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Triamcinolone: Adjuvant Therapy for Vesical Neck Contractures
TRIA1\1ICINOLONE: ADJUV ANT' THERAPY FOR V.ESICAL NECK CHARLES F. DAMICO, WINSTON K. MEBUST, vVILLIAM L. VALK
AND
JOHN D. FORET
From the Department of Urology, U.viiuersity of Kansas Medical Center, Kansas City, Kansas and the Kansas City Veterans Administration Hospitai, Kansas City, Missouri
The occurrence of vesical neck contracture, in a form and as a secondary vv,upL,vC;o,•UH of prostatectomy, has been known for some time. 1 Some investigators relate the etiology to the nature of prostatic hyperplasia, 2 -• while others have investigated the role of trauma to high frequency currents, •-s Although the course and treatment of vesical neck contracture after transurethrnl resection of the prostate (TURP) o-1 2 have been studied <>v 1"'"''""'" they remain controversial. The rnn.1rn,,t.1>·r,.,.,r1 triamcinolone, has been used in the treatment of esophageal strictures and in reducing hypertrophic soars. 13 • " Triamcinolone differs from hydrocortisone in that a fluorine atom is added in the 9 position and an acetyl radical Accepted for Read in
February 1973. annual meeting South Central A~ssociation St. Louis) American October 24-29, F. M.: Recurrence of obstruction J.A.M.A., 70: 441, R. · Endoscopic Prostatic Surgery. St. Louis: C. Mosby Co., p. 216, 1943. 3 Nesbit, R. M.: Transureth:ral prostatic resections: a discussion of some principles and problems. Urol., 66: 362, 1951. 4 Holtgrewe, H. L. and Valk, W. L.: Late results of trans urethral ""J~cac,,c J. Urol., 92: 51, 1964. 5 Uhle, C. v,r and F. P.: Postoperative vesical neck contracture. J. UroL, 302, 1969. • Rolnick, H. C. and Robbins, M. A,: Functional results following transurethral resection and retropubic J. UroL, 65: 408, i95L 7 Flocks, H.: Local repair following transurethra! prostatic resections: its role in the clinical events as., sociated with this nn<>n1r.1Cm J. 40: 208, 1938. 1
H.
L.:
J4"VU!U!HS
replaces the atom in the 16 as an acetonide. This property makes the chemical less soluble and, therefore, absorbed much more Ketchum has verified that the maximum effect at 3 weeks. 15 However,---.,----- suspensions stay in lesions for as long as 3 months. triamcinolone acts as a which of the endogenous nase. The steroid would thus interfere with the catabolic or anabolic mechanism of collagen formation imd hence contracture formation. MATERIAL
The patients were divided into 2 gToups. sis was established visual examination with the panendoscope. The first group consisted of patients who were deen1ed at to have a small intraurethral prostate with fibrous or fi. bromuscular hyperplasia at the bladder neck After resection of the adenoma the vesical neck remained fixed and The age of in this group was 54 years. mean of the resected tissue was 5 gm. This group of patients was considered as primary vesical neck contracturn. The second consisted of !''°'"""""" a severe or a after TURP. Blind difficult or ,u,p,,c,c,,u,c was n,..,1-,n,.·m, was referred to us because of recurrent symptoms. This group of was considered as having vesical neck contractures. The interval between the original resection and the G!JlU
contracture tion of contractures in dogs: In,rnmreu1ra 87: 6101 1962. 11 Greent\ L. F. and Robinson, H. P.: contracture of the ,1esical neck. and diagnosis. J.
L. F. and Leary, F. transurnthral Gynec. & 124: 1277, K. W. and T. M.: The tal of esophageal by steroid injection. J. Thorac. ,._,,aul!uvct1,1e Smg., 58: 685, 1969. "Ketchum, L. D., Smith, J., Robinson, D. W. and Masters, F. W.: The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast. Reconstr. Surg., 38: 209, 1966.
15 Ketchum, L. D., Robinson, D. VV. and Masters, F. W.: Degradation of mature collagen: a laboratory study. Plast. Reconstr. Surg., 40: 89, 1967.
