Standard Location for Bladder Neck Incision with Holmium Laser
The standard locations for performing bladder neck incision (BNI) with holmium laser for bladder neck contracture are the 3 and 9 o'clock positions (lateral incisions), though alternative approaches at 5 and 7 o'clock or 2 and 10 o'clock positions have also been described depending on clinical context. 1
Primary Technique: Deep Lateral Incisions
The most commonly recommended approach involves:
Deep lateral transurethral incisions at the 3 and 9 o'clock positions using holmium laser, which has demonstrated high success rates (86% after up to 2 procedures) with long-term patency in recurrent and resistant cases 2, 3
These lateral incisions should be sufficiently deep to ensure adequate opening of the bladder neck while avoiding damage to critical structures 3
The procedure typically uses a 550-micron fiber holmium laser through a pediatric cystoscope (7.5 F) for better maneuverability 2
Alternative Incision Locations
For Specific Clinical Scenarios:
5 and 7 o'clock positions have been successfully used with 2-micron continuous wave laser (thulium), particularly in recurrent cases, with mean operating times of 7 minutes 4
2 and 10 o'clock positions are specifically recommended for female bladder neck obstruction, with careful sufficiently deep incisions to ensure success while avoiding posterior incisions that risk vesicovaginal fistula 5
3,9, and 12 o'clock positions represent a novel three-point approach used in female primary bladder neck obstruction, offering protection of the external sphincter from thermal damage 6
Critical Technical Considerations
Avoid posterior incisions (6 o'clock position) in female patients as this significantly increases the risk of vesicovaginal fistula formation 6, 5
The choice between bladder neck incision versus transurethral resection can be made based on surgeon preference, as the 2023 AUA guidelines note comparable outcomes between these approaches 1
Success Rates and Outcomes
Deep lateral incisions at 3 and 9 o'clock achieve 72% success after initial procedure and 86% overall success after up to 2 procedures 3
Patients with >10 pack-year smoking history or ≥2 previous endoscopic procedures have higher failure rates and may require repeat intervention 3
Adjunctive steroid injection (triamcinolone) at incision sites can be considered for recurrent/resistant cases, with 83% success rates reported 2