title: Two-stage management of severe postprostatectomy bladder neck contracture associated with stress incontinence.
abstract: OBJECTIVE
  To report our experience using a two-stage, rather than a synchronous, approach in the management of bladder neck contracture (BNC). Anastomotic BNC associated with urinary incontinence is a major complication after radical prostatectomy. Patients may present with a decreased force of stream, urinary retention, or stress, urge, or overflow urinary incontinence.
  
  
  METHODS
  The pertinent data of 15 patients (age range 52 to 78 years, mean 62) with postradical prostatectomy BNC associated with stress urinary incontinence (mean pad use 3 per day) were retrospectively reviewed. Video-urodynamic evaluation in 10 of 15 patients revealed a Valsalva leak point pressure of less than 80 cm H2O in all 10 patients. Bladder outlet obstruction was noted in 4 of 10 patients. Of the 15 patients, 2 declined an artificial urinary sphincter (AUS), the other 13 proceeded with our two-stage management. Step one consisted of deep transurethral incision of the BNC (TUIBNC) with Collin's knife electrocautery. Step two consisted of implantation of an AUS (AMS-800) 6 to 8 weeks after TUIBNC once bladder neck patency had been demonstrated cystoscopically.
  
  
  RESULTS
  During a mean follow-up of 15 months, 3 patients developed early recurrence of BNC: 2 at the 5-week cystoscopy, 1 at 8 weeks discovered at the scheduled AUS placement. All 3 patients underwent repeat TUIBNC and remained clinically patent at a mean follow-up of 9 months. The remaining 10 patients were clinically patent after a single TUIBNC, with good subjective flow and postvoid residual volume of less than 30 mL at a mean follow-up of 11 months. Of the 13 patients who underwent AUS placement, 12 were socially continent (wearing 0 to 1 thin pad daily). The thirteenth patient remained incontinent after AUS placement. One of the 12 continent patients developed an infection at the device 8 months postoperatively and required explantation.
  
  
  CONCLUSIONS
  We recommend a two-stage approach (TUIBNC followed by AUS insertion) rather than synchronous management for postprostatectomy BNC associated with stress urinary incontinence. Such an approach allows identification of BNC recurrence and its safe management before AUS implantation.
authors.affiliation: Division of Female Urology, Voiding Dysfunction and Reconstructive Urology, Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida 33101, USA. A.gousse@med.miami.edu
authors.forename: Angelo E
authors.initials: AE
authors.lastname: Gousse
authors.forename: Hari S G R
authors.initials: HS
authors.lastname: Tunuguntla
authors.forename: Line
authors.initials: L
authors.lastname: Leboeuf
mesh_terms: D000368:Aged; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D011468:Prostatectomy; D019919:Prosthesis Implantation / Q000379:methods*; D012008:Recurrence; D012189:Retrospective Studies; D001748:Urinary Bladder Neck Obstruction / Q000150:complications / Q000601:surgery*; D014550:Urinary Incontinence, Stress / Q000209:etiology*; D016741:Urinary Sphincter, Artificial