Reconstructive Pelvic Surgery
Dr. Gonzalez is a Professor of Urology at Northwestern University, Director of Genitourinary Reconstruction, and Director of Surgery for Surgical Services at Northwestern Memorial Hospital.
Betsy Haberl is the editor of QUEST.
BH: What types of conditions do you treat in your practice?
CG: I specialize in reconstructive pelvic surgery. We generally see men who have an obstruction in their lower urinary tracts due to a urethral stricture or a bladder neck contracture. I also treat men with erectile dysfunction.
BH: What symptoms would a man experience with a urethral stricture?
CG: A urethral stricture blocks the flow of urine in the urethra, the tube through which urine flows from the bladder out of the penis. A man with a stricture would experience a slow urinary stream, possible urinary tract infection and an inability to completely empty the bladder. These symptoms should prompt a consultation with a urologist.
BH: When should a man discuss reconstructive surgery with his doctor?
CG: A urologist will often refer a man with a serious urethral stricture to a genitourinary reconstructive specialist. The goal is to avoid repeated dilation, or stretching, of a urethral stricture because it’s not a definitive or effective treatment. The stricture often comes back lengthier and thicker, making it more difficult to fix later.
BH: What causes the blockages?
CG: We don’t always know. Sometimes it can be due to surgery on the urinary tract, radiation treatment for any kind of pelvic malignancy, trauma or previous urethral catheter placement. Surgery for prostate cancer can sometimes lead to blockage of the urethra or the bladder neck.
BH: Are urethral strictures common?
CG: In our specialized practice, we see many men with these issues. With radiation treatment for prostate cancer, the rate of developing a urethral stricture is as high as 1-3%. Radiation destroys cancer tissue and normal tissue, so our challenge is to help restore the patient’s functions. In men with traumatic pelvic fracture the rate can be as high as 10%.
“The most important goal for me as a surgeon is making my patients feel comfortable and that there is hope if they have a urinary tract blockage or erectile dysfunction, especially if they’ve just had cancer treatment. There are definitive therapies – not just temporary measures – that can actually fix the problem.”
– Dr. Gonzalez
BH: How do you treat urethral strictures?
CG: If the stricture involves only a short segment of the urethra, we remove the diseased segment. This is called a urethroplasty. If the stricture is in a longer segment, we take buccal mucosa from inside the cheek and use it for reconstruction of the urethra. It’s very effective and this harvest site heals nicely.
BH: You said that men could also have blockages in the bladder neck.
CG: This is called a bladder neck contracture. The bladder neck is the area that connects the bladder to the prostate. The bladder neck can get scarred after removal of the prostate or from radiation therapy. This makes it difficult for a man to empty his bladder. Many times we can excise the scar tissue in that area using a scope with or without steroid or mitomycin injection. These medications reduce inflammation following the procedure, which often prevents recurrence of the stricture. If these approaches don’t work, in extreme cases we perform open surgery and reconstruct the bladder neck. We generally try the conservative options first because it’s easier for the patient.
BH: Are the treatments successful?
CG: Generally, patients who had a blockage have an 85-90% success rate measured 2-5 years after reconstructive surgery.
BH: What is the recovery like for these procedures?
CG: Patients usually go home the same day or the morning after a urethroplasty. Blood loss is minimal. Patient recovery is usually 3 weeks.
After a bladder neck incision, the patient has a catheter for 4-5 days and and can resume normal activity in 5-6 days.
If we have to perform open surgery and a bladder neck reconstruction, the recovery is 3-4 weeks.
BH: Are there any risks of complications for these procedures?
CG: People very rarely have a problem with bleeding after urethral reconstruction, and infection occurs 1- 2% of the time. Generally, a man’s ability to sustain an erection is only affected temporarily by the operation. Rarely, depending on where the blockage is, urinary incontinence may occur. We’re able to fix incontinence if it does occur after urethroplasty.
Complications for the bladder neck procedures are relatively similar, although there may be a higher chance of developing urinary incontinence. But we can correct this later.
BH: What could happen if a urethral stricture is not addressed?
CG: The man’s urinary tract would continue to be obstructed, potentially leading to urinary tract infection and damage to the kidneys because the urine cannot be adequately eliminated. The urethra is like a pipe that backs up into the bladder and kidneys. It can be very dangerous for kidney function if the urine does not drain properly.
BH: Can other conditions be treated with reconstructive surgery?
CG: Yes, conditions such as complications related to pediatric hypospadias repair can be repaired. This is a condition where the urethra does not fully develop in newborns and is reconstructed in the first year of life. In some men the repair eventually fails and requires reconstruction of the urethra.
BH: How do you treat erectile dysfunction?
CG: Men can have erectile dysfunction (ED) after treatment for pelvic cancer, but it’s also pretty common in the general population due to heart disease, diabetes, high blood pressure, smoking or the use of certain medications. There are many ways to restore a man’s sexual function and erections.
The main pills we use for ED all work the same way. If pills don’t work, the next option is injection of a medication into the penis with a tiny needle. We teach the man how to do this. If that doesn’t work and the man is still motivated to obtain an erection, we consider implantation of inflatable penile prosthesis. The penile prosthesis involves inserting inflatable cylinders inside the penis shaft. When the man wants an erection, he squeezes a pump in the scrotum to inflate the cylinders and later presses a button to deflate them.
Patient and partner satisfaction with an inflatable penile prosthesis is the highest of all treatment modalities for ED because of its reliability and ease of use.
BH: What percentage of men develops erectile dysfunction after prostate cancer treatment?
CG: It ranges from 30-70%, regardless of whether a man has had radiation or surgery. Many times men with prostate cancer already have some underlying ED as a result of aging, diabetes, high blood pressure and smoking, which makes the chances of post-treatment ED even higher.