Incidence of Bladder Neck Contracture

Bladder neck contracture is a common occurrence after prostate surgery. The most common surgical causes are radical prostatectomy for prostate cancer and transurethral prostate surgery for benign prostatic enlargement (BPE). In a recent Surveillance Epidemiology and End Results (SEER)–Medicare analysis the cumulative incidence of bladder outlet obstruction after radical prostatectomy was 5% greater than that of controls and 12% higher for men who were also receiving adjuvant or salvage radiotherapy after radical prostatectomy. These findings are similar to those of other large population-based studies of prostate cancer treatment complications, in which the cumulative need for either internal urethrotomy or incision of bladder neck contracture after radical prostatectomy was 7.5% to 8.4%. The advent of robotic-assisted radical prostatectomy and the ability to perform continuous and precise suturing of the vesicourethral anastomosis has been shown in some single-center studies to decrease the rate of bladder neck contracture, whereas in other studies this has not been shown to be true.

Transurethral prostate surgeries for BPE also can result in bladder neck contracture. A recent meta-analysis of 31 trials comparing monopolar with bipolar transurethral resection of the prostate (TURP) reported a pooled 3.5% incidence of bladder neck contracture. Incontinence after TURP is rare, but in some studies of AUS placement that reported on patients with mixed causes of incontinence, post-TURP incontinence was the reason for implant in 7.5% to 18.5% of cases.

Endoscopic Management of Bladder Neck Contracture

The first-line treatment of bladder neck contracture, regardless of its cause, is generally endoscopic management. Some studies show that endoscopic management is successful in greater than 80% of bladder neck contractures with a single transurethral incision of the bladder neck (TUIBN). A recent analysis of SEER-Medicare data for the burden of bladder outlet obstruction in men after treatment of prostate cancer showed at a median of 8.8 years that 56% of men required only 1 procedure for bladder neck contracture. More recent studies have focused on recalcitrant bladder neck contractures that have not responded to initial endoscopic management, and the success of further endoscopic interventions before AUS placement. The Lahey Clinic published a recent small series of men undergoing treatment of bladder neck contracture with intralesional injection of mitomycin C at the time of TUIBN. They found very high success (72%) at a median follow-up of 12 months with this approach despite most of the men having failed prior endoscopic management. The Trauma and Urologic Reconstruction Network of Surgeons (TURNS; TURNSresearch.org ) subsequently published a retrospective case series of men undergoing treatment of bladder neck contracture with mitomycin C injection. The study had major limitations because there were a variety of mitomycin C doses and endoscopic techniques. However, the strength of the study was a strict criterion for anatomic success based on cystoscopic examination. They found a lower success rate of 58% at a median follow-up of 9.2 months compared with the Lahey Clinic study; however, because of restricting follow-up to men with cystoscopic examination only, asymptomatic recurrences were detected, thus decreasing the overall apparent success. Other contemporary studies report similar or better outcomes to the TURNS study with endoscopic management alone (no injection). These studies vary by follow-up protocols and reporting of how many procedures were required, but the successful resolution of bladder neck contracture with endoscopic management was 72% to 73%. These study results are summarized in Table 1 . In all of these recent studies, investigators emphasize the need for a deep incision to perivesical fat with either a urethrotomy or Collins hot knife ( Fig. 1 ). Some factors that influenced the success of the procedure were smoking and 2 or more previous failed endoscopic procedures.

Deep incisions up to the level of the capsule and or perivesical fat are essential to successful endoscopic resolution of bladder neck contracture.

A recent white paper released from the AUS consensus group, sponsored by the International Continence Society, suggested a balanced and reasonable treatment algorithm for bladder neck contracture before AUS placement. The group suggested that men undergo standard TUIBN or dilation; if this fails they should have aggressive endoscopic management of the contracture. If endoscopic management fails to resolve the bladder neck contracture or there was complete urethral obliteration, then open urethral reconstruction should be performed.

