Bladder Neck Contracture After Radical Prostatectomy: What Is the Reality of Care?

Abstract

Objectives:

To evaluate the therapeutic methods and algorithms currently used in the treatment of bladder neck contracture (BNC) after radical prostatectomy (RP).

Materials and Methods:

Heads of 170 urologic departments in Germany, listed at the German Society of Urology (DGU), were invited to participate in an Internet-based customized survey. The questions consisted of an epidemiologic part (kind of hospital, state of practice) and questions inquiring used surgical techniques with their respective incidence and given algorithms for therapy.

Results:

Of 170 contacted heads of urologic departments in Germany, 84 responded to the questionnaire (return rate 49.41%). The most common treatment modalities are transurethral resection, cold knife incision, hot knife incision, and dilation in descending order. For those institutions using several treatment modalities, 56 (66.67%) follow a therapeutic algorithm, while 28 (33.33%) follow no set order of treatment. However, among the 56 institutions with a set algorithm, 33 different approaches were identified. Of 84 institutions, 29 (34.52%) perform open reanastomosis in case of recurrent BNC, the remaining 55 (65.48%) do not.

Conclusion:

Despite several published guidelines on urethral strictures, numerous self-employed treatment algorithms are used to treat BNC. Although treatment results of these algorithms and the underlying treatment modalities cannot be determined with this work, it highlights the necessity for further studies comparing the different surgeries to allow for a more evidence-based approach.

Introduction

Bladder neck contracture (BNC) is a troublesome complication after radical prostatectomy (RP). The frequency of BNC has been decreasing in the era of robot-assisted laparoscopic prostatectomy (RALP) compared with open prostatectomy. Recent studies reported an incidence of BNC of 1.4% after RALP,¹ whereas it ranges from 2.6% to 20.5% after open prostatectomy.^1,2 Regardless of the decreasing frequency of BNC after RP, it remains a condition difficult to treat, especially in recurrent cases.

A number of techniques are available for BNC treatment and can be summarized as dilations, incisions, stenting, open reanastomosis, and ultimately urinary diversion. Table 1 gives an overview on various techniques available. Coburn attributes much of the variability in success rates at treating BNC to the properties of the stenosis rather than to the technique applied.³ However, success rates differ considerably between most techniques. Although therapeutic algorithms have been published^4,5 and the issue has been addressed by the European Association of Urology (EAU) and Société Internationale d'Urologie/International Consultation on Urological Diseases (SIU/ICUD) with concomitant guidelines published in 2016⁶ and 2014,⁷ the regimens are not widely accepted. While it is generally accepted that in BNC, endoscopic treatment is the initial therapy of choice, open surgery can be considered in patients with highly recurrent BNC. Despite the fact that BNC is treated in most urology departments, currently no comprehensive data exist regarding the various techniques used.

Table 1.

Literature Overview on Various Treatment Possibilities and Concomitant Initial Results for Bladder Neck Contracture After Radical Prostatectomy

