Posterior urethral stenosis: Contemporary management options

Abstract

Posterior urethral stenosis (PUS) is a known complication following prostate cancer treatment as well as other benign endoscopic treatments. Patients with PUS often fail initial endoscopic treatments and have persistent symptoms negatively affecting quality of life. In the past decade, a variety of different surgical techniques and approaches have changed the landscape of PUS management. The goal of this review is to provide details on the historical, current, and future direction of the surgical management for PUS.

Keywords

bladder neck contracture / posterior urethral stenosis / vesicourethral anastomotic stricture

1 INTRODUCTION

Posterior urethral stenosis (PUS) is a challenging urological condition characterized by the narrowing of the posterior urethra, which leads to obstructive urinary symptoms. Nontraumatic PUS encompasses both bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). In BNC, the prostate is in situ and there is stenosis of the proximal prostatic urethra or bladder neck. VUAS refers to stenosis that occurs specifically after radical prostatectomy (RP) at the anastomosis of the urethra and the bladder. PUS is an encompassing term referring to any stenosis of the bladder neck to the distal end of the membranous urethra[1].

Each year in the USA, 65 000–90 000 RPs and 126 000–150 000 transurethral resections of the prostate are performed[2]. VUAS occurs in 3%–10% of men following RP[3], while BNC occurs in 3%–12% following transurethral resections of the prostate[4]. This means approximately 1950–9000 men develop VUAS and 3780–18 000 men develop BNC each year. The incidence of stenosis after primary external beam radiation therapy or brachytherapy alone for prostate cancer is 2%–15%[5].

PUS can pose significant morbidity and negatively impact patients' quality of life because treatment is challenging, and it usually unmasks severe stress incontinence that is distressing for patients. Stress incontinence should be treated until the stenosis is stabilized. Hence, understanding its etiology, natural history, risk factors, and management strategies is crucial for effective clinical intervention.

2 METHODS

A narrative review of the literature regarding the etiology, management, and outcomes of PUS was conducted using PubMed, Embase, Google scholar, and targeted search of international urological guidelines.

3 RESULTS

3.1 Etiology

PUS typically arises from trauma, inflammation, or iatrogenic causes. BNC may stem from instrumentation of the bladder neck, transurethral resection of the prostate, or prostate radiation/brachytherapy. Trauma, particularly, pelvic fractures, is a common precipitating factor, leading to disruption and subsequent scarring of the urethra[6]. Inflammatory conditions such as urethritis and balanitis xerotica obliterans also contribute to urethral narrowing[7]. Patient risk factors for PUS include cigarette smoking and coronary artery disease[8]. Postoperative complications such as prolonged urine leak and pelvic hematoma increase the risk of recurrence[9]. Advancements in surgical methods as well as technique with robotic assistance have contributed to a decline in the incidence of PUS[10]. A prospective study published in 2019 found a VUAS incidence of 1.3% after 24 months of follow‐up in the group receiving robotic‐assisted‐RP compared to open RP which yielded a 2.2 times higher incidence of VUAS[11]. Long‐term sequelae of PUS may include acute and chronic renal impairment and urinary retention, highlighting the importance of timely diagnosis and intervention.

3.2 Evaluation

The evaluation for suspected PUS should include a detailed history, physical exam, assessment of postvoid residual (PVR) urine, and evaluation of the length and caliber of the defect. The etiology and history of prior treatments are important to delineate. Furthermore, the history should depict the impacts of PUS on the patient. Adjunctive imaging such as a retrograde urethrogram or voiding cystourethrogram can ascertain the anatomy of stenosis. Additional evaluation may include urinalysis, prostate‐specific antigen testing, and urodynamics analysis.

