What procedures are available for treating a high bladder neck?

Procedures for Treating High Bladder Neck

There are several procedures available for treating high bladder neck, with bladder neck incision (BNI) being the most effective first-line surgical approach for functional bladder neck obstruction. 1

Initial Management Options

Medical Management

• Alpha-blockers: First-line medical therapy for functional bladder neck obstruction
  • Effective in approximately 50% of patients 2
  • Mechanism: Decreases smooth muscle tone in the bladder neck by blocking alpha-1 adrenoreceptors 3
  • Limitation: Some patients experience side effects or inadequate response

Surgical Management Options

1. Bladder Neck Incision (BNI)

   • Most common and effective surgical approach for high bladder neck
   • Techniques:
     • Unilateral incision (UI)
     • Bilateral incision (BI)
   • Long-term success rates of 83-88% 4
   • Can be performed using:
     • Adult resectoscope with Collins knife
     • Pediatric resectoscope (13F) - associated with lower risk of stress incontinence 2

2. Bladder Neck Procedures (BNPs)

   • For patients with incontinence due to outlet issues 1
   • Types include:
     • Autologous fascial sling to narrow the outlet
     • Creation of a long and narrow channel at the bladder neck
     • Implantation of an artificial sphincter

3. Transurethral Resection of Bladder Neck

   • Less commonly used than incision
   • Higher risk of complications including retrograde ejaculation 5
   • Reserved for selected cases with more significant obstruction

4. Obstructing Pubovaginal Sling (PVS)

   • For severe outlet dysfunction or recurrent/persistent SUI after anti-incontinence surgery 1
   • Preferred over retropubic midurethral slings (RMUS) for patients with fixed immobile urethra

5. Bladder Neck Closure with Urinary Drainage

   • For severe cases with compromised bladder outlet 1
   • Options include:
     • Catheterizable stoma
     • Artificial urinary sphincter (AUS)
     • Total urinary diversion via ileal conduit or continent diversion

Choosing the Appropriate Procedure

Algorithm for Treatment Selection:

1. Initial approach: Trial of alpha-blockers with clean intermittent self-catheterization (CIC)
2. If medical management fails:
   • For mild to moderate obstruction: Bladder neck incision (BNI)
   • For severe obstruction with intact sphincter: Bladder neck resection
   • For cases with incontinence: Consider bladder neck procedures (BNPs)
   • For refractory cases: Consider bladder neck closure with urinary diversion

Special Considerations

• For patients with neurogenic bladder: BNI has shown good effects on flow, reflux, hydronephrosis, and infection rates 6
• For patients with spina bifida: Carefully tailored BNPs are recommended 1
• For women with functional bladder neck obstruction: Pediatric resectoscope for BNI shows better outcomes with lower risk of stress incontinence 2

Outcomes and Complications

Outcomes

• BNI provides significant improvement in peak flow rates (from 8.5 to 19.6 mL/s) 7
• Symptom scores improve significantly (from 26.9 to 3.6) 7
• Durable results with >80% maintaining improvement over long-term follow-up 7

Potential Complications

• Stress urinary incontinence (more common with adult resectoscope) 2
• Need for reoperation (12-17% within 6 years) 4
• Retrograde ejaculation (less common with BNI than with transurethral resection) 5

BNI remains the gold standard surgical approach for functional bladder neck obstruction with excellent long-term outcomes and minimal complications when performed appropriately.