Another management strategy for bladder neck contracture before treatment of incontinence with AUS implantation is use of a urethral stent. The UroLume endoprosthesis or stent (American Medical Systems, Minnetonka, MN) was an expandable metal stent that was recently withdrawn from the market by AMS. The intention of the UroLume was to expand to about 30 French and then epithelialize and incorporate into the wall of the urethra, serving as an alternative to urethroplasty. The initial results were promising for the treatment of urethral strictures, but longer-term experience revealed that patients often had worsening progressive stricture at either end of the UroLume, obstruction of the stent with fibrosis, and very poor patient satisfaction. In addition, subsequent urethroplasty was significantly more complicated after UroLume placement. The UroLume stent was also used for a variety of other indications, including the treatment of BPE, detrusor sphincter dyssynergia, and recalcitrant bladder neck contracture.

Several centers were proponents of treatment of recalcitrant bladder neck contracture with placement of the UroLume stent. Even though the UroLume is off the market and there are currently no alternative urethral stents available in the United States, management of urethral strictures in the setting of a UroLume stent warrants discussion because there are still many patients with these in place. The University of California, San Francisco (UCSF) reported the use of the UroLume for treatment of posterior urethral stricture (including bladder neck contracture) in 2007, mostly in patients after radiation therapy for prostate cancer, and noted that although there was a high intervention rate for restenosis and stent obstruction, the stent only had to be removed in 15% of patients. The ability to successfully manage posterior urethral restenosis was in contrast with stent obstruction in the anterior urethra, where the stents almost always had to be removed in a urethroplasty to prevent restenosis. The investigators updated their series in 2010 and found that in 38 men with obstruction of the posterior urethra the success was only 47%, with the remaining 53% of men requiring 1.6 procedures each with only 2.3 years of average follow-up. In an editorial in Journal of Urology, investigators from UCSF concluded that, “In our experience open surgical reconstruction is superior to UroLume stenting in patients with a reasonable life expectancy, and favorable cancer and health status.”

Other centers also reported a similar rate of resolution of bladder neck contracture and/or urethral stenosis after UroLume. Duke reported a 53% rate of resolution of stenosis at an average of 55 months of follow-up with the UroLume, but the investigators had to perform an average of 2.4 procedures in patients with restenosis or ingrowth of the urethral stent. Mayo clinic reported almost exactly the same results in 25 men: 52% stabilization of bladder neck contracture after a first procedure at a median follow-up of 2.9 years. Although this is largely a moot point because the UroLume stent is no longer available, the contemporary concerns associated with the UroLume are worsening of the stricture and inflammatory process, which can lead to chronic (in some cases debilitating) discomfort in the perineum, intractable irritative bladder symptoms, and inability to subsequently reconstruct the lower urinary tract after UroLume placement.

Incontinence Rates After Treatment of Bladder Neck Contracture

Incontinence rates can be very high after treatment of bladder neck contracture, especially in men after radical prostatectomy and in patients with recalcitrant contractures. First-time treatment of bladder neck contracture may not carry nearly as much risk of incontinence, with 83% of patients reporting no problems or very slight problems with urinary leakage. Subsequent treatment of recurrent contractures has a much higher risk because the bladder neck contracture often occurs essentially within the membranous sphincter. It is paramount that patients are warned about this eventuality with treatment of the contracture. In recent reports on the treatment of recalcitrant contractures, the rate of AUS placement for incontinence varied and preoperative incontinence was often not quantified (see Table 1 ). There was a 56% to 100% rate of AUS placement in these studies. However, AUS placement as a proxy for postoperative incontinence probably underestimates the problem substantially because many men in whom TUIBN failed may still be incontinent (leaking essentially through a fixed strictured area). Because of recurrent contracture these incontinent men may not be candidates for AUS placement and thus the rates of overall incontinence in these studies may be even higher.

Placement of Artificial Urinary Sphincter After Endoscopic Treatment of Bladder Neck Contracture

Establishing the stability of the bladder neck or strictured area is essential before placement of an AUS, because, after AUS placement, further endoscopic management can be limited and lead to an AUS complication. How long to wait before placement of an AUS is not well understood. In some cases, bladder neck contractures can recur very slowly over time and most men do not tolerate prolonged waiting periods, such as a year, which would be required to safely identify all recurrences before treatment of their incontinence. The endoscopic appearance of the bladder neck after TUIBN and the surgeon’s judgment about healing in the area is probably the best guide. Those contractures that occur without a history of pelvic irradiation and are well healed without contracture ( Fig. 2 ) probably can have placement of an AUS at 3 months, whereas those patients with necrosis, poor healing, or a history of radiotherapy probably warrant a longer observation time.

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