3.3 Management

3.3.1 Endoluminal

For nonobliterative stenoses, endoluminal management is the primary treatment recommended by the Société Internationale d'Urologie[12]. Similarly, the American Urological Association (AUA) urethral stricture guidelines state “Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure”[13]. The exception is obliterative stenoses. For obliterative stenoses, clinicians should consider upfront open or robotic reconstruction as blind “cut to the light” procedures have a high failure rate and potential for rectal injury[14]. Endoluminal management of PUS may include dilation, endoscopic incision, or resection of stenosis, and repeat treatments may be needed for successful treatment of the same[15]. There are no prospective comparative studies evaluating the outcomes of different endoluminal procedures. Dilation of a VUAS can be performed with sequential dilators or balloon dilation with varying success rates of 50%–80% for the first‐time treatment[16,17]. Endoscopic incision of PUS is classically performed at 3 and 9 o'clock positions, though varying locations are depending on clinician preference[15,18]. Generally, the 6 and 12 o'clock positions are avoided due to risk of rectal injury and urosymphyseal fistula respectively[19,20]. There are a variety of different incision modalities to include cold knife, “hot” knife, and Holmium laser[21]. Patency after the first cold or “hot” knife direct vision internal urethrotomy ranges from 53% to 71%[9]. Patency after the first Holmium incision ranges from 50% to 100%[22]. Resection of VUAS and bladder neck stenosis yields similar success to bladder neck incision but is associated with a lower rate of de novo incontinence[23]. De novo incontinence is approximately 10% in studies that captured pre‐endoluminal continence status[24]. Injection of antifibrotic agents with stenosis incision or resection is proposed to stabilize the urethral stenosis and subsequently reducing the risk of recurrence[25]. Corticosteroids and mitomycin C are two intralesional agents that are associated with patency rates between 50% and 95% in nonradiated patients[26–28]. The dose of mitomycin C to be injected is 0.4 mg/cc, injecting 1–2 cc/site. Endoluminal approaches are well‐established within the armamentarium of the general urologist. However, the role of proceeding with additional endoluminal treatment in recalcitrant PUS is debated.

3.3.2 Transurethral incision with transverse mucosal realignment

Abramowitz et al. described a novel minimally invasive technique for managing PUS. With a cystoscopic incision of the VUAS or BNC followed by transurethral suture using a laparoscopic suture device and an off‐set cystoscope they brought healthy mucosa across the defect—performing a cystoscopic V‐Y plasty in effect[29]. In the 19 patients in this series with more than 4 months of follow‐up, urethral patency was achieved in 89% after one procedure and 100% after two procedures. There were no significant complications, particularly, no new onset of urinary incontinence. Curiously, there was no significant change in International Prostate Symptom Score and PVR following surgery and longer‐term outcome data and multi‐institutional trials are ongoing to verify these published results.

3.3.3 Stent

Historically, urethral stents were employed in the management of PUS to facilitate urinary flow. The Allium stent has been reported to be inserted into the posterior urethra of a patient during RP to achieve immediate widening of the occlusion and maintain good passage of urine flow[30]. The use of the Memokath^®045 bladder neck stent involves a two‐stage procedure. First, an incision of the PUS to 30 French and then placement of the Memokath^®045 bladder neck stent for 1 year. After a follow‐up period of 1 year, patients yielded a 93% efficacy rate in managing patients with VUAS following RP with the Memokath^®045[31]. The in‐dwelling urethral stents have since been proven to be a poor solution leading to severe fibrosis and encrustation that is very challenging to treat, and are hence not routinely employed anymore.

3.4 Open surgery

In cases where endoscopic treatment fails to treat nontraumatic PUS, posterior urethral reconstructive surgery is an excellent option for patients willing and fit to undergo surgery[13,14,32]. Open repair options most commonly include abdominal, perineal, and abdominoperineal approaches[15,33]. The approach should be individualized to the patient as no approach fits all posterior urethral stenoses.

