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Female bladder neck incision
FEMALE BLADDER NECK INCISION HOWARD N. FENSTER, M.D. From the Division of Urology, Shaughnessy Hospital, The University of British Columbia, Vancouver, B.C., Canada
~ ~e ~ ~i ~i
~'T--Bladder neck resection or incision in the female is not a new urologic procedure; has not been widely accepted because of poor results and complications. From January ~ier, 1986, ten such operations have been performed on females with obstructive uropathy. ~}ievious anti-incontinence procedures and postoperative obstruction developed. Bladder ~ons rather than resections have been performed with encouraging results, Urologic pres' i ~ir°dynamic investigations, and details of the surgery are presented. Bladder neck incision !~ii:able adjunct in the management of bladder neck obstruction in the female.
m in w o m e n is uncomelating to it are usually and similar to other :hough the evaluation of laily ehore of the urolojeetively obtained. Uro,e revolutionized the aper neck obstruction. 2 m or incision in the fe~dure, but modern textlrologie surgery do not ; in any detail. Material and Methods
.............
~"'~ll;~'J(~'~'~
/
FEBRUARY 1990
)er, 1986, 10 female seventy-two years, aented bladder neck ft. All patients had proeedures, either h, and all described lout urinary incontt complete clinical, evaluation. A Life[th video capability ag the urodynamic ,'riteria for obstruc:s than 15 cc per seewing no evidence of tl urine greater than ~ressures, and video obstruction. Cystos-
/
copy revealed bladder trabeculation with bladder neck elevation without urethral stricture. No patients showed intrinsic obstructive anatomic causes for urologic disease or underlying neurogenic bladder to explain bladder neck obstruction. All patients had initial attempts at conventional treatment, including urethral dilatation, without success. Transurethral bladder neck incision was performed rather than bladder neck resection. The 26-inch resectoseope with hot knife was used, and incisions were full thickness at the 12:00 o'clock position, approximately 0.5 em in length and 0.5 cm in depth. The bladder neck was examined from the mid urethra during the procedure to be certain that it opened and dropped appropriately during surgery. Results Seven of the 10 patients treated with bladder neck incision had excellent clinical improvement. Of the 5 patients restudied, all had flow rates greater than 20 ec per second without residual urine. Two patients were not benefitted by surgery and did not have further therapy. One patient required a Y-V-plasty of the bladder neck, with good clinical resutts. Comment Bladder neck obstruction is an uncommon condition and can be difficult to diagnose. ~
VOLUME XXXV, NUMBER 2
109
Older techniques, such as urethral calibration, 3 voiding cystourethogram, and cystoscopy~'4 are not entirely reliable and urodynamies must be utilized. A flow rate greater than 20 cc per second usually rules out obstruction in the female, but complete studies are required to document obstruction. Video studies are necessary to localize the level of obstruction. Female bladder neck resection has had a bad reputation over the years related to complications and poor results. A modification, namely bladder neck incision, appears to be a safe and efficient procedure. Other authors have also documented good results with this technique.4,s Turner-VVarwick has demonstrated the value of bladder neck incision and has recommended incising at the 12:00 o'clock position because it avoids the possibility of vaginal injury and provides the easiest opportunity for full repair if this becomes necessary. 4 Bladder neck incision, does require considerable care as continence in women appears to be more dependent on closure of the bladder neck than the more distal mechanisms. One must be careful about caus-
110
ing recurrent urinary incontinence follow~ this type of surgery. Although other authors have treated postobstructive surgical patients with oth gical techniques, such as urethrolysis a n d ~ die resuspension procedures, with rep6~:~¢-good results, 6 bladder neck incision is a s procedure with similar results. ~;~ 4500 Oak $ ~ Vancouver, B.C. V6 Re~erences 1. Farrar DJ, et al: A urodynamic view of obstruction in the female, Br J Uro147:815 (19 2. Blaivas JG, and Norten LJ: Primary blade ton, World J Urol 2:191 (1984). 3. Tanagho EA, and MeCurry E: Pressure an lated to lumen caliber and entrance eorffiguratio~ (1971), 4. Turner-Warwick R: Impaired voiding effi~ tion, in Stanton SL (Ed): Clinics in Obstetrics Philadelphia, W.B. Saunders Co, vol. 5, 1978, ] 5. Axelrod SL, and Blaivas JG: Bladder n~ women, ] Urol 137:497 (1987). 6. Zhnmern PE, Hadley HR, Leach GE, and Raz S : : . I ~ urethral obstruction after Marshall-Marchetti-Krantz O ~ J Urol 138:517 (1987).
UROLOGY
/
FEBRUARY1990
/
VOLUME XXXV, N ~
~ ~e ~ ~i ~i
~'T--Bladder neck resection or incision in the female is not a new urologic procedure; has not been widely accepted because of poor results and complications. From January ~ier, 1986, ten such operations have been performed on females with obstructive uropathy. ~}ievious anti-incontinence procedures and postoperative obstruction developed. Bladder ~ons rather than resections have been performed with encouraging results, Urologic pres' i ~ir°dynamic investigations, and details of the surgery are presented. Bladder neck incision !~ii:able adjunct in the management of bladder neck obstruction in the female.
m in w o m e n is uncomelating to it are usually and similar to other :hough the evaluation of laily ehore of the urolojeetively obtained. Uro,e revolutionized the aper neck obstruction. 2 m or incision in the fe~dure, but modern textlrologie surgery do not ; in any detail. Material and Methods
.............
~"'~ll;~'J(~'~'~
/
FEBRUARY 1990
)er, 1986, 10 female seventy-two years, aented bladder neck ft. All patients had proeedures, either h, and all described lout urinary incontt complete clinical, evaluation. A Life[th video capability ag the urodynamic ,'riteria for obstruc:s than 15 cc per seewing no evidence of tl urine greater than ~ressures, and video obstruction. Cystos-
/
copy revealed bladder trabeculation with bladder neck elevation without urethral stricture. No patients showed intrinsic obstructive anatomic causes for urologic disease or underlying neurogenic bladