August 27, 2017
Complications after prostate surgery – Stricture/Bladder Neck Contracture >> Optical Urethrotomy
“17.91% (range 5% to 30%) of patients have post operative perineal pain. A quick survey of those on the call it appears between 10 and 20% of men undergoing robotic prostatectomy have post operative perineal pain. Open procedures result in 25 to 30% post operative pain especially the perineal approach.” [Source]
TEAR IN ANASTOMOSIS
This is a very serious complication when the stitches that join the bladder and urethra are torn due to strain. Straining can occur from constipation.
“Walsh had warned of the danger of straining the muscles while passing a stool—it was the thing that any patient recovering from a radical prostatectomy had to be most careful about.”
Straining can also occur from bicycling or weight lifting.
STRICTURE IN THE URETHRA
Link these properly later:
Many strictures are caused by poor use of catheters: “Judicious use of catheters and instrumentation may decrease the risk of urethral strictures”.
THE ANATOMY OF THE URETHRA
The urethra is subdivided into several segments:
- The urethral meatus, which is the opening at the tip of the peni
- The fossa navicularis, which is the urethra located proximal to the urethral meatus and within the glans, head of the penis
- The penile urethra, which is the urethra that goes from the urethral meatus to the distal edge of the muscle, the bulbocavernosus muscle
- The bulbar urethra, which goes from the beginning of the proximal urethra back to the end of the membranous urethra
- The membranous urethra is a short area of the urethra that extends from the proximal bulbar urethra to the distal verumontanum (the verumontanum is a small mound in the urethra where the ejaculatory ducts open into and sperm enters the urethra).
- The prostatic urethra is the urethra that goes from the end of the bladder neck (outlet of the bladder) to the verumontanum.
- The bladder neck, the outlet of the bladder
VERY UNCOMMON AFTER PROSTATECTOMY
“Urethral stricture disease (other than bladder neck contracture) is uncommon after radical prostatectomy.” [Source]
WHEN IT HAPPENS, MOST COMMON AREA AFFECTED IS FOSSA NAVICULARIS
“When urethral strictures occur as a complication of prostate surgery, the most common location is the fossa navicularis, the portion of the urethra near the tip of the penis. This is likely related to the urethral catheter that is required during and after prostate surgery. Although the catheter passes through the entire urethra, the fossa navicularis is particularly susceptible to narrowing.” [Source]
“Symptoms of urethral strictures are mostly urinary – painful urination, reduced urine output, slow urine stream, spraying of the stream, incomplete emptying of the bladder, and inability to void. Urinary tract infections are also common, and blood will occasionally appear in the urine. Diagnostic tests include urinalysis, urine cultures, uroflowmetry studies measuring the flow from the bladder, and post-void residual studies, in which an ultrasound measures the amount that is left after a normal voiding.” [Source]
This article has a good list of tests for locating a stricture.
Remedy through optical urethrotomy
Also known as Direct vision internal urethrotomy (DVIU)
“The literature is relatively uniform in stating that the patient who may enjoy success from an internal urethrotomy or dilation with curative intent will have a short segment stricture (1 to 1 1?2 cm.), will have relatively superficial spongiofibrosis, and the stricture will be located in the bulbous urethra. The success rate for internal urethrotomy and dilation for strictures other than in the bulbous urethra is dismally poor.” [Source]
BUT OPTICAL URETHROTOMY IS NOT EFFECTIVE IN FOSSA NAVICULARIS
“Although the catheter passes through the entire urethra, the fossa navicularis is particularly susceptible to narrowing. This is not a common complication. However, when there is a stricture, the narrowing is usually severe and NOT cured with dilation.” [Source]
“For individuals with a soft stricture that is short, <1 cm long, located in a segment of the urethra called the bulbar urethra, DVIU has a stricture-free rate of 50%-70%. The success of DVIU in other locations and more dense strictures is often less.” [Source]
“Strictures which respond better to DVIU are those <1 cm in length, located in the bulbar urethra, and have a larger urethral lumen at the time of treatment.” [Source]