Author	Year	n	Treatment	Initial success (%)
Surya et al.¹²	1990	18	Dilation with Van Buren dilators or filiform and followers	17
Mark et al.²¹	1994	26	Collins knife at 3- and 9-o'clock positions (electrocautery)	96
Ramchandani et al.²²	1994	45	Baloon dilation, incision	60
Carr and Webster²³	1996	4	Cold knife incision + followed by dilation	100
Chiou et al.²⁴	1996	2	Endourethroplasty	50
Dalkin et al.²⁵	1996	17	Dilation and cold knife incision	47
Wessells et al.²⁶	1998	4	Open reanastomosis	75
Meulen et al.²⁷	1999	2	Incision + UroLume stent	100
Borboroglu et al.¹⁵	2000	52	Dilation, incision	58
Theodoros et al.²⁸	2000	6	Abdominoperineal reanastomosis	100
Yurkanin et al.²⁹	2001	61	Cold knife incision	87
Park et al.³⁰	2001	26	Dilation (1–2 times)	73
Elliott et al.³¹	2001	9	UroLume stent	89
Besarani et al.³²	2004	48	Dilation	81
Anger et al.³³	2005	54	Incision with electrocautery, ante- and retrograde endoscopic recanalization	72
Lagerveld et al.³⁴	2005	10	Holmium laser incision	100
Gousse et al.³⁵	2005	13	Collins knife at 3- and 9-o'clock positions (electrocautery)	77
Thiel et al.³⁶	2006	43	Dilation	77
Simonato et al.³⁷	2007	3	Perineal end-to-end	100
Lai et al.³⁸	2007	79	Incision	75
Bach et al.³⁹	2007	5	RevoLix incision	60
Kumar et al.⁴⁰	2007	9	Baloon dilation	89
Giannarini et al.⁴¹	2007	46	Cold knife incision, dilation	76
Eltahawy et al.⁴²	2008	24	Laser incision	79
Gillitzer et al.⁴³	2010	33	Incision/TUR/dilation	94
		113	Incision/TUR/dilation	73
Vanni et al.¹⁷	2011	17	Incision + MMC	77
Pfalzgraf et al.⁴⁴	2011	20	Abdominal reanastomosis	60
Ramirez et al.¹⁹	2013	33	Incision w Collings knife, cutting current 30–50 W	73
Weissbart et al.⁴⁵	2013	5	Holmium laser incision	60
Nikolavsky et al.⁴⁶	2014	12	Open reanastomosis	67
Reiss et al.⁴⁷	2014	15	Perineal end-to-end anastomosis	93
Zhang et al.⁴⁸	2014	40	Baloon dilation	80
Parihar et al.⁴⁹	2014	15	Cold knife incision + CIC for 3 months	100
Ishii et al.⁵⁰	2015	10	High-pressure balloon dilation	80
Öztürk et al.⁵¹	2015	28	Plasma button vaporization	82
Kovell et al.⁵²	2015	9	Incision + MMC	89
Wagner et al.⁵³	2015	36	Dilation and/or transurethral incision	61

CIC = clean intermittent catheterization; MMC = mitomycin C; TUR = transurethral resection.

The aim of this study is to evaluate the estimated number of treatments per hospital to get an overview of the techniques currently used and the availability of open reconstruction.

Material and Methods

Heads of 170 urologic departments in Germany, listed in the German Society of Urology (DGU), were invited to participate in an Internet-based customized survey. The questions consisted of an epidemiologic part (kind of hospital, state of practice) and questions inquiring used surgical techniques with their respective incidence and given algorithms for therapy. Statistical analysis was performed using R, version 3.0.2.⁸ Circular migration plots were generated using the circlize package⁹ as described by Abel and Colleagues.¹⁰

Results

Of 170 contacted heads of urologic departments in Germany, 84 responded to the questionnaire, equal to a return rate of 49.41%. Demographic data of participants are shown in Tables 2 and 3, which give an overview on the estimated frequency of BNC treatment per institution.

Table 2.

Demographic Data

What kind of hospital are you working in?
Kind of hospital	n	%
University hospital	9	10.71
Large speciality hospitals	24	28.57
Large community hospital	35	41.67
Community hospital	16	19.05
Health center	0	0.00

What is the town's size your hospital is in?
Size of town	n	%
Major city (more than 100,000 inhabitants)	45	53.57
City (20,000 to 100,000 inhabitants)	35	41.67
Small town (as many as 20,000 inhabitants)	4	4.76

Table 3.

Distribution of the Number of Bladder Neck Contracture Treatments per Year Among the Hospitals

Estimated No. of treatments within the last year	n	%
0	3	3.57
1–5	34	40.48
6–10	27	32.14
11–20	13	15.48
20–40	4	4.76
>40	3	3.57

Several treatment modalities are available for BNC and institutions use one or multiple of them (Tables 4 and 5). The most common treatment modalities used are transurethral resection (TUR), cold knife incision, hot knife incision, and dilation in descending order (Table 4). For those institutions using several treatment modalities, the majority (n = 56, 66.67%) follows a therapeutic algorithm, while 28 (33.33%) follow no set order of treatment. However, among the 56 institutions with a set algorithm, 33 different approaches were identified (Table 6). The first-line treatment options of the respective clinical pathways were rather balanced between cold knife incision (10/33, 30.3%), laser incision (8/33, 24.24%), and TUR (8/33, 24.24%). Fewer clinics started to perform hot knife incision (4/33, 12.12%) or dilation (2/33, 6.06%) for primary treatment of BNC. Open reanastomosis as subsequent treatment option is suggested by 13/33 (39.39%) of the different algorithms. Secondary endoscopic treatment is performed using cold or hot knife incision or TUR (14/33, 42.42%). Laser incision as second-line treatment seems to be uncommon (3/33, 9.09%). Apart from these various treatment algorithms, treatment modalities were selected taking into account such diverse factors as patients' age, comorbidities, stricture modalities (length, amount of scar tissue), patients' preference, and surgeons' choice in the remaining institutions. Figure 1 illustrates the primary and the ultimate treatment for the different algorithms as circular migration plot. Arrows indicate the sequence from primary treatment to ultimate treatment. The most common primary treatment is incision, and the most common ultimate treatment is open reconstruction or TUR.

FIG. 1.

Circular migration plot illustrating sequence therapy in bladder neck contracture. Arrows indicate sequence from primary treatment to ultimate treatment. The most common primary treatment is incision, and the most common ultimate treatment is open reconstruction or TUR. TUR = transurethral resection; MMC = mitomycin C.

Table 4.

Different Techniques of Bladder Neck Contracture Treatment with Their Respective Number of Treatments per Year (Mean, Range, and Standard Deviation)

Kind of treatment	Mean	Range	Standard deviation	p
TUR	4.39	0–40	7.14	—
Cold knife incision	2.58	0–60	7.2	0.1037
Hot knife incision	2.45	0–20	4.11	0.0323
Dilation	1.05	0–30	3.55	0.0002
Laser incision	0.81	0–6	1.41	<0.0001
Other techniques^a	0.58	0–12	1.97	<0.0001
Open reanastomosis	0.5	0–8	1.42	<0.0001
Cortison injection	0.12	0–4	0.54	<0.0001
Mitomycin injection	0.08	0–3	0.44	<0.0001

p-Values are compared with TUR, values <0.0001 show that techniques are performed significantly less often than TUR.

Other techniques are discussed separately (Table 5).

Table 5.

Other Treatment Techniques Used by the Institutions

Kind of treatment	No. of institutions using the treatment
Continent vesicostomy	1
Stent implantation	3
Dilation, followed by stent implantation	1
Customized cold punch	1
Early resection of anastomotic sutures	1
Vesical advancement flap	1
Dilation, followed by cold knife incision	1

Table 6.

