Contractura de cuello vesical después de ciruía por HPB - MInerva Urol Neprol 17

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Minerva Urologica e Nefrologica 2017 April;69(2):133-43 DOI: 10.23736/S0393-2249.16.02777-6

REVIEW

Bladder neck contracture after surgery for benign prostatic obstruction Luca CINDOLO  1  *, Michele MARCHIONI  2, Esteban EMILIANI  3, Piergustavo DE FRANCESCO  2, Giulia PRIMICERI  2, Pietro CASTELLAN  1, Luigi SCHIPS  1 1Robotic

Unit, Department of Urology, ASL Abruzzo 2, SS. Annunziata Hospital, Chieti, Italy; 2Department of Urology, SS. Annunziata Hospital, G. D’Annunzio University, Chieti, Italy; 3Department of Urology, Tenon Hospital, Université Pierre et Marie Curie Paris IV, Paris, France *Corresponding author: Luca Cindolo, Robotic Unit, Department of Urology, ASL Abruzzo 2, SS. Annunziata Hospital, Chieti, Italy. E-mail: [email protected]

A B S T RAC T INTRODUCTION: Over the last few decades, numerous surgical procedures have been proposed to treat lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). However, all are characterized by a certain rate of treatment failure due to bladder neck contracture (BNC). Treatment of secondary BNC appears to be challenging. The main purpose of this review is to evaluate current published knowledge on this topic. EVIDENCE ACQUISITION: The MEDLINE/PubMed database was searched for all original articles published between 2000 and 2016 analyzing the incidence, prevalence and management of BNC as a post-operative complication following surgical treatment of LUTS/BPH. Prospectively designed studies, and those with prospectively maintained databases and/or rigorous inclusion and exclusion criteria were included. Given the lack of prospective studies examining treatment options for BNC, retrospective studies were also included in this section. EVIDENCE SYNTHESIS: Thirty-four studies were included. The huge heterogeneity of patients, gland characteristics, surgical strategies and follow-up procedures limited the overall quality of results. BNC incidence after surgery for LUTS/ BPH ranges from 0% to 9.6%. Given the dearth of well-designed studies, it seems rational to leave the choice of treatment procedure to the specialist’s own decision. CONCLUSIONS: BNC incidence varies greatly depending on the examined cohorts, with only few precautionary measures available for prevention. Treatment is challenging and it seems reasonable to leave the choice of BNC treatment technique to the surgeon’s own judgement. (Cite this article as: Cindolo L, Marchioni M, Emiliani E, De Francesco P, Primiceri G, Castellan P, et al. Bladder neck contracture after surgery for benign prostatic obstruction. Minerva Urol Nefrol 2017;69:133-43. DOI: 10.23736/S03932249.16.02777-6) Key words: Urinary bladder neck obstruction - Prostatic hyperplasia - Complications - Solid-state lasers - Prostatectomy.

Introduction

L

ower urinary tract symptoms (LUTS) are often related to bladder outlet obstruction (BOO) secondary to benign prostatic enlargement caused by hyperplasia (BPH). This condition may set off numerous complications such as detrusor and renal failure, recurrent urinary tract infections, urinary retention, hematuria, bladder diverticula and bladder

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stones.1, 2 Over the last decades, several treatment procedures have been proposed.3, 4 Of these, monopolar transurethral resection of the prostate (M-TURP) remains the current surgical standard for men with prostate sizes of 30-80 mL and bothersome moderate-to-severe LUTS secondary to BPH and BOO (LUTS/ BPH). It is also indicated as a second treatment option for prostates of less than 30 mL.4 Bipolar transurethral resection of the prostate

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POSTOPERATIVE BLADDER NECK CONTRACTURE

