Management of prostatic necrosis and the devastated bladder outlet—a narrative review

Abstract

Background and Objective

Although devastating complications of the bladder outlet resulting from prostate cancer (PC) treatments are relatively uncommon, they do exist. These complications deteriorate patients’ quality of life (QoL), and with the combination of increased incidence of PC and patient longevity after treatment, awareness of adverse outcomes in recent years have increased. This review discusses the incidence, risk factors, diagnostic work-up, and management options for devastated bladder outlet (DBO), resulting from PC treatment complications, requiring urinary diversion (UD).

Methods

A systematic literature search was conducted via OvidSP covering 1946 to present. The selection was limited to English language studies.

Key Content and Findings

DBO can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments and especially multimodal PC treatments. Patients with a combination of complications, typically recalcitrant bladder outlet obstruction, urinary incontinence, urinary fistula, and/or severe bladder dysfunction end up in a situation we can call DBO. Initially patients will be offered conservative treatment or reconstruction. However, in the worst circumstances, such as prior radiotherapy, failed reconstruction, DBO with end-stage bladders, or patient’s severe comorbidities, reconstruction may neither be realistic nor justified. UD with or without cystectomy may be the best option for these patients. Outcomes and repercussions on QoL vary extensively with management options. Meticulous preoperative diagnostic evaluation and thorough patient counseling are paramount in selecting the right treatment strategy for each individual patient. There are a wide range of UD options including a suprapubic catheter to more sophisticated solutions like augmentation cystoplasty with continent catheterizable channel and many others.

Conclusions

There is a non-negligible risk of DBO after treatment of PC, especially following multimodal treatment. In the worst circumstances, management with UD may be necessary. Possible UD options are discussed.

Introduction

Devastating complications of the bladder outlet resulting from pelvic treatments of benign or malignant disorders are relatively uncommon. However, there has been higher awareness on these outcomes in the last decade, partly due to patient longevity and incidence of these long-lasting adverse events (AEs) deteriorating patients’ quality of life (QoL) many years after treatment. Prostate cancer (PC) treatments, especially multimodal, are among the most common etiologies of devastated bladder outlet (DBO). There is increasing literature on the field, with mainly smaller case series, regarding those patients with an unsalvageable outlet, where a urinary diversion (UD) is indicated.

This narrative review discusses the risk factors, diagnostic work-up and management options for DBO, resulting from PC treatment complications, requiring UD. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-433/rc).

Methods

Data acquisition

The literature search was done with assistance from an information specialist at the University of Oslo Library, using the Ovid MEDLINE^® database via OvidSP. The search identified publications in English, with no limitations on study design, publication status, or publication year. The aim of the search was to identify publications about patients with DBO after surgical treatment, radiotherapy or focal therapy of PC, ending with a UD. The exact search strategy and terms are described in Table 1 and Table S1.

Table 1. The search strategy summary.

Items	Specification
Date of search	May 1, 2025
Databases and other sources searched	Ovid MEDLINE(R) ALL*
Search terms used	Please see Table S1 for details. The search can be summarized as follows:
	(I) Prostate cancer
	(II) Treatment of (I)
	(III) Complications of (II) and treatment thereof
	(IV) Urinary diversion following (III)
Timeframe	1946 to present
Inclusion and exclusion criteria	Inclusion: all studies yielded from the above search without filter or limitations on study type
	Exclusion: publication language other than English
Selection process	The search strategy was developed by an information specialist at the University of Oslo and the final strategies were peer-reviewed by the two authors. The selection was finally conducted independently by the two authors, which included the exclusion of non-English publications. Both authors read and analyzed all the results of the search
Any additional considerations, if applicable	None

*, Ovid Database Field Guides: https://ovidsp.dc1.ovid.com/ovid-new-b/ovidweb.cgi?&S=fbdbcf38-5db6-454f-bb65-1eb455303226%7cmain&Database+Field+Guide=9.

The search was conducted on May 1, 2025, and yielded 31 publications published from 1994 to 2025. Seventeen articles were retrospective cohort studies with 3–201 patients, two were cases studies, and 12 articles were narrative literature reviews. The two authors individually reviewed the selected articles.

Other studies considered relevant to each topic discussed have also been included.

