JU INSIGHT Vesicourethral Anastomotic Stenosis Following Radical Prostatectomy
By: Cameron J. Britton, MD, Mayo Clinic, Rochester, Minnesota; Vidit Sharma, MD, Mayo Clinic, Rochester, Minnesota; Anthony E. Fadel, MD, Mayo Clinic, Rochester, Minnesota; Elizabeth Bearrick, MD, Mayo Clinic, Rochester, Minnesota; Bridget L. Findlay, MD, Mayo Clinic, Rochester, Minnesota; Igor Frank, MD, Mayo Clinic, Rochester, Minnesota; Matthew K. Tollefson, MD, Mayo Clinic, Rochester, Minnesota; R. Jeffrey Karnes, MD, Mayo Clinic, Rochester, Minnesota; Boyd R. Viers, MD, Mayo Clinic, Rochester, Minnesota | Posted on: 30 Aug 2023
Britton CJ, Sharma V, Fadel AE, et al. Vesicourethral anastomotic stenosis following radical prostatectomy: risk factors, natural history, and treatment outcomes. J Urol. 2023;210(2):312-322.
Study Need and Importance
Current guidelines for vesicourethral anastomotic stenosis (VUAS) management are limited by low-level evidence and lack of standardized practices. Endoscopic approaches are generally considered first-line management for VUAS. Prior studies assessing VUAS have been limited by small patient cohorts and limited follow-up. Therefore, we sought to assess the natural history and risk factors for VUAS formation, as well as treatment and recurrence patterns in a large cohort with durable long-term follow-up.
What We Found
Approximately 1 in 20 men were diagnosed with VUAS at a median 3.4 months after surgery. Major risk factors associated with VUAS formation included early postoperative urinary tract infection and urine leak. Meanwhile, robotic approach and complete nerve sparing were associated with a reduced risk of VUAS formation. Adjuvant radiation was predictive of VUAS formation, and these patients were found to be at risk for late VUAS formation (>1 year following surgery). VUAS was highly recurrent following endoscopic management, with many patients requiring retreatment at 5 years (see Figure). Ultimately, VUAS was independently associated with a greater incidence of bothersome stress urinary incontinence 1 year postoperatively.
The retrospective study design predisposes to potential selection biases. Diagnosis of VUAS was based on patient symptomatology; therefore, the incidence of asymptomatic VUAS remains unknown. Additionally, the number of symptomatic patients who did not undergo cystoscopy to identify VUAS, or those lost to follow-up, is unknown. Lastly, variations in VUAS treatment patterns among surgeons may have influenced endoscopic management outcomes.
Interpretation for Patient Care
Patient-related factors, perioperative morbidity, and surgical technique influence VUAS formation. Endoscopic management is temporizing in many patients with a high retreatment rate at 5 years. Patients should be counseled regarding increased risk of incontinence associated with VUAS development.