(B-TURP) achieves short- and mid-term results comparable to M-TURP; however using 0.9% saline solution eliminates the risk of TUR-syndrome.5, 6 Over the past two decades new laser technologies have provided a wider range of surgical solutions for treatment of LUTS/BPH,7 competing with and limiting use of M-TURP.8, 9 Nowadays, holmium laser enucleation of the prostate (HoLEP) is the first treatment option for prostates larger than 80 mL, along with open prostatectomy (OP).4 However, these new technologies and procedures may still cause a wide range of complications,8 the most common being bleeding, urethral stricture, recurrent adenoma, and bladder neck contracture (BNC).10, 11 Little is known about the physiopathology, etiology and real incidence of BNC. All is known is that the latter varies widely across series and ultimately depends on the technique employed.8, 12 To date, despite the large number of surgical procedures proposed, treatments of BNC remains challenging.13, 14 The aim of this review is to summarize the available evidence on the occurrence and management of BNC after LUTS/BPH treatment. Evidences acquisition The MEDLINE/PubMed database was searched for all original articles published between 2000 and 2016 analyzing the incidence, prevalence and management of BNC as a postoperative complication following surgical treatment of LUTS/BPH. The following key words were used: “BPH”, “GreenLight laser”, “holmium laser”, “open prostatectomy”, “photoselective vaporization of the prostate”, “prostate enucleation”, “prostate”, “PVP”, “simple prostatectomy”, “thulium laser”, “transurethral resection of the prostate” and “TURP”, all in combination with “bladder neck contracture”. These key words were then combined with several phrases relevant to each planned subsection of the report, including physiopathology, presentation, management and outcomes. Titles and abstracts were reviewed to assess relevance. The most significant papers were selected for

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analysis based on study design, study sample or size and follow-up duration. Finally, only prospectively designed trials were included in the analysis. But we also retained those with prospectively maintained databases and/or rigorous inclusion and exclusion criteria. Given the lack of prospective studies specifically examining the available treatment options for BNC, retrospective studies were also included in this section. Figure 1 resumes the process of paper selection according to the PRISMA statement.15 Evidence synthesis A total of 549 articles were found. Among these, a total of 34 full-text studies were included for final analysis: 30 focused on different surgical techniques for BPH and 4 on treatment options for BNC.5, 7, 13, 14, 16‑45 The total number of patients included in the studies was 7707; of these, 129 had been treated for BNC. Patient treatment allocation was as follows: OP or laparoscopic simple prostatectomy (LSP) (N.=5); TURP (N.=3); holmium laser (N.=3); GreenLight lasers (N.=14), and thulium laser (N.=5). Four studies are discussed in the Discussion section. Seven studies among the selected ones were from multicenter trials, and only one of them focused on BNC treatment.5, 7, 17, 27, 29, 37, 44 Table I summarizes the main characteristics of the selected studies and population series. There is substantial heterogeneity in terms of patients and gland characteristics, surgical strategies and follow-up procedures, which ultimately impinged on quality of results. Open prostatectomy (OP) and laparoscopic simple prostatectomy (LSP) Nowadays, there are numerous minimally invasive procedures available to manage LUTS/BPH; however, simple (open) prostatectomy remains the treatment of choice for glands larger than 80 mL, or in case of associated bladder stones or need of bladder diverticula resection.4, 18 LSP — by various approaches  19, 20 — is in itself an evolution of

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Figure 1.—Study selection as per the PRISMA statement.

OP. BNC incidence varies across population series. In both the OP and LSP series, the reported range was 0-6%, with BNC incision being the most common treatment method (when indicated).16‑20 As a precaution, it is advisable to avoid excessive and prolonged balloon filling as a prophylactic measure against major bleeding; this will prevent mucosal ischemia and successive BNC formation.17

possible complications.4, 21 To reduce TURP morbidity and mortality a variety of surgical modifications have been proposed, including B-TURP.4, 5 In our analysis, BNC after TURP had an incidence range of 0-4.9%.5, 21, 22 In patients with severe LUTS no significant differences in BNC occurrence were found between M-TURP and B-TURP at short- and midterm follow-up (1.9% vs. 3.2%; P=1.0).5

Transurethral resection of prostate

Holmium laser enucleation and ablation

TURP is the most common surgical procedure for LUTS/BPH treatment, with high success rates and safety profiles.4, 21 This notwithstanding, BNC, bleeding, TURP syndrome, urinary infection, retrograde ejaculation, impotence, and incontinence are considered

HoLEP is increasingly used in the treatment of LUTS/BPH. Its main drawbacks are the long learning curve and surgical experience required to avoid complications.25 BNC incidence ranges from 0.4 to 1.7% after HoLEP and is around 7% for holmium laser ab-

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POSTOPERATIVE BLADDER NECK CONTRACTURE

Table I.—Studies, baseline characteristics and reported incidence of BNC. Study

Year

Design

Technique

N.

