a combined trans-perineal/supra-pubic approach. After six months, when a stable patent urethral lumen is obtained, the patient can undergo AUS implantation.