Management of the devastated posterior urethra and bladder neck: refractory incontinence and stenosis

Abstract

Stricture of the proximal urethra following treatment for prostate cancer occurs in an estimated 1-8% of patients. Following prostatectomy, urethral reconstruction is feasible in many patients. However, in those patients with prior radiation therapy (RT), failed reconstruction, refractory incontinence or multiple comorbidities, reconstruction may not be feasible. The purpose of this article is to review the evaluation and management options for patients who are not candidates for reconstruction of the posterior urethra and require urinary diversion. Patient evaluation should result in the decision whether reconstruction is feasible. In our experience, risk factors for failed reconstruction include prior radiation and multiple failed endoscopic treatments. Pre-operative cystoscopy is an essential part of the evaluations to identify tissue necrosis, dystrophic calcification, or tumor in the urethra, prostate and/or bladder. If urethral reconstruction is not feasible it is imperative to discuss options for urine diversion with the patient. Treatment options include simple catheter diversion, urethral ligation, and both bladder preserving and non-preserving diversion. Surgical management should address both the bladder and the bladder outlet. This can be accomplished from a perineal, abdominal or abdomino-perineal approach. The devastated bladder outlet is a challenging problem to treat. Typically, patients undergo multiple procedures in an attempt to restore urethral continuity and continence. For the small subset who fails reconstruction, urinary diversion provides a definitive, "end-stage" treatment resulting in improved quality of life.

Keywords: Bladder neck contracture (BNC); posterior urethral stenosis (PUS); prostate cancer; urethral stricture.

Figure 1

Pre-operative and post-operative images of a patent with a 4 cm stricture 2 years after brachytherapy and EBRT. The stricture began at the proximal bulbomembranous urethra and extended proximally to the bladder neck. He was successfully treated with a 6 cm BMG placed ventrally.

Figure 2

Bladder preservation vs. cystectomy algorithm.

Figure 3

Urinary diversion options with bladder preservation.

Figure 4

Urethral transection with spongiosum used as rotational coverage flap. Acknowledgement: Photograph courtesy of Dr. Kenneth Angermeier. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015. All rights reserved.

Figure 5

Intra-operative photograph of the bladder neck following extensive resection and retropubic prostatectomy in a patient with severe radionecrosis.