What is the recommended treatment approach for bladder neck obstruction or contracture using bladder neck incision?

Bladder Neck Incision for Bladder Neck Obstruction or Contracture

Bladder neck incision (BNI) is the recommended first-line surgical approach for treating bladder neck obstruction or contracture, with success rates exceeding 80% when performed properly. 1

Indications for Bladder Neck Incision

• Bladder neck contracture following endoscopic prostate procedures
• Primary bladder neck obstruction in both men and women
• Vesicourethral anastomotic stenosis
• Refractory bladder neck contracture not responding to dilation

Preoperative Assessment

• Confirm diagnosis with:
  • Retrograde urethrography (RUG)
  • Voiding cystourethrogram (VCUG)
  • Urodynamic studies to document obstruction
  • Cystoscopy to visualize the contracture

Surgical Technique Options

Standard Approach

• Transurethral incision at 5 and 7 o'clock positions (most common)
• Alternative positions: 3,9, and 12 o'clock (for women)
• Depth of incision should reach perivesical fat

Equipment Options

1. Standard adult resectoscope with Collins knife - Traditional approach
2. Pediatric resectoscope (13F) - Preferred for women to reduce risk of stress incontinence 2
3. Holmium laser - Novel technique offering precise incision with minimal thermal damage 3

Treatment Algorithm

1. First-line treatment for bladder neck contracture after endoscopic prostate procedures:

   • Bladder neck incision, dilation, or transurethral resection (surgeon's preference) 1

2. For primary bladder neck obstruction in women:

   • Initial trial of alpha-blockers (successful in 50% of cases)
   • If poor response or side effects: Proceed to bladder neck incision using pediatric resectoscope 2
   • Consider holmium laser technique for precise incision 3

3. For vesicourethral anastomotic stenosis:

   • Treat before addressing any associated urinary incontinence
   • Patients with bladder neck contracture have decreased success rates with male slings and may be better candidates for artificial urinary sphincter 1

4. For refractory cases:

   • Deep transurethral incision with concomitant balloon dilation 4
   • Consider multiple incisions (at 3,9, and 12 o'clock positions) 3

Outcomes and Complications

Success Rates

• 83.3% improvement rate in women with primary bladder neck obstruction 5
• Significant improvements in maximum flow rates (from 7.6 to 20.6 mL/s) and post-void residual volumes (from 132.1 to 31.3 mL) 5

Potential Complications

• Stress urinary incontinence (more common with adult resectoscope)
• Retrograde ejaculation (7% in men) 6
• Need for repeat procedure (16.7% of cases) 5
• Failure rate approximately 2.4% 5

Special Considerations

• Pediatric resectoscope is preferred for women to reduce risk of stress incontinence 2
• Holmium laser offers advantages of higher maneuverability and precise incision with protection of external sphincter 3
• Avoid posterior incisions in women to prevent vesicovaginal fistula 3
• Patients with symptomatic vesicourethral anastomotic stenosis should have treatment of their obstruction prior to surgical correction of incontinence 1

Follow-up

• Assess improvement in symptoms, peak flow rates, and post-void residual volumes
• Consider repeat procedure if symptoms recur (safe to perform if necessary) 5
• Monitor for potential complications, particularly stress incontinence

By following this structured approach to bladder neck incision, clinicians can effectively manage bladder neck obstruction or contracture with high success rates and minimal complications.