The principles of posterior urethral stricture repair include maintaining robust blood flow to the anastomosis and graft if used, and a tension‐free, water‐tight anastomosis. Prior to surgical intervention, the etiology, length, and location of the PUS should be considered for surgical planning. If an open perineal approach is chosen, a standard or high‐lithotomy position is used. This approach allows the surgeon to utilize a virgin surgical space if the patient has had prior abdominal surgery like in the case of treating a VUAS. A step‐wise perineal approach was popularized by Webster and Ramon[6]. The step‐wise maneuvers include bulbar urethral mobilization, crural separation, inferior pubectomy, and supracrural rerouting[34]. The length and location of the proximal urethral stenosis will dictate the need to progress from one step to the next. Exposing the bulbar urethra can be done using a midline incision extending from the perineoscrotal junction to at least 1 cm proximal to the anal verge or using a lambda incision and then dividing the bulbospongiosus muscle[35]. The proximal bulbo‐membranous urethra is mobilized free from the perineal body and proximally to the point of stenosis. The urethra is transected at this point and the scar tissue is excised. The proximal urethra is then dissected until adequate circumferential mucosa is evident. The proximal and distal urethra should be spatulated on opposing sides and a tension‐free anastomosis made with absorbable suture as is typical in an exicison and primary anastomosis. If a tension‐free anastomosis cannot be achieved, corpora cavernosa can be separated in the midline, also known as the elaborated perineal approach, to reroute the distal end of the urethra more directly to the proximal urethral end[6]. If the anastomosis is still under tension, an inferior wedge or partial pubectomy can be performed to directly route the distal urethra towards the proximal defect. The extent of pubectomy has shifted from total to partial pubectomy when necessary to avoid complications such as gait disturbance, cosmetic deformity, and increased blood loss[33,36,37]. Supracrural rerouting involves rerouting the urethra around the left corporal body, swinging the distal urethral end underneath the corporal body directly onto the proximal urethral end. These maneuvers eliminate the curved route that the normal bulbar urethra takes into a straight line. In the modern urethral reconstruction era, supracrural rerouting is rarely used due to high reported failure rates of up to 82%[38]. When additional mobilization of the bladder and proximal urethra are required, an abdominoperineal approach may be required[39]. Following RP or pelvic radiation, the bladder neck and surrounding tissue may be significantly scarred preventing adequate mobility from a pure perineal approach. It is suggested that posterior urethral strictures of >2 cm is more likely to require a combined abdominoperineal approach[40]. Superior pubectomy can be used as well to expose the proximal urethral stenosis and assist in the caudal mobilization of the bladder.

Substitution urethroplasty using oral mucosa graft is an invaluable tool for the reconstructive urologist. Both ventral and dorsal buccal mucosal onlay techniques have excellent postoperative patency rates in the treatment of PUS[41,42]. While radiation certainly affects the tissue quality in reconstructive surgery, the use of buccal mucosa grafts has been shown to have similar outcomes in both radiated and nonradiated patients[43,44].

In the case of a short BNC or even some cases of VUAS, a V‐Y plasty with a bladder flap can be utilized[33]. This technique utilizes a pure abdominal approach. The stenotic area is approached anteriorly, and the stricture is opened longitudinally. A V‐shaped bladder flap is then advanced into the longitudinal incision which widens the circumference of the urethra. Given the importance of supple and well‐vascularized tissue for this technique, surgeons should select patients without a history of pelvic radiation[45]. A T‐plasty may be required if a larger defect is created from extensive scar tissue resection[46]. A longitudinal incision is made along the anterior bladder midline which creates two bladder flaps that can be advanced into the bladder neck defect and closed in a V‐shaped fashion.

The perineoscopic bladder neck reconstruction technique combines an open perineal incision with robotic optics. Notably, the technique eliminates the need for expanded dissection usually needed for visualization during traditional open surgery because the surgeon can view the surgical field on a screen like in laparoscopic surgery. Overall success at one institution using this technique for VUAS management was 81.25% success rate achieved[47]. Further prospective studies are needed to define the role of this technique in posterior urethral reconstruction.

