What minimally invasive procedures are available for bladder neck obstruction?

Minimally Invasive Procedures for Bladder Neck Obstruction

For bladder neck obstruction, the primary minimally invasive procedures include bladder neck incision, bladder neck resection, and transurethral resection, with the choice depending on prostate size and specific patient factors. 1

First-Line Minimally Invasive Options

Bladder Neck Incision/Resection

• Bladder neck incision (BNI) or transurethral incision of the bladder neck (TUIBN) is recommended for:
  • Smaller prostates (<30-40g) 1, 2
  • Younger patients concerned about preserving ejaculatory function 3
  • Patients with primary bladder neck obstruction 4

Transurethral Resection

• Transurethral resection (TUR) options:
  • Monopolar TURP (M-TURP): Traditional gold standard with durable outcomes up to 22 years 1
  • Bipolar TURP (B-TURP): More favorable perioperative safety profile than M-TURP 1
  • Bladder neck resection: Comparable to TURP for prostates ≤30g with shorter operating time and lower transfusion requirements 5

Laser-Based Procedures

• Thulium laser procedures:
  • ThuVARP (Thulium:YAG vaporesection): Similar operation, catheterization, and hospitalization times to TURP 1
  • ThuVEP/ThuLEP (Thulium vapoenucleation/enucleation): Effective for larger prostates; safe in patients on anticoagulants 1
• Holmium laser enucleation (HoLEP):
  • Similar efficacy to TURP for smaller prostates and to open prostatectomy for larger prostates
  • Shorter catheterization and hospitalization times
  • Reduced blood loss compared to TURP 1

Procedure Selection Algorithm

1. For small prostates (<30-40g):

   • First choice: Bladder neck incision/resection
   • Advantages: Shorter operative time, less bleeding, preservation of antegrade ejaculation (62-100%) 2, 3

2. For medium-sized prostates (40-80g):

   • First choice: Bipolar TURP or laser procedures (ThuVARP, HoLEP)
   • Advantages: Better safety profile than monopolar TURP 1

3. For large prostates (>80g):

   • First choice: Laser enucleation (HoLEP, ThuLEP) or bipolar enucleation (B-TUEP)
   • Advantages: Similar efficacy to open prostatectomy with less invasiveness 1

Special Considerations

For patients on anticoagulants:

• Laser procedures (particularly HoLEP) can be performed safely without discontinuation of anticoagulant therapy 1
• Bipolar TURP is safer than monopolar TURP but may still require anticoagulant management 1

For patients with neurogenic bladder:

• Urethroplasty may be offered for urethral strictures causing difficulty with self-catheterization 1
• Consider bladder function before intervention 1

For post-prostatectomy vesicourethral anastomotic stenosis:

• Delayed urethroplasty is preferred over repeated endoscopic procedures 1

Potential Complications

• Retrograde ejaculation: More common with TURP (62%) than BNI (0%) 3
• Erectile dysfunction: Similar short-term effects between HoLEP and TURP; better long-term IIEF scores with HoLEP 1
• Bladder neck contracture: Less common after BNI than TURP 6
• Blood transfusion: Higher rates with TURP than BNI or laser procedures 1, 2

Follow-up Considerations

• Monitor for symptom recurrence and urinary flow rates
• Assess for complications such as urinary tract infections or bladder neck contracture
• For persistent or recurrent obstruction after initial procedure, consider alternative or more definitive surgical approaches

Remember that proper preoperative evaluation with urodynamic studies may help determine the exact nature of bladder neck obstruction and guide appropriate procedure selection 1.