Transurethral incision with transverse mucosal realignment surgery, simple solution for a complex problem

May 21, 2022

J. (Nick) Nicholas Warner, M.D., is a urologist at Mayo Clinic in Rochester, Minnesota, specializing in reconstructive urology and benign prostatic hyperplasia. Dr. Warner and his team are pioneering minimally invasive treatment options. With these options, even the most challenging bladder neck contractures that typically require incisions in either the abdomen or the perineum can be done without any incisions. As a result, Dr. Warner's patients enjoy leaving the hospital the same day without prolonged recovery.

What is a bladder neck contracture?

Bladder neck contracture is a term used to describe a narrowing of the bladder outlet where it joins the urethra. Symptoms usually present after benign prostate surgery or prostate cancer treatment. They can include weak urinary stream, frequent urination or the inability to urinate.

While bladder neck contracture is commonly used to describe any narrowing involving the bladder opening, reconstructive urologists commonly divide the site of narrowing into:

  • Bladder neck stenosis, which is a narrowing at the junction of the bladder and prostate that occurs usually after enlarged prostate surgery
  • Vesicourethral anastomotic stenosis, which is a narrowing that occurs at the junction of the urethra and bladder after the prostate has been removed for cancer

What causes bladder neck contractures?

A disrupted or inadequate blood supply can cause bladder neck contractures. This can happen following operations to remove prostate cancer or treat benign prostatic hypertrophy. Bladder neck stenosis is frequently caused by scarring that can occur after any procedure for benign prostate surgery, but it most commonly happens after transurethral resections, greenlight photovaporization or laser enucleations.

Vesicourethral anastomotic stenosis occurs at the location where the urethra and bladder are sewn together after the prostate is removed. It is particularly common after radiation therapy.

What is the work-up?

  • Cystoscopy. A camera passes through the urethra into the bladder to inspect the location of the narrowing. This is a crucial step to make sure the narrowing is at the bladder neck.
  • Voiding cystourethrogram. An X-ray of the bladder and urethra after the bladder has been filled with contrast is taken. This is not required in most cases but can sometimes aid in diagnosis.
  • Uroflow. The strength of urine stream is measured.
  • International Prostate Symptom Score. This questionnaire helps doctors better understand and rate symptom severity.

What is the treatment?

Traditionally, the treatment of bladder neck contracture was to dilate it open or to make a cut in the stricture (direct visual internal urethrotomy) in hopes that the scar would not return. This can work in some cases. But if it doesn't work the first time, continued dilations or incisions will not be effective. That said, many men are still treated with repeated dilations or serial self-dilations. While these interventions are transurethral, they are not highly effective. Definitive management often involves a more invasive robotic abdominal surgery (V-Y advancement flap) or a transperineal anastomotic revision.

Building on equipment typically used in laparoscopic surgery, Dr. Warner has pioneered a way to definitively fix bladder neck contracture transurethrally for patients who have bladder neck contractures. The procedure is called a transurethral incision with transverse mucosal realignment. By using an endoscopic suturing device fit through a transurethral sheath, Dr. Warner can pull the healthy bladder tissue across the incision and then use an absorbable suture that is held in place with a titanium clip. This procedure takes about 30 minutes, and patients go home the same day of the procedure with a catheter in the bladder. The finished product is similar to that of the robotic V-Y advancement flap, and it boasts equivalent success rates in an initial experience with more than 50 patients.

What is the follow-up care?

In patients with nonradiated tissue, a catheter is left in, draining the bladder for three days. If there is a history of radiation, the catheter stays in longer, ranging from two weeks up to a month in some patients. Another cystoscopy is performed after four months to ensure the narrowing has not returned and make sure the titanium clip used to hold the suture has passed. In some patients, the clip will need to be grasped and removed because it can cause a bladder stone.

What are the side effects?

In patients with prostate cancer, there is a chance that there may be urinary leakage after the procedure. If patients do not have urinary leakage before the operation, they usually will not have urinary leakage afterward. Another theoretical side effect is a bladder stone forming on the titanium clip. While this has not occurred in the initial experience, it is especially important for patients to get the four-month cystoscopy to ensure the clip has passed.

In some situations, for example, when there's a complete urethral obstruction or stricture in the membranous urethra, a patient may not be an ideal candidate for this operation. In these rare instances or if the bladder neck contracture returns, Dr. Warner's reconstructive urology team has the expertise to perform robotic repairs when needed.

For more information

Refer a patient to Mayo Clinic.