Successful outcome after PUS reconstruction is defined as the lack of evidence of recurrent stricture which requires further treatment[48]. Open surgery has a high success rate of 70%–100%[49,50]. The perineal approach is associated with higher incontinence rate postoperatively compared with a retropubic approach. Studies report an 83% incontinence rate after perineal reconstruction and a 10% incontinence rate after the retropubic approach[51]. This is likely due to the trans‐sphincteric mobilization of the urethra that occurs with a perineal approach[52]. As such, patients should be counseled that PUS reconstruction may require two surgeries: one to unobstruct the urethra and another to address postoperative urinary incontinence.

3.5 Robotic surgery

One of the many challenges of posterior urethral reconstruction is optimizing visualization and repair in deep and narrow spaces. Progressive steps in the transperineal approach such as pubectomy to optimize visualization during open surgery are associated with complications such as increased intraoperative blood loss, urethrocutaneous fistula, and wound infections[53]. Morbidity from open surgery techniques can potentially be mitigated while improving intraoperative visualization using robotic assistance[54,55]. Transabdominal posterior urethral reconstruction can be performed using the well‐perfused bladder mucosa as a flap and can be ergonomically better for the surgeon. Robotic port placement is a standard pelvic configuration. Single‐port robotic reconstruction in a transvesical fashion has also been described[54]. In cases of urethral obliteration, if circumferential dissection is possible an anastomotic urethroplasty can be performed similar to the transperineal technique. If dystrophic calcification and necrosis are noted, the surgeon should rule out osteomyelitis of the pubic symphysis with a magnetic resonance imaging of the pelvis. Once ruled out, the dissected segment must be resected, the bladder neck (with poor blood supply) closed and a neovesicourethral anastomosis created. Buccal mucosa and a bladder advancement flap can be used for augmented anastomoses[56]. If the distal extent of urethral stenosis cannot be accessed, a perineal dissection can be combined with the robotic approach[54]. Another reported benefit of using robot assistance is the preservation of urinary continence[57]. Series evaluating outcomes or robotic posterior urethral reconstruction of BNC and VUAS report patency of 75%–100% with up to 2 years of follow‐up and 71%–82% urinary continence[58,59]. The patient should, of course, always be counseled on the risk of urinary incontinence and the need for a secondary procedure if this were to happen. When outlet reconstruction fails, the last line of treatment for recurrent PUS is urinary diversion.

3.6 Future research

As the use of robotic surgery for PUS becomes more prevalent, long‐term data will provide more granularity to surgical and quality‐of‐life outcomes. Furthermore, the role of immediate robotic reconstructive intervention in vesicourethral anastomotic leak (VUAL) may change the natural history of this feared complication[60]. Long‐term data is needed to further define the role of robotic surgery in the management of VUAL. While the principles of managing PUS withstand the test of time, the development of minimally invasive techniques will continue to add to the armamentarium of the reconstructive urologist in the management of this challenging disease. Optilume^® drug‐coated balloon dilation has shown durable 3‐year success in patients with short, recurrent bulbar urethral strictures[61]. Optilume^® drug‐coated balloon dilation in patients with recurrent post‐TURP bladder neck stenosis may offer a promising endoluminal alternative[62]. An interesting avenue for PUS research centers around transurethral suturing, which provides a new approach to performing an anastomosis of the urethra to the bladder following prostatectomy[63]. Future research is necessary to determine the effectiveness, safety, and time efficiency of small intraluminal anastomotic devices.

4 CONCLUSION

Nontraumatic PUS is an uncommon disease process that typically arises as a complication of prostate cancer treatment or benign prostatic disease. The patient must be cautioned about the unmasking of new‐onset severe stress incontinence that usually follows the treatment of PUS. The armamentarium to treat PUS is vast but must be tailored to the individual patient and the skillset of the clinician.

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