Dr. Ryan P. Terlecki, MD, FACS, presented “Bladder Neck Contractures After Prostatectomy” at the 26th Annual Perspectives in Urology: Point-Counterpoint, November 12, 2017 in Scottsdale, AZ

How to cite: Terlecki, Ryan P. “Bladder Neck Contractures After Prostatectomy” November 12, 2017. Accessed Aug 2018. https://grandroundsinurology.com/bladder-neck-contractures-after-prostatectomy/

Summary:

Dr. Ryan P. Terlecki, MD, FACS, discusses bladder neck contractures and the causes behind them, the possible sources of the symptoms, the outcomes of what has been done in the past, and what could potentially work in the future. He also focuses on HiFU and its use in targeted therapy of the prostate.

Bladder Neck Contractures After Prostatectomy

Transcript:

Thank you.  I just want to say thank you again to David and to the organizers here for having been included in what’s really a terrific meeting.  Certainly you have choices in when you go for your CMEs, and I think your attendance here is a testament to not only David’s expertise but to all the contributions he’s made over the course of a career thus far.

So this is not something I see a lot of in terms of refractory bladder neck contractures.  I think the condition itself is more common than the ones that don’t succeed with transurethral management, but we’ll talk a little bit about the more difficult ones that you may or may not see in practice.  

So my objectives, again, to go over what we think causes these, the potential sources, and the outcomes of what we’ve done in the past, and then perhaps what we can do a little bit differently moving forward.

So as far as an audience response question, which of the following is associated with an increased risk of post-treatment bladder neck contracture?  Younger patients, larger prostate, a history of prostatitis, diabetes, or obesity?  

So let’s see, what was the most popular?  Spread out, okay.  Well, good, another opportunity there.  Next question.

Based on CaPSURE data, which of the following primary therapies for prostate cancer is associated with the highest post-treatment incidence of bladder neck contracture?  Is it radical prostatectomy, cryotherapy, brachy, external beam, or the combination of brachy and external beam?

Surgery; all right, pretty good.  So I see a reasonable percentage also picked the last answer, and I don’t find that surprising.  I’ll go to the next slide.

So as I mentioned, a lot of these can be managed easily, but when they keep coming back it can be quite the challenge, and usually we see it after treatment for prostate cancer, but every now and then you’ll see patients that have had treatments for BPH and develop contractures as well, and unfortunately for a certain subset of men they may go on to a cycle of never-ending self-cath, or even just catheter-based diversion.  

So as I mentioned, it’s not unique to any one modality, and the obstruction could be related to what I refer to as intrinsic versus extrinsic fibrosis.  So what do I mean by that?  Well, essentially if you have ischemia the anastomosis that leads to contracture, on the basis of that, I refer to that as intrinsic disease.  However, if you build up a wall of scar from extravasation and you’re getting compression from the outside I refer to that as extrinsic fibrosis.  

So either way, ischemia is a bad thing and especially as it relates to healing following transurethral attempts at management.

So Shawn Elliot had looked at CaPSURE data, okay, and looked at structure rates based on primary therapy.  Now, not all groups are equally powered in terms of the number, but if you look here, if you take the average overall, it’s about 5.2%, okay?  But radical prostatectomy did have the highest at 8.4, and then brachy and external beam was second at 5.2%, okay?  

One of the issues, though, with this data, is occasionally you might manage a patient, and depending on what your coders do, it might not be listed as a bladder next contracture, it might be listed as urethral stricture, depending if you’re doing a dilation or DVIU.  

So the range, again, is about 1-8%, risk highest after surgery followed by combination radiation, and the risk appears to be highest in older and more obese patients.  Now, we can make inferences, but I can’t say for certain as to why that is, and it may make for more challenging surgery, poorer vascular status, but the stricture appears to be diagnosed typically within two years after surgery and it may be more delayed in those patients that have been managed with radiation therapy.

So what are we going to do to get the plumbing open?  

So we’ve tried a variety of things.  So one of my former fellows is now at UPenn, Dr. Kovell, looked at this previously, and we wanted to do a summary of how well we’ve done traditionally compared to what we’re looking at as far as novel therapeutics.  

So just doing an incision, whether it’s cold knife or hot knife or using a dilation, has a single-procedure success rate that varies across the literature, anywhere from 25 to 73%.  However, the data suggests that about one in four of these patients are going to be refractory to even three or more procedures.

So transurethral resection of the bladder neck still has pretty good successes, but you’re going to have some patients that will fail.  In the past we had UroLume on the market, and in my opinion that was a tool of the Devil, but I didn’t see the success rates, right?  I didn’t see the guys that did well, I saw the ones that didn’t do so well, and that was somewhat complex surgery.

So you may have heard about mitomycin-C being used for this.  Many of you are probably more familiar using this as it relates to cancer therapy, but in ophthalmology and in ENT it’s been used to reduced fibrosis in the setting of surgery.  So it was applied about a decade ago in a series of DVIU patients and it appeared to reduce recurrence rates.  

So the Lahey clinic, headed by Lenny Zimmon [phonetic], so Alex Vanni was the first author and he’s still there, they reported on a series of 18 patients.  It doesn’t sound like a large volume of patients, but again, no one sees a ton of these really refractory cases.  They might not be referred, or a lot of them, as I mentioned, can be successfully managed with more simplistic maneuvers.

So they looked at these patients that were treated with an incision of the bladder neck with injection of mitomycin-C at the injection site; sites is what it should say.  So at a median follow up of a year, 13 of them, so 72%, were patent after one procedure.  Another three, or 17% after two, and another one after two, and one patient failed.  

So this is actually pretty good success rate considering the types of patients that are being considered for this.  These are people having their first-ever procedure.  These are people that have failed elsewhere.  

So I started trying this and we looked at our own data to see, well, are we seeing similar success rates or not?  

So one technique, so this is actually–might not project as well–but this is the needle going in, standard injection needle, and this is before the contracture has been opened up.  I don’t always do this; sometimes I just do it after I’ve opened it up, but depending on how well the needle comes through into your field of view, having the tissue pulled in can sometimes make it easier to get the angle and to penetrate the tissue to deliver the medication.  

So I use a hot knife, so a Collings knife here.  I find a devia I use a little bit more challenging, especially with some of the tissue that you’ll see.  So I try to stay away from 6:00.  

I’m always scared about the rectum depending on the type of patient, and I also avoid 12:00 because if you haven’t encountered a fistula between the bladder neck and the pubic synthesis, they exist, and they can be a source for chronic pain in patients.  So I know Drew Peterson and some others have reported on a series that they’ve managed and I’ve had a handful that I’ve seen in practice at Wake as well.  

So the question is, well, how deep do you go?  Well, I try to get it where it springs open, to where I estimate about a 30-fringe opening.  Do I always have to see fat?  No, that makes me a little bit nervous, as I imagine would be the same for some of you.  

Even though we’re using a small volume and a lower concentration of mitomycin, if ever of you have ever had experience treating a patient or operating on a pelvis of somebody who’s had mitomycin extravasation from bladder installation, it’s bad.  I mean, I’ve never seen tissue like that.  Some of the most complex cases have been those gentlemen that have had unrecognized bladder perforations and been treated with mitomycin.

So again you see it getting open.  Here’s the needle going in again.  It’s the same kind of needle you would use to inject perhaps D-flux or back when collagen was available.

So same thing on the opposite side.

So what was our experience?  Well, we only had 13 patients, somewhat less than the 18 patients at – – Clinic.  Mean age, pretty typical, and the etiology was spread out, but the majority of patients had radical prostatectomy.

So nine of these patients, again, this is retrospective, small volume, or small series.  So that incision with mitomycin, so nine patients there, and two patients we tried tacrolimus with informed consent, based on some data we’ve read in the literature.  Then two had laser incision alone.  

