Abstract: PD29-07
Sources of Funding: none

Introduction

BNC are thought to occur in approximately 0.4-32% of patients after radical prostatectomy (RP). The majority are managed endoscopically but a small number are refractory to all forms of treatment. This study describes our experience in this group of patients.

Methods

42 patients, aged 49 - 76 (mean 63.5 years) presented with refractory BNC between March 07 and March 15. 32 had a RP alone. 10 had RP and adjuvant or salvage radiotherapy. Because of our previous experience in treating patients with urorectal fistulae, patients having revision of their vesico-urethral anastomosis with a history of radiotherapy were very carefully selected and only those with a bladder capacity of at least 200ml and with relatively normal urodynamic parameters were selected for reconstruction. All surgery was performed through a transperineal approach as for a pelvic fracture-related urethral injury. All patients required full mobilisation of the bulbar urethra, opening of the inter crural plane and an inferior wedge pubectomy. An artificial sphincter (AUS) was implanted 3 to 6 months later to restore continence.

Results

Of the 32 post-surgical patients 31 (97%) had a successful outcome. 3 of these had a simultaneous repair of a urorectal fistula (9%). Of the 10 patients who had had radiotherapy, 7 had a patent anastomosis and 6 (60%) of these were dry following implantation of an AUS. 1 other patient had 4 consecutive sphincter implants all of which eroded. 1 patient developed a re-stenosis and was managed thereafter by suprapubic catheterisation. Two had incomplete healing of their anastomosis and developed a urosymphyseal fistula and unfortunately were subsequently worse off as a result of their surgery.

Conclusions

Patients with a recalcitrant BNC after RP with no history of radiotherapy can be treated as with any other traumatic urethral stenosis – in this instance iatrogenic trauma by revision of the vesico-urethral anastomosis. The results are very satisfactory. With careful selection some patients who have had radiotherapy can be treated in the same way but there should be careful evaluation of the state of the pubis and pubic symphysis preoperatively as well as careful urodynamic evaluation of the bladder function, to avoid the very poor outcome in patients who fail such surgery. _x000D_ _x000D_ All patients must be counseled that this will almost certainly be a two-stage reconstruction - the first to dis-obstruct them by revision of the VUA and then secondly to implant an AUS for the almost (but not necessarily) inevitable sphincter weakness incontinence following dis-obstruction. _x000D_

Funding

none