Successful urethral stricture, fistula repair feasible in most cases

Key Points

Aurora, CO-Managing the urethral strictures and fistulas that sometimes follow prostate cancer therapies can be intimidating, but with experience, the presentations can be resolved with high success in a near majority of patients, according to results of a recent study.

Study authors David Hadley, MD, and Brian Flynn, MD, reported that reconstructive success rates in resolving recto-urinary fistulas, radiation-induced cystitis, anterior urethral stricture, and obstruction ranged from 60% to 100% depending upon the initial presentation.

To arrive at these findings, the authors looked at outcomes in the hospital's prospectively maintained database of men who had undergone open reconstruction for problems that followed radical prostatectomy (open, laparoscopic, robotic), brachytherapy, external beam radiation, proton therapy, cryotherapy, and varied combinations of the preceding. They identified 37 patients who developed recto-urinary fistula (15), radiation cystitis (three), anterior urethral stricture (three), or obstruction (16).

Dr. Hadley told Urology Times that no single procedure or combination of initial approaches to prostate cancer seemed to be definitively associated with increased problematic outcomes, but a history of radiation was more likely to be predictive of reconstructive failure.

"It is less likely that you will see a urethral stricture after open or robotic surgery as compared to radiation, at least not an anterior urethral stricture. An anastomotic stricture, or bladder neck contracture, is much more likely. Although a perineal, or a combined perineal and abdominal, approach has typically been described to repair refractory or obliterative anastomotic strictures, we advocate an abdominal approach with pubectomy, as we feel continence is better preserved," said Dr. Hadley, who was a fellow in reconstructive surgery at the University of Colorado Hospital, Aurora, at the time of the study.

Of the 15 patients with recto-urinary fistula, four that occurred after prostatectomy underwent reconstruction. One of these reconstructive procedures failed and underwent diversion. The remaining 11 fistulas appeared after radiation treatment or cryoablation. Six of these underwent diversion and five underwent reconstruction. Two of the five reconstructions failed initially but were successfully resolved with a second reconstruction. Three patients with severe radiation cystitis underwent successful diversion. Three patients with anterior urethral stricture were successfully reconstructed.

Of the 16 cases of obstruction, 11 were vesicourethral strictures after prostatectomy and five were cases of radionecrosis secondary to radiation therapy or cryotherapy. Eight of the 11 vesicourethral strictures underwent successful reconstructive procedures, with two of the 11 requiring a second reconstruction procedure that was successful. The remaining patient, who also had adjuvant radiation, required urinary diversion. There were five cases of obstructive radionecrosis, four of which underwent successful diversions and one of which failed a reconstruction.

It was noted that the four stricture repairs that initially failed were posterior urethral repairs. Secondary procedures resolved three of these, and one went on to a diversion. In all, only three of the 24 patients who underwent reconstruction in the study failed both primary and follow-up interventions. The remaining 13 patients underwent primary urinary diversion, as it was felt their case was not amenable to reconstruction.

"These can be difficult surgeries, and each presents different problems. Anterior repairs can usually be augmented or excised with great success. Posterior strictures, however, can be significantly more difficult because of access and exposure," said Dr. Hadley, who is currently in group practice in Banning, CA.

The study emphasized that proper procedure selection-reconstruction or urinary diversion-is central to success. All factors must be weighed.

"If radiation is involved, it is necessary to understand to what extent. Many of these patients have had primary radiation treatment for their cancer or adjuvant radiation treatment for recurrence," said Dr. Hadley, who presented the findings at the 2011 AUA annual meeting in Washington.

Dr. Hadley noted that a limited number of centers see and treat these challenging cases in significant numbers and that the study, though it involved only 37 patients, was probably one of the largest and most comprehensive of its kind.