Extracorporeal shock wave lithotripsy in combination with transurethral surgery for management of large bladder calculi and moderate outlet obstruction.

In 5 men evaluated for symptoms of obstructive voiding flexible cystoscopy revealed large or multiple bladder calculi along with small to moderate prostatic enlargement. All patients had successful localization and fragmentation of calculi with the Dornier HM3 lithotriptor. Of these patients 4 underwent transurethral resection or incision of the prostate under the same epidural anesthesia for moderate prostatic obstruction without complication and 1 subsequently required suprapubic prostatectomy of a gland with a large middle lobe that made a transurethral operation difficult. Extracorporeal shock wave lithotripsy should be considered for the primary management of large or hard bladder calculi and it is of particular value in combination with a transurethral operation for patients with small to moderate prostatic obstruction.     

Unsuspected proximal urethral obstruction in young and middle-aged men

Proximal urethral obstruction, a common cause of prostatism in young and middle-aged men, often is misdiagnosed as prostatitis, neurogenic bladder or a psychogenic voiding disorder. Simple urodynamic studies (uroflowmetry and cystometry) do not distinguish a poor flow owing to bladder neck obstruction from that caused by poor detrusor contractility in these patients. Only the simultaneous measurement of detrusor pressure and uroflowmetry can make this distinction. A total of 23 patients with unsuspected proximal urethral obstruction underwent synchronous video-pressure-flow electromyography studies, and were treated and followed for a minimum of 1 year. Treatment by transurethral prostatic resection or bladder neck incision almost always was curative but alpha-adrenoceptor blocking agents have not been effective. All patients who underwent transurethral prostatic resection or bladder neck incision at the 5 and 7 o'clock positions have had retrograde ejaculation but both patients who underwent unilateral bladder neck incision reported antegrade ejaculation.     

Bladder neck resection and transurethral resection of the prostate: a randomized prospective trial

Transurethral resection of the prostate and bladder neck incision are accepted methods in the treatment of obstructive prostatic hyperplasia. Bladder neck incision is particularly useful in cases of small prostates. We have modified the method of bladder neck incision to bladder neck resection. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate (30 patients) and the new method of bladder neck resection. Bladder neck resection was comparable to transurethral resection of the prostate with respect to postoperative hospital stay, maximal flow rates and postoperative complications. Bladder neck resection was better than transurethral resection with respect to the operating time, transfusion requirement, volume of irrigation fluid and postoperative urinary infection. We conclude that bladder neck resection is the operation of choice in patients with a prostate of 30 gm. or less.     

The nature of the abnormality in bladder neck obstruction.

There is no dispute that there exists, in men, a condition of obstruction at the bladder neck in the absence of fibrous stricture or prostatic enlargement. The condition was clearly described by Guthrie (1836) and Young (1913) reported the results ff punch resection operation in over 50 cases. The large measure of success now achieved following resection of the bladder neck in these patients has perhaps been allowed to mask our ignorance of the nature of the abnormality and thus discourage studies of its cause. It is perhaps most often thought to result from fibrosis but a number of studies--for example Baadenoch (1949)--have shown no associated increase in fibrous tissue. Certainly the condition is in no way similar to the hard fibrous stricture seen more often in the distal urethra, or at the bladder neck as an occasional complication of prostatectomy. Our study shows that the obstruction if functional in nature and is due to the tightening of the bladder neck as the detrusor contracts.     

Transurethral treatment of bladder diverticula

We performed transurethral fulguration of the diverticular mucosa and incision of the diverticular neck in combination with transurethral prostatectomy or bladder neck resection to treat all aspects of diverticula in 9 patients. Eight cases with bladder outlet obstruction, involving 2 cases of large diverticula, have been successfully treated. A case with neurogenic bladder has failed. We found the transurethral procedure to be equally effective as open operation.     

A comparison of bladder neck incision and transurethral prostatic resection.