Follow‑up (months)

OP or LSP Kuntz et al.16

2008

Prospective single‑center RCT

HoLEP vs. OP

60 vs. 60

60

Djaladat et al.17

2006

Prospective multicenter RCT

OP using different catheter type

96 vs. 50

6

Moslemi et al.18

2010

Single-center trial

OP

202

24

Wang et al.19 Xie et al.20

2012 2014

Single-center trial Prospective single‑center RCT

Single port laparoscopic EPLA vs. B-TURP

9 36 vs. 54

17.3±2.12 36

2001

Prospective single‑center RCT

TURP vs. vapor cut

50 vs. 50

6.7 (6-10)

Li et al.22

2013

Prospective single‑center RCT

61 vs. 63

Skolarikos et al.5 a

2016

Prospective multicenter RCT

TURP vs. STURP+TUIBN M‑TURP vs. B‑TURP

57 vs. 69

9.0±0.8 vs. 8.5±1.9 36

2013

Prospective single‑center RCT

57 vs. 52

70

Elkoushy et al.24 Shah et al.25

2015 2007

1216 280

7.6 years 24

GreenLight™ laser Elshal et al.26

Single-center Prospective single‑center

HoLAP vs. 80-W KTP PVP HoLEP HoLEP

2012

Longitudinal single‑center Prospective multi-center

80-W KTP PVP and 120-W HPS

288

40.5 (3-114)

80-W KTP PVP vs. M-TURP 60-W and 80W KTP PVP

30 vs. 31

60

94

60

80-W KTP PVP 80-W KTP PVP vs. M-TURP 80-W KTP PVP in NUR vs. RUR

100 112 vs. 98

12 24

183

11.2 vs. 12.1

M-TURP and B-TURP Kupeli et al.21

Holmium laser Elshal et al.23

Guo et al.27

2015

Malek et al.28

2005

Tugcu et al.30 Tugcu et al.29

2007 2008

Ruszat et al.31 b

2006

Single-center

Al-Ansari et al.32

2010

Prospective single‑center RCT

TURP vs. 120‑W HPS

60 vs. 60

36

Chen et al.33

2013

Single-center

120‑W HPS

120

Gu et al.34

2011

120‑W HPS

170

Taşçi et al.35

2011

120‑W HPS

550

17.80

Spaliviero et al.36

2009

Prospective single‑center Prospective single‑center Prospective single‑center

20.8±3.2 (18-24) 36

120‑W HPS

70

13

136

Prospective single‑center Single-center Prospective multi-center

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Prostate size

Age

Preoperative IPSS

Preoperative Qmax

BNC incidence

Management

114.6±21.6 vs. 113.0±19.2 Adenoma weight: 63.3±15.6 g vs. 64.3±16.3 g Adenoma weight: 83 g 83.8±19.9 93.3±14.8 vs. 96.6± 12.1

69.2±8.4 vs. 71.2 ±8.3 69.9±7.5

–

1.7% vs. 5%

Transurethral holmium laser BN incision

31.6±3.5 vs. 31.6±3.3

3.8±3.6 vs. 3.6± 3.8 4.1±2.8 vs. 4.2±2.4

0% vs. 6%

–

69.7

19.5

–

0.4%

–

71.9± 6.39 71.7 ±9.3 vs. 72.1±8.8

25.6 22.4 ±5.6 vs. 23.3±5.7

9.8 6.5±2.5 vs. 6.7±1.9

0% 0% vs. 1.9%

– Transurethral BNC incision

56.7±6.3 vs. 57.8±4.1 29.9±4.9 vs. 31.5±6.9 60.1±22.3 vs. 59.6±23.5

58.9±3.6 vs. 61.4±3.2 68.6±7.5 vs. 66.8±4.9 68.1±8.0 vs. 68.0±7.8

21.6 vs. 19.4 25.6±7.6 vs. 24.7±8.3 25.0±4.2 vs. 25.3±3.7

9.2±2.6 vs. 7.9±2.1 7.2±3.4 vs. 7.2±2.1 8.6±2.3 vs. 9.0±3.3

0% vs. 0%

-

4.9% vs. 0%

-

1.9% vs. 3.2%

BN resection or BN incision

33.1±14.5 vs. 37.3±13.6 94.8±52.7 54.62 g (8-225 g)

