Posterior urethral complications of the treatment of prostate cancer
Institute of Urology, London, UK. BJU International
(Impact Factor: 3.53).
02/2012; 110(3):304-25. DOI: 10.1111/j.1464-410X.2011.10864.x
What's known on the subject? and What does the study add?
Urethral strictures, bladder neck and posterior urethral contractures, and urorectal fistulation are three well-recognised complications of the treatment of prostate cancer, whether by surgery or non-surgical treatment. Because these are relatively rare problems the treatment is uncertain. There is a heavy reliance on endoscopic or instrumental management of urethral strictures and of bladder neck and posterior urethral contractures, and there is little discrimination in any of these conditions between those that are the result of surgery and those that are the result of radiotherapy and other treatment methods using external energy sources.
This review aims to clarify out current understanding of these three clinical problems and draws attention to the role of reconstructive surgery, particularly when dealing with bladder neck contractures, prostatic urethral stenoses and urorectal fistula. This also shows that the nature of the problem, the recovery time after treatment and the degree of functional recovery is radically different in the surgical as against the non-surgical group, to a degree that the authors believe is not sufficiently stressed when patients are counselled and consented before their primary treatment.
Available from: PubMed Central
- "Bladder neck stenosis (BNS) is a known complication of prostatectomy, prostate radiotherapy, and transurethral resection of the prostate (TURP) . Although the majority of patients can be treated successfully with one to two endoscopic procedures, approximately 27% develop refractory bladder neck stenoses requiring multiple and increasingly complex treatments, potentially culminating in open reconstruction     . Many go on to require intermittent selfdilation to avoid major reconstruction, which has been shown to decrease quality of life . "
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ABSTRACT: . To determine the efficacy of bipolar transurethral incision with mitomycin C (MMC) injection for the treatment of refractory bladder neck stenosis (BNS).
Materials and Methods
. Patients who underwent bipolar transurethral incision of BNS (TUIBNS) with MMC injection at our institution from 2013 to 2014 were retrospectively reviewed. A total of 2 mg of 40% mitomycin C solution was injected in four quadrants of the treated BNS. Treatment failure was defined as the need for subsequent intervention.
. Thirteen patients underwent 17 bipolar TUIBNS with MMC injection. Twelve (92%) patients had failed a mean of 2.2 ± 1.1 prior endoscopic procedures. Median follow-up was 16.5 months (IQR: 14–18.4 months). Initial success was 62%; five (38%) patients had a recurrence with a median time to recurrence of 7.3 months. Four patients underwent a repeat procedure, 2 (50%) of which failed. Overall success was achieved in 77% (10/13) of patients after a mean of 1.3 ± 0.5 procedures. BNS recurrence was not significantly associated with history of pelvic radiation (33% versus 43%,
). There were no serious adverse events.
. Bipolar TUIBNS with MMC injection was comparable in efficacy to previously reported techniques and did not result in any serious adverse events.
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To characterize conservative management of urorectal fistulae (URF).
URF are a recognized but rare complication of treatments for prostate and rectal cancers. URF can lead to incontinence, fecaluria, pain, urinary infection, and sepsis, and thus are usually treated surgically. We present a series of 3 patients whose complex URF were managed conservatively. Between 2004 and 2010, 43 patients were diagnosed with URF resulting from treatment for prostate or rectal cancer. All patients were evaluated and offered surgical treatment; 40 patients elected surgical therapy, and 3 patients chose conservative, nonoperative management of the URF. The primary outcome was the patient choosing or needing formal surgical URF closure. Because this was not a comparative study, no formal statistical analysis was undertaken.
The 3 patients have been regularly monitored and have required symptomatic and episodic care. None, however, has opted for formal surgical fistula repair, and to date, all continue in conservative management of their URF.
Spontaneous URF closure is uncommon and is unknown to occur in complex URF. Surgery is the mainstay of treatment. Patients should consider treatment options, potential outcomes, and their quality of life when choosing or not choosing treatment. The applicability and durability of conservative management of URF remains unclear.
Available from: Martin Schostak
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In patients with low-risk prostate cancer (PCa) the standard therapies carry a risk of overtreatment with potentially preventable side effects whereas restrained therapeutic strategies pose a risk of underestimation of the individual cancer risk. Alternative treatment options include thermal ablation strategies such as high-intensity focused ultrasound (HIFU).
Patients and methods:
96 patients with low-risk PCa (D'Amico) were treated at 2 HIFU centres with different expertise (n=48, experienced centre Lyon/France; n=48 inexperienced centre Charité Berlin/Germany). Matched pairs were formed and analysed with regard to biochemical disease-free survival (BDFS) as well as postoperative functional parameters (micturition, erectile function). The matched pairs were discriminated as to whether they had received HIFU treatment alone or a combination of HIFU with transurethral resection of the prostate (TURP). Patients of the Lyon group were retrospectively matched through the @-registry database whereas patients of the Berlin group were prospectively evaluated. In the latter patients quality of life assessment was additionally inquired.
Postoperative PSA-Nadir was lower in the Berlin group for patients with HIFU only (0.007 vs. Lyon 0.34 ng/ml; p=0.037) and HIFU+TURP (0.25 vs. Lyon 0.42 ng/ml; p=0.003). BDFS was comparable in both groups for HIFU only (Berlin 4.77, Lyon 5.23 years; p=0.741) but patients with combined HIFU+TURP in the Berlin group showed an unfavourable BDFS as compared to the Lyon group (Berlin 3.02, Lyon 4.59 years; p=0.05). In an analysis of Berlin subgroups especially patients who had received HIFU and TURP (n=4) within the same narcosis had an unfavourable BDFS (p=0.009). Median follow-up was 3.36 years for HIFU only and 2.26 years for HIFU+TURP. Neither HIFU only (p=0.117) nor HIFU+TURP (p=0.131) showed an impact on postoperative micturition. Erectile function was negatively influenced (HIFU: p=0.04; HIFU+TURP: p=0.036). There was no measurable change in quality of life after the treatment.
The 4-year BDFS after HIFU and HIFU+TURP is comparable to that of the standard therapies. The erectile function is sustainably negatively influenced whereas postoperative micturition and quality of life were not affected by HIFU or HIFU+TURP. These results are strongly limited by the low patient count and the short follow-up period and require validation in prospective multicentre studies with higher number of cases.
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