0022-,~84 7 /90/l 434-07Sii$02. 00/0 THE ,JOt:RNAL O~~ L1ROLOGY
Copyright
Vol. 143,
Printed in
1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
ANASTOMOTIC STRICTURES FOLLOWING RADICAL PROSTATECTOMY: RISK FACTORS AND MANAGEMENT BABU V, SURYA, JOHN PROVET, KARL-ERIC JOHANSON
AND
JORDAN BROWN
From Urology Service, Department of Veterans Affairs Medical Center and Department of Urology, New York University School of Medicine, New York, New York
ABSTRACT
Stricture of the anastomosis between the bladder neck and membranous urethra after radical prostatectomy can cause significant voiding dysfunction, Of 156 patients undergoing radical prostatectomy for localized prostatic carcinoma 18 had anastomotic stricture for an over-all incidence of 11.5%. The risk factors for anastomotic stricture and the treatment outcome in these patients were analyzed. Excessive intraoperative blood loss, extravasation of urine at the anastomotic site and a prior transurethral prostatic operation significantly contributed to the development of stricture. More than half of the patients did not respond to simple dilation alone. Cold knife incision of the stricture by itself was effective in only 62% of the patients. The remaining patients required periodic dilation to maintain an adequate urine flow, Incision of the stricture with electrocautery resulted in urinary incontinence in all patients. (J. Ural., 143: 755-758, 1990) Radical prostatectomy is a well accepted mode of treatment for localized carcinoma of the prostate. Several recent technical innovations have brought this procedure into the repertoire of the practicing urologist. Anastomosis of the bladder neck to the proximal urethra is an important part of this operation. The technical challenges in performing this procedure have long been acknowledged.' A less frequently discussed complication after radical prostatectomy is stricture of the anastomosis between the bladder neck and proximal urethra. These anastomotic strictures can cause significant voiding dysfunction. The risk factors for these strictures are not well defined. The strictures usually are managed by dilation. We recently encountered a group of patients with anastomotic stricture resistant to conventional therapy, which prompted us to review our experience in the management of these patients. MATERIALS AND METHODS
A total of 162 patients underwent radical retropubic prostatectomy for clinically localized carcinoma of the prostate between January 1980 and December 1988 at our medical center. In patients in whom the diagnosis was established by transurethral resection a radical operation was delayed up to a minimum of 6 weeks (mean 47.2 days, range 40 to 64 days) after resection. In patients whose diagnosis was established by needle biopsy an operation was performed after a varying delay (mean 12 days, range 4 to 48 days). The procedure was performed with the patient in a modified lithotomy position. After the prostate and seminal vesicles were removed, a direct anastomosis between the bladder neck and proximal urethra was made in all patients. A mucosa-to-mucosa anastomosis was attempted in all patients. The bladder neck, when necessary, was reconstructed with 2-zero chromic catgut suture. Care was taken to include the mucosa on the bladder neck and the urethral sides. To ensure the mucosal inclusion in the urethral sutures an indwelling catheter or a sound was used to identify the urethral lumen. Perinea! pressure was used to gain additional exposure of the urethra. In several patients the bladder mucosa was everted before placement of the sutures.2 An average of 6 sutures of 2-zero chromic catgut was used to complete the anastomosis. The sutures were placed through the urethra and bladder neck, and were tied after the catheter was placed to avoid entanglement of the sutures. A silicone catheter (20 to 24F) was used to stent the anastomosis. Accepted for publication September 18, 1989. 755
The sutures were tied to keep the knots outside the lumen. Two drains (Penrose or Jackson) were placed in the pelvis around the anastomotic site. No anastomosis was done by the Vest technique. 1 Urinary drainage varied with the preference of the surgeon. A urethral catheter alone was used in 128 patients and an additional suprapubic catheter was used in 34. In addition to the suprapubic and the urethral catheters 14 patients had bilateral ureteral catheters. Between 12 and 16 days postoperatively the integrity of the anastomosis was verified by a retrograde urethrogram around the catheter and a voiding cystourethrogram. If there was no or minimal extravasation (part A of figure) the catheters were removed. Significant extravasation was treated by continued catheter drainage until there was radiological evidence of an intact anastomosis (part B of figure). All patients were followed in the urology clinic every 3 months for continence, voiding problems and disease progression. When patients presented with voiding symptoms they were evaluated by radiographic studies and cystoscopy. Biopsies were obtained when appropriate to exclude recurrent or residual disease. In patients with anastomotic stricture dilation was done with Van Buren sounds or filiform and followers. Strictures were incised with direct vision urethrotomy or they were resected with the conventional resectoscope knife. All charts were reviewed. Cystograms were reviewed when available. In 64 patients the cystogram results were obtained from the chart review. Data expressed as proportions were analyzed with the chi-square test. Means were compared with Student's t test. RESULTS
The mean followup of all patients was 3.4 years (range 0.5 to 6.8 years). Of the 162 patients 75 were followed for more than 4 years, 36 for more than 3 years, 25 for more than 2 years and 10 for more than 1 year, while 17 were followed for less than 1 year. Three patients died within 6 months postoperatively and 3 were lost to follow up. These patients were excluded from further analysis of the data. A total of 18 patients presented with anastomotic stricture for an incidence of 11.5%. All 18 patients presented within 1 year after the radical operation: 8 within 3 months, 4 within 6 months and 6 within 1 year. All patients were continent at presentation. Cystoscopy established the diagnosis in all patients. In 2 patients cystoscopy revealed silk sutures insinuating
756
SURYA AND ASSOCIATES
A, voiding cystourethrogram 12 days after radical prostatectomy shows intact anastomosis. B, voiding cystourethrogram in different patient 12 days postoperatively documents extravasation at anastomotic site.
at the anastomotic site with associated inflammation and stricture. Biopsies were obtained in 7 patients (1 who presented within 3 months after the radical operation had a positive biopsy for recurrent and/or residual tumor). The role of potential risk factors for the development of anastomotic strictures was analyzed. Of the 72 patients who underwent prior transurethral resection 13 had anastomotic strictures, compared to 5 of 84 who did not undergo transurethral prostatectomy (p
Copyright
Vol. 143,
Printed in
1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
ANASTOMOTIC STRICTURES FOLLOWING RADICAL PROSTATECTOMY: RISK FACTORS AND MANAGEMENT BABU V, SURYA, JOHN PROVET, KARL-ERIC JOHANSON
AND
JORDAN BROWN
From Urology Service, Department of Veterans Affairs Medical Center and Department of Urology, New York University School of Medicine, New York, New York
ABSTRACT
Stricture of the anastomosis between the bladder neck and membranous urethra after radical prostatectomy can cause significant voiding dysfunction, Of 156 patients undergoing radical prostatectomy for localized prostatic carcinoma 18 had anastomotic stricture for an over-all incidence of 11.5%. The risk factors for anastomotic stricture and the treatment outcome in these patients were analyzed. Excessive intraoperative blood loss, extravasation of urine at the anastomotic site and a prior transurethral prostatic operation significantly contributed to the development of stricture. More than half of the patients did not respond to simple dilation alone. Cold knife incision of the stricture by itself was effective in only 62% of the patients. The remaining patients required periodic dilation to maintain an adequate urine flow, Incision of the stricture with electrocautery resulted in urinary incontinence in all patients. (J. Ural., 143: 755-758, 1990) Radical prostatectomy is a well accepted mode of treatment for localized carcinoma of the prostate. Several recent technical innovations have brought this procedure into the repertoire of the practicing urologist. Anastomosis of the bladder neck to the proximal urethra is an important part of this operation. The technical challenges in performing this procedure have long been acknowledged.' A less frequently discussed complication after radical prostatectomy is stricture of the anastomosis between the bladder neck and proximal urethra. These anastomotic strictures can cause significant voiding dysfunction. The risk factors for these strictures are not well defined. The strictures usually are managed by dilation. We recently encountered a group of patients with anastomotic stricture resistant to conventional therapy, which prompted us to review our experience in the management of these patients. MATERIALS AND METHODS
