~022-5347/98/1604-1373$03.00/0 zyxwvutsrq THE zyxwvutsrqponm JOURNAL OF UROLOGY Copyright zyxwvutsrqponm 0 zyxwvutsrq 1998 by AMERICAN UROL~CICAL ASSOCIATION, INC. Vol. 160,1373-1375, Odober 1998 zy Printed zy in USA. OBLITERATIVE VESICOURETHRAL STRICTURES FOLLOWING RADICAL PROSTATECTOMY FOR PROSTATE CANCER: RECONSTRUCTIVE ARMAMENTARIUM HUNTER WESSELLS,* ALLEN F. MOREY AND JACK W. McANINCHt From the Department of Urology, University of California School of Medicine and San Francisco General Hospital, San Francisco, California ABSTRACT Purpose: We report the reconstructive techniques used to correct obliterative vesicourethral strictures related to prostate cancer surgery. Materials and Methods: Four men with anastomotic obliteration after radical prostatectomy underwent primary excision with end-to-end anastomosis, penile fasciocutaneous flap, free-graft urethroplasty with rectus muscle flap or anterior bladder tube with omental pedicle flap proce- dure. Results: At mean followup of 33.8 months all patients had urethral patency but none was continent. Conclusions: Single stage reconstruction of the obliterated vesicourethral anastomosis after prostatectomy successfully restored urethral patency. No technique was applicable in all cases. Sphincteric function is likely to be compromised after the primary procedure, resulting in incontinence after successful urethral reconstruction. Subsequent artificial sphincter placement appears to be safe and helpful in restoring continence. KEY WORDS: prostatectomy; anastomosis surgical; zyxw urethra The increasing number of men undergoing prostate cancer treatment has been accompanied by vesicourethral compli- cations, despite refinements in surgical and radiotherapeutic techniques. Although endoscopic treatment of anastomotic strictures after radical prostatectomy is usually successfd,l failure of repeated transurethral incision of bladder neck contractures can lead to complete obliteration of the vesi- courethral junction. The reconstructive considerations in these strictures are unique. Prior surgery, pelvic irradiation and residual malignancy may impair wound healing and patient outcome. Urethral reconstruction in these patients is complex and challenging, and there are few reports in the literature.24 We describe the surgical techniques used to correct obliterative vesicourethral strictures after radical prostatectomy, and report the results of continence and pa- tency after reconstructive surgery. PATIENTS AND METHODS Between 1992 and 1996, 4 patients were referred with posterior urethral strictures as a result of prostate cancer therapy. Mean patient age was 61 years, and duration be- tween cancer treatment and presentation ranged from 5 to 18 months (mean 10.5). Anastomotic obliterations occurred in 2 patients after radical perineal surgery, 1 after radical retro- Accepted for publication April 17,1998. * Current Address: Section of Urology, The University of Arizona, Tucson, Arizona 85724-5077. t Requests for reprints: Urology 3A20, San Francisco General HOS- Pital, 1001 Potrero Ave., San Francisco, California 94110. pubic prostatectomy and 1 after salvage radical retropubic prostatectomy. All patients had undergone attempts at en- doscopic incision and urethral dilation. We performed con- trast urethrography and cystography as well as re-staging of prostate cancer before reconstruction. Staging information and the nature of previous cancer treatments are listed in the table. Single stage reconstruction was performed in all 4 patients. Catheter drainage was maintained for 3 to 6 weeks postoperatively. Patient 1 underwent excision of the stricture and end-to- end anastomosis. Initial approach via a vertical perineal incision allowed access to the bulbar urethra, which was mobilized and transected at the point of obliteration. A com- bined abdominal and perineal approach with cystostomy was necessary to visualize and mobilize the bladder neck for suture placement. Patients 2 and 3 underwent pubectomy as the initial ap- proach. Patient 2 had a urethropubic sinus tract requiring excision. Because of concern for possible rectal injury, the scar was not completely excised but rather incised to allow use of an onlay full-thickness penile skin zy graft. A rectus muscle flap based on the inferior epigastric artery was used for graft coverage (fig. 1). Patient 3 underwent pubectomy, excision of the stricture, penned mobilization of the bulbar urethra, construction of an anterior bladder tube and omen- tal flap coverage (fig. 2). Patient 4 had a long stricture extending from the bladder neck to the mid bulbar urethra as a result of radiotherapy, Preoperative history and reconstructive a ppmh R. -Age (yrs.) stage Prior Radiotherapy Prior Surgery Reconstructive Approach No. 1-70 T3NOMO None Radical perineal prostatedomy AwominaUperined 2-66 T3NOMO None Radical retmpubic pmtateetomy Transpubic 3-55 T3NOMO None Radical perineal prostatedomy Rsnspubic 4-51 nNOMO Definitive Salvage radical retropubic prastateetomy Perineal 1373