Hypothesis / aims of study
Bladder neck incision (BNI) and bladder neck resection (BNR) have been the primary surgical approaches for Primary Bladder Neck Obstruction (PBNO) but is not commonly practiced for fear of complications and limited literature available. (1) Long-term success of BNI and BNR and its potential complications, such as bladder neck contracture, incontinence, vesico-vaginal fistula and recurrences, remain under investigation. (2)Data on durability of symptom relief and frequency of post-operative issues are limited, underlining the importance of extended follow-up studies. Additionally, there is no consensus on the optimal BNI technique, as incision depth, location, and tools (e.g., laser vs. electrocautery) vary. Standardizing these approaches through comparative research could improve patient care. This study assesses the trifecta outcomes - long-term effectiveness of surgical intervention, reoperation rates and postoperative complications and also evaluates the impact of technique modifications on surgical outcomes.
Study design, materials and methods
This retrospective analysis includes 41 patients diagnosed with PBNO between 2018 and 2024, all of whom underwent BNI and BNR. Their clinical features, renal function tests (RFT) , ultrasonography (USG) findings, uroflowmetry results, and video-urodynamic study (VUDS) data were analyzed. Initially, 10 patients had BNI at 5 and 7 o’clock positions. Later, the technique was modified : BNI at 3 and 9 o’clock with resection (BNR) of interposing tissue was used for next 31 patients (Figure 1). Different perioperative parameters along with complications if any, were evaluated during follow-up.
Results
Out of 41 patients, 9, 11, and 14 patients presented with Lower Urinary Tract Symptoms (LUTS) with chronic retention, acute retention, and hydroureteronephrosis with deranged RFT, respectively. The mean serum creatinine and IPSS were 2.8±1.9 mg/dl and 21.8±10.7, respectively. On VUDS, the mean Qmax, pdet@Qmax, and PVR were 6.7±3.08 ml/s, 58.2±14.2 cm H2O, and 280±80 ml, respectively. The mean operating time and blood loss were 20.7±6.4 minutes and 28.6±10.5 ml, respectively. The mean follow-up was 41.6±13.2 months.
In assessing trifecta outcomes, the mean IPSS, Qmax, and PVR were 6.2±1.5, 22.6±6.8 ml/s, and 29.5±12.7 ml, respectively after a minimum one year follow up. Of the 10 patients operated in first two years, 4 had no immediate symptom relief probably due to inadequate resection and underwent re-resection within a week after which they were symptom-free. Subsequently, after the modification of the surgical technique, only one patient experienced symptom recurrence at 2 years and required re-do surgery. Two patients developed urinary incontinence, one of which resolved spontaneously within 3 months. No bladder neck contracture or urethrovaginal fistula were noted. Two patients underwent BNR after a failed wrongly done female urethroplasty elsewhere. Both the patients improved with no incontinence.
Interpretation of results
It is believed that unique arrangement of muscle fibers around bladder neck tends to shift toward the bladder as it fills. The incision site gradually migrates towards the urethra, which increase risk of SUI, and fistulas. It is necessary to regularly empty the bladder in order to reassess the incision and make adjustments as needed. As the surgeon gains experience and progresses through the learning curve, a more detailed understanding of depth perception develops. BNI at 3 and 9 o’clock with controlled BNR improves outcomes by creating a wider channel, lowering outlet resistance.