Bladder neck contracture after radical surgery

New data suggest a slightly lower incidence of bladder neck contracture (BNC) in patients treated with robot-assisted (RALP) as opposed to open (ORP) radical prostatectomy in a modern series of patients.

Historically, BNC was a relatively regular and well-described complication of ORP. The precise reasons for BNC in any specific patient could often be difficult to determine, but there have certainly be good reasons to believe that surgical technique was one cause of BNC.

Breyer et al. have published a retrospective analysis of data from 988 patients treated surgically for localized prostate cancer at the University of California San Francisco between 2002 and 2008. Eligible patients were all followed for a minimum of 12 months post-surgery. The investigators were interested in learning whether the incidence of BNC was associated with the type of surgery being carried out.

Their results showed the following:

  • 695 underwent ORP and 293 underwent RALP.
  • The average age of the patients (mean ± SD) was 59.3 ± 6.80 years.
  • 91 percent of the patients were Caucasian.
  • When categorized by D’Amico risk group at diagnosis, 38 percent of patients were low risk, 38% were intermediate risk, and 24 percent were high risk.
  • The total number of cases of BNC was low: 22/988 (2.2 percent).
  • BNC occurred in 4/293 patients treated with RALP (1.4 percent) and in 18/695 patients treated with ORP (2.6 percent); this difference was not statistically significant.
  • BNC was diagnosed at a median of 4.7 months post-surgery ( range, 1 to 15 months).
  • A slow urinary stream was the most common presenting complaint, followed by urinary retention.
  • At 18 months after surgery, the BNC-free rate was 97 percent for patients treated with ORP and 99 percent for patients treated with RALP.
  • Among the ORP patients, earlier year of surgery, older age at diagnosis, and higher PSA level at diagnosis were significantly associated with BNC.
  • Among the RALP patients, none of the covariates examined were specifically associated with BNC.

There are a number of interesting conclusions that can be inferred from this study. The authors draw two:

  • The overall incidence of BNC was clearly relatively low in both surgical groups.
  • Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group.

However, The “New” Prostate Cancer InfoLink believes that the occurrence of BNC reported in this study is, in fact, notably lower than the numbers we used to see 10 to 15 years ago (i.e., before the advent of laparoscopic radical prostatectomy). The fact that older age at diagnosis, earlier year of surgery, and higher PSA level at diagnosis were all associated with a higher risk for BNC in the ORP patient cohort tends to suggest that earlier diagnosis reduces the difficulty of re-attaching the urethra to the bladder neck and that surgical technique has improved overall in recent years.

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