From the Guidelines
Cysto-urethroscopy with bladder neck dilatation is indicated for patients with symptoms of bladder neck obstruction or stenosis, such as weak urinary stream, incomplete bladder emptying, urinary hesitancy, increased urinary frequency, or recurrent urinary tract infections that have not responded to medical management, as supported by the most recent guideline amendment 1.
Indications for Cysto-Urethroscopy
The procedure is typically recommended for patients with documented bladder neck contracture, which may occur as a complication following prostate surgery, radiation therapy, or trauma.
- Patients with lower urinary tract symptoms due to bladder neck obstruction or stenosis
- Patients with recurrent urinary tract infections that have not responded to medical management
- Patients with symptoms such as weak urinary stream, incomplete bladder emptying, urinary hesitancy, or increased urinary frequency
Evaluation Prior to Procedure
Prior to recommending this procedure, patients should undergo a thorough evaluation including:
- Urinalysis
- Uroflowmetry
- Possibly urodynamic studies to confirm bladder outlet obstruction at the level of the bladder neck
Procedure Details
The procedure involves inserting a cystoscope through the urethra to visualize the lower urinary tract, followed by mechanical dilation of the bladder neck using graduated dilators or balloon dilators.
- The procedure is typically performed under general or spinal anesthesia as an outpatient procedure
- Patients usually able to return home the same day
Post-Procedure Care
Post-procedure care includes:
- Antibiotic prophylaxis (such as ciprofloxacin 500mg twice daily for 3 days)
- Adequate hydration
- Temporary urinary catheterization for 24-48 hours in some cases
Importance of Recent Guidelines
The most recent guideline amendment 1 emphasizes the importance of proper evaluation and treatment of urethral stricture disease, and surgeons should offer urethroplasty, instead of repeated endoscopic management, for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy.
Considerations for Urethral Stricture Disease
In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain temporary urethral patency, as supported by the guideline amendment 1.
- Varying self-catheterization schedules after DVIU have demonstrated that stricture recurrence rates were significantly lower among patients performing self-catheterization.
From the Research
Indications for Cysto-Urethroscopy + Dilatation of Bladder Neck
- Cysto-urethroscopy with dilatation of the bladder neck may be indicated for the treatment of primary bladder neck obstruction, as seen in a study published in 2014 2.
- This procedure can also be used to manage urethral stricture and bladder neck contracture following primary and salvage treatment of prostate cancer, as discussed in a 2017 article 3.
- Additionally, cystoscopy with dilatation can be used to evaluate and treat urethral stricture following transurethral prostatectomy, with a study from 2020 showing its superiority over urethrography in this context 4.
Evaluation of Urethral Stricture
- Urethral dilatation compared to cystoscopy alone has been studied in the treatment of women with recurrent frequency and dysuria, with no significant difference in outcome found between the two groups in a 1988 study 5.
- MRI and MR voiding cystourethrography have also been used to evaluate male primary bladder neck obstruction, providing useful anatomical and functional information, as seen in a preliminary study from 2022 6.
Potential Complications
- Complications such as hemorrhage, re-BNI, vesicovaginal fistula, stress urinary incontinence, and urethral stricture can occur after bladder neck incision, as reported in the 2014 study 2.
- Urethral stricture and bladder neck contracture can also occur after prostate cancer treatment, with various management options available, including urethral dilation, urethroplasty, and open reconstruction, as discussed in the 2017 article 3.