Various Treatment Algorithms Applied in the Different Institutions

Primary treatment	Secondary treatment
Dilation
Dilation	TUR
	If highly recurrent: YV bladder advancement flap (robot-assisted)
Dilation	TUR
Incisions
Cold knife
Cold knife incision	Suprapubic catheter
Cold knife incision	Hot knife incision
	If highly recurrent: laser incision or open reconstruction
Cold knife incision	Cold knife incision plus mitomycin injection
Cold knife incision	Hot knife incision or TUR
Cold knife incision	Suprapubic catheter
Cold knife incision or TUR	Open reconstruction
	Alternative: cold knife incision plus self-dilation
Cold knife incision or TUR	Dilation
Cold knife incision plus TUR	Cold knife or hot knife incision
Cold knife incision plus cold punch	Self-dilation
Hot knife
Hot knife incision	Laser incision
Hot knife incision (as much as twice)	YV bladder advancement flap
Hot knife incision	Dilation
	If highly recurrent: laser incision
	If highly sclerotic: TUR
Hot knife incision, sometimes combined with TUR
Laser incision
Laser incision	Open reconstruction
Laser incision	Suprapubic catheter or open reconstruction
Laser incision	Perineal reanstomosis
Laser incision	Cold knife incision
Laser incision	TUR
	If highly recurrent: open reconstruction
Laser incision	TUR
Laser incision	Hot knife incision
Laser incision (TUR if local recurrence is suspected)
TEVAP	Cold knife incision plus cortison
	If recurrent: stent
	If still recurrent: open reconstruction
TUR
Endoscopic (twice)	Open reconstruction
TUR	Open reconstruction
	If still recurrent: stent
TUR
TUR (as much as three times)	Open reanastomosis
	If highly sclerotic: primary open reanstomosis
Other
	Open bladder neck reconstruction
Hot or cold knife incision (as much as three times)	Open reconstruction
Incision, followed by TUR
Early resection of anastomotic sutures	Hot knife incision plus TUR
	If highly recurrent: self-dilation

TEVAP = transurethral electrovaporization of the prostate.

Of 84 institutions, 29 (34.52%) perform open reanastomosis in case of recurrent BNC, the remaining 55 (65.48%) do not. Open reanastomosis is conducted using a retropubic approach in 18 (62.07%), perineal approach in 9 (31.03%), and combined abdominoperineal approach in 5 (17.24%) institutions (multiple selections were enabled). Table 7 shows the treatment modalities of recurrent BNC at institutions not performing open reconstruction sorted by the kind of hospital. Differences between hospital sizes were not statistically significant. Laser incision is performed by 28 of 84 institutions. A holmium laser was used by 17 of 28 institutions, a thulium laser by 12, a GreenLight laser by one, and a diode laser by one institution (multiple selections were enabled).

Table 7.

Treatment Modalities of Highly Recurrent Bladder Neck Contracture at Institutions Not Performing Open Reconstruction: Results for 54 of 55 Institutions (Multiple Answers Were Enabled)

	All	University hospital	Large speciality hospital	Large community hospital	Community hospital	p
No. of institutions	55	6	14	24	11
No highly recurrent BNC	14	1	2	7	4	0.5665
Repeated TUR	9	1	3	5	0	0.4292
Laser resection	1	0	0	0	1	0.2536
Dilation alone	7	1	3	2	1	0.6625
Dilation, followed by CIC	6	0	2	2	2	0.6455
MMC	1	0	0	1	0	0.7254
Hot knife incision	1	0	0	1	0	0.7254
Cold knife incision	1	0	0	0	1	0.2536
Laser incision	1	1	0	0	0	0.03988
Suprapubic catheter	8	1	2	4	1	0.9458
Suprapubic diversion	6	1	2	3	0	0.6197
Referral to tertiary center	11	1	3	5	2	0.9927

BNC = bladder neck contracture.

The likelihood to be treated by open reanastomosis in case of highly recurrent BNC did not differ much between the different kinds of hospitals and showed no statistical significance (Table 8).

Table 8.

Frequency of Open Reanastomosis Itemized by the Kind of Hospital

Kind of hospital	n/total	%
University hospital	3/9	33.33
Large speciality hospital	10/24	41.67
Large community hospital	11/35	31.43
Community hospital	5/16	31.25

There was no statistically significant difference between the hospitals (χ ² = 0.7715, degrees of freedom = 3, p-value = 0.8563).

