Management of Bladder Neck Contracture in the Prostate Cancer Survivor

Introduction

Bladder neck contracture (BNC) is an infrequent but commonly recognized complication encountered by the urologist in patients following prostate surgery. While the number of patients seeking surgery or radiation therapy for prostate cancer has increased in the prostate-specific antigen (PSA) era, the number of bladder neck contractures has decreased due to advancements in surgical methods and the introduction of robotic surgery. Nonetheless, there exists a small population of patients who will seek treatment for symptomatic bladder neck stricture. A large number of these will be managed nonoperatively with success, while others may require minimally invasive or endoscopic efforts. Even still, a minority will develop complex, refractory disease, and it is this population for whom a defined treatment strategy remains elusive. Here, the natural history of bladder neck contracture in the prostate cancer survivor is presented along with established treatment modalities for uncomplicated patients. In addition, a recently published, novel experience with a hybrid balloon dilation and transurethral incision approach for the standard treatment of BNC is reviewed. Finally, options for refractory cases are discussed including novel therapies for the management of this complex condition.

Epidemiology and pathophysiology

Treatment for prostate cancer is ultimately the most common etiology of BNC. However, BNC is not a uniform phenomenon and can exist subsequent to a multitude of pathophysiologic mechanisms depending on the primary treatment modality that preceded it. For example, patients with a history of pelvic radiation therapy for prostate cancer may develop BNC as a result of tissue necrosis and fibrosis secondary to obliteration of the microvasculature supplying the bladder neck. This process usually occurs for years before the establishment of symptomatic stricture. On the other hand, patients treated with surgery for prostate cancer may develop BNC a mere months after intervention due to increased blood loss or technical issues preventing the operator from achieving the desired tension-free, water-tight vesicourethral anastomosis. Foreign bodies, such as hemostatic clips placed at the time of surgery and/or undissolved suture material, may act as a nidus for fibrosis at the anastomosis as well. The era of robotic prostate surgery has alleviated many of these procedural confounders, offering the surgeon a more unobstructed view of the working anastomosis, broader range of motion, and a drier operative field. In addition, the adoption of a running vesicourethral anastomosis, often employed in robotic surgery and rarely employed in the open approach, has been credited with a more reliable mucosal approximation necessary for a water-tight seal. As a result, the incidence of BNC has decreased from rates as high as 32% in some open prostatectomy series toward zero in many reports utilizing a minimally invasive approach.

However, BNC still affects upward of 30% of patients receiving salvage prostatectomy following radiation therapy, and perhaps the most devastated patients are those who undergo multimodal treatment with brachytherapy followed by either salvage radiation or surgery. BNC is a documented complication following surgery for benign disease states as well, such as benign prostatic hyperplasia (BPH), and the urologist must suspect this condition in active surveillance prostate cancer patients undergoing bladder outlet reduction surgery. Conventional transurethral resection of the prostate (TURP) has been shown to offer a higher risk of developing postoperative BNC (1–12.3%) compared with newer modalities such as KTP-laser prostatectomy (3–5%).

Patient demographic factors and behaviors also contribute to risk for developing BNC. Borboroglu et al. conducted a multivariable analysis on 52 patients who underwent retropubic prostatectomy. Diabetes mellitus, coronary artery disease, and smoking were all positive predictors of BNC. The experience reported by Ramirez et al. substantiated the link between BNC and smoking in patients with recurrent bladder neck stricture who smoked greater than 10 pack-years and underwent deep lateral transurethral incision of the bladder neck. Age and BMI were also associated with BNC occurrence requiring interventions when the Cancer of the Prostate Strategic Urologic Research Endeavor database was queried in a recent analysis.

Management of BNC