Between 1978 and 1988, 108 patients underwent bladder neck incision (BNI) for bladder outflow obstruction. These patients were compared to a similar group who underwent transurethral resection of the prostate (TURP), during the same time period. Only patients with minimal prostatic enlargement (less than 10 g) with prominent bladder necks and small lateral lobes were included in the study. In addition, all patients in the resection group had a resection weight of less than 10 g on the histopathology report. Patients were followed up by means of a posted questionnaire to which 59 patients in the BNI group and 86 in the TURP group responded. Pre-operative and peri-operative data were also collected from these respondents by a retrospective case record review. This found both operations to be safe with low morbidity and mortality. BNI was better than TURP in terms of shorter operation length (P less than 0.017) and shorter duration of catheterization (P less than 0.004). No other peri-operative differences were found. Follow-up results from the questionnaire showed no significant differences in symptoms between the two groups. Similarly, there was no difference in the number of re-operations performed over the 10 year period studied. Patient assessment of their operation was initially favourable in both groups (greater than 80% patient approval) however, both treatment groups experienced a gradual drop in patient approval over the 10 year period. There were no differences in the level of approval between the BNI and TURP groups.     

Primary lymphoma of prostate presenting as bladder outflow obstruction

We report on a patient with prostatic lymphoma who presented with symptoms of bladder neck obstruction. Biopsy specimens from transurethral resection confirmed the diagnosis of prostatic lymphoma. There was no evidence of lymphoma spread. Treatment was by local x-ray therapy to the prostate gland. Since prostatic lymphoma is rare, the clinical literature is briefly reviewed.     

Unilateral bladder neck incision: endoscopic treatment of bladder neck obstruction. Results in 100 patients

Endoscopic diathermy unilateral incision of the bladder neck was carried out in 100 consecutive male patients. This procedure was performed for bladder neck obstruction and small benign prostate. The operative details of this technique are given. Follow-up after 2 months revealed excellent symptomatic and urodynamic results. Morbidity was low. Results remain stable after 13 +/- 9 months. One patient needed a transurethral resection of the prostate. Retrograde ejaculation occurred in 5% of the patients. Unilateral bladder neck incision is a simple procedure safe, and easy to learn, with a low risk of retrograde ejaculation. It is the operation of choice for small benign prostate, bladder neck obstruction and young patients.     

Prevention of post-prostatectomy vesical neck contracture by prophylactic vesical neck incision

Most vesical neck contractures occur after resection of adenomas weighing less than 20 gm. This complication is believed to be secondary to excessive resection or fulguration of an undilated bladder neck. Prophylactic bladder neck incision was performed in conjunction with transurethral resection of the prostate on 114 patients with prostatic adenomas weighing less than 20 gm. Vesical neck contracture occurred in 1 patient (0.87 per cent), compared to 12 contractures in 161 patients who underwent transurethral resection of the prostate alone (7.5 per cent). Increasing bladder neck diameter by incision appears to be protective against formation of vesical neck contractures in patients with small obstructing prostatic adenomas.     

Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomized controlled trials

PURPOSE: Transurethral prostatic resection is the gold standard surgical treatment in men with lower urinary tract symptoms suggestive of bladder outlet obstruction but it has also been related to some risks, such as a relatively high rate of blood transfusion, sexual function problems and so forth. Transurethral prostatic incision is a simpler and less invasive procedure than transurethral prostatic resection. However, it is underused. We systematically reviewed all published randomized controlled trials comparing the effectiveness of transurethral prostatic incision with standard transurethral prostatic resection for bladder outlet obstruction and performed a meta-analysis of the available relevant data. MATERIALS AND METHODS: Nine randomized controlled trials comparing the treatment effectiveness of transurethral prostatic resection and transurethral prostatic incision were identified, evaluated and reviewed in a meta-analysis. The quality of these studies was also appraised. RESULTS: Each treatment achieved clear improvements in subjective and objective outcomes. The improvement in symptoms was equivalent 12 months postoperatively for transurethral prostatic incision and resection. For maximum flow rate transurethral prostatic resection resulted in greater improvement than transurethral prostatic incision. However, transurethral prostatic incision had several advantages over transurethral prostatic resection, such as lower incidence of complications, fewer blood transfusions, decreased risk of retrograde ejaculation, and shorter operative time and hospital stay. Also, the treatments had an equivalent incidence of postoperative catheterization duration and reoperation rate within the first 12 months. Furthermore, patients in each group had a similar subjective view of the treatments received. CONCLUSIONS: In the first 12 months after surgery transurethral prostatic incision has effectiveness that is equivalent to transurethral prostatic resection for treating patients with suspected benign prostatic obstruction who have a relatively small prostate. However, there is little evidence on the relative long-term effectiveness of the 2 treatments 2 to 5 or 10 years after surgery. There is no clear cutoff point for prostate size that leads to good results after transurethral prostatic incision. A large-scale, multicenter randomized controlled trial is now required to evaluate comprehensively the effectiveness, impact on quality of life and overall cost of transurethral prostatic incision compared with transurethral prostatic resection.     

