Salvage surgery for bladder outlet obstruction after prostatectomy or cystectomy.
OBJECTIVE
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.


RESULTS
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.


CONCLUSIONS
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.
Westney
Ouida L
OL
Division of Urology, Department of Surgery, University of Texas-Houston Medical School, Houston, Texas 77030, USA. Ouida.L.Westney@uth.tmc.edu
D015653:Cystectomy / Q000009:adverse effects*; D004106:Dilatation; D004564:Electrocoagulation; D006801:Humans; D008297:Male; D011468:Prostatectomy / Q000009:adverse effects*; D012008:Recurrence; D016879:Salvage Therapy; D015607:Stents; D014521:Urethra / Q000601:surgery; D001743:Urinary Bladder / Q000601:surgery*; D001748:Urinary Bladder Neck Obstruction / Q000209:etiology / Q000601:surgery*; D016741:Urinary Sphincter, Artificial; D013521:Urologic Surgical Procedures, Male / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods