October 31, 2014

   A Publication of the James Buchanan Brady
   Urological Institute Johns Hopkins Medical Institutions

Volume II, Autum 2005

STRICTURE-FREE AND CONTINENT
Help for SevereBladder Neck Contracture

One infrequent but troublesome complication of radical prostatectomy is bladder neck contracture. This happens when dense scar tissue forms in the bladder neck, the area where the bladder and urethra are joined together after the prostate is removed. The thickened scar tissue narrows the inside of the urethra, causing a slow-down — or sometimes even an outright blockage — of urine flow. Exactly why this scar tissue forms is unknown, but it may be due to poor healing at the surgical site.

Mild cases are fairly simple to treat; a urologist dilates the area, using instruments passed through the urethra. Or, if the contracture is more significant, the urologist uses a cystoscope, passed through the penis, to make cuts in the scar tissue and break its stranglehold on the urethra. Rarely, however, severe contracture can cause the urethra to become completely obstructed.

“In the past, the only option when the opening was completely blocked was major surgery,” says Thomas W. Jarrett, M.D., associate professor of urology, and chief of the Division of Endourology and Laparoscopy. This was especially tough on men who had just undergone major surgery, radical prostatectomy. Recovering from this procedure could take months, and involved the long-term use of a catheter (placed either in the urethra or directly into the bladder, through the skin in the lower abdomen).Worse, men faced a high risk of impotence and long-term incontinence from the extra surgical trauma.

Jarrett has developed a new technique that avoids a second open surgical procedure, and all of the complications that go with it. “In this technique, we place small telescopes simultaneously through the penis and through a tiny incision above the pubic bone,” Jarrett explains. “We have been able to successfully reestablish the channel between the bladder and urethra in a minimally invasive fashion in all patients.” Once the urethra is reopened, Jarrett cuts the scar tissue, using a laser beam to minimize trauma to the tissues. Then, very gently and gradually, over the next few months, he enlarges the urinary tract until it is stable.The theme of this approach, borrowing from Aesop, is “Slow and steady wins the race.” The process may require several minor surgical revisions to treat additional scar tissue. Also, during this time of healing, “the patient must catheterize himself on a regular basis to prevent the opening from closing.”

However, the results are worth the wait, Jarrett concludes: “Using this technique, we have been able to successfully treat most patients without major surgery and the devastating side effects of impotence and incontinence.”

 

 

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