Bladder-neck incision for relief of obstruction after anti-incontinence surgery

Bladder-neck resection or incision in the female has been performed for many years, with variable results. As it has not been widely accepted in the past, the authors decided to review the indications and the surgical technique. From January to December 1986, ten such operations were performed on females with documented outlet obstruction related to previous anti-incontinence procedures. Bladder neck incisions rather than resections were performed, and the surgical technique is discussed. Also, the urological presentations of these patients including their investigations through urodynamics, are given. Bladder-neck incision is a valuable adjunct in the treatment of female bladder-neck obstruction.     

Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision

PURPOSE: Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. MATERIALS AND METHODS: A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin's knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. RESULTS: Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p <0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p <0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. CONCLUSIONS: Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.     

Bladder neck obstruction in women

Bladder neck obstruction in women is rare. The symptoms are confounding and nonspecific. The diagnosis depends on demonstrating poor uroflow, a detrusor contraction of adequate magnitude and duration, and radiographic evidence of obstruction at the vesical neck. We treated successfully 3 women with vesical neck obstruction by transurethral vesical neck incision.     

Use of alpha1-blockers in female functional bladder neck obstruction

INTRODUCTION: Bladder outflow obstruction may cause obstructive or irritative symptoms. The diagnosis of female functional bladder neck obstruction requires a pressure/flow study and electromyography performed by videourodynamics. The treatment includes self-catheterization or bladder neck incision. We administered tamsulosin, an alpha1A/alpha1D-selective adrenergic antagonist, in women with functional bladder neck obstruction to evaluate its potential therapeutic effects. PATIENTS AND METHODS: A group of 18 women affected by functional bladder neck obstruction was selected. The diagnosis was made by means of a pressure/flow study combined with electromyography and a fluoroscopic test. The diagnostic criteria were: high detrusor pressure with reduced maximum flow, silent electromyography activity, and bladder neck nonfunnelling during the fluoroscopic test. Tamsulosin 0.4 mg once daily was administered for at least 30 days. Patients with a postvoid residual urine volume > or = 100 ml performed intermittent self-catheterization. Patients with a postvoid residual urine volume < 100 ml performed self-catheterization every 7 days. After 30 days of therapy, all patients underwent a new pressure/flow study and a micturition fluoroscopic test. RESULTS: 10 (56%) out of 18 treated patients showed a statistically significant improvement in symptoms, maximum flow, and postvoid residual urine volume (p < 0.01). CONCLUSION: The use of alpha1-blockers may be an initial treatment option for female functional bladder neck obstruction, as this therapeutic option proved to be effective in more than 50% of our patients suffering from this voiding dysfunction.     

Sphincterotomy failure in neurogenic bladder disease

Among 60 spinal cord injury patients who underwent external urethral sphincterotomy 45 experienced success and 15 failed. Failure was established when symptomatic urinary tract infections and high vesical residuals persisted. Urodynamic findings demonstrated detrusor areflexia in 10 patients (66 per cent), detrusor-sphincter dyssynergia in 2 (13.2 per cent), detrusor hyperreflexia with unsustained bladder contractions in 1 (6.6 per cent), and detrusor hyperreflexia and bladder neck obstruction in 2 (13.2 per cent). Among these failures poor detrusor contractility predominated. Detrusor-sphincter dyssynergia may indicate an inadequate surgical relief of obstruction. Bladder neck obstruction may indicate that a bladder neck incision should be considered when an external sphincterotomy is performed.     

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.     

Bladder neck stenosis in the male.

Bladder neck stenosis is defined. The symptoms, signs, diagnosis and treatment are discussed. The results of simple transurethral incision of the bladder neck, performed in 60 patients, are recorded.     

Unrecognized congenital posterior urethral minivalves in men

Removal of small congenital posterior urethral valves, unrecognized in prior urologic investigations of 10 men, relieved “prostatic” symptoms in 9. In follow-ups (5–20 years, average 12.5 years), 3 have experienced a recurrence attributed to bladder neck obstruction in 2 and to unknown causes in 1. Bladder neck incision carried out in 2, cured 1. The other was lost to follow-up.     

Ejaculation and sexual function after endoscopic bladder neck incision

Endoscopic incision of the bladder neck, performed to relieve outflow obstruction, was evaluated as regards effects on ejaculation and orgasm in 61 men (mean age 48 years) by analyses of seminal fluid and a questionnaire. Relief of obstruction was confirmed by post-operative normalisation of urinary flow. In 47 cases there was unchanged antegrade ejaculation, while reduced semen volume was reported by 11 men and retrograde ejaculation by only 3. The quality of orgasm and sexual satisfaction were not permanently changed by the operation. Post-operative analysis of seminal fluid was performed in 27 patients, with normal results in 26. In 16 men who provided specimens both before and after bladder neck incision, no consistent change was found in the semen. An incision completely splitting the bladder neck but not extending distal to the verumontanum will relieve outlet obstruction. Maintenance of antegrade ejaculation can be expected in most patients undergoing this operation.     

