Management of Urethral Stenosis after Treatment for Prostate Cancer
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Department of Urology
Case of the Month
Management of Urethral Stenosis
after Treatment for Prostate Cancer
CASE PRESENTATION
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 last 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 in an effort to maintain urethral patency, but he became unable to catheterize
because of the development of the penile urethral stricture from repeated catheter trauma.
EVALUATION AT NYU LANGONE HEALTH
In addition to non-obliterative VUAS, the patient was found to have a 2 cm proximal penile
urethral stricture.
MANAGEMENT
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, California) 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, California) 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.
DC 10/2/2020
CASE OF THE MONTH
Figure 1. Dorsal 12, 3, and 9 o’clock incisions of the Figure 2. BMG sutured into place to widen the bladder neck.
VUAS performed.
Figure 3. Dorsal onlay BMG urethroplasty for proximal Figure 4. Cystourethroscopy demonstrating patent urethra
penile urethral stricture performed via penoscrotal incision. and watertight anastomosis.
FOLLOW-UP
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.
COMMENT
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
DC 10/2/2020
CASE OF THE MONTH
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, which results in decreased
operative time and which 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,
which otherwise would have had to be addressed in a staged manner.
CONCLUSION
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.
REFERENCES
1. Rebuck DA, Haywood S, McDermott K, Perry KT, Nadler RB. What is the long-term relevance of clinically detected postoperative
anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy? BJU Int. 2011:108(5):733-738.
2. Simhan J, Ramirez D, Hudak SJ, Morey AF. Bladder neck contracture. Transl Androl Urol. 2014;3(2):214-220.
3. Kirshenbaum EJ, Zhao LC, Myers JB, Elliott SP, Vanni AJ, Baradaran N, Erickson BA, Buckley JC, Voelzke BB, Granieri MA,
Summers SJ, Breyer BN, Dash A, Weinberg A, Alsikafi NF. 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. Urology. 2018;118:227-233.
4. Granieri MA, Weinberg AC, Sun JY, Stifelman MD, Zhao LC. Robotic Y-V plasty for recalcitrant bladder neck contracture. Urology.
2018;117:163-165.
5. Shahrour W, Hodhod A, Kotb A, Prowse O, Elmansy H. Dorsal buccal mucosal graft urethroplasty for vesico-urethral anastomotic
stricture postradical prostatectomy. Urology. 2019;130:210.
6. Kaouk J, Sawczyn G, Wilson C, Aminsharifi A, Fareed K, Garisto J, Lenfant L. Single-port percutaneous transvesical simple
prostatectomy using the SP robotic system: initial clinical experience. Urology. 2020;141:173-177.
7. Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. Outcomes of gender affirming peritoneal flap vaginoplasty using the
da Vinci single port versus Xi robotic systems. Eur Urol. 2020;S0302-2838(20)30469-3. Online ahead of print.
LEE C. ZHAO, MD
Lee C. Zhao, MD, MS, is assistant professor of urology at NYU Grossman
School of Medicine and a reconstructive urologist at NYU Langone
Health. Before becoming a physician, he attended graduate school for
biomedical engineering and volunteered in the Peace Corps. Dr. Zhao’s
double desire to fix problems and improve people’s quality of life led
him to the field of urologic reconstructive surgery. At NYU Langone,
Dr. Zhao treats urethral strictures, ureteral obstruction, urinary fistulae,
and complications of surgery. As a component of his reconstructive
urology practice, Dr. Zhao performs both primary and revision
gender-affirming surgery as part of a multidisciplinary team. Dr. Zhao
has written or co-written numerous articles on trauma, urologic
reconstruction, and surgical outcomes. He is a co-author of the
American Urological Association core curriculum on gender-affirming
surgery and clinical guidelines on male urethral stricture.
DC 10/2/2020
Department of Urology
Our renowned urologic specialists have pioneered numerous advances in the surgical and pharmacological
treatment of urologic disease.
For questions and/or patient referrals, please contact us by phone or by e-mail.