Interestingly, all the patients that got mitomycin were patent at follow up.  One patient did require a single dilation in 10 months and then a repeat incision with mitomycin at 13 months, and then remained patent thereafter.

So I included the raw data in the publication.  So two of the patients that obliterated I think were actually my fault, because I kept them at the suprapubic catheter, and we debated as to whether or not the dry outlet is a potential problem, and I think it makes sense that it might have been, so not having the patient void in capping these tubes early on I think was a mistake.  But again, the mitomycin patients did do pretty well.

So then there was a retrospective review, a multicenter series from the TURNS group, which is a group of reconstructive surgeons that do similar work, so they pooled data from six centers from ’09 to 2014, and 80% of those patients had failed prior dilation or incision, so some patients were having their first ever procedure.  

Their overall success rate was similar to our series and that reported by the Lahey clinic at about 75%.  15 of the patients did require two procedures, but interestingly, four did have series adverse events.

So again, sometimes where we feel that it’s reasonable after with urethral strictures or bladder neck contractures to put these patients on self-cath to maintain patency.  So because we have may have patience doing it who don’t empty their bladders well and kind of lump them in as if it’s the same experience.  

So Dr. Morey, myself, and some others distributed a questionnaire to kind of look at if they perceive it and experience it the same way as other patients.  

So there were 85 patients on dilation for stricture or bladder neck contracture, and median again, again, similar to the prior studies I showed you.  Median time on self-cath was about three years, doing it on average about once a day.  

Unlike the patients, perhaps, with neurogenic bladders, self-dilation was associated with moderate pain and poor quality of life.  It’s not really surprising but it hadn’t been establish in literature.   

We had grouped the bladder neck contracture patients into the group with posterior strictures and they had the greatest degree of difficulty.  That’s not surprising, right, if you think about the shorter length of the catheter, if you’re just dilating penile stricture you have better control, right?  You have better rigidity.  So after you make the turn in the bulbar urethra, pushing that catheter forward if it’s meeting any resistance gets to be a little bit more of a challenge.

So what about open reconstruction, right?  This sounds drastic, it sounds challenging; it is challenging.  

So Dr. Flynn whose partners, Dr. Donahue and Dr. Crawford and I looked at his series, some of the patients that I had been involved with, and there were 12 cases over a period from ’04 to 2012.  So again, it’s not a high volume, but again, you’re not going to see a lot of these patients that are so recalcitrant to consider open reconstruction.  

Most of them were done purely abdominally.  Some had a combination approach and some just through the perineum.  All of them had had prior radical proctectomy, and one in four had prior radiation.  Just shy of half had complete obliteration.  Two of these patients had early anastomotic disruption following their prostate cancer surgery.

So the median length of stenosis was 2.5 cm.  Median length of stay was only three days, which is pretty good considering the nature of the operation, and we had considerable follow up.  Patency rates were good, right?  Over 90%.  But continence rates, not so good.  So incontinence was the rule.

So George Webster, when he was in practice at Duke, described a progressive series of maneuvers doing post-urethroplasty, so similarly we would mobilize the urethra.  Oftentimes we would split the two corporal bodies proximally to get some additional space.  On rare occasions we would take out part of the pubis, and never have we had to perform supracrural rerouting either for posterior urethraplasties or for reconstruction for bladder neck contractures.

So again, here’s a view from surgery, here’s the pubic synthesis, and kind of carving out this component here to get the space together.  So Dr. Pierce, back when he was alive, I think it was in the early 60s, that Wayne State has described this total symphyseotomy for posterior strictures, and without destabilization of the pelvis.  So we feel pretty comfortable performing this at the time of reconstruction.  

So here’s a case where a patient had a prior laparoscopic radical prostatectomy.  You can see the defect here and it failed endoscopic management, so it was a combined approach both through the abdomen and the perineum, and the sphincter was divided at the time of repair, and it’s a pretty long defect.