A COMPARISON OF BLADDER NECK INCISION AND TRANSURETHRAL PROSTATIC RESECTION

Book reviews in this article: Between 1978 and 1988, 108 patients underwent bladder neck incision (BNI) for bladder outflow obstruction. These patients were compared to a similar group who underwent transurethral resection of the prostate (TURP), during the same time period. Only patients with minimal prostatic enlargement (< 10 g) with prominent bladder necks and small lateral lobes were included in the study. In addition, all patients in the resection group had a resection weight of less than 10 g on the histopathology report. Patients were followed up by means of a posted questionnaire to which 59 patients in the BNI group and 86 in the TURP group responded. Pre-operative and peri-operative data were also collected from these respondents by a retrospective case record review. This found both operations to be safe with low morbidity and mortality. BNI was better than TURP in terms of shorter operation length (P < 0.017) and shorter duration of catheterization (P < 0.004). No other peri-operative differences were found. Follow-up results from the questionnaire showed no significant differences in symptoms between the two groups. Similarly, there was no difference in the number of re-operations performed over the 10 year period studied. Patient assessment of their operation was initially favourable in both groups (> 80% patient approval) however, both treatment groups experienced a gradual drop in patient approval over the 10 year period. There were no differences in the level of approval between the BNI and TURP groups.     

Bladder function following rectal resections

Fifteen patients with urinary retention following rectal resection were examined urodynamically, including cystometry and simultaneous measurement of flow and pressure in the bladder and in the abdomen.Five patients suffered from bladder neck obstruction. This was in most cases put down to a preexisting prostatic enlargement. In 4 patients it was impossible to detect any function of the bladder muscle. Detrusor insufficiency was the cause of retention in the remaining 6 patients.     

Evaluation and treatment of dyssynergic bladder neck obstruction Is synchronous pressure-flow cystourethrography necessary?

Eighteen male patients underwent unilateral bladder neck incision for relief of bladder neck obstruction. The presence of obstruction was determined by clinical symptoms, residual urine, and uroflowmetry only. The decision to perform bladder neck incision was based on the typical endoseopic appearance of the prostatic urethra and bladder neck. Sixteen of 18 patients (89 per cent) had normal postoperative uroflowmetry. Subjectively, all patients judged themselves improved by the procedure. In those patients who are judged to be obstructed by clinical symptoms and uroflowmetry, dyssynergic bladder neck obstruction may be diagnosed by classic endoscopic findings rather than the routine use of synchronous pressure flow cystourethrography.     

Internal urethrotomy of the prostatic urethra or transurethral resection in benign prostatic hyperplasia.

Transurethral resection of the prostate is the most common technique for the treatment of benign prostatic enlargement. The inconveniences of prostatic resection are retrograde ejaculation and bladder neck stenosis in small prostates. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate in 22 patients and urethrotomy of the prostatic urethra in 27 with respect to postoperative retrograde ejaculation, persistent urinary symptomatology and maximal flow rates. After a mean followup of 25 months we concluded that internal urethrotomy of the prostatic urethra is the operation of choice in patients with a prostate of up to 30 gm.     

Nd:YAG laser ablation of the prostate as a treatment for benign prostatic hypertrophy.

Many techniques have been used to relieve obstructive symptoms associated with benign prostatic hypertrophy. Transurethral resection of the prostate (TURP) with an electrocautery loop is the most commonly performed operation to relieve bladder neck and urethral obstruction caused by prostatic adenoma. There is increased interest in alternative therapies to reduce prostatic size for symptom relief in this condition. We describe a technique using the neodymium:YAG (Nd:YAG) laser and a 600-microns laser quartz fibre with an attached terminal gold-plated metal alloy reflector to provide reliable deep penetration into prostatic tissue for prostatic adenoma ablation. We report the first use of this technique in three patients with benign prostatic obstruction and one with localised adenocarcinoma of the prostate.     

Dysfunction of the bladder neck: a urodynamic study.