A total of 162 patients underwent radical retropubic prostatectomy for clinically localized carcinoma of the prostate between January 1980 and December 1988 at our medical center. In patients in whom the diagnosis was established by transurethral resection a radical operation was delayed up to a minimum of 6 weeks (mean 47.2 days, range 40 to 64 days) after resection. In patients whose diagnosis was established by needle biopsy an operation was performed after a varying delay (mean 12 days, range 4 to 48 days). The procedure was performed with the patient in a modified lithotomy position. After the prostate and seminal vesicles were removed, a direct anastomosis between the bladder neck and proximal urethra was made in all patients. A mucosa-to-mucosa anastomosis was attempted in all patients. The bladder neck, when necessary, was reconstructed with 2-zero chromic catgut suture. Care was taken to include the mucosa on the bladder neck and the urethral sides. To ensure the mucosal inclusion in the urethral sutures an indwelling catheter or a sound was used to identify the urethral lumen. Perinea! pressure was used to gain additional exposure of the urethra. In several patients the bladder mucosa was everted before placement of the sutures.2 An average of 6 sutures of 2-zero chromic catgut was used to complete the anastomosis. The sutures were placed through the urethra and bladder neck, and were tied after the catheter was placed to avoid entanglement of the sutures. A silicone catheter (20 to 24F) was used to stent the anastomosis. Accepted for publication September 18, 1989. 755
The sutures were tied to keep the knots outside the lumen. Two drains (Penrose or Jackson) were placed in the pelvis around the anastomotic site. No anastomosis was done by the Vest technique. 1 Urinary drainage varied with the preference of the surgeon. A urethral catheter alone was used in 128 patients and an additional suprapubic catheter was used in 34. In addition to the suprapubic and the urethral catheters 14 patients had bilateral ureteral catheters. Between 12 and 16 days postoperatively the integrity of the anastomosis was verified by a retrograde urethrogram around the catheter and a voiding cystourethrogram. If there was no or minimal extravasation (part A of figure) the catheters were removed. Significant extravasation was treated by continued catheter drainage until there was radiological evidence of an intact anastomosis (part B of figure). All patients were followed in the urology clinic every 3 months for continence, voiding problems and disease progression. When patients presented with voiding symptoms they were evaluated by radiographic studies and cystoscopy. Biopsies were obtained when appropriate to exclude recurrent or residual disease. In patients with anastomotic stricture dilation was done with Van Buren sounds or filiform and followers. Strictures were incised with direct vision urethrotomy or they were resected with the conventional resectoscope knife. All charts were reviewed. Cystograms were reviewed when available. In 64 patients the cystogram results were obtained from the chart review. Data expressed as proportions were analyzed with the chi-square test. Means were compared with Student's t test. RESULTS
The mean followup of all patients was 3.4 years (range 0.5 to 6.8 years). Of the 162 patients 75 were followed for more than 4 years, 36 for more than 3 years, 25 for more than 2 years and 10 for more than 1 year, while 17 were followed for less than 1 year. Three patients died within 6 months postoperatively and 3 were lost to follow up. These patients were excluded from further analysis of the data. A total of 18 patients presented with anastomotic stricture for an incidence of 11.5%. All 18 patients presented within 1 year after the radical operation: 8 within 3 months, 4 within 6 months and 6 within 1 year. All patients were continent at presentation. Cystoscopy established the diagnosis in all patients. In 2 patients cystoscopy revealed silk sutures insinuating
756
SURYA AND ASSOCIATES
A, voiding cystourethrogram 12 days after radical prostatectomy shows intact anastomosis. B, voiding cystourethrogram in different patient 12 days postoperatively documents extravasation at anastomotic site.
at the anastomotic site with associated inflammation and stricture. Biopsies were obtained in 7 patients (1 who presented within 3 months after the radical operation had a positive biopsy for recurrent and/or residual tumor). The role of potential risk factors for the development of anastomotic strictures was analyzed. Of the 72 patients who underwent prior transurethral resection 13 had anastomotic strictures, compared to 5 of 84 who did not undergo transurethral prostatectomy (p
