Elsevier

Urology

Volume 83, Issue 3, Supplement, March 2014, Pages S59-S70
Urology

ICUD on Urethral Strictures
SIU/ICUD Consultation on Urethral Strictures: Posterior Urethral Stenosis After Treatment of Prostate Cancer

https://doi.org/10.1016/j.urology.2013.08.036Get rights and content

Posterior urethral stenosis can result from radical prostatectomy in approximately 5%-10% of patients (range 1.4%-29%). Similarly, 4%-9% of men after brachytherapy and 1%-13% after external beam radiotherapy will develop stenosis. The rate will be greater after combination therapy and can exceed 40% after salvage radical prostatectomy. Although postradical prostatectomy stenoses mostly develop within 2 years, postradiotherapy stenoses take longer to appear. Many result in storage and voiding symptoms and can be associated with incontinence. The evaluation consists of a workup similar to that for lower urinary tract symptoms, with additional testing to rule out recurrent or persistent prostate cancer. Treatment is usually initiated with an endoscopic approach commonly involving dilation, visual urethrotomy with or without laser treatment, and, possibly, UroLume stent placement. Open surgical urethroplasty has been reported, as well as urinary diversion for recalcitrant stenosis. A proposed algorithm illustrating a graded approach has been provided.

Section snippets

Material and Methods

The committee assessed and reviewed the epidemiology, evaluation, and management of PUS after localized treatment of prostate cancer. Studies from the past 15 years from peer-reviewed journals, abstracts from scientific meetings, and published data searches manually and electronically formed the basis of the present review. The search terms used included “prostate cancer,” “radical prostatectomy,” “radiation, brachytherapy,” “cryotherapy,” and “high-intensity focused ultrasound (HIFU).”

As a

Radical Prostatectomy

PUS after RP manifests as a narrowing of the anastomosis between the bladder neck and the membranous urethra, commonly termed “bladder neck contracture” (BNC), which occurs in 1.4%-29% of patients after RP (Table 1).4, 5, 6, 7, 8 The number of RPs performed in the United States exceeded 80,000 in 2001 and has continued to remain constant despite concerns about the public health benefit of prostate-specific antigen screening. Using conservative estimates from published studies, it has been

Evaluation and Preoperative Management

Men who develop PUS after treatment of prostate cancer can present with lower urinary tract symptoms (LUTS), both storage and voiding. The usual timing of the onset of the stenosis is dependent on the type of treatment administered. With RT, both EBRT and BT, it usually occurs within a few years. After RP (with or without EBRT), TURP, or interventions such as HIFU and cryotherapy that result in tissue sloughing, the symptoms of obstructed voiding can occur immediately after catheter removal or,

Treatment

Strictures related to prostate cancer therapy result from a number of interacting mechanisms, including anatomic tissue loss from surgery, postoperative fibrosis, ionizing radiation, and electrical injury. Thus, treatment must take into consideration the surrounding anatomic characteristics, capacity for healing, and ability to support transfer of adjacent or distant donor tissue sites. The continence status of the patient and the relationship of the stricture to the external sphincter further

Conclusion

The risk factors for the development of VUAS identified in case series and large prospective RP studies can be divided into preoperative, intraoperative, and postoperative categories and include excessive blood loss, type of bladder neck dissection, postoperative urinary leakage, adjuvant RT, previous TURP, smoking, older age, obesity, and surgeon experience (LE 2-3). Other risk factors include open vs minimally invasive surgery (LE 2-3) and acute postoperative retention treated with suprapubic

References (99)

  • M.L. Gonzalgo et al.

    Classification and trends of perioperative morbidities following laparoscopic radical prostatectomy

    J Urol

    (2005)
  • C.R. deVries et al.

    Hemorrhagic cystitis: a review

    J Urol

    (1990)
  • T.P. Mate et al.

    High dose-rate afterloading 192Iridium prostate brachytherapy: feasibility report

    Int J Radiat Oncol Biol Phys

    (1998)
  • L. Aström et al.

    Long-term outcome of high dose rate brachytherapy in radiotherapy of localised prostate cancer

    Radiother Oncol

    (2005)
  • G.C. Morton

    The emerging role of high-dose-rate brachytherapy for prostate cancer

    Clin Oncol (R Coll Radiol)

    (2005)
  • Z.A. Allen et al.

    Detailed urethral dosimetry in the evaluation of prostate brachytherapy-related urinary morbidity

    Int J Radiat Oncol Biol Phys

    (2005)
  • M.J. Zelefsky et al.

    Five-year outcome of intraoperative conformal permanent I-125 interstitial implantation for patients with clinically localized prostate cancer

    Int J Radiat Oncol Biol Phys

    (2007)
  • C.A. Lawton et al.

    Long-term treatment sequelae after external beam irradiation with or without hormonal manipulation for adenocarcinoma of the prostate: analysis of Radiation Therapy Oncology Group studies 85-31, 86-10, and 92-02

    Int J Radiat Oncol Biol Phys

    (2008)
  • B.G. Gardner et al.