“DVIU may be repeated if the stricture recurs, however, after the third treatment or recurrence of the stricture less than three months after the procedure, repeat DVIU offers no long-term success.” [Source]
“Strictures which recur <3 months following treatment with DVIU have a stricture-free rate of 30% at 2 years and 0% at 4 years. Patients undergoing ?3 DVIUs have a 100% failure rate.”[Source]
INTERMITTENT CATHERISATSION NOT EFFECTIVE/ CAN WORSEN THINGS
“There is a conflicting data regarding intermittent catheterization (IC), and if it reduces time to recurrence, however, IC necessitates continued urethral instrumentation and increases the likelihood of progression of the initial stricture.[22,23] Patients who perform IC have a greater chance of complication (urinary tract infection, infection, bleeding, etc.,).” [Source]
AUGMENTED URETHROPLASTY: THE ONLY SUSTAINABLE SOLUTION IN FOSSA NAVICULARIS:
“If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). To allow the tissue to heal and minimize urine leakage during healing, a catheter is left in place. The duration of the catheter may vary with the extent and location of the stricture and whether the procedure is being performed in a single stage or in two stages.” [Source]
In such cases, “our preferred treatment is a urethral reconstruction using a small amount of penile skin (as a flap) as a patch to widen the narrow urethra. To date, we have had uniform success with this treatment, first published by Dr. Gelman’s mentor, Dr. Gerald Jordan.” [Source]
“The preferred treatment for penile urethral strictures and pan-urethral strictures is a buccal graft urethroplasty. This is a versatile option that can be placed anywhere along the urethra and can even extend the entire length of the urethra.” [Source]
REPEATED CUTTING OR DILATION IS A BAD IDEA
- “Dilations and incisions should only be performed on short strictures
- Repeat dilations and incisions don’t cure the problem and they may decrease the success of future urethroplasty.
- The current standard of care is imaging, one incision or dilation, followed by the urethroplasty procedure.” [Source]
“Patients should only have one DVIU, as repeat DVIUs do not cure the disease and can render more effective urethroplasties less effective.” [Source]
DO NOT UNDERGO ANY MORE DVIU: STRAIGHT URETHROPLASTY
“multiple studies have evaluated cost-effectiveness of treatment of urethral strictures and found that either immediate urethroplasty or a single attempt at DVIU, followed by urethroplasty for failures, was more cost-effective than long-term dilation, or DVIU with urethroplasty used only for salvage procedures.” [Source]
UNFORTUNATELY, THERE IS NO UNANIMITY BETWEEN UROLOGISTS ON THIS ISSUE
“Treatment for urethral stricture and stenosis remains inconsistent between reconstructive and nonreconstructive urologists due to varying treatment algorithms and approaches to disease management.” [Source]
SPECIALISTS IN MELBOURNE
BLADDER NECK CONTRACTURE (BNC)
“Internal scarring from the operation is a further potential complication. If your urine flow deteriorates after surgery, it may mean that you will have to undergo dilatation (stretching) of the join between the bladder and urethra; this is usually curative, but sometimes has to be repeated. Some patients will require a period of self-catheterization to ensure that the join between the bladder neck and the urethra remains wide open as it heals. The risk of this is now thankfully much lower after laparoscopic or robot-assisted surgery.” [Source]
“Some men develop a narrowing of the urethra where it is surgically attached to the bladder, and thus a narrowing of the urinary stream. Severe cases of this bladder neck obstruction require surgical dilation, which can be done as an outpatient procedure.”
Some of the symptoms associated with contracture of the bladder neck include:
- Needing to push to begin urination
- Delayed onset of urination (following the urge to urinate)
- Slow or diminished force of urine stream
- Urine stream that starts and stops
- Sensation of incomplete emptying [Source]
Source for info below:
Men usually begin to experience symptoms of bladder neck contracture within 3 to 6 months after prostate surgery. At first, a man may notice a gradual reduction in the flow of urine. This symptom may be overlooked at first, and can progress to the point where he becomes unable to urinate. In other cases, a man might experience urine leakage when the bladder becomes too full. This condition is known as overflow incontinence.
