High pressure balloon dilation for vesicourethral anastomotic strictures after radical prostatectomy


Worldwide, open RP is performed as a standard procedure for organ-confined prostate
cancer. VAS is one of the most common complications after open RP, although rates
of VAS development vary widely 1], 2]. Occasionally, VAS can be associated with severe voiding dysfunction, and consequently
a deterioration in quality of life. In both laparoscopic and robotic assisted laparoscopic
RP, there are lower incidences of VAS, in the ranging from 0–3 % 8]–10]. While there is no definitive cause of VAS, it has been suggested that the suturing
technique is the most important preventative aspect 10].

Numerous approaches are available for the managing VAS, and much has been published
on the various procedures (Table 3). Simple dilation using catheters or bougies is often performed as the initial treatment
modality; however, this is associated with high recurrence rates. Cold knife incision
is the most commonly performed invasive procedure, with high success rates 7], 11]. More recently, new modalities using bipolar electrocautery or the holmium YAG laser
have been reported with acceptable efficacies 12], 13].

Table 3. Managing vesicourethral anastomotic strictures (VAS) following radical prostatectomy
reported in the literature

Transurethral balloon dilation is an established method of treatment for urethral
stricture. The radial application of forces dilates the stricture, while avoiding
the potentially traumatic shearing forces associated with sequential rigid dilation.
Although transurethral balloon dilation has been performed for VAS previously, there
are limited data regarding the outcomes in comparison to other modalities. Ramchandani
et al. reported a recurrence rate of 41 %. In their series, the balloon of the dilation
catheter did not expand completely 6].

We used a new urethral balloon catheter that achieves sufficient dilation against
a more severe VAS using high pressure of up to 30 ATM. However, it is unclear whether
a higher pressure of balloon dilation is more effective than conventional balloon
dilation.

In the present study, balloon dilation was associated with a high success rate (80 %),
and recurrent strictures could be controlled by performing repeated balloon dilation.
However no patients required further treatment. Such findings are comparable to those
associated with cold knife incision, which is considered the standard management for
VAS.

Transurethral balloon dilation is simpler and less invasive than cold knife incision.
Balloon dilation also has the advantage of a lower risk of urethral vascular injury.
There is a wide range of complications associated with cold knife incision. Perineal
hematoma and urethral hemorrhage are the most common complications ranging up to 20 %
15], and also de novo incontinence as a result of VAS has an incidence of 75 % 7].

However, no complications were reported in our study, except for worsened urinary
incontinence in one patient (10 %).

Although our study was limited by the small number of patients and relatively short
follow-up duration, dilation using this new high pressure balloon catheter appears
to be an effective and minimally invasive treatment for VAS.