Is the Transurethral Ultrasound Ablation (TULA) procedure effective for treating bladder neck obstruction?

Transurethral Bladder Neck Incision is Effective for Bladder Neck Obstruction

Transurethral bladder neck incision (TUBNI) is an effective surgical treatment for bladder neck obstruction with success rates of approximately 85-91% in properly selected patients. 1, 2

Diagnostic Approach for Bladder Neck Obstruction

Before considering any intervention, proper diagnosis is essential:

• Video-urodynamic study (VUDS) is the primary diagnostic tool for confirming bladder neck obstruction 1
• Key diagnostic findings include:
  • High voiding pressure with low flow rate
  • Narrow bladder neck during voiding on cinefluoroscopy
  • Elevated urethral pressure

Surgical Technique and Considerations

The TUBNI procedure involves making strategic incisions at the bladder neck:

• Standard approach involves incisions at 2 different sites on the bladder neck 1
• For male patients with small prostates (≤30g), bladder neck resection may be preferred over traditional TURP 3
• In female patients, KTP (potassium-titanyl-phosphate) laser can be effectively used for the incision with minimal bleeding 4

Outcomes and Benefits

TUBNI demonstrates significant improvements in both objective and subjective measures:

• Significant decrease in:
  • International Prostate Symptom Score (IPSS)
  • Quality of life (QOL) scores
  • Postvoid residual urine volume
  • Voiding pressure
• Significant increase in:
  • Maximum urinary flow rate
  • Average flow rate
  • Voided volume

Potential Complications

While generally safe, patients should be counseled about potential complications:

• Bladder neck reobstruction (7.1%)
• Urethral stricture (10%)
• Stress urinary incontinence (10%)

Special Considerations

• For male patients concerned about sexual function, TUBNI/BNI offers a significant advantage over TURP with preservation of antegrade ejaculation 5
• For patients with neurogenic bladder who require intermittent self-catheterization, surgical options should be carefully considered as underlying detrusor dysfunction may alter treatment outcomes 6
• In cases of severe outlet dysfunction that doesn't respond to initial treatments, more aggressive approaches may be needed, including autologous pubovaginal sling or bladder neck closure with urinary diversion 6

Algorithm for Management

1. Confirm diagnosis with video-urodynamic study
2. Rule out other causes of obstruction (stricture, prostate enlargement, etc.)
3. Attempt TUBNI as first-line surgical treatment
4. For recurrent obstruction after TUBNI, consider:
   • Repeat TUBNI
   • Alternative approaches based on gender and specific anatomy
   • More aggressive interventions for refractory cases

TUBNI represents an effective, minimally invasive approach for bladder neck obstruction with high success rates and relatively low complication rates when performed by experienced surgeons.