Definitions: the DBO

The DBO is a condition characterized by refractory bladder outlet obstruction (BOO), sometimes combined with prostatic necrosis, and/or urinary incontinence (UI) due to external sphincter damage, in which reconstruction is considered very unlikely or impossible (1,2). There has been increasing focus on this condition recently, as iatrogenic causes have become more common and apparent. The most common cause being PC treatment, especially in complicated cases with a history of combined treatment modalities including radiation followed by several treatments of minor or major complications such as BOO and UI (2,3).

BOO is a non-specific term covering all conditions causing a narrowing or obliteration of the bladder outlet, not regarding the level of obstruction, previous history, gender, or whether the prostate in a man has been removed. Posterior urethral stenosis (PUS) refers to a narrowed urethral segment anywhere between the distal bladder neck and the proximal bulbar urethra. If the prostate is present, PUS can be described as bladder neck stenosis (BNS) or contracture (BNC), prostatic urethral stenosis, and membranous/bulbomembranous urethral stenosis (BMUS). The term vesicourethral anastomotic stenosis (VUAS) should be reserved for stenosis following total removal of the prostate (2). The vesicourethral anastomosis is the location mostly affected by stenosis following radical prostatectomy (RP), and the bulbomembranous urethra is the location typically affected by radiation therapy (RT) or ablative therapies (AT) (4).

End-stage bladder dysfunction may be defined as a decreased bladder capacity <100 mL, decreased bladder compliance demonstrated on urodynamic analysis, refractory detrusor overactivity at low volumes, and/or severe lower urinary tract symptoms (5,6).

PC treatments can cause several types of AEs, including those related to the bladder outlet (BOO, UI, urinary fistulae), bladder (radiation cystitis and other forms of severe bladder dysfunction), chronic pelvic pain, and sexual dysfunction (2,7-9). Repeated failed treatments of these AEs can cause an even more severe dysfunction as well as new AEs, like urethral stricture or fistula following failed incontinence surgery or endoscopic BOO surgery.

Hence, DBO may be the result for patients going down this rabbit hole. Typically, patients undergo multiple different therapeutic attempts to restore lower urinary tract continuity and function. For some unfortunate patients who have failed, eventually multiple, reconstructive attempts, UD can provide a definitive treatment option improving QoL.

This updated narrative review is based on a recent review on the same subject but with a focus on the difficult patient group whose devastated bladder and outlet are unsalvageable and requiring a UD (2). UD options can range from a simple suprapubic catheter to sophisticated reconstructive options. Hence, abandoning the bladder outlet does not necessarily mean abandoning reconstructive solutions, if the patient is fit for major surgery (10).

Results

Epidemiology and risk factors

It is widely documented that the prevalence of PC treatments and their long term AEs are rising, partly due to an ageing population and high rate of cancer survivors (8,9,11-16). However, the long-term incidence of BOO after PC treatment is not as well documented as UI and erectile dysfunction (ED). Studies have shown a 10-year incidence of PUS of 9.6% to 25.9%, following external beam radiotherapy (EBRT) and a combination of RP and EBRT, respectively (13). The authors showed that PC treatments, especially combined treatment modalities (radiation and surgery), carry a risk of AEs such as BOO and bladder dysfunction.

A large recent study from the Surveillance, Epidemiology, and End Results (SEER) database (N=67,527) compared the 5-year cumulative incidence rates of functional outcomes between single and multiple modalities (17). RT-only compared to RP-only showed lower rates of ED (30.4% vs. 56.1) and UI (29.7 vs. 44.5%), similar rates of fistulae (1.3%), and higher rates of urethral stricture disease (8.44% vs. 5.35%), cystitis (33.1% vs. 20.3%), and proctitis (14.7% vs. 2.75%) (17). (The term ‘urethral stricture disease’ was not defined and may include all forms of BOO including VUAS, PUS, and anterior urethral strictures.) Both multimodality groups (RP-then-RT and RT-then-RP) showed significantly worse functional outcomes compared to single modalities, especially the latter group with 19.34% BOO and 10.35% fistula rates. However, radiated patients were relatively less likely to be treated for their complications (17).

