Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis

Abstract

ObjectivesThe objective of this study was to compare the recurrence rate and de novo incontinence after endoscopic treatment of vesicourethral stenosis (VUS) after radical prostatectomy (RP) and for bladder neck stenosis (BNS) after transurethral resection of the prostate (TURP).MethodsRetrospective analysis of patients treated endoscopically for VUS after RP or for BNS after TURP at three German tertiary care centers between March 2009 and June 2016. Investigated endpoints were recurrence rate and de novo incontinence. Chi-squared tests and t-tests were used to model the differences between groups.ResultsA total of 147 patients underwent endoscopic therapy for VUS (59.2%) or BNS (40.8%). Mean age was 68.3 years (range 44–86), mean follow-up 27.1 months (1–98). Mean time to recurrence after initial therapy was 23.9 months (1–156), mean time to recurrence after prior endoscopic therapy for VUS or BNS was 12.0 months (1–159). Patients treated for VUS underwent significantly more often radiotherapy prior to endoscopic treatment (33.3 vs. 13.3%; p = 0.006) and the recurrence rate was significantly higher (59.8 vs. 41.7%; p = 0.031). The overall success rate of TUR for VUS was 40.2%, success rate of TUR for BNS was 58.3%. TUR for BNS is significantly more successful (p = 0.031). The mean number of TUR for BNS vs. TUR for VUS in successful cases was 1.5 vs. 1.8, which was not significantly different. The rate of de novo incontinence was significantly higher in patients treated for VUS (13.8 vs. 1.7%; p = 0.011). After excluding those patients with radiotherapy prior to endoscopic treatment, the recurrence rate did not differ significantly between both groups (60.3% for VUS vs. 44.2% for BNS; p = 0.091), whereas the rate of de novo incontinence (13.8 for VUS vs. 0% for BNS; p = 0.005) stayed significantly higher in patients treated for VUS.ConclusionMost patients with BNS are successfully treated endoscopically. In patients with VUS, the success rate is lower. Both stenoses differ with respect to de novo incontinence. Patients must be counseled regarding the increased risk of de novo incontinence after endoscopic treatment of VUS, independent of prior radiotherapy. Longer follow-up is warranted to address long-term outcomes.

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia

“…Recently, robot-assisted laparoscopic subtrigonal inlay of buccal mucosa for recurrent BNC was reported [15]. In our algorithm, open reconstruction is performed latest after three attempts of endoscopic treatment, as Kranz et al [8] showed a significantly lower success rate for endoscopic treatments if performed more often.…”

“…While some risk factors for the development of BNC have been established or proposed, apparently, little can be done to safely avoid them. Established risk factors are small prostatic size at surgery [8,9], untreated prostatitis at time of surgery, long resection time, and extensive resection at the bladder outlet [10].…”

“…Given the entirely different etiology, anatomy, and outcomes of both entities, this approach should be reassessed. The clinical significance of such distinction between BNC and VUAS was recently underlined with significantly deviating success rates of 30% vs. 53% after treatment for VUAS and BNC, respectively [8].…”

Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy

“…Success rates after primary incision or resection range between 37 and 69%. This rate may increase up to 91% after numerous sequential surgical procedures (8,10,32). There are only two publications to exclusively report on endoscopic treatment of VUAS and most of the published series do not distinguish between a BNC after surgery for benign prostatic hyperplasia and VUAS after RP.…”

“…Moreover, it seems inevitable to us to distinguish between a bladder neck contracture (BNC) after surgical procedures for benign prostatic hyperplasia and VUAS after RP (7). It is a known fact, that etiology, anatomy, recurrence rates, and functional outcomes differ significantly between BNC and VUAS (8). BOO after PCa treatment includes radiation-induced bulbomembranous urethral stricture (9) as well as VUAS after RP (10).…”