To present our experience with 2-stage management for recalcitrant refractory bladder neck contracture (BNC) after radical prostatectomy.

A 15-year retrospective medical record review was performed for patients referred for BNC using current procedural terminology code or by International Classification of Diseases - Ninth Revision code for bladder neck incision (BNI). Treatment consisted of deep cold-knife BNI, followed by cystoscopy at 3-4 months. If stable and healed, an artificial urethral sphincter (AUS) or male sling was placed depending on continence level. Recurrent BNC at 3 months was treated with a second BNI.

Sixty-three patients were referred with median (range) age of 66 (41-82) years, body mass index 30.1 (21.9-64.8) kg/m², and follow-up of 11 (1-144) months. Seventeen (27%) underwent adjuvant radiation therapy. Of the 46 who had successful management of the BNC, 91.3% were satisfied with level of continence after BNI alone or with a single additional operation. Of the 33 who underwent AUS or sling, only 2 failures occurred: 1 ultimately required cystectomy after multiple urethral erosions, and 1 with mild incontinence was satisfied with a secondary sling procedure. Four patients progressed to permanent urinary diversion. Together, either BNI (n = 4) or the secondary incontinence procedure (n = 1) was not successful in a total of 5 patients and required permanent urinary diversion. Nine had concurrent severe membranous strictures with no coaptation of the external urethral sphincter and were treated with direct vision internal urethrotomy and AUS and were continent.

This represents the largest known experience with BNC after radical prostatectomy. Patients can be managed with cold-knife incision, followed by AUS or sling, with 66% achieving continence.