A total of 38 men met study inclusion criteria (). in 24 men (63%) radiation therapy was the primary treatment (16) or adjuvant therapy after radical prostatectomy for PCa (8). A total of 14 men (37%) underwent radical prostatectomy alone. Comparison of irradiated to nonirradiated men revealed that radiation induced strictures developed later (3.8 vs 1.3 years, p = 0.008) but were longer (3.6 vs 2.0 cm, p = 0.003, ). All nonirradiated men had anastomotic BNC, which in 2 (14%) extended into the bulbar urethra. Radiation induced strictures involved the proximal bulbar urethra in 3 patients (13%), the membranous urethra in 15 (63%), the prostatic urethra in 14 (58%) and BNC in 18 (75%) with many strictures spanning multiple anatomical sites.
Demographics in men with posterior urethral strictures after prostate cancer treatment managed by stents
At an average 2.3 ± 2.5-year followup the primary success rate of Urolume stent placement was 47% (). After a total of 33 secondary endoscopic procedures in 19 men the overall success rate was 89%. In 4 men (11%) treatment ultimately failed. All had received radiation therapy. Three of the 4 patients elected urinary diversion while 1 underwent salvage prostatectomy.
Outcomes in men with posterior urethral stricture after PCa treatment managed by stents
Overall median time to stricture recurrence after stent placement was 7.4 months (range 3.5 to 91.0). Men with recurrence had longer initial strictures than those without recurrence (3.6 vs 2.1 cm p = 0.04) but were equally as likely to have received radiation (54% vs 50%, p = 0.5, ). However, men with radiation experienced recurrence sooner (mean 10.2 ± 11.2 vs 21.1 ± 20.1 months, p <0.001) and required more secondary procedures (mean 1.9 ± 0.8 vs 1.1 ± 0.4) at a similar mean followup (2.0 ± 2.0 vs 2.6 ± 3.1 years, p = 0.4). On multivariate analysis neither stricture length (HR 1.4, 95% CI 0.8 –2.3, p = 0.4) nor radiation exposure (HR 1.2, 95% CI 0.6–11.4, p = 0.5) was an independent risk factors for failure. The site of recurrent obstruction varied but was proximal to the stent in 10 men (53%), in the stent in 6 (32%) and distal to the stent in 5 (26%) while in 2 it was proximal to as well as in the stent. In 8 men (42%), including 6 (75%) with prior radiation therapy, the additional procedure included placement of a second Urolume stent. In 6 of the men obstructing calcification was present in the stent, which was treated with laser ablation. Stone analysis done in 5 of these men revealed a stone composition of 100% CaHPO4.
Perioperative complications included perineal pain in 6 patients (16%), urinary tract infection in 7 (18%) and clot retention in 3 (8%). All men with perineal pain had membranous strictures and had received radiation. Median time to pain resolution was 4 months (range 1 to 13). One man still had improved but persistent pain 15 months postoperatively. In 1 patient with prior sigmoid resection for carcinoid tumor a postoperative rectourethral fistula developed at 3 weeks, which was treated with diverting ileostomy. This was reversed after spontaneous fistula closure at 1.5 months.
The overall incontinence rate was 82% with a higher rate in men who did vs did not receive radiation (96% vs 50%, p <0.001, ). Incontinent men had longer strictures (3.3 ± 0.6 vs 2.4 ± 1.9 cm, p = 0.05). All men with strictures involving the bulbar or membranous urethra were incontinent. Only 1 of the 7 nonirradiated patients with incontinence postoperatively had been continent preoperatively. All 7 men who remained continent after stent placement had strictures less than 2 cm (mean 1.5) and all had pure BNC that required a single 2 cm or less stent. Of the 14 men who had received radiation and reported continence preoperatively only 1, who had BNC, remained continent after stent placement.
An AUS was inserted in 19 men with incontinence after stent placement at a mean of 7.2 ± 2.4 months after stenting. At a median followup of 42.3 months (range 3 to 129) the AUS was removed in 3 men (19%) due to infection in 2 and erosion in 1. Two of these men received prior radiation therapy. A transcorporeal sphincter technique was used in 7 cases, of which none had failed to date. One patient with incontinence underwent successful InVance® placement 9.5 months after Urolume placement. In 6 men an AUS was in place at the time of a secondary procedure, of which all were done with the sphincter deactivated. One patient required an additional stent placed through the sphincter using the 24Fr insertion device. Otherwise all procedures were done using a flexible cystoscope and/or pediatric resectoscope. None showed any perioperative complication involving the sphincter.