So we were able to get it together; here’s the post-op urethra gram, and here’s urethroscopy, and you can see the comparison pre-op and post-op side-by-side; it was about a 3.5 cm defect, and the patient did well long-term.  

So we were able to get it together; here’s the post-op urethra gram, and here’s urethroscopy, and you can see the comparison pre-op and post-op side-by-side; it was about a 3.5 cm defect, and the patient did well long-term.  

So what about diversion, right?  I don’t know how many of you have had to have this discussion with patients, but initially it seems pretty drastic, right?  End of the road.  However, you will occasionally see that patient if you practice long enough that’s just so despondent, so traumatized and having to use pads, diapers, dealing with diaper rash, candula [phonetic] infections, and having to undergo multiple transurethral procedures, and sometimes an ostomy doesn’t seem so extreme.  

So you had multiple choices for diversion, right?  You can do ileal conduit with or without cystectomy; same thing for an Indiana pouch.  Occasionally you can close the bladder neck and leave a suprapubic tube or catheterizable channel.  The failure rate in this kind of depends on what the primary modalities involved for the prostate were in the past.  Occasionally if they completely obliterate it might just make the most sense to place a suprapubic tube.

So what are the implications for survivorship?  Well, we talked before about comments, we talked about sexual health.  So if you perform open reconstruction and then the patient’s leaking and now you’ve got to think about what am I going to do for the leaking?  

Then they’re going to need subsequent surgery, an artificial sphincter, perhaps.  Maybe you feel that they’re going to need what we call a transcorporal approach where we include the corporal bodies, or part of them, in the cuff itself.  

Then you’ve got to think about, well, what if it comes back and they’ve got a sphincter?  That could be challenging to maneuver, especially if you want to use a larger caliber scope or sheath, excuse me.  Then again, if they’re young enough to have gone through this process and they’re still thinking about wanting their sexual health back, that has to impact your planning as well.  

So I get asked, well, what about the patient that we believe is not disease-free?  Would you still consider intervening for these types of conditions?  

So understanding that they’re going to receive further therapy, a lot of what you’ve discussed here at this meeting, if the patient has already received surgery and radiation, my approach is not changed by whether or not they’re going to get medical therapy targeting their prostate cancer if they have a reasonable life expectancy, and if I feel it’s a reasonably safe operation.  

If, however, they already have a contracture, and we don’t talk a lot about dystrophic calcifications in the literature, but if any of you have seen these, these big, chunky stones that just keep coming from within the prostate, it’s a problem.  

So if they’ve had combination radiation therapy, in my opinion, and again, I’m not speaking from a cancer-control perspective, I’m speaking from a quality of life and future procedure perspective, I think salvage cryo is kind of a bad idea, especially if they don’t want a chronic suprapubic tube or to wear an ostomy.

All right, so let’s go back to the questions.  Which of the following is associated with increased risk of post-treatment bladder neck contracture?  Younger, bigger prostate, history of prostatitis, diabetes, or obesity?

Absolutely correct.  Okay, good.

Again, based on the CaPSURE data I showed you data I showed you, which of the following primary therapies has the highest post-treatment incidence of bladder neck contracture?  Radical prostatectomy, cryo, brachy, external beam, or combination radiation therapy?

Right on, absolutely.

Okay, so in conclusion, again, the overall rate is low and they often do well with just a resection of the bladder neck contracture.  Self-cath or maintenance of self-patency, it’s detrimental to some patients.  

Some refractory cases can be managed with injectable therapy, but again, based on what I said with the TURNS group, there may be adverse event risk, but 4 out of 55 patients, again, retrospective multicenter, different complications, so it’s hard to know.  We haven’t had any safety issues in our series.  

Open reconstruction, I would suggest that that’s an option for some well-selected patients; it’s certainly not going to represent a large percentage of this group, and you want to send this to someone who does this type of case.  Occasionally urinary diversion is the best option.  Thank you.