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 obstruction in young male patients

Seven men under age forty have been reviewed following bladder neck revision for bladder neck obstruction. Bladder neck obstruction in young men appears to be an uncommon entity. The diagnostic features, the incidence of retrograde ejaculation, and the pathologic findings are discussed.     

Bladder outlet obstruction in women: difficulties in the diagnosis

OBJECTIVE: To identify the difficulties in diagnosing bladder outlet obstruction in women. MATERIAL AND METHODS: 53 women with a mean age of 37.2 (range 16-70) with chronic lower urinary tract symptoms and no neurogenic or organic diseases were examined. The prevalent symptoms were frequency (96%), urgency (92%) and nocturia (75%), and the mean duration of symptoms was 3.8 years. After pressure-flow studies and voiding cystourethrography were conducted, patients either underwent bladder neck or urethral incisions based on their diagnosis. These patients were subsequently subjected to follow-up uroflow studies. RESULTS: Abnormal uroflow curves were observed in 19 of 53 women. In 10 of them (52.6%), bladder outlet obstruction based on pressure-flow results was confirmed. Voiding cystourethrography results from these 19 women confirmed that 17 patients had bladder neck obstruction, while the remaining 2 had urethral obstruction. 16 of 19 were treated endoscopically, with 14 patients undergoing bladder neck incisions through the 5- and 7-o'clock positions and 2 patients having a distal urethral incision through the 12-o'clock position. In all of these 16 cases, there were both a statistical increase in the maximum flow rate (Qmax) as well as an improvement in the flow curves. Symptomatic improvement was observed in 12 of the 16 women subjected to surgical intervention. CONCLUSION: Bladder outlet obstruction exists in women with lower urinary tract symptoms. Pressure-flow studies and voiding cystourethrography are reliable modalities for confirming bladder outlet obstruction. Bladder outlet obstruction can be functionally or structurally caused.     

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.     

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.     

Bladder neck reconstruction using an anterior bladder flap in post-prostatectomy incontinence

Bladder neck reconstruction using an anterior bladder flap was used in 10 patients with total diurnal urinary incontinence, persistent 1 year after suprapubic (n = 6) or transurethral (n = 4) prostatectomy. 8 patients achieved symptomatic improvement, 6 of them with excellent or good results. Bladder neck reconstruction is undoubtedly able to correct post-prostatectomy incontinence, provided there is no residual bladder neck obstruction or alteration of the bladder musculature due to previous surgery. These cases should be considered for artificial sphincter implantation.     

Diagnosis and treatment of functional bladder neck obstruction

The experience with 32 patients with functional bladder neck obstruction is presented and this condition is discussed. This disease occurred mainly in males from the age of 6 months to 50 years. There was only one female patient. The most important investigations were the micturating cystogram, the flow-rate and the measurement of the residual urine. The bladder neck incision, as proposed by Turner-Warwick, relieved symptoms and obstruction in all patients efficiently.     

Identification and dissection of bladder neck during laparoscopic radical prostatectomy

Bladder neck identification and dissection is a difficult step in performing laparoscopic radical prostatectomy. We describe a transurethral technique that facilitates laparoscopic identification and incision of the bladder neck. All cases were successful, with clear and sharp bladder neck margins. All bladder neck surgical margins were tumor free.     

Comparison of the incidence of bladder hyperreflexia in patients with benign prostatic hypertrophy and age-matched female controls

Detrusor hyperreflexia long has been recognized as a condition associated with certain neurological disorders (that is multiple sclerosis, cerebrovascular accidents, spinal cord injuries and parkinsonism). Bladder outlet obstruction (primarily benign prostatic hypertrophy) recently has been added to the list. Hyperreflexia associated with bladder outlet obstruction does not always resolve with relief of the obstruction. Our study of age-matched female controls indicates that there is a baseline rate of hyperreflexia associated with the aging process alone. This baseline hyperreflexia probably explains persistent symptoms in men with hyperreflexia following relief of the obstruction.     

The site of functional infravesical obstruction in children

In an attempt to localise the site of obstruction in children suffering from functional infravesical obstruction, it was found that primary bladder neck obstruction was rare. Only one boy suffering from prune belly syndrome and three children with megacystis demonstrated primary bladder neck obstruction. All of the others had functional bladder neck obstruction as a secondary phenomenon, following either an antireflux operation or electroresection. Bladder neck hypertrophy was found to be a typical secondary alteration following any kind of reactive detrusor hyperactivity.     

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.