Urodynamic investigations were performed in 9 males, suffering from dysfunction of the bladder neck (detrusor bladder neck dyssynergia). The parameters of micturition were compared with the values in normal males and in patients with prostatic obstruction. By introducing a new factor, the maximum opening time, we found a characteristic pattern in dysfunction of the bladder neck, making selection of patients for endoscopic incision of the bladder neck possible. The maximum and mean flow rates increased significantly in 5 patients treated with incision of the bladder neck. The diagnostic value of voiding cystourethrography and urodynamic investigation is discussed.     

Treatment of cervico-prostatic obstruction by endoscopic incision of the prostate. Apropos of 16 patients

Several teams over recent years have proposed deep transurethral incision of the prostate as treatment for obstructive symptoms secondary to primary bladder neck sclerosis or to a small prostatic adenoma. We have performed this technique in 16 patients over a period of 9 months: 9 cases of primary bladder neck sclerosis and 7 prostatic adenomas weighing less than 20 grams. There were no post-operative complications. This technique was definitely effective on the dysuria with 93% good results at 6 months. The preservation of post-operative anterograde ejaculation was less certain; 27% of our patients developed post-operative retrograde ejaculation. The indication for TUI amongst the other available surgical techniques depends on a rigorous pre-operative assessment evaluating the size and the nature of the obstruction. It is a remarkably simple technique which effectively cures the dysuria. It also markedly decreases the risk of retrograde ejaculation. As this complication is difficult to predict, the patients should be informed of the risks prior to the operation.     

经尿道手术治疗小体积前列腺增生所致膀胱出口梗阻

目的探讨经尿道前列腺电切(transurethral resection of prostate,TURP)+经尿道膀胱颈切开术(transurethralincision of bladder neck,TUIBN)治疗小体积前列腺增生所致膀胱出口梗阻的疗效。方法 2002年3月～2007年1月,采用TURP+TUIBN治疗小体积前列腺增生所致膀胱出口梗阻31例,其中有完整随访资料的25例,年龄46～71岁,平均56岁,病程8～77个月,平均32个月,前列腺重量15～30 g,平均24 g。比较术前、术后国际前列腺症状评分(IPSS)、最大尿流率(Qmax)、残余尿量(PVR)等指标,以评估疗效。结果手术时间25～47 min,平均38 min。经尿道切除前列腺组织重量6～17 g,平均9.8 g。术后病理报告25例均为良性前列腺增生(其中20例为纤维增生型),15例伴慢性前列腺炎。术后随访6～24个月,平均15个月。23例排尿通畅,1例尿道狭窄(行尿道扩张后排尿通畅),1例膀胱颈挛缩。术前、术后6个月IPSS评分分别为(26.60±3.07)分、(6.92±1.26)分,Qmax为(7.96±2.30)ml/s、(19.60±2.31)ml/s,PVR为(132.80±64.84)ml、(18.60±7.97)ml,差异均有显著性(P=0.000)。结论 TURP+TUIBN是治疗小体积前列腺增生所致膀胱出口梗阻的一种较为理想的术式。     

Transurethral incision versus transurethral resection of the prostate. A subjective and objective analysis.

A prospective study was undertaken comparing transurethral incision of the prostate (TUIP) with transurethral resection (TURP) in the treatment of 220 patients with urinary obstruction caused by a small, benign prostate. Patients were managed alternately by TUIP and TURP, and their symptoms and urodynamic findings evaluated before and after surgery. Subjectively and objectively, the results were comparable in both groups. Pre- and post-operative complications were significantly less for the TUIPs than the TURPs. TUIP was significantly better than TURP in terms of shorter operating time, duration of hospitalisation and reduced need for transfusion. We recommend TUIP as the operation of choice for the relief of obstruction in the presence of a small, benign prostatic enlargement.     

Transurethral resection of the prostate and bladder neck incision: a review of 700 cases

Transurethral resection (TUR) is regarded as the treatment of choice for relief of outflow tract obstruction in the male, but bladder neck incision (BNI) is an acceptable alternative when the gland is small. Seven hundred cases of TUR/BNI have been reviewed (TUR = 388; BNI = 312). BNI was performed when the gland was less than 35 g and where there was no clinical suspicion of malignancy. The operative details of our single incision technique are given. While the patients in the BNI group were younger, catheter stay was shorter, there was less infection, a significantly reduced need for blood transfusion and a satisfactory outcome in terms of control and need for further surgery. BNI is a technically simpler procedure than TUR and is easy to teach and learn. Results show it is safe and effective for patients in acute retention as well as those treated electively and it is the operation of choice for small benign prostates.