JCU - January 2022 - 48

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Journal of Clinical Urology 15(1)
Six out of seven patients had a follow-up of ⩾12 months.
The latest follow-ups for these seven patients are 9, 12, 20,
22, 30, 46 and 66 months. The two patients who failed BNI
and injection with triamcinolone previously both had a successful
outcome following BNI and MMC injection.
Two of the three patients with recurrence of BNC or
VUAS underwent a second BNI and injection of MMC. The
first patient had a repeat BNI and 4 mg dose of MMC injected
two months following the initial BNI and MMC injection.
On follow-up flexible cystoscopy nine months following the
second BNI and MMC injection, the bladder neck was wide
open. The second patient had a repeat BNI and 1 mg dose of
MMC injected five months following the initial BNI and
MMC injection. This patient had recurrence of symptoms
and repeat BNI four months later. This patient had Hem-olok®
eroded into the vesicourethral anastomosis removed at
a separate endoscopic procedure prior to the first MMC
injection. Another Hem-o-lok® was again seen protruding
into the VUAC at this final BNI. The final patient with recurrent
BNC was not bothered symptomatically by flow but
eventually underwent radical cystectomy for recurrent haemorrhagic
radiation cystitis and severe incontinence which
was present prior to MMC injection. The diagnosis of recurrent
BNC was made at the time of radical cystectomy and
ileal conduit with cystoscopy preoperatively.
Both patients who had BNC secondary to endoscopic
prostatectomy were continent preoperatively and remained
continent after the operation. Out of the eight patients with
incontinence preoperatively, five patients had the same
degree of incontinence postoperatively, two patients had
worse incontinence and one patient had reduced incontinence.
Of these incontinent patients, four patients eventually
progressed to having an artificial urinary sphincter
(AUS) placed. Two patients refused an AUS, as they were
not significantly bothered with their current symptoms.
One patient underwent radical cystectomy for haemorrhagic
radiation cystitis, and another died from pneumonia
whilst on the waiting list for an AUS.
History of radiotherapy was not associated with a
higher rate of BNC or VUAS recurrence following the first
procedure (25% vs. 33.3%, p=1.0, Fisher's exact test) or
overall success rate (25% vs. 11.1%, p=1.0, Fisher's exact
test). There were no serious adverse events or Clavien-
Dindo grade 3 or above complications directly related to
the injection of MMC in our cohort of men.
Discussion
This study demonstrates that intra-lesional injection of
MMC following BNI for the treatment of recalcitrant BNC
or VUAS is a safe, minimally invasive treatment option
with a reasonable success rate. The findings from this
study are comparable to the six previously published case
series which are summarised in Table 2. The median age of
patients from all seven studies are similar and ranged from
59 to 68 years. The majority of causes of BNC or VUAS in
all studies were secondary to radical prostatectomy or
endoscopic prostatectomy. Previous history of radiotherapy
is not a contraindication to this procedure, and the percentage
of patients who had prior radiotherapy ranged
from 9.1% to 46.2% across the different studies. The vast
majority patients included in all studies had at least one
prior endoscopic management of BNC or VUAS, with
many patients having had two or more prior procedures.
Operative technique
A variety of operative technique were described for the dilation
of BNC or VUAS by different studies, and included
serial dilation over guidewire, cold-knife incision, Collins
knife incision, bipolar incision and transurethral resection of
scar tissue.14-17,21,22 The most common method employed
was cold-knife incision.14-16,21 One study showed that incision
with electrocautery (i.e. Collins knife) was associated
with a higher chance of success of treatment,14 and this is
the preferred method by the authors of this study. Most studies
performed three to four incisions, and the authors would
recommend avoiding a 6 o'clock incision to prevent rectal
injury in patients following radical prostatectomy. Except
for one study which injected MMC prior to urethral dilation,22
all other studies performed intra-lesional injection of
MMC at the wound bed after incision of scar tissue.14-17,21
The dose of MMC once again varied between the different
studies, with the lowest reported dose being 0.1 mg and the
highest 10 mg. Six of seven studies reported leaving an IDC
following the procedure for three to seven days. Despite the
variation in surgical technique and dose of MMC used, the
success rate appears to be similar. However, given the small
number of cases in each series, a larger multi-centre randomised
controlled trial would be required to determine the
optimal dose and technique to employ.
Success rates
This study shows that BNI and intra-lesional MMC injection
can achieve a good success rate for the treatment of refractory
BNC or VUAS, with minimal side effects when low doses of
MMC are used. The success rate of 70% after the first treatment
and 80% after the second treatment mimics that of other
case series published in the literature.14-17,21,22 The median
follow-up of previous studies ranged from 9.2 to 58 months,
with a reported success rate after the first procedure ranging
from 58% to 79%, and from 75% to 89% after two or more
procedures. The study with the longest follow-up also
reported the highest success rate of 79% after the first procedure.22
Redshaw et al. reported the lowest success rate of 58%
after the first procedure.14 The heterogeneity of operative
technique included in this multi-centre retrospective study
may have played a role in this finding. This current study
found that previous pelvic radiation is not associated with
BNC or VUAS recurrence, which is consistent with some
previous studies.14,15 However, given the small number of

JCU - January 2022

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