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

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).

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

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.

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.