    Late normal tissue sequelae in the second decade after high dose radiation therapy with combined photons and conformal protons for locally advanced prostate cancer

    J Urol

    (2002)
  • D.B. Chism et al.

    Late morbidity profiles in prostate cancer patients treated to 79-84 Gy by a simple four-field coplanar beam arrangement

    Int J Radiat Oncol Biol Phys

    (2003)
  • M.J. Zelefsky et al.

    Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer

    Int J Radiat Oncol Biol Phys

    (2008)
  • O.K. MacDonald et al.

    Prostate-specific antigen control with low-dose adjuvant radiotherapy for high-risk prostate cancer

    Urology

    (2007)
  • C. Cozzarini et al.

    Hypofractionated adjuvant radiotherapy with helical tomotherapy after radical prostatectomy: planning data and toxicity results of a phase I-II study

    Radiother Oncol

    (2008)
  • G.S. Merrick et al.

    Temporal resolution of urinary morbidity following prostate brachytherapy

    Int J Radiat Oncol Biol Phys

    (2000)
  • L. Sullivan et al.

    Urethral stricture following high dose rate brachytherapy for prostate cancer

    Radiother Oncol

    (2009)
  • A.C. Pellizzon et al.

    Late urinary morbidity with high dose prostate brachytherapy as a boost to conventional external beam radiation therapy for local and locally advanced prostate cancer

    J Urol

    (2004)
  • G.S. Merrick et al.

    The dosimetry of prostate brachytherapy-induced urethral strictures

    Int J Radiat Oncol Biol Phys

    (2002)
  • C.H. Seymore et al.

    The effect of prior transurethral resection of the prostate on post radiation urethral strictures and bladder neck contractures

    Int J Radiat Oncol Biol Phys

    (1986)
  • S. Deger et al.

    High dose rate (HDR) brachytherapy with conformal radiation therapy for localized prostate cancer

    Eur Urol

    (2005)
  • I.S. Grills et al.

    High dose rate brachytherapy as prostate cancer monotherapy reduces toxicity compared to low dose rate palladium seeds

    J Urol

    (2004)
  • T.M. Koppie et al.

    Patterns of treatment of patients with prostate cancer initially managed with surveillance: results from the CaPSURE database. Cancer of the Prostate Strategic Urological Research Endeavor

    J Urol

    (2000)
  • J.P. Long et al.

    Five-year retrospective, multi-institutional pooled analysis of cancer-related outcomes after cryosurgical ablation of the prostate

    Urology

    (2001)
  • K.R. Han et al.

    Treatment of organ confined prostate cancer with third generation cryosurgery: preliminary multicenter experience

    J Urol

    (2003)
  • J.P. Long et al.

    Preliminary outcomes following cryosurgical ablation of the prostate in patients with clinically localized prostate carcinoma

    J Urol

    (1998)
  • J.I. Izawa et al.

    Major surgery to manage definitively severe complications of salvage cryotherapy for prostate cancer

    J Urol

    (2000)
  • J.T. Wei et al.

    Urologic diseases in America project: benign prostatic hyperplasia

    J Urol

    (2005)
  • Y.H. Lee et al.

    Comprehensive study of bladder neck contracture after transurethral resection of prostate

    Urology

    (2005)
  • J. Rassweiler et al.

    Laparoscopic versus open radical prostatectomy: a comparative study at a single institution

    J Urol

    (2003)
  • M. Riehmann et al.

    Transurethral resection versus incision of the prostate: a randomized, prospective study

    Urology

    (1995)
  • A. Orandi

    Transurethral incision of the prostate

    J Urol

    (1973)
  • P. Abrams et al.

    Evaluation and treatment of lower urinary tract symptoms in older men

    J Urol

    (2009)
  • K.T. McVary et al.

    Update on AUA guideline on the management of benign prostatic hyperplasia

    J Urol

    (2011)
  • T.L. Bullock et al.

    Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States

    J Urol

    (2007)
  • A. Gómez-Iturriaga Piña et al.

    Median 5 year follow-up of 125iodine brachytherapy as monotherapy in men aged < or = 55 years with favorable prostate cancer

    Urology

    (2010)
  • S.P. Elliott et al.

    Management of severe urethral complications of prostate cancer therapy

    J Urol

    (2006)
  • J.J. Meeks et al.

    Urethroplasty for radiotherapy induced bulbomembranous strictures: a multi-institutional experience

    J Urol

    (2011)
  • R. Park et al.

    Anastomotic strictures following radical prostatectomy: insights into incidence, effectiveness of intervention, effect on continence, and factors predisposing to occurrence

    Urology

    (2001)
  • S. Herschorn et al.

    S-shaped coaxial dilators for male urethral strictures

    Urology

    (2007)
  • R.K. Chiou et al.

    Treatment of recurrent vesicourethral anastomotic stricture after radical prostatectomy with endourethroplasty

    Urology

    (1996)
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    Financial Disclosure: S.H. receives royalties from Cook Medical. The remaining authors declare that they have no relevant financial interests.

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