Faculty Specialty Phone Number/Email
Kidney stones, Kidney Cancer, Ureteral Stricture, UPJ obstruction, Endourology, 646-825-6387
James Borin, MD
Robotic Renal Surgery, Partial Nephrectomy, Ablation of Renal Tumors, PCNL james.borin@nyulangone.org
Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse-Vaginal
646-754-2404
Benjamin Brucker, MD and Robotic Surgery, Voiding Dysfunction, Male and Female Incontinence,
benjamin.brucker@nyulangone.org
Benign Prostate Surgery, Neurourology
Female Sexual Dysfunction, Male Sexual Dysfunction, General Urology, Benign Disease 646-825-6318
Seth Cohen, MD
Prostate, Post-Prostatectomy Incontinence, Erectile Dysfunction, Hypogonadism seth.cohen@nyulangone.org
Robotic and Minimally Invasive Urology, BPH and Prostatic Diseases,
718-630-8600
Frederick Gulmi, MD* Male and Female Voiding Dysfunction, Kidney Stone Disease,
frederick.gulmi@nyulangone.org
Lasers in Urologic Surgery, and Male Sexual Dysfunction
Urologic Oncology, Open, Laparoscopic, or Robot-Assisted Approaches to Surgery,
646-825-6325
Mohit Gupta, MD† Surgical Management of Genitourinary Malignancies including Kidney, Bladder,
Mohit.Gupta2@nyulangone.org
Prostate, Adrenal, Penile, and Testis Cancers
Urologic Oncology (Open and Robotic) – for Kidney Cancer (Partial and Complex 646-744-1503
William Huang, MD
Radical), Urothelial Cancers (Bladder and Upper Tract), Prostate and Testicular Cancer william.huang@nyulangone.org
Pediatric Urology including Hydronephrosis, Hypospadias, Varicoceles, Undescended
212-263-6420
Grace Hyun, MD Testicles, Hernias, Vesicoureteral Reflux, Urinary Obstruction, Kidney Stones, Minimally
grace.hyun@nyulangone.org
Invasive Procedures, Congenital Anomalies
Male and Female Voiding Dysfunction, Neurourology, Incontinence, Pelvic Pain, 646-825-6322
Christopher Kelly, MD
Benign Prostate Disease chris.kelly@nyulangone.org
Prostate Cancer: Elevated PSA, 3D MRI/Ultrasound Co-registration Prostate Biopsy, 646-825-6327
Herbert Lepor, MD
Focal (Ablation) of Prostate Cancer, Open Radical Retropubic Prostatectomy herbert.lepor@nyulangone.org
Urologic Oncology, Prostate Cancer, Benign Prostatic Disease, Men’s Health, 718-261-9100
Stacy Loeb, MD, MSc**
General Urology stacy.loeb@nyulangone.org
Benign Prostatic Hyperplasia, Erectile Dysfunction, Urinary Tract Infection, Elevated 718-376-1004
Danil Makarov, MD, MHS***
Prostate-specific Antigen, Testicular Cancer, Bladder Cancer, Prostate Cancer danil.makarov@nyulangone.org
Male Infertility, Vasectomy Reversal, Varicocele, Post-Prostatectomy, 646-825-6348
Bobby Najari, MD
Erectile Dysfunction, Male Sexual Health, Hypogonadism, Oncofertility bobby.najari@nyulangone.org
Female Pelvic Medicine and Reconstructive Surgery, Pelvic Organ Prolapse, 646-825-6324
Dominique Malacarne Pape, MD
Incontinence in Women, Female Voiding Dysfunction dominique.malacarne@nyulangone.org
Female Pelvic Medicine and Reconstructive Surgery, Voiding Dysfunction,
646-825-6311
Nirit Rosenblum, MD Neurourology, Incontinence, Female Sexual Dysfunction, Pelvic Organ Prolapse and
nirit.rosenblum@nyulangone.org
Robotic Surgery
Pediatric Urology including: Urinary Tract Obstruction (ureteropelvic junction
646-825-6326
Ellen Shapiro, MD obstruction), Vesicoureteral Reflux, Hypospadias, Undescended Testis, Hernia,
ellen.shapiro@nyulangone.org
Varicocele, and Complex Genitourinary Reconstruction.
Kidney stones, PCNL, Kidney Cancer, UPJ obstruction, Endourology, Robotic Renal 718-630-8600
Mark Silva, MD*
Surgery, Ablation of Renal Tumors mark.silva@nyulangone.org
Muscle-Invasive Bladder Cancer; Non-Invasive Bladder Cancer; Radical Cystectomy; 646-825-6327
Gary D. Steinberg, MD
Urinary Tract Reconstruction After Bladder Removal Surgery gary.steinberg@nyulangone.org
Urologic Oncology – Prostate Cancer (MRI-Guided Biopsy, Robotic Prostatectomy,
646-825-6321
Samir Taneja, MD Focal Therapy, Surveillance), Kidney Cancer (Robotic Partial Nephrectomy,
samir.taneja@nyulangone.org
Complex Open Surgery), Urothelial Cancers
Urologic Oncology-Prostate Cancer, MRI-Guided Biopsy, Kidney and Prostate Cancer
646-754-2470
James Wysock, MD, MS Surgery, Robotic Urological Cancer Surgery, Prostate Cancer Image Guided Focal
james.wysock@nyulangone.org
Therapy (Ablation, HIFU) and Testicular Cancer
Robotic and Open Reconstructive Surgery for Ureteral Obstruction, Fistulas,
646-754-2419
Lee Zhao, MD Urinary Diversions, Urethral Strictures, Peyronie’s Disease, Penile Prosthesis, and
lee.zhao@nyulangone.org
Transgender Surgery
Kidney Stone Disease, Upper Tract Urothelial Carcinoma, Ureteral Stricture Disease, 646-754-2434
Philip Zhao, MD
and BPH/Benign Prostate Disease philip.zhao@nyulangone.org
*at NYU Langone Hospital – Brooklyn ** NYU Langone Ambulatory Care Rego Park NYU Langone Levit Medical †222 East 41st street; NYU Langone Ambulatory Care Bay Ridge, and NYU Langone Levit Medical
***
nyulangone.org DC
222 East 41st Street New 10/2/2020
York, NY 10017
U1019
You can also read