72.7±10.3 vs. 71.6±10.3 71.9±12.3 65.9 (51-103)

–

–

7% vs. 9.6%

BN incision with holmium laser

18.5±7.9 –

6.5±5.6 7.2 (0.9-22.4)

1.1% 0.4%

– BN incision

43.6±20.5

71.4±9

19.6±6.7

7.7 ±3.6

3.4%

BN incision

52.3±19.3 vs. 44.2±19.1 45±17

69.7±8.9 vs. 66.4±8.4 68±8

19.4±6.3 vs. 18.4±6.3 –

8.3±6.0 vs. 10.0±5.2 7.8±2.3

3% vs. 0%

–

2%

Dilatation

1% 1.8% vs. 0%

– –

0.5%

KTP laser incision

3.6% vs. 7.4%

BN incision

1.7%

–

0%

–

98.2±18.9 67±7.9 19.2±4.1 6.3±1.8 49.1±11.9 67.5±7.4 17.9±4.9 vs 6.9±1.9 vs. vs. 17.7±3.5 vs. 47.7±8.4 66.3±7.9 7.2±1.7 53.2±29.1 70±8.6 18.6±6.2 7.1±3.1 vs. vs. vs. 60.8±33.3 74.5±10.4 15.5±6.6 60.3±20 67.1±8 27.9±2.7 6.4±2 vs. vs. vs. vs. 61.8±22 66.3±9.4 27.2±2.3 6.9±2.2 TRUS80 mL: 5.5 65.3±36.7 67.2±9.5 – 9.3±3.8 71.9±29.2

67.6±8.0

22.8±4.7

9.0±4.6

1.1%

–

61.6 (20.9-263.0)

67 (45-86)

–

9.4 (1.9-24.6)

0%

– (To be continued)

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POSTOPERATIVE BLADDER NECK CONTRACTURE

BNC.(continues). Table I.—Studies, baseline characteristics and reported incidence of BNC Year

Design

Technique

N.

Follow‑up (months)

Thomas et al.37 (GOLIATH)

2016

Prospective multi-center

180‑W PVP vs. TURP

136 vs. 133

Altay et al.38

2015

180‑W PVP

68

Campbell et al.39

2013

Prospective single‑center Prospective single‑center

23.3±3.1 vs. 23.2±3.6 12

180‑W vs. 120‑W PVP

50 vs. 50

3

Thulium laser Netsch et al.41

2012

Prospective single‑center

70-w ThuVEP vs. 120-w ThuVEP

44 vs. 40

12

Netsch et al.40

2012

120-W ThuVEP

207

12

Netsch et al.42

2012

Prospective single‑center Prospective single‑center

200-W vs. 120-W ThuVEP

28 vs. 28

12

Wei et al.43

2014

Prospective single‑center RCT

TmLRP-TT vs. PKRP

45 vs. 45

18

Sun et al.7

2015

Prospective multi-center

TmLRP

2216

96

Study

Values are presented as mean±SD (range) or as median (interquartile range). When mean or median follow-up duration was not provided, the maximum follow-up duration was considered. a Only patients with severe LUTS are considered here; data are reported at 6 weeks; b LUTS secondary to BPH with (RUR) and without (NUR) refractory urinary retention. LUTS: lower urinary tract symptoms; BPH: benign prostate hyperplasia; IPSS: International Prostate Symptom Score; BNC: bladder neck constriction; OP: open prostatectomy; LSP: laparoscopic simple prostatectomy; EPLA: extraperitoneal laparoscopic adenomectomy;

lation (HoLAP).16, 23-25 Contracture incision was the chosen strategy in all studies reporting on management. While incidence is relatively low after HoLEP/HoLAP, it can increase when treating small-volume prostates, which seems to be an independent risk factor for BNC development.23-25 To reduce the incidence of contractures, a prophylactic incision of bladder neck was recommended; avoiding excessive laser energy on bladder neck also proved beneficial.23, 25 The frequency of BNC occurrence after HoLEP could be considered low. In a series of 1216 procedures with a median follow-up of 7.6 years, Elkoushy reported 52 (4.3%) patients needing repeated surgery for recurrent LUTS, of whom only 14 (1.1%) had developed bladder neck contracture. BNC