203
204
DAMICO AND ASSOCIATES
Stern-McCarthy panendoscope
should be noted that the normal vesical neck is composed of smooth muscle, elastic tissue and collagen. RESULTS
Twenty-four cases of primary vesical neck contracture were treated by TUR and injection with triamcinolone. This was accomplished with an injection needle* inserted through a SternMcCarthy panendoscope (see figure). Then 120 mg. triamcinolone was injected circumferentially into the vesical neck at 4 to 6 sites. In 2 patients the followup was not adequate but the clinical course up to 9 months was satisfactory. Convalescence was excellent in 21 cases with an average followup of 32 months (20 to 48 months). In a 38-year-old patient with ankylosing spondylitis, the vesical neck was calibrated at 24 French and responded to 1 dilatation. Twenty-seven cases of postoperative vesical neck contracture treated by TUR of the contracture and triamcinolone injection were followed for an average of 33 months (20 to 48 months). In 23 cases the postoperative result has been excellent. Two patients required a postoperative dilatation for mild recurrent vesical neck contractures but have done satisfactorily. Recurrent diaphragmatic contractures developed in 2 patients. Both initial failures responded well to a repeat TUR and injection. The results were confirmed by panendoscopy. * American Cystoscope Makers, Inc., Pelham Manor, New York.
DISCUSSION
Vesical neck contractures are analogous to a hypertrophic scar. Since triamcinolone has been useful in alleviating this problem, we thought that it would be useful in the treatment of vesical neck contractures. Although the etiology can be complex, resection of small intraurethral fibrous prostates with a non-pliable bladder neck tends to lead to the development of secondary vesical neck contracture. Triamcinolone acts as a catalyst to enhance the endogenous collagenase and hence to reduce contracture formation. The corticosteroid is injected into the vesical neck after TUR of the contracture. Twenty-four cases of primary vesical neck contracture were treated in such a way and followed. An excellent result was established in 95 per cent of the patients. Of 27 cases of secondary vesical neck contracture treated with TUR and injection with triamcinolone, an excellent or satisfactory course was established in 93 per cent. Recurrent diaphragmatic contractures developed in 2 patients. Repeat TUR and injection of the bladder neck were then successful. These results were confirmed with panendoscopy. CONCLUSION
Triamcinolone is a useful adjuvant in the treatment of vesical neck contracture. We have had no morbidity or mortality associated with this technique.
AND
JOHN D. FORET
From the Department of Urology, U.viiuersity of Kansas Medical Center, Kansas City, Kansas and the Kansas City Veterans Administration Hospitai, Kansas City, Missouri
The occurrence of vesical neck contracture, in a form and as a secondary vv,upL,vC;o,•UH of prostatectomy, has been known for some time. 1 Some investigators relate the etiology to the nature of prostatic hyperplasia, 2 -• while others have investigated the role of trauma to high frequency currents, •-s Although the course and treatment of vesical neck contracture after transurethrnl resection of the prostate (TURP) o-1 2 have been studied <>v 1"'"''""'" they remain controversial. The rnn.1rn,,t.1>·r,.,.,r1 triamcinolone, has been used in the treatment of esophageal strictures and in reducing hypertrophic soars. 13 • " Triamcinolone differs from hydrocortisone in that a fluorine atom is added in the 9 position and an acetyl radical Accepted for Read in
February 1973. annual meeting South Central A~ssociation St. Louis) American October 24-29, F. M.: Recurrence of obstruction J.A.M.A., 70: 441, R. · Endoscopic Prostatic Surgery. St. Louis: C. Mosby Co., p. 216, 1943. 3 Nesbit, R. M.: Transureth:ral prostatic resections: a discussion of some principles and problems. Urol., 66: 362, 1951. 4 Holtgrewe, H. L. and Valk, W. L.: Late results of trans urethral ""J~cac,,c J. Urol., 92: 51, 1964. 5 Uhle, C. v,r and F. P.: Postoperative vesical neck contracture. J. UroL, 302, 1969. • Rolnick, H. C. and Robbins, M. A,: Functional results following transurethral resection and retropubic J. UroL, 65: 408, i95L 7 Flocks, H.: Local repair following transurethra! prostatic resections: its role in the clinical events as., sociated with this nn<>n1r.1Cm J. 40: 208, 1938. 1
H.
