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Journal of Clinical Urology 15(1)
history of previous treatment, perform a single urethral
dilation to 24Fr followed by urethral catheterisation for
one week. If a patient already had previous dilation or
incision performed at the time of referral, perform deep
lateral incisions, as described by Ramirez et al., with one
week of urethral catheterisation.9 Patients with BNC or
VUAS recurrence following this would progress to deep
lateral incisions using hot Collins knife plus intralesional
MMC injection using 1 mg MMC in 10 mL normal
saline. Recurrence following the first dose of MMC
can be re-treated with deep lateral incisions with hot
Collins knife plus intra-lesional MMC injection using 4
mg MMC in 10 mL normal saline. The first two steps of
the algorithm offer a success rate of 73-86% each,8-10
and deep lateral incision plus MMC offers a success rate
of ~80% after two procedures. As such, only 1-2% of
patients with BNC or VUAS would be refractory to maximal
endoscopic management. In these cases, bladder
neck reconstruction using open, laparoscopic or robotassisted
surgery11 should be considered in men who are
fit for surgery and are willing to undergo a potentially
two-stage procedure, including the insertion of an AUS
at a delayed stage. Alternatively, urinary diversion is
another potential treatment option.
Limitations
Limitations of this study include our relatively small sample
size. However, this is consistent with other case series,
as BNC or VUAS are uncommon complications of prostatectomy,
with most responding to urethral dilation or BNI
without the need for intra-lesional MMC injection. To our
knowledge, this is the largest Australasian series in the literature.
Another limitation of this study is the lack of a
control arm and therefore inability to determine efficacy in
direct comparison to other treatment groups such as intralesional
steroid injection or bladder neck reconstruction
(open, laparoscopic or robot assisted).
Conclusion
BNI and intra-lesional MMC injection is a minimally
invasive treatment for refractory bladder neck contractures
with a good success rate and minimal risk of side effects
when a low dose of MMC is used. Further prospective
assessments, including randomised controlled trials, are
required to assess its efficacy further in comparison to
other treatment options.
Conflicting interests
There is no conflict of interests to declare for all authors.
Funding
The authors received no financial support for the research,
authorship and/or publication of this article.
Informed consent
Written approval was obtained from a legally authorised committee
for anonymised patient information to be published in this
article.
Ethical approval
Ethical approval to report these cases was obtained from Western
Health Human Research Ethics Panel (QA2019.23/ERMID54561).
Guarantor
H.Y.
Contributorship
H.Y. contributed to the design of the study, data collection, data
analysis, drafting of manuscript and final approval of manuscript.
S.S. contributed to the conception of the study, data interpretation,
critical editing of the manuscript and final approval of the
manuscript. J.C. contributed to the conception of the study,
design of the study, data interpretation, drafting of manuscript
and final approval of manuscript.
Acknowledgements
None.
ORCID iD
Henry H. Yao
https://orcid.org/0000-0003-1955-6992
References
1. Krambeck AE, DiMarco DS, Rangel LJ, et al. Radical prostatectomy
for prostatic adenocarcinoma: a matched comparison
of open retropubic and robot-assisted techniques. BJU
Int 2009; 103: 448-453.
2. Msezane LP, Reynolds WS, Gofrit ON, et al. Bladder
neck contracture after robot-assisted laparoscopic radical
prostatectomy: evaluation of incidence and risk factors
and impact on urinary function. J Endourol 2008; 22:
97-104.
3. Webb DR, Sethi K and Gee K. An analysis of the causes
of bladder neck contracture after open and robot-assisted
laparoscopic radical prostatectomy. BJU Int 2009; 103:
957-963.
4. Carlsson S, Nilsson AE, Schumacher MC, et al. Surgeryrelated
complications in 1253 robot-assisted and 485
open retropubic radical prostatectomies at the Karolinska
University Hospital, Sweden. Urology 2010; 75: 1092-
1097.
5. Lee YH, Chiu AW and Huang JK. Comprehensive study
of bladder neck contracture after transurethral resection of
prostate. Urology 2005; 65: 498-503; discussion 503.
6. Kim HS, Cho MC, Ku JH, et al. The efficacy and safety
of photoselective vaporization of the prostate with a potassium-titanyl-phosphate
laser for symptomatic benign prostatic
hyperplasia according to prostate size: 2-year surgical
outcomes. Korean J Urol 2010; 51: 330-336.
7. Puppo P, Bertolotto F, Introini C, et al. Bipolar transurethral
resection in saline (TURis): outcome and complication rates
after the first 1000 cases. J Endourol 2009; 23: 1145-1149.
https://www.orcid.org/0000-0003-1955-6992

JCU - January 2022

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