Doiron et al. showed that urethral complications after PC RT are seldom isolated problems and rather a combination of complications can be expected (3). Mayer et al. did a study to identify patients with Radiation Therapy Oncology Group (RTOG) grade 4 urinary AEs and identified 73 patients with severe bladder dysfunction (8%), outlet dysfunction (including fistulae, BOO, UI) (71%), and a combination thereof (21%) (16). Sack et al. studied patients who underwent cystectomy and UD for DBO following RT/AT and found that events leading to UD included BNC, prostatic necrosis, UI, fistulae, urethral strictures, abscesses, necrotizing fasciitis, and radiation/hemorrhagic cystitis (18).

Time since treatment also increases the risk of developing AEs, which emphasizes that these treatments have long-term repercussions (13,19). In the CaPSURE study published in 2007, the incidence of BOO following PC treatment ranged from 1.7% (post-EBRT) to 8.4% (post-RP), with a cumulative incidence of 5.2% (19). However, a delayed escalation of radiation-related stenosis was observed at the latest follow-up (FU) evaluation (19). Treatment modality and the chronological occurrence and severity of BOO have been demonstrated as VUAS usually occurs within the first 12–24 months after RP, while AEs after RT occur gradually and are cumulative over time, especially following salvage RP (RT-then-RP) (2,13,17,19,20).

In 2014, Ishiyama et al. reported in a systematic review a greater risk of PUS after RT if transurethral resection of prostate (TURP) had been performed prior to RT (21). In another study, Seymore et al. noticed a difference in the incidence of PUS in patients who received RT after TURP versus patients without previous TURP, specifically 15% and 6%, respectively (22).

The risk of developing BOO and DBO increases after salvage treatment for PC recurrence, as it exposes previously treated tissues to additional injury. Corcoran et al. reported VUAS to be the main postoperative complication with rates of up to 40% in a 21-patient cohort study of salvage prostatectomy after primary RT over a 15-year period with a median FU of 68 months (23). In a study of nearly 200 patients with median FU of 7 years after salvage prostatectomy and cystoprostatectomy, Ward et al. reported a VUAS rate of 22%, as well as rectal injury in 5–10% and UI in 44% (24).

There are hardly any studies reporting the true incidence of DBO after PC treatments. Rather, case series of patients with DBO and associated risk factors have been published (2). These include patient related factors (age, smoking, comorbidities, history of radiation therapy and outlet surgery) and operative factors (technique, complications) (2). However, there are no studies comparing patients developing DBO and patients who did not, unfortunately.

A Cochrane review reported a risk of BOO between 3% and 10% after adjuvant or salvage EBRT after RP (12). Salvage AT such as cryoablation and high-intensity focused ultrasound (HIFU) resulted in BOO rates of 5–12% and 15–30%, respectively (25-30). Other severe debilitating complications such as refractory UI and fistulae were also inherently associated with these salvage treatment protocols. Subsequent endoscopic treatment of BOO carries a high risk of fistulae (31). Furthermore, the occurrence of a rectourethral or urosymphyseal fistula in the setting of previous RT significantly increases the risk of UD (18,31-33).

The timing of RT after RP is significantly associated with the risk of developing complications. Until recently, the literature recommended adjuvant RT to patients at high risk for PC recurrence, especially in case of positive surgical margins and a high-risk profile (34,35). However, this has been contradicted by the RADICALS trial in which a more conservative approach is favored over adjuvant RT (36). Observation and only, if necessary, salvage RT should be recommended due to the increased risk of urinary complications related to adjuvant RT (36). Several studies have shown that adjuvant RT carries a higher risk of BOO compared to salvage RT (35-37). This impact difference may be explained by the fact that adjuvant RT is delivered earlier after surgery than salvage RT (36).

Prognosis of AEs leading to DBO

AEs following PC treatments, like SUI and BOO, are commonly treated with artificial urinary sphincter (AUS) and endoscopic incisions, respectively. In uncomplicated cases most patients do well and are satisfied with their outcome. However, some of these patients experience recurrent complications and may end up with a DBO and UD.

AUS erosion

Proposed risk factors for AUS erosion are many and include comorbidity (hypogonadism, obesity, diabetes mellitus, coronary artery disease), history of pelvic radiation, urethroplasty, prior AUS complication, as well as surgical technique and choices (small cuff size, penoscrotal approach, transcorporal cuff, double cuff) (38-40).

