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Management Of Severe Urethral Complications Of Prostate Cancer Therapy

March 26, 2017

UroToday- Urethral stenosis after prostate cancer therapy (PCT) occurs in 2% to 28% of patients and may manifest as anterior or posterior urethral stenosis. Post radical prostatectomy urethral stenosis occurs as bladder neck contractures but if the prostate is left in-situ, as in patients choosing radiation therapy, posterior urethral stenosis includes membranous urethral stricture, prostatic urethral stricture and bladder neck contracture. Rectourinary fistula is a rare complication occurring 1% to 1.8% after prostate cancer therapy.

A recent review by Elliot and McAninch from San Francisco examines the management of urethral stenosis and rectourinary fistula resulting from prostate cancer therapy. The review is published in the December 2006 issue of the Journal of Urology.

A total of 48 patients with urethral complications after treatment for prostate cancer comprised the study group. Sixteen of these patients had rectourinary fistulas and 32 had urethral stenosis. Mean time from first PCT was 5.3 years. During that time, patients underwent certain procedures including 1 urethrotomy in 20, multiple urethrotomies in 17, one dilation in 16, multiple dilations in 6, transurethral resection for stenosis on 9, urethral stent placement in 2, urethroplasty in 1, fistula repair in 4, and AUS placement in 4.

Of the 32 cases of stenosis, 5 occurred after brachytherapy (BT), 5 occurred after external beam radiotherapy (EBRT), 11 occurred after radical prostatectomy (RP), 4 occurred after BT plus EBRT and 7 occurred after RP plus EBRT. Of the 16 cases of fistula, 7 occurred after RP, 3 occurred after BT plus EBRT, 2 occurred after cryotherapy plus EBRT. Complications occurred more often in patients who had a form of radiation therapy.

Stenosis repair was successful in 23 of 32 cases (73%) utilizing an anastomotic urethroplasty in 19 cases, flap urethroplasty in 2, perineal urethrostomy in 2 and urethral stent in 9. Thirteen of the patients were incontinent after repair, mostly after bulbar urethra to bladder neck anastomosis.

Fistula repair was successful in 14 of 15 cases (93%) and this was established in a variety of ways. The authors subdivided the patients into 3 groups depending on fistula size and the presence or absence of urethral stenosis. The more severe the fistula, the less chance that a transanal approach was utilized and the higher chance that a pubectomy was required.

Urethral stenosis or rectourethral fistula following prostate cancer therapy can be managed by urethral reconstruction, such that normal voiding via the urethra is maintained, rather than abandoning the urethral outlet and performing heterotopic diversion. Utilizing principles outlined in this paper, repair can be accomplished with an acceptable rate of failure given the complexity of the cases.

Elliott SP, McAninch JW, Chi T, Doyle SM, Master VA
J Urol. 2006 Dec; 176(6):2508-13

Reviewed by UroToday Contributing Editor Michael J. Metro, MD

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