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was significantly related to younger aged patients and smaller glands.24 In a comparison with other techniques, incidence of BNC was similar between HoLAP vs. PVP (80 W KTP GreenLight™ Laser System) and open prostatectomy series.16, 23 GreenLight™ Lasers Currently, the main use of GreenLight™ laser is in the treatment of patients with LUST/ BPH, although this technique also has been used successfully for treating LUTS secondary to prostate carcinoma.46 The PV System 80-W KTP laser (LaserScope®), was launched in the year 2000 by American Medical System (Minnetonka, MN, USA).1 Since then, it

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Prostate size

Age

Preoperative IPSS

Preoperative Qmax

BNC incidence

Management

48.6±19.2 vs. 46.2±19.1 104.3±29.7

67.2±6.8 vs. 66.7±6.6 71.1±9.8

21.2±5.9 vs. 21.7±6.4 19.9±9.5

9.5±3 vs. 9.9±3.5 7.6±5.4

5.9% vs. 2.3%

–

0%

–

68 (45.5-94.0) vs. 51 (37.8-72.3)

66.5 (60-71.8) vs. 68 (60-73.8)

20 (14-25) vs. 21 (17-26)

9 (6.2-12.2) vs. 9 (7-11)

4% vs. 0%

–

79.9±27.4 (60-167) vs. 88.5±25.1 (60-170)

70.6±8.6 (46-87) vs. 69.5±6.1 (55-82) 70.0±8.0 (49-98) 70.2±8.4 (53-90) vs. 68.5±7.3 (49-87) 69.9±8.2 (53-83) vs. 69.0±7.0 54-85) 69 (64-74)

17.7±7.4 (7-28) vs. 17.6±8.5 (7-30) 21.8±7.2 (8-35) 23.0±6.7 (8-35) vs. 21.2±7.8 (8-35) 21.7±6.8 (8-35) vs. 21.2±7.0 (8-35) 22 (18-27)

8.1±3.1 (4.7-14.0) vs. 8.44±3.86 (1.3-14.4) 9.3±3.8 (1.3-15) 7.9 ±2.7 (4.8-13.6) vs. 10.2±3.9 (3.6-15)

2.3% vs. 2.5%

70-W thulium laser incision

1.9%

–

3.6% vs. 3.6%

70-W thulium laser incision

8.1±3.3 (2.6-14.1) vs. 7.9±2.9 (2.9-14.2) 6.9 (4.3-10.5)

0% vs. 2.2%

BN incision with thulium laser

1.6%

Endoscopic scar excision

57.7±31.5 (15-180) 65.4±39.1 (20-170) vs. 68.6± 38.7 (20-160) 112.9±28.4 (81-161) vs. 115.0±39.4 (80-177) 66 g (41-88 g)

HoLEP: holmium laser enucleation of the prostate; HoLAP: holmium laser ablation of the prostate; BN: bladder neck; M‑TURP: monopolar transurethral resection of the prostate; B‑TURP: bipolar transurethral resection of the prostate; STURP+TUIBN: selective transurethral resection of the prostate + transurethral incision of the bladder neck; PVP: photoselective vaporization of the prostate; KTP: potassium titanyl phosphate; HPS: high-performance system; ThuVEP: thulium vapoenucleation of the prostate; TmLRP-TT: Tm:YAG resection of the prostate by “tangerine technique”; TmLRP: Tm:YAG resection of the prostate; PKRP: plasmakinetic resection of the prostate.

has received two upgrades: in 2006, when the HPS System (120 W) was implemented, and in 2011, with the GreenLight™ XPS (180 W), which saw significant design changes in laser fiber.1 Incidence of BNC varies with different laser technology and power outputs. Specifically, reported ranges were 0-9.6%,23, 26‑31 0-7.4%,32‑36, 39 and 0-5.9% 37‑39 for the 80-W KTP, 120-W HPS and 180-W XPS systems, respectively. When indicated, the primary treatment choice was, again, bladder neck incision 26, 31, 32 or dilatation;28 however, rates of success for these manoeuvres were not clearly indicated. Spaliviero et al. suggested incising bladder neck during PVP and avoiding complete circumferential vaporizations by omitting the 12-o’clock position to prevent BNC;