According to a study of the TURNS database 2008–2018, a study of 324 redo AUS cases, the AUS 5-year revision-free survival changes significantly if the patient has one or more risk factors, with survival of 83.1% if the patient has no risk factor, 72.6% in case of a history of pelvic radiation, 63.9% in case of previous urethroplasty, and as low as 46% in case of both previous pelvic radiation and urethroplasty (38). The same study revealed that the median time to explantation was longer for nonirradiated patients than irradiated patients after the initial and second AUS (35 and 38 months for nonirradiated and 26 and 30 for irradiated patients, respectively), but after the third AUS there was no difference (30 and 28 months, respectively). This signifies that nonirradiated patients/tissue approximates irradiated tissue after several revisions, leading to a worse prognosis (41).

Urethral erosion prevention and management methods may reduce the risk of future complications but are no guarantees of success (10,39). Urethral repair at the time of AUS explantation for cuff erosion appears to prevent stricture development. However, large erosions have a high risk of lower urinary tract complications (stricture, diverticulum, fistula) and future UD compared to small erosions nevertheless (41). In case of end-stage urethra, urethral ligation and UD may a better option (42). Hence the approach to each patient depends on individual history and findings.

BOO treatment

The treatment of BOO ranges from dilation, transurethral incision with or without anti-fibrotic agents, to lower urinary tract reconstruction (urethroplasty, reanastomosis, VY- or T-plasty, etc.) with various success rates depending on the type of BOO and previous history. Pseudo-continence in patients with BOO can become evident after treatment, leading to further treatments of UI and possibly more complications (2,6). In refractory cases with recalcitrant BOO, UD with or without bladder preservation may be indicated (2). Patients with a BOO after EBRT requiring endoscopic management have a high risk of developing a urosymphyseal fistula and in those patients UD will be almost inevitable (5) (Table 2).

Table 2. Urosymphyseal fistula after prostate cancer treatment: previous history and final treatment.

Author	Number of patients; age* (years)	History of RT	History of BOO tx	Fistula excision + reconstruction	Urinary diversion + extirpative surgery
Matsushita et al. 2012 (43)	12; 65 [58–75]	100%	100%	0	83%
Bugeja et al. 2016 (44)	16; 71 [66–79]	100%	81%	44%	50%
Nosé et al. 2020 (45)	36; 71 [62–85]	92%	86%	0	100%
Kahokehr et al. 2021 (46)	36; 71 [67–76]	92%	86%	3% (no RT)	97%
Inouye et al. 2022 (47)	18; 77 [72–80]	100%	89%	0	100%
Ambrosini et al. 2022 (48)	4; 70 [11]	100%	100%	0	75%

Publications regarding the treatment of urosymphyseal fistula after prostate cancer treatment, including size of the study, patient history of radiotherapy and bladder outlet obstruction treatment, final treatment (extirpative surgery with fistula excision and reconstruction or urinary diversion and cystectomy). *, age is listed as median [range or interquartile] as originally reported. BOO tx, bladder outlet obstruction treatment; RT, radiation therapy.

Fistulae

The occurrence of a rectourethral or urosymphyseal fistula in the setting of previous RT significantly increases the risk of UD (18,31-33) (Table 2). Faris et al. found that although fistula rates were similar across radiation modalities with a mean of 37%, the types of fistulae were different, with urosymphyseal and urethrocutaneous fistulae in patients who underwent EBRT and rectourethral fistula (RUF) occurring in patients with brachytherapy (BT) seeds (5). UD rates were 42.5% in irradiated patients compared with 4% in nonirradiated patients with RUF (5). Yamashita et al. reported a severe case of urosymphyseal fistula and necrotizing fasciitis after high-dose rate BT and EBRT followed by transurethral incision of a BOO (32).

Implantation of AUS after endoscopic treatment of BOO in irradiated patients may reveal urosymphyseal fistula with dramatic and devastating consequences (49).

