Elsevier

Urology

Volume 118, August 2018, Pages 227-233
Urology

Reconstructive Urology
Patency and Incontinence Rates After Robotic Bladder Neck Reconstruction for Vesicourethral Anastomotic Stenosis and Recalcitrant Bladder Neck Contractures: The Trauma and Urologic Reconstructive Network of Surgeons Experience

https://doi.org/10.1016/j.urology.2018.05.007Get rights and content

Objective

To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates.

Materials and Methods

Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence.

Results

Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement.

Conclusion

RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.

Section snippets

Materials and Methods

We utilized the TURNS database as our data source. TURNS is a multi-institutional group of fellowship-trained reconstructive urologists focused on advancements in the field of genitourinary trauma and reconstruction with a prospectively maintained database.

Patients with a BNC or VUAS resulting from endoscopic prostate surgery (transurethral resection of prostate or photoselective vaporization of the prostate) or open or robotic prostatectomy who underwent RBNR were identified. As both pelvic

Results

Between 2015 and 2017, a total of 6 institutions with a single surgeon had patients that met inclusion and exclusion criteria, for a total of 12 patients. The surgeons varied in their number of cases performed. One surgeon performed 4 cases, 3 surgeons performed 2 cases while 2 surgeons performed a single case. Table 1 includes baseline patient characteristics and preoperative variables. In our series, the etiology of 7 rBNO was an endoscopic prostate procedure, while the other 5 had an open or

Comment

RBNR is a safe alternative for the treatment of rBNO with an acceptable risk of intraoperative and postoperative complications. We found a success rate of 75%, defined by the ability to successfully pass a 17 Fr cystoscope into the bladder or uroflow rate >15 ml/sec. Compared to the expected total incontinence for the perineal approach, only 18% of patients in this series experienced >1 pad per day incontinence after reconstruction if they were continent preoperatively. RBNR is a reasonable

Conclusion

rBNO is a difficult entity to treat, with nearly total incontinence after repair via the perineal approach. Robotic bladder neck contracture repair is a viable surgical option with a high patency rates and improved incontinence rates. If future incontinence procedures are needed, their outcomes may be improved.

References (30)

Cited by (51)

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    Citation Excerpt :

    The aforementioned techniques are significantly easier to perform with the working space of the SP platform, which facilitates dissection and suturing under the pubic bone and allows for concurrent endoscopic or transperineal manipulation. In terms of patency and continence, the short and mid-term outcomes reported thus far are highly encouraging,23 though these patients should be counseled on the possible need for adjunct procedures to restore continence including slings or artificial urinary sphincters. Crucially, if a perineal dissection can be avoided, long-term durability and continence may be improved.

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Financial Disclosure: The authors declare that they have no relevant financial interests.

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