JCU - January 2022 - 47

Yao et al.
47
treatment options have been described, including bladder
neck reconstruction, which is a technically complex and
potentially morbid surgery performed via an open or robotassisted
approach.10-12 As such, several second-line endoscopic
managements have been described in the literature,
including BNI and intra-lesional injection of triamcinolone or
mitomycin C (MMC).13-17
MMC is an alkylating agent that cross-links complementary
DNA strands to inhibit DNA replication.18 It has also
been shown to inhibit fibroblast proliferation and collagen
production.18 This anti-scarring property of MMC has been
applied to the treatment of oesophageal and anal strictures.19,20
Previous series examining the use of MMC in the treatment
of VUAS or BNC have shown a success rate ranging from
58% to 79% following a single injection.14-17,21,22 One multicentre
study has previously reported a 7% rate of serious
adverse events, including osteitis pubis and recto-urethral fistula.14
As such, the uptake of MMC in the treatment of refractory
VUAS or BNC is low, despite the minimally invasive
nature of the procedure. This study aimed to describe the
experience of a single-surgeon series with the use of intralesional
MMC in the treatment of BNC and VUAS.
Methods
Single-surgeon case-series audit
From July 2014 to January 2019, patients who underwent
BNI and intra-lesional MMC injection performed by a single
surgeon were included in this retrospective study. Clinicopathological
data were extracted from medical records and
included demographic data, cause of BNC or VUAS, history
of pelvic radiotherapy, history of prior endoscopic treatment
for BNC, dose of MMC injected and follow-up cystoscopic
and symptomatic findings. The primary outcome was recurrence
rate following BNI and MMC injection. The secondary
outcome was changes to incontinence and other significant
complications following BNI and MMC. Ethics approval was
obtained from the human research ethics panel of the hospital
attended by the surgeon performing the procedure.
Operative technique
Under general anaesthesia, the patient is placed in a lithotomy
position with thromboembolic prophylaxis, antibiotic
prophylaxis and pressure-point protection. Initial cystoscopy
is performed to determine the degree of BNC or
VUAS. If the contracture or stenosis is too tight to allow the
passage of a 20Fr rigid cystoscopy, then an atraumatic
hydrophilic wire is placed into the bladder to facilitate serial
dilation over guidewire. Deep lateral incisions are then performed
using electrocautery Collins knife to fat.9 This is
performed at 3 and 9 o'clock only to avoid the risk of erosion
into the pubic symphysis or rectum. For the first procedure,
we usually use 1 mg MMC in 10 mL normal saline.
This is injected into the incisions at four sites, with approximately
2.5 mL at each site: (a) right side near bladder neck,
Table 1. Causes of bladder neck contracture in our study
cohort.
Radical prostatectomy
* Open retropubic radical prostatectomy
* Laparoscopic radical prostatectomy
* Robotic-assisted radical prostatectomy
Endoscopic prostatectomy
* Transurethral resection of prostate
* Transurethral vaporisation of prostate
6
1
1
1
1
(b) right side approximately 1-2 cm from bladder neck, and
(c) left side near bladder neck, (d) left side approximately
1-2 cm from bladder neck. If a patient has recurrence on
follow-up despite the above treatment, then we repeat the
procedure with 4 mg MMC in 10 mL normal saline. A largesize
22Fr urethral catheter is placed in the urethra for
approximately one week after the operation.
Results
Ten patients were included in this retrospective study. The
median age of this cohort was 68 years (interquartile range
(IQR) 62-71 years). The cause of BNC or VUAS was secondary
to radical prostatectomy in eight patients and to
endoscopic prostatectomy in two patients (Table 1). There
were four (40%) patients with a history of pelvic radiotherapy.
The median time from date of operation to development
of BNC or VUAS was eight months (IQR 2-113
months). The median number of endoscopic procedures
prior to BNI and MMC injection attempt was three (IQR
2-4). The various endoscopic BNC treatments attempted
prior to BNI and MMC injection included: urethral dilation;
cold-knife, hot-knife or laser BNI; transurethral
resection of scar tissue; and BNI with injection of triamcinolone.
The median time between each endoscopic treatment
prior to BNI and MMC injection was 2.5 months
(IQR 1-7 months). All patients with VUAS following radical
prostatectomy were incontinent preoperatively, with
severity ranging from very mild to completely incontinence.
Neither of the two patients with BNC following
endoscopic prostatectomy was incontinent preoperatively.
Of the 10 patients, 0.8 mg MMC was used in two patients,
1 mg in seven patients and 2 mg in one patient (4 mg MMC
in 8 mL). Three patients had an indwelling urethral catheter
(IDC) placed for one day, one patient for two days, five
patients for seven days and one patient for 10 days.
The median follow-up for this cohort was 16.4 months
(IQR 11.6-27.9 months). Of the 10 patients, nine had at least
one cystoscopic follow-up to ensure no recurrence of BNC
or VUAS. Seven had a successful outcome following a single
injection of MMC. All seven of these patients reported no
recurrence of symptoms at the most recent clinic follow-up.

JCU - January 2022

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