Date Published: April 26, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Thomas King, Y. Zaki Almallah.
Urinary incontinence postradical prostatectomy is a common problem which adversely affects quality of life. Concomitant bladder neck contracture in the setting of postprostatectomy incontinence represents a challenging clinical problem. Postprostatectomy bladder neck contracture is frequently recurrent and makes surgical management of incontinence difficult. The aetiology of bladder neck contracture and what constitutes the optimum management strategy are controversial. Here we review the literature and also present our approach.
Despite advances in surgical technique in recent years, urinary incontinence remains a relatively common complication following radical prostatectomy . The true incidence of postprostatectomy incontinence (PPI) is difficult to ascertain owing to the lack of a single definition of what actually constitutes continence after radical prostatectomy. EAU guidelines define continence following radical prostatectomy as either total control with no leakage or pad usage, no pad use but loss of a few drops of urine, or use of up to one “safety” pad per day . Nevertheless radical prostatectomy does represent the commonest cause of stress urinary incontinence in men , and it has been estimated that 14–20% of men who undergo radical prostatectomy will use absorbent pads on the long term to manage incontinence . With the increasing number of radical prostatectomies currently performed, the incidence of PPI is also likely to rise .
Bladder neck contracture, bladder neck stenosis, and anastomotic stenosis are synonymous terms and constitute a well-recognised complication following radical prostatectomy with a reported incidence of 0–32% [6–10]. Various technical and patient-based factors have been found to be associated with the formation of bladder neck contracture. However, few factors are reported with consistency between different studies and the precise aetiology remains to be firmly established.
BNC typically presents with lower urinary tract symptoms in particular reduced stream shortly following radical prostatectomy or ultimately retention of urine. Retrospective series have reported that the majority of BNCs present within 6 months following prostatectomy [18, 19]. In a series with prospective followup, Giannarini et al. reported development of BNC at a median time of 3.8 months after radical prostatectomy . Investigations usually reveal a reduced Qmax and an obstructive pattern on uroflowmetry following which the diagnosis is typically made at urethroscopy with the finding of a narrowed bladder neck which will not admit a flexible cystoscope.
The optimum treatment for bladder neck contracture is controversial, and various authors have advocated differing strategies. Often success is reported differently between studies, and direct comparison of outcomes is difficult. Overall, treatment should be considered in light of the planned strategy for dealing with PPI. Where there is no plan to intervene for PPI, the ideal treatment for BNC would be minimally invasive and have no adverse effects on continence. In this situation simple transurethral procedures are most appropriate although, owing to the recurrent nature of the problem, repeat intervention may be required. Ramchandani et al. have advocated transurethral balloon dilatation and reported a success rate of 59% after initial treatment . Park et al. reported a 92% success rate at 12 months with dilatation using the Nottingham dilators followed by a 3 month self catheterisation protocol; however, 27% required more than 2 procedures . The findings of Surya et al.  illustrate the recurrent nature of bladder neck contracture; in their series, patients were managed initially with dilatation using either the Van Buren sounds or filiform bougies and followers with those requiring dilatation more than once every 6 weeks going onto having either cold knife incision or incision with electrocautery. Only 28% were managed with dilatation alone whilst only 62% responded to a single cold knife incision with the remainder of patients requiring additional periodic dilatation. In addition this study reported de novo incontinence in all patients whose contracture was treated with electrocautery. In contrast Popken et al. reported no adverse effects on continence with their strategy of endoscopic resection using electrocautery . Yurkanin et al. have used cold knife incision at 4 o’clock and 8 o’clock and report a low retreatment rate of 17% . Giannarini et al. also used cold knife incision and were able to demonstrate a positive effect on continence following treatment of BNC in 90% of patients as assessed by one-hour pad testing. Of the 21 originally incontinent men in their series, 11 had become continent (less than one gram increase in pad weight) and 8 had improved on pad testing at one month following incision of their contractures .
The insertion of a synthetic suburethral male sling for the treatment of PPI is a relatively new procedure but is gaining worldwide popularity as a less invasive alternative to implantation of an AUS which also maintains spontaneous urethral voiding . Sling devices seem to offer the best results in men with mild-to-moderate stress incontinence . However, the global experience is still limited and more long-term results are awaited. Consequently experience of patients with concomitant BNC undergoing male sling is even more limited. Our standard practice is to attempt to identify patients with BNC prior to the insertion of a male sling. Patients with significant contracture will need bladder neck incision with Collings’ knife with the possibility of upgrading their PPI. This itself may lead to a change in the overall management plan for their urinary incontinence. In our experience, patients with concomitant BNC who initially appear to be suitable for the insertion of male sling often need the AUS once their BNC has been treated. However, in patients with mild BNC, it can be argued that synchronous treatment of BNC with insertion of a male sling may be appropriate . Treatment of mild bladder neck stenosis is unlikely to change the grade of PPI, and the possibility of those patients having significant recurrence of BNC, which will require treatment in the future, is likely to be small.
Our unit has ran a specialist service dedicated to the management of PPI for a number of years, and the framework of our basic approach is illustrated in Figure 1. All patients receive a thorough initial clinical evaluation in terms of history, clinical examination, and ICIQ scoring. Subsequent investigation centres on high-quality video urodynamic studies to demonstrate stress incontinence and assess bladder capacity, any coexistent detrusor overactivity, or evidence of bladder outflow obstruction. Following this, patients found to have evidence of obstruction on urodynamics; those with voiding LUTS or a history of prior bladder neck contracture precede to flexible cystoscopy for further assessment and management as illustrated. Practically speaking almost all our patients undergo flexible cystoscopy as it also provides an opportunity to evaluate the sphincter condition; however, a small number with severe stress incontinence and no evidence of obstruction precede directly to surgery following urodynamic assessment.
The management of bladder neck contracture in the presence of PPI is challenging. Most patients can be successfully managed endoscopically, and cases requiring open excision and reconstruction are fortunately rare. Treatment of bladder neck contracture in the setting of mild PPI can be managed with conservative steps in the form of dilatation followed if necessary by intermittent self-catheterization to maintain patency. However, if the PPI warrants surgery, any concomitant BNC must be treated aggressively, and a stable, patent bladder neck should be ensured prior to placement of any prosthesis in order to avoid complicated recurrence.