L.:
J4"VU!U!HS
replaces the atom in the 16 as an acetonide. This property makes the chemical less soluble and, therefore, absorbed much more Ketchum has verified that the maximum effect at 3 weeks. 15 However,---.,----- suspensions stay in lesions for as long as 3 months. triamcinolone acts as a which of the endogenous nase. The steroid would thus interfere with the catabolic or anabolic mechanism of collagen formation imd hence contracture formation. MATERIAL
The patients were divided into 2 gToups. sis was established visual examination with the panendoscope. The first group consisted of patients who were deen1ed at to have a small intraurethral prostate with fibrous or fi. bromuscular hyperplasia at the bladder neck After resection of the adenoma the vesical neck remained fixed and The age of in this group was 54 years. mean of the resected tissue was 5 gm. This group of patients was considered as primary vesical neck contracturn. The second consisted of !''°'"""""" a severe or a after TURP. Blind difficult or ,u,p,,c,c,,u,c was n,..,1-,n,.·m, was referred to us because of recurrent symptoms. This group of was considered as having vesical neck contractures. The interval between the original resection and the G!JlU
contracture tion of contractures in dogs: In,rnmreu1ra 87: 6101 1962. 11 Greent\ L. F. and Robinson, H. P.: contracture of the ,1esical neck. and diagnosis. J.
L. F. and Leary, F. transurnthral Gynec. & 124: 1277, K. W. and T. M.: The tal of esophageal by steroid injection. J. Thorac. ,._,,aul!uvct1,1e Smg., 58: 685, 1969. "Ketchum, L. D., Smith, J., Robinson, D. W. and Masters, F. W.: The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast. Reconstr. Surg., 38: 209, 1966.
15 Ketchum, L. D., Robinson, D. VV. and Masters, F. W.: Degradation of mature collagen: a laboratory study. Plast. Reconstr. Surg., 40: 89, 1967.
203
204
DAMICO AND ASSOCIATES
Stern-McCarthy panendoscope
should be noted that the normal vesical neck is composed of smooth muscle, elastic tissue and collagen. RESULTS
Twenty-four cases of primary vesical neck contracture were treated by TUR and injection with triamcinolone. This was accomplished with an injection needle* inserted through a SternMcCarthy panendoscope (see figure). Then 120 mg. triamcinolone was injected circumferentially into the vesical neck at 4 to 6 sites. In 2 patients the followup was not adequate but the clinical course up to 9 months was satisfactory. Convalescence was excellent in 21 cases with an average followup of 32 months (20 to 48 months). In a 38-year-old patient with ankylosing spondylitis, the vesical neck was calibrated at 24 French and responded to 1 dilatation. Twenty-seven cases of postoperative vesical neck contracture treated by TUR of the contracture and triamcinolone injection were followed for an average of 33 months (20 to 48 months). In 23 cases the postoperative result has been excellent. Two patients required a postoperative dilatation for mild recurrent vesical neck contractures but have done satisfactorily. Recurrent diaphragmatic contractures developed in 2 patients. Both initial failures responded well to a repeat TUR and injection. The results were confirmed by panendoscopy. * American Cystoscope Makers, Inc., Pelham Manor, New York.
DISCUSSION
Vesical neck contractures are analogous to a hypertrophic scar. Since triamcinolone has been useful in alleviating this problem, we thought that it would be useful in the treatment of vesical neck contractures. Although the etiology can be complex, resection of small intraurethral fibrous prostates with a non-pliable bladder neck tends to lead to the development of secondary vesical neck contracture. Triamcinolone acts as a catalyst to enhance the endogenous collagenase and hence to reduce contracture formation. The corticosteroid is injected into the vesical neck after TUR of the contracture. Twenty-four cases of primary vesical neck contracture were treated in such a way and followed. An excellent result was established in 95 per cent of the patients. Of 27 cases of secondary vesical neck contracture treated with TUR and injection with triamcinolone, an excellent or satisfactory course was established in 93 per cent. Recurrent diaphragmatic contractures developed in 2 patients. Repeat TUR and injection of the bladder neck were then successful. These results were confirmed with panendoscopy. CONCLUSION
Triamcinolone is a useful adjuvant in the treatment of vesical neck contracture. We have had no morbidity or mortality associated with this technique.