Management of Urethral Stenosis After Treatment for Prostate Cancer
NYU Case of the Month, August 2020
Lee C. Zhao, MD, MS
Department of Urology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
[Rev Urol. 2020;22(3):133–134]
© 2020 MedReviews®, LLC
A 70-year-old man was referred for penile urethral stricture and vesicourethral anastomotic stenosis (VUAS) after robot-assisted radical prostatectomy at an outside institution. There was no evidence of cancer recurrence, but over the past 5 years, he had had multiple episodes of urinary retention. He had received 10 endoscopic treatments for recurrent VUAS. His surgical history was also notable for bilateral inguinal hernia repair with mesh. He was placed on intermittent catheterization to maintain urethral patency, but he became unable to catheterize because of the development of the penile urethral stricture from repeated catheter trauma.
In addition to non-obliterative VUAS, the patient was found to have a 2-cm proximal penile urethral stricture.
Given the synchronous VUAS and penile urethral stricture, the patient underwent concurrent urethroplasty and VUAS repair with buccal mucosal graft (BMG). To avoid the scarred space of Retzius from bilateral inguinal hernia repair, transvesical access was obtained with a 2-cm vertical suprapubic incision. The da Vinci SP (Intuitive Surgical, Sunnyvale, CA) single-port robot was used for VUAS repair. A floating dock technique was used with the aid of a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA) to allow for improved articulation within the bladder. Simultaneously, BMG needed for repair of both the VUAS and the penile urethral stricture was harvested. The penile urethra was exposed via a penoscrotal incision. Flexible cystourethroscopy was performed, and a wire passed across the VUAS.
The VUAS was incised at 3, 9, and 12 o’clock to create a widely patent bladder neck (Figure 1). BMG was delivered into the bladder and sutured into the incised area, beginning at the most distal aspect of the stenosis (Figure 2). Concurrently, a dorsal onlay BMG penile urethroplasty was performed (Figure 3). Final cystourethroscopy demonstrated a patent urethra and bladder neck with watertight anastomoses (Figure 4), and the final closure was made.
The patient was discharged on postoperative day 1, and the urethral catheter was removed at 2 weeks. The urethra and the bladder neck were patent on outpatient flexible cystourethroscopy at 9 months.
Initial management of post-prostatectomy VUAS generally involves endoscopic treatment, including transurethral incision or balloon dilation.1 Although these procedures are often successful in restoring bladder neck patency, urologists may encounter VUAS refractory to endoscopic management. Historically, recalcitrant VUAS has been managed with a perineal or a combined open abdominoperineal technique. The disadvantages of this approach include difficult exposure, potentially necessitating pubectomy and need for extensive urethral mobilization, with nearly universal rates of subsequent stress urinary incontinence.2
Robot-assisted transabdominal VUAS repair results in significantly improved continence outcomes, as the dissection is above the level of the external urinary sphincter.3 Furthermore, if incontinence does occur, the lack of prior perineal dissection may improve artificial urinary sphincter durability. Surgical options include (1) excising the scar and performing a new vesicourethral anastomosis, (2) creating an anterior V-Y bladder advancement flap, or (3) incising the VUAS, with BMG repair.4,5
In this case, because of the patient’s prior hernia repair, a transvesical approach was used, avoiding the need for dissection of the space of Retzius and providing direct access to the VUAS. Docking the robotic platform in a floating manner permits full articulation of the robotic arms in the narrow working space, allowing for reaching the distal-most portion of the stenosis.6 The single arm of the SP system permits concurrent perineal surgery that results in decreased operative time and that would be difficult using traditional multi-port robotic systems because of the lack of space.7 This feature allowed for simultaneous treatment of the penile urethral stricture that otherwise would have had to be addressed in a staged manner.
VUAS refractory to endoscopic management can be treated successfully with a variety of robot-assisted techniques. The smaller profile of the SP platform enables transvesical surgery and simultaneous surgery at multiple locations. BMG repair via a transvesical approach avoids the potential morbidity from bowel manipulation and posterior bladder neck dissection.