Discussion

BNC after RP is a fibrotic narrowing of the anastomotic region.^11,12 Proposed risk factors for the development of BNC are multiple, but no single, easy to eliminate risk factor has been established so far. Risk factors include multiple previous interventions,¹³ excessive blood loss,^12,14 narrow bladder neck reconstruction,¹⁴ and timing of the RP.¹¹ In a series of 467 pts. Borboroglu and Colleagues identified current smoking as the most important risk factor. Furthermore, diabetes mellitus, hypertension, and coronary heart disease are associated with development of BNC after RP.¹⁵ Other risk factors are controversial: while extravasation at the time of catheter removal was implicated as a risk factor in some series,^12,13 in another, it showed no adverse effect.¹⁶

For treatment of BNC, the techniques used can be summarized as dilations, incisions (sometimes combined with the application of substances such as mitomycin C¹⁷), urethral stents, and open reanastomosis. As ultimate solution, suprapubic catheterization or urinary diversion can be employed. Despite the EAU guideline and the SIU/ICUD consultation on urethral Strictures, no widely accepted therapeutic algorithm for the treatment of BNC after RP exists. Congruent with this, the German S3 guideline on prostate cancer¹⁸ states that despite BNC being the third most perioperative complication beside incontinence and erectile dysfunction, no standard treatment exists. Moreover, no studies subsist regarding the prevalence of the different techniques used for treatment. This study aims at closing this gap by providing a comprehensive depiction of the current situation in German urological hospitals. As is obvious from the data in Tables 3 and 5, endoscopic treatment is the accepted initial treatment of choice; hence, the technique remains a matter of controversy. Furthermore, open reanastomosis or urinary diversions are accepted only for the treatment of recalcitrant BNC. This is in accordance with treatment algorithms suggested by Ramirez and Colleagues,^4,19 moving from a more conservative to a more complex surgical treatment. Moreover, the abovementioned techniques and algorithms apply to primary or recurrent BNC after RP—in case of concomitant recto-anastomotic fistula or prior radiation therapy, therapeutic approaches can be different. While in some patients open reanastomosis is a viable option, in others—especially multimorbid—a continent vesicostomy or even a suprapubic tube can be the treatment of choice.

The guidelines published so far on this subject illustrate a similar approach. However, they slightly differ between each other. The EAU guideline on urological trauma,⁶ which addresses urethral injuries caused by surgical treatment of prostate cancer as well, suggests the use of dilation or endoscopic optical bladder neck incision. In case of failure of these procedures, open surgery (i.e., reanastomosis) or urinary diversion can be applied. Level of evidence or grade of recommendation underlying the guideline is not addressed. On the contrary, the SIU/ICUD consultation on urethral strictures⁷ suggests dividing BNC patients into continent and incontinent patients. This results in an algorithm suggesting dilation/direct visual internal urethrotomy as initial treatment in continent patients and extensive transurethral incision in recurrent BNC or incontinent patients with persistent urethral continuity. In patients with highly recurrent BNC or obliterated urethral continuity, open reconstruction can be used. All of these recommendations exhibit a level of evidence, 3, and a grade of recommendation, C. In April 2016, the American Urological Association (AUA) newly released a guideline on male urethral strictures. In this study, in postprostatectomy vesicourethral anastomotic stenosis, surgeons may perform dilation, vesicourethral incision, or TUR. Furthermore, surgeons may perform open reconstruction for this condition. Both are graded conditional recommendations with an evidence strength C. For this statement type, the AUA refers to as balance between benefits and risks/burden unclear; alternative strategies may be equally reasonable; and better evidence likely to change confidence.²⁰

As a limitation to this study, the return rate of the survey was only about a half. Hence, the results of the survey do not necessarily represent the real situation of the country. Meanwhile, it is not clear that the outcome of this study can be transferred to other European or non-European countries. To further address this, a similar survey should be conducted in other countries.

Although all institutions participating in this survey have more or less set ways of treating patients with BNC after RP, few institutions adhere consequently to one of the mentioned guidelines, possibly due—even though speculative—to the low level of recommendation evidence. We suggest that as a first step, institutions should adhere to one of the existing guidelines, ultimately stating which guideline is used. This will produce more robust data for retrospective studies on this issue. Additionally, as well postulated by the SIU/ICUD consultation and AUA guideline committee, prospective, randomized controlled trials should be initiated to generate a more evidence-based approach and thereby convince the institutions to adhere to further revised guidelines.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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