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incision was also the recommended treatment strategy for BNC.36 Thulium lasers Thulium:yttrium aluminum garnet (Tm:YAG) lasers are available with different power settings.40‑42 Thulium vapoenucleation of the prostate (ThuVEP) has shown promising results as a size-independent method for LUTS/BPH management.41 After ThuVEP, BNC incidence was reported around 1.9-3.6%, with energy settings having no significant influence.40‑42 A study by Wei et al. described the so-called Tm:YAG resection of the prostate-tangerine technique (TmLRP-TT) and compared it with plasmakinetic resection of

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POSTOPERATIVE BLADDER NECK CONTRACTURE

the prostate (PKRP). The comparison yielded BNC rates of 0 and 2.2%, respectively, in a randomized series of 90 patients.43 Likewise, Sun et al. used a resection technique with thulium laser in 2216 patients, with a BNC rate at follow-up of 1.6%.7 Use of thulium lasers has also been reported for bladder neck incision when treating BNC;41‑43 however, Sun et al. opted for endoscopic resection.7

TURP BNC.13, 44, 45 However, because of the different anatomical factors involved in radical prostatectomy and BPH surgery, a comparison cannot be drawn without somewhat sacrificing methodological validity. Interestingly, Pansadoro et al. analyzed the changes in prostatic fossa anatomy after surgical management of LUTS/BPH. They described three types of strictures: type I, which may be called BNC proper, where the fibrous tissue involves only the bladder neck, strongly reducing outflow; type II, where the stricture is localized to the median part of the prostatic fossa, the so-called prostatic fossa sclerosis; and type III, where the stricture involves the whole prostatic urethra.46, 47 In the literature, treatment options range from balloon dilatation to cold-knife incision, transurethral resection of the bladder neck, stent placement, bipolar plasma vaporization or laser incision, with recurrence rates

Discussion BNC is still a relatively frequent complication, with post-operative rates ranging from 0 to 9.6% depending on the procedure used. Evidence supporting specific solutions is lacking in the literature, particularly in relation to treatment of secondary BNC after LUTS/BPH surgery. A number of series have been designed including post-radical prostatectomy and postTable II.—Bladder neck contracture management options. Study

Year

Design

BNC cause

N.

Bach et al.13

2007

Single-center Trial

RRP TURP

14

Redshaw et al.44

2015

Retrospective multi-center

Ramirez et al.45

2013

Retrospective single-center

OP/LSP Transurethral procedure BPH RP + RT

50 (78% presented after failing previous attempts at BNC treatment elsewhere with 30 [60%] having failed at least 2 previous endoscopic treatments)

Reiss et al.14

2016

Single-center

TURP HoLEP

10

OP 55 TURP (dilations or prior TUIBNC RALP had failed in majority of Radical cystectomy + neobladder patients [44/55, 80%] and ≥2 RT TUIBNCs had failed in 47% RRP [26/55])

RRP: radical retropubic prostatectomy; TURP: transurethral resection of the prostate; RALP: robotic assisted laparoscopic prostatectomy; RT: radiotherapy; BPH: benign prostatic hyperplasia; HoLEP: holmium laser enucleation of the prostate; TUIBNC: deep lateral transurethral incisions for recurrent bladder neck contracture (RBNC); CW: continuous-wave.

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up to 50%.13 Bach and colleagues proposed laser incisions of bladder neck at the 5- and 7-o’clock positions using a 70-W 2-micron continuous wave laser (RevoLix™, LISA® laser products, Katlenburg, Germany).13 However, this technique had a relapse rate — and consequently a retreatment rate — of 14.3%.13 Recently, a multicenter study by the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) group concluded that the efficacy of intralesional injection of mitomycin C at transurethral incision of BNC was lower than previously reported. The group studied this technique in a widely heterogeneous cohort of 55 patients affected by BNC from several causes; in 80% of these patients previous bladder neck dilatation or incision had failed. Injection of mitomycin C at transurethral incision of BNC was associated with serious adverse events in 4 patients (7%), 3 of which involved patients who needed or were plan-

Follow-up (months)