The symptoms of Bladder Neck Contracture usually start to appear within 5-6 months after a prostate surgery. There will be a gradual decline in the urinary output. This may sound normal first but over time the individual may not be able to urinate.
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
The effect of bladder neck contracture on urinary incontinence may be several fold. Firstly, bladder outflow obstruction due to a contracture may aggravate overactive bladder symptoms and thus worsen any component of urge incontinence contributing to the patients overall symptoms. Secondly, it has been suggested that, in determining the rigidity of the anastomotic region, presence of a bladder neck contracture may impair the ability of even a preserved external sphincter contraction to close the bladder outlet efficiently . THIS MIGHT BE CAUSING INCONTINENCE IN MY CASE
“Bladder neck contracture (BNC) or vesicourethral stenosis is a known complication of RP occurring in 0% to 17.5% of cases.”
“Bladder neck obstruction after prostate surgery or radiation is suggested by a slow urinary stream. However, patients can develop other symptoms such as male urinary incontinence. Although incontinence in men after prostate cancer treatment is often due to a lack of sphincter function and control, when there is bladder neck obstruction, the leakage can be from what is called overflow incontinence. The blockage associated with bladder neck contractures can lead to bladder and possibly kidney damage.” [Source]
Scar tissue can form between the bladder and urethra. The symptoms usually include a slow urinary stream, increased urinary frequency, painful urination, or urinary retention. Treatment includes dilation (stretching the tissue under anesthesia with an instrument that is passed up the urethra). In severe cases, it may require cutting the scar tissue away (under anesthesia) and injection of a cortisone-like drug.[Source]
Just over 8 out of every 100 men (8%) need treatment to help them pass urine more easily again. A doctor stretches the narrow area during a short operation. They might slide a thin rod into the urethra to widen it. Or they may use a thin flexible tube with a light and camera on the end. They can see the narrowed area and put a tiny knife down the tube to cut away tissue and open up the urethra. You have these operations under local or general anaesthetic. You might need to have this operation repeated if the urethra gets narrower again.[Source]
Further: – diagnosis tools
There are several tests available to confirm the diagnosis of Bladder Neck Contracture. To begin with the physician will take a history of the patient inquiring as to whether there is a history of prior prostate problems and/or surgery. If the history of the patient points towards Bladder Neck Contracture then the physician may perform a cystoscopy in which a thin tube is inserted through the urethra into the bladder to look at the internal structures. The bladder is filled with sterile water so as to expand the bladder for a better view. This test will clearly show scar tissue formation within the bladder neck and confirm the diagnosis of Bladder Neck Contracture. Additionally, a cystourethrogram may be performed which utilizes x-ray.
In this study, a catheter is inserted through the urethra into the bladder. A contrast material is introduced into the bladder and x-ray studies are taken. This study will also show the presence of scar tissue formation near the bladder neck confirming the diagnosis of Bladder Neck Contracture. [Source]
FIX IT AS SOON AS POSSIBLE
“I had a bladder neck contracture after my RP three years ago. I noticed a gradually diminished flow for about six months, then a rapid decrease in volume and rate. Eventually, I needed a dilatation and had to self-catheterize once daily over six weeks. Not a lot of fun, but my urologist had wanted to do the dilation months earlier, at the first sign of decreased flow. As soon as you can reach your urologist, you may want to ask for this to be done, as waiting in the ER for someone to come dilate you while your bladder is maximally filled cannot be enjoyable. Better to do it on your schedule.” [Source]
“A slowly diminishing stream and eventually constant trips to the bath room because I couldn’t empty the bladder totally. I didn’t wait around (fear of ER visit and cath). Two trips to the Uro involved dilation and catheter for a few days and the third time actual surgery to correct the stricture. Pay attention to the problem because as David can affirm, you don’t want to get totally plugged up. ” [Source]
“I patiently (maybe not so much) waited about 2 months before I complained to my uro. After about 90 days of no progress he scheduled surgery to remove a stricture in the bladder neck. That solved the problem” [Source]
A new surgery approach to fix this: http://urology.jhu.edu/newsletter/prostate_cancer825.php