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Salvage surgery for bladder outlet obstruction after prostatectomy or cystectomy

Westney, Ouida L

doi: 10.1097/MOU.0b013e328311c9de
Reconstructive surgery: Edited by Christopher Woodhouse
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Purpose of review Obstruction of the outlet secondary to a recurrent bladder neck contracture postprostatectomy or cystectomy presents a reconstructive challenge combined with the goal of restoring normal lower urinary tract function. The majority of bladder neck contractures are responsive to urethral dilation or cold knife direct visual internal urethrotomy. Urethral stents and anastomotic urethroplasty have been used with increasing frequency to regain urethral continuity. In the postcystectomy patient, obstruction due to stricture must be differentiated from dysfunctional voiding – unfavorable pouch voiding mechanics, insufficient pouch pressure generation or failure of external sphincter relaxation.

Recent findings Aggressive electrocautery resection with urethral stent placement and anastomotic urethroplasty are viable options for achieving patency after bladder neck obstruction. For those desirous of achieving a continent endpoint, artificial urinary sphincter should be planned as a second stage procedure after stabilization of the bladder neck. Creation of a catheterizable limb remains an option for the unreconstructable urethra. If augmentation cystoplasty is necessary due to storage pressure abnormalities, an appendicovesicostomy or reconfigured ileum segment is a reasonable method to achieve continence.

Summary The incidence of recurrent obstruction due to tissue in-growth or stricture is similar between urethral stent placement and anastomotic urethroplasty, respectively. The high incontinence rate after either initial treatment should be expected and factored into the overall treatment plan.

Division of Urology, Department of Surgery, University of Texas – Houston Medical School, Houston, Texas, USA

Correspondence to Dr Ouida L. Westney, MD, Division and Residency Program Director, Division of Surgery, Department of Surgery, University of Texas – Houston Medical School, 6431 Fannin, Suite 6.018, Houston, TX 77030, USA. Tel: +1 713-500-7328; fax: +1 713-500-7319; e-mail: Ouida.L.Westney@uth.tmc.edu

© 2008 Lippincott Williams & Wilkins, Inc.