(I). Urosymphyseal fistula treatment

Urosymphyseal fistula carries a high risk of UD. Both conservative treatment and reconstruction with fistula excision have very low success rates. Published studies are small with 4–36 patients included (Table 2). Most cases have a history of RT (92–100%) and endoscopic BOO treatment (81–100%). Success rates of reconstruction are mostly very discouraging except one study from Bugeja et al. with success rate of 44% and cystectomy only in case of end-stage bladder (44). Kahokehr et al. reported that 3% were successfully repaired, but these patients did not have a history of RT (46). Most patients were treated with extirpative surgery (cystectomy, fistula excision) and UD (43-45,47,48). Inouye et al. showed that resection of the pubic symphysis and cystectomy significantly improved patient-reported physical functioning and decreased opioid use (47).

(II). Rectourethral fistula treatment

Risk factors for RUF include RT, RP with perioperative damage to rectum, salvage RP post-RT, and salvage HIFU post-RP as well as endoscopic treatment of BOO following RT. RT leads to fistulae with a larger diameter, longer fistula-tracks, and ischemic fibrotic tissue. A literature review of studies of the surgical treatment of RUF is listed in Table 3 (50-54). The take home messages from these studies include the following: Patients with RUF secondary to RT/AT were older and had larger fistulas. RUF post-RP are usually amenable to primary repair, but they are unlikely to heal with conservative management if more than 6 weeks have passed since the RP. RUF post-RT will never heal with conservative management and severe RT- and AT-indued fistulae have a high risk of UD. A fecal diversion is not always necessary but one should consider the use of interposition flaps or buccal mucosa graft in case of reconstruction (50). Preoperative hyperbaric oxygen therapy (HBOT) can improve the success of reconstructive attempts.

Table 3. Rectourethral fistula after prostate cancer treatment: previous history and final treatment.

Author	Number of patients; age* (years)	History of RT/AT	Fecal diversion	Reconstruction	Success (%) history of RT +/−
Mundy & Andrich 2011 (50)	40; not reported	43%	68%	100%	100%/100%
Linder et al. 2013 (51)	42; 68 [56–75]	64%	64%	38%	17%/87%
Bislenghi et al. 2020 (52)	52; 68 [33–85]	58%	38%	64%	16%/58%
Sbizzera et al. 2022 (53)	21; 66 [64–68]	14%	57%	100%	100%/100%
Khouri et al. 2024 (54)	23; 64 [50–69]	65%	100%	100%	100%/100%

Publications regarding the treatment of rectourethral fistula after prostate cancer treatment, including size of the study, patient history of radiotherapy/ablative therapy, and final treatment (fecal diversion and reconstruction), including success rates overall and in case of a history of radiotherapy/ablative therapy or not. A mix of different types of radiation and ablative therapies were reported, including either EBRT or BT or both, or salvage cryotherapy or salvage HIFU. *, age is listed as median [range or interquartile range] as originally reported. AT, ablative therapy (cryotherapy, HIFU); BT, brachytherapy; EBRT, external beam radiotherapy; HIFU, high intensity focused ultrasound; RT, radiation therapy.

Combination of complications and end-stage bladder dysfunction

Although not part of the DBO complex, many patients with outlet complications have concomitant bladder dysfunction. Incidence of radiation cystitis is 23–80%, reported to occur 36–79 months after RT (20). Late radiation cystitis can develop up to 20 years after treatment. Several conservative management options exist (endoscopic, intravesical, HBOT, embolization), however, in case of end-stage devastated bladder, cystectomy and UD is indicated (5). Severe bladder dysfunction can also occur post-RP without a history of radiation, especially in case of BOO.

The combination of any of the abovementioned complications and severe bladder dysfunction will become devastating for patients, making reconstruction of the outlet futile on its own.

Diagnosis and decision-making

Patients may present with BOO or a DBO after PC treatments, early (within 24 months) after RP or later after RT (19). Symptoms usually include obstructive voiding and/or UI. Additionally, irradiated patients may complain of severe symptoms of overactive bladder and pelvic or urethral pain. Subsequent treatment of the BOO most likely causes new-onset UI or exacerbates preexisting UI (55). Symptoms of DBO are usually in the more severe end of the spectrum. RUF, urosymphyseal fistula, and total obliteration of the vesicourethral anastomosis may be the most severe complications requiring treatment (2,10,16,24,33,56,57).

