mitomycin C for recurrent bladder neck contracture

Jeremy Myers, MD

Overview

• Background• Prior experience with MMC• TURNS MMC experience• Comparison with recent series of deep

excision alone

Background

• Usually iatrogenic following radical prostatectomy, XRT for CaP and TURP

• CaPSURE and SEER-Medicare reported incidence of 5.8% to 14%1,2

• Can be recurrent and recalcitrant to treatment

1. Hu et al. JAMA. 2009 Oct.2. Elliott et al. The Journal of Urology. 2007

Background

• Complicates the treatment of post-prostatectomy incontinence (PPI)

• Independent risk factor for PPI• Combination of patient and technical

factors have been implicated in its etiology

Eastham et al. JURO. 1996

• Prospectively collected data on 4,592 consecutive patients undergoing RP (open and laparoscopic*)

• Patient factors Age, BMI, comorbid status

• Technical factors Surgical approach, indiv. surgeon, EBL, post-

operative urine leak/hematoma• Median time to stricture 3.5 months (IQR 2.1-6.1)

Sandhu et al. JURO. 2011

Borboroglu et al. Urology. 2000

Treatment Options

• Patients often endure multiple procedures• Endoscopic vs Open reconstruction

Open reconstruction

• Usually last resort• High morbidity• Experience with a variety of

reconstructive techniques required

• Long term success rate only ~70%1

• Diversion may ultimately be needed

1. Elliott et al. JURO. 2006 Dec;176(6):2508–13.2. Wessells et al. JURO. 1998 Oct;160(4):1373–5

.

Endoscopic Management

King et al. Advances in Urology. 2012

• Lahey Clinic• 18 patients with recurrent BNCX and at least one prior TUIBN (56% had >2

prior TUIBN)• All treated with cold-knife incision• Median of 12 months (range 4-26) of cystoscopic follow up• 72% with stable bladder neck after one treatment, 89% after 2• Improvement in median PVR

Vanni et al. JURO. 2011

Initial experience with MMC

TURNS MMC Experience

TURNS MMC Experience

TURNS MMC Experience

TURNS MMC Experience

• Adverse events: 63 yom – 4 mg (0.4mg/ml) MMC – Bladder pain and non-

healing ulcer extending from the site of incision to the trigone seen on cystoscopy at 3 and 6 months. No evidence of stricture recurrence.

69 yom – 4.5 mg (0.75 mg/ml) MMC - Osteitis pubis and rapid recurrence of his stricture 2 months later for which a suprapubic tube was placed. Ultimately underwent cystectomy with creation of right colon pouch

59 yom - 4 mg (2mg/ml) MMC –Osteitis pubis and rapid recurrence of the stricture. Ultimately underwent cystectomy with creation of right colon pouch

TURNS MMC Experience

Summary of TURNS MMC Experience

• 66 patients underwent a total of 90 injections (55 w/greater than 3 months of fu)

• 58% primary success, 75% after 2 procedures• Collins knife, OR of 10.7 compared with cold-

knife• 3 patients experienced serious adverse

events

• Morey et al (2013) 50 patients, 78% had failed prior TUIBN All treated with deep lateral incision using

Collins knife 72% achieved stable bladder neck after one

procedure, 86% after 2 >10 pack/yr hx of smoking and >2 prior BNC

procedures associated with treatment failure

Deep incision alone

Ramirez et al. Urology. 2013

• Wood et al (2014) 63 patients all treated with cold-knife 51% primary success (70% primary after 2

procedures) Median 11 months of follow up (clinical)

Deep incision alone

Brede et al. Urology. 2014

Incontinence

• Safe interval to place AUS unknown Incontinence present in 61-78% with recurrent

BNCX Recurrence in TURNS 3.7-4.2 months Consider transcorporal AUS placement in case

of future recurrence

Brede et al. Urology. 2014Ramirez et al. Urology. 2013

Future

• Technical factors (cold-knife vs. hot knife)• Efficacy and safety of adjuvant agents

(MMC)• New agents (Xiaflex)