Technique

12

ning cystectomy.44 Ramirez et al. performed a deep lateral transurethral incision at the 3and 9-o’clock positions down through muscle fibers at the bladder neck, reporting an overall success rate of 86% after two procedures. However, complete success without stress urinary incontinence after the first procedure was only attained for 12 patients (24% of those treated).45 Better results were achieved in a small series by using a more complex open surgery technique, the so-called T-plasty, which is basically a modified YV-plasty for highly recurrent BNC with a success rate of 100%.14 Studies on BNC treatment are summarized in Table II. With one exception, none of the studies was specifically designed to test a particular treatment for BNC secondary to LUTS/ BPH surgery.14 This was considered a major bias that warrants more in-depth investigation. The main risk factors for BNC develop-

Outcomes

Bladder neck incision 14.3% of restenosis using a 70-W 2-micron CW laser (RevoLix) 9.2 Intralesional injection Cumulative success after 2 (3.8-15.4) of mitomycin C procedures of 75%; 4 patients at transurethral experienced serious adverse incision of BNC events related to mitomycin C and 3 needed or are planning cystectomy 12.9

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TUIBNC

T-plasty (a modified YV-plasty)

Conclusions

BNI with the RevoLix 2-micron CW laser is a safe, rapid and promising procedure in patients with recurrent BNC In a multi-institutional cohort the efficacy of intralesional injection of MMC at TUIBN is similar to the success rates reported for deep lateral incision alone, suggesting that technique, in particularly deep incision down to the perivesical fat, may have more of a role than adjuvant agents in establishing long-term patency Deep lateral TUIBNC alone is a highly effective treatment modality for RBNC. Smokers and those having 2 or more previous transurethral procedures appear to have greater risk for failure. Subsequent AUS placement can be safely performed with >90% long-term urethral patency

72% required no further surgery for obstruction at a mean follow-up of 12.9 months; of the 14 who failed initial TUIBNC, 7 underwent repeat TUIBNC with success, with an overall success rate of 86% after 2 procedures At the time of follow-up, success Highly recurrent BNC represents a challenging rate, defined as no need for therapeutic condition. After repeated transurethral treatment failures, the T-plasty is a valuable option further instrumentation, was in treatment for highly recurrent BNC caused by 100%. The urinary stream was transurethral surgery of the prostate, which offers described as very strong by multiple advantages compared to other approaches 50% of the patients, moderate and techniques by 30% and weak by 20%

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POSTOPERATIVE BLADDER NECK CONTRACTURE

ment are small prostates, extensive resection of bladder neck, use of large resecting loops combined with excessive energy on the bladder neck itself and inappropriate filling and traction of the balloon.14, 17, 22 Conversely, small resectoscopes, gentle instrument introduction and proper dilatation of urethral lumen are generally considered appropriate prophylactic measures to avert urethral injury.12 Finally, a smoking history and having undergone more than two previous endoscopic BNC procedures are recognized as significant factors associated with BNC treatment failure.45 Given the lack of well-designed studies, we cannot recommend one approach over another. It seems reasonable to leave this choice to the surgeon, who is ultimately the sole responsible for selecting the best treatment for each patient. Conclusions BNC incidence after surgery for LUTS/ BPH varies greatly depending on the examined cohorts. Specific causes and risk factors are unknown; however, preventive measures are available. Treatment is challenging, and evidence supporting specific solutions is lacking in the literature. In light of the above, it seems reasonable to leave the choice of treatment procedure to the surgeon’s own judgement. References   1. Castellan P, Castellucci R, Schips L, Cindolo L. Safety, efficacy and reliability of 180-W GreenLight laser technology for prostate vaporization: review of the literature. World J Urol 2015;33:599-607.   2. Cindolo L, Pirozzi L, Fanizza C, Romero M, Tubaro A, Autorino R, et al. Drug Adherence and Clinical Outcomes for Patients Under Pharmacological Therapy for Lower Urinary Tract Symptoms Related to Benign Prostatic Hyperplasia: Population-based Cohort Study. Eur Urol 2015;68:418-25.   3. Berardinelli F, Hinh P, Wang R. Minimally invasive surgery in the management of benign prostatic hyperplasia. Minerva Urol Nefrol 2009;61:269-89.  4. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118-40.

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Article first published online: December 12, 2016.

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