After PC recurrence has been excluded, PC survivors considered for lower urinary tract reconstructive procedures should undergo routine preoperative blood tests including renal function parameters, urinalysis, and urine culture. Cystourethroscopy provides evaluation of the location and severity of the obstruction, degree and extent of tissue damage with areas of calcification and/or necrosis, urinary sphincter function or destruction, bladder stones, and concurrent or recurrent neoplasms.

Antegrade cystoscopy via suprapubic cystotomy should be considered to determine the proximal extent of the obstruction, especially in individuals presenting with a suprapubic catheter, complete obliteration, and in those requiring open surgical reconstruction, and is essential to surgical planning. The status of the bladder and bladder neck will help determine the salvageability of the lower urinary tract. Visualizing relatively healthy mucosa in the urethra distal and proximal to the BOO may give an indication of possibility of successful reconstruction, while fibrotic and/or calcified conditions of the lower urinary tract does the opposite.

Diagnosing the exact extent of any BOO is essential and can be done endoscopically and radiologically. Radiographic imaging of the urethra is an indispensable part of the diagnostic evaluation of a patient with BOO after PC treatment. Combined retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) provide invaluable information on the status of both anterior and posterior urethra.

Pelvic magnetic resonance imaging (MRI) gives valuable data about the rectal-prostatic interface, peri-vesical cavities, as well as the presence or exclusion of tumor (1). This information is useful when considering the perioperative risk of rectal injury and the need for flap interposition at the time of reconstruction (1). Some authors consider MRI urethrography, performed with retrograde and antegrade images concomitantly, more informative for evaluating obliterated PUS than conventional retrograde and antegrade X-ray urethrography (58). MRI may be valuable in select cases but will often be unnecessary if an adequate combined RUG/VCUG is available and assessed together with cystoscopy findings.

Bladder function is highly important to evaluate before commencing on reconstruction of a BOO. Urodynamic evaluation is indicated when patients present symptoms of radiation cystitis or bladder dysfunction with poor capacity (59). If the patient has carried a suprapubic catheter for a longer period, a urinary catheter valve should be worn facilitating intermittent bladder emptying, to be able to assess bladder function. Unless the patient can fill the bladder to at least 4 dL without pain or urgency, a bladder training period should be implemented and a new evaluation including urodynamic studies done before commencing reconstructive surgery or augmentation cystoplasty (59). In patients with severe radiation cystitis after RT or severe bladder dysfunction after RP, reconstruction of the bladder outlet would be futile if the patient does not have a urine storage unit post-reconstruction of the BOO. Before making the final decision, however, HBOT can be effective for the treatment of radiation cystitis and may be worth considering, if available (60).

Hence, the primary objective of the patient evaluation and choice of the therapeutic strategy is to decide if bladder preservation is viable (1). In the presence of significant necrosis, severe pain, small bladder capacity, and recurrent cancer, patients should not be considered for reconstruction of the bladder outlet. They should rather be offered cystectomy and reconstructive surgery with some type of UD as the best option (1,10).

Treatment options

Management options for complications following PC treatment include conservative and endoluminal options and reconstruction. These options are described in detail elsewhere in this issue. The options differ depending on previous treatment and exact status of the patient, whether the main problem is UI or BOO (2). Two reviews from 2017 on the treatment options for BOO concluded that careful evaluation is necessary to choose optimal treatment, from endoscopic (with or without scar modulators), reconstruction, or UD, the latter for “poor surgical candidates” (61,62). Recalcitrant VUAS can be repaired after RP but has a high failure rate after RT (62,63). Some fistulae are possible to repair (like rectourethral post-RP), while others are close to impossible to repair (like urosymphyseal fistulae post-RT) (16,33,48,56).

Patients with a combination of complications, typically recalcitrant BOO, UI, fistula, and/or severe bladder dysfunction end up in a situation we can call DBO. In studies reporting patients with DBO finally ending up with UD, the number of failed reconstructive or conservative treatment attempts range from one to 12, including treatment of VUAS, PUS, BMUS, RUF, refractory UI with redo AUS, and combinations of these, which without a doubt may be exhausting for the patients (5,10,18).

In cases of DBO where reconstruction of the outlet is deemed impossible or has already been tried and failed, UD is the last option (2,10,18). Indications for UD include fistula (10–37%), DBO including AUS complications (27–81%), end-stage bladder dysfunction (20%), and combinations of these (17–19%) (5,10).

However, the options for UD are many and include anything from a suprapubic catheter to more sophisticated solutions like augmentation cystoplasty with continent catheterizable channel (CCC), and supravesical UD like continent urinary reservoir (like e.g., Indiana pouch) (10,64-66). The different solutions and a review of the literature are discussed below.

UD

The type of UD should be based on the status of the bladder and sphincter function, as well as the performance status of the patient. Table 4 lists types of UD options and criteria. In case of a good bladder function with adequate storage capability and adequate compliance with low pressure but a recalcitrant BOO, select cases be offered a CCC. If the bladder is not optimal but the patient insists on a continent solution, a bladder augmentation may be added, e.g. with a simple clam cystoplasty or a continent cutaneous ileocecal cystoplasty (65,66). Otherwise, a continent cutaneous reservoir with an ileal or right colon pouch (so-called Kock, Indiana, Lundiana, Mainz I, etc) may be considered (64). These solutions are usually reserved for relatively young and fit patients, however. The most common UD utilizing bowel in the setting of DBO after PC treatment is by far an ileal conduit (5,10).

Table 4. Urinary diversion options in case of devastated bladder outlet.

Bladder status	Continence solution	Option	Premise
Bladder preserving options (can be combined with bladder neck closure or urethral ligation, unless already obliterated)	Incontinent	Suprapubic catheter	Unfit patient, unsuitable for major surgery
	Continent	Continent catheterizable channel (CCC, e.g., Yang-Monti, Casale, Mitrofanoff)	Fit patient with good cognition and hand dexterity and bowel available for the reconstruction
			Good bladder function
	Continent	Continent catheterizable channel with augmentation cystoplasty (e.g., ileocecal cystoplasty or combined CCC and ileocystoplasty)	Fit patient with good cognition and hand dexterity and bowel available for the reconstruction
			Reduced bladder function, but not end-stage bladder dysfunction/severe radiation cystitis with recurrent hematuria
Supravesical options, abandoning the bladder (in case of end-stage bladder dysfunction/severe radiation cystitis with recurrent hematuria. Patient unsuitable for abovementioned continent UD options)	Incontinent	Ureterocutaneostomy	Hostile pelvis, severe radiation damage to bowel and pelvis
		Ileal conduit	Relatively fit patient, available bowel for reconstruction
	Continent	Continent cutaneous urinary reservoir (e.g., Kock, Lundiana, Indiana, Mainz I, or several other similar options)	Fit patient with good cognition and hand dexterity and bowel available for the reconstruction
			Willing to undergo major surgery with relatively high risk of complications and reoperations

CCC, continent catheterizable channel; UD, urinary diversion.

Patients with end-stage bladders and unwilling or unfit for major revisional surgery at a later stage, are better off with heterotopic supravesical UD, like ileal conduit or, rarely, ureterocutaneostomy (64). Additionally, some patients may prefer or benefit more from non-continent UD, as it is less complex, with a shorter operative time and less prone to surgical revisions, than continent diversions (6,10). Cystectomy can alleviate intractable bladder/pelvic pain, spasms, and hematuria, not uncommon following pelvic irradiation (6,33,66-68). A supravesical UD may also be performed without a cystectomy, making the burden as small as possible, and with little risk of late complications in select patients (10).

The satisfaction rate was close to 100% and most patients would have undergone cystectomy and UD much sooner according to a study by Sack et al. (18). In another study by Faris et al. bowel diversion in addition to UD was necessary in 27% of this sort of patients (5).

Some authors have suggested that other reconstructive/UD solutions may be offered up front. Pisters and De have proposed the possibility of bladder neck closure, CCC, and bladder augmentation at the time of salvage prostatectomy as a solution to the high rates of complications following salvage surgery (67,68). Patients considered for this procedure had preexisting voiding symptoms after RT. They reported outcomes in 11 patients treated 2000–2003 at a mean FU of 32 months with 8/11 being continent and 3/11 requiring stomal revision. In 2015, Patil et al. published a series of eight patients with severe bladder dysfunction and recalcitrant PUS successfully treated with cystectomy, ileal neobladder, and urethral pull-through, as well as an AUS in a staged fashion (69). They reported no major complications and social continence in all after a median of two (0–4) revision surgeries with a median FU of 58 months. Neither of the two abovementioned methods have gained popularity, which may be due to the complexity of the surgery and potential for long-term complications and revisions.

Postoperative complications

Surgical treatment of DBO may lead to complications as well. Potential complications include de novo UI, new onset ED, fistulation, but also any complication associated with transperineal and intra-abdominal surgery. UD in this setting is not an easy way out but may cause less total harm than several reconstructive attempts. Patients may have a hostile pelvis and salvage cystectomy or cystoprostatectomy may not be straightforward. However, retrospective studies of patients treated with UD following DBO report relatively few major complications, and high satisfaction rates (10,18).

Agarwal et al. included different types of patients (N=8), including one PC patient, for their modified double-T ileal continent cutaneous UD using Yang-Monti tube and reported these early complications: two intestinal obstructions, three ureteroileal anastomotic leakages, and one vesicoileocutaneous fistula (70).

Sack et al. reported in 2016 that 15 patients who underwent cystectomy and UD for DBO following RT/AT for PC, experienced complications including abdominal dehiscence, bowel anastomosis leak, pelvic abscess, enterocutaneous fistula, incisional and parastomal hernia, and ureteroenteric stricture (18). However, their QoL survey (N=13) revealed that they did well and would undergo the procedure again and sooner, if given the choice.

Shen et al. reported in 2020 that 13 patients were successfully treated with continent cutaneous ileocecal cystoplasty of refractory BNC and UI after PC treatment (65). At a FU of median 78 months all patients were satisfied. The overall complication rate was 69% with 38% occurring within 30 days, which included one internal hernia and one bleeding, both requiring reoperations. Long-term complications included perineal fistula after bladder neck closure (post-RT), urethral and stomal UI.

In a recent multicenter retrospective study by Holm et al., 19 patients with iatrogenic DBO had been treated with different types of UD utilizing bowel including ileal conduit (N=14), bladder augmentation and CCC (N=3), and continent urinary reservoir a.m. Indiana (N=2) (10). Complications were reported in 11 patients and included ureter-bowel anastomotic insufficiency and stenosis, stomal stenosis, stomal UI, urethrocutaneous fistula following urethral ligation, and one pelvic abscess after ileal conduit. Ten patients had cystectomy at the time of UD while one had delayed cystectomy due to BOO and pyocystis. Of the 16 patients who had reported an answer to the question “Would you undergo UD if you were offered again?”, 13 replied “yes”, two replied “unsure” and one replied “no”.

Limitations

This review is limited by the scarce and diverse literature on the field of devastating urinary complications following PC treatments leading to UD. We identified 17 original articles reporting the AEs and their treatment quite differently. Hence, there is no singular, unequivocal approach to reporting the result of this review, rather it requires careful consideration of its many complexities. We chose to use the extracted information to report how these patients have been treated, which events increase the risk of DBO, and in which cases a UD should be considered, as well as the many options thereof. For future research consensus regarding definitions, diagnosis, tracking, and reporting of AEs is much needed.

Conclusions

Refractory BOO, and its more severe form, the DBO, is a demanding and complex scenario resulting from PC treatments, significantly affecting patients’ QoL. The exact incidence is difficult to assess due to limited and inconsistent reporting. Radiotherapy has a pivotal role in the development of this devastating condition and long-term FU and salvage treatments are associated with increasing rates. Radiotherapy has an additional serious negative impact on further treatment outcomes. For this challenging patient cohort, a multidisciplinary reconstructive team may be required, including reconstructive urologists, urologic oncologists, plastic surgeons, and colorectal surgeons. UD is the last option for patients with an unsalvageable DBO. Thorough preoperative evaluation is imperative before making the choice between further reconstructive attempts or UD. There are many UD options, from a suprapubic catheter to more sophisticated solutions like augmentation cystoplasty with a CCC and supravesical UD like ileal conduit or continent urinary reservoir.

These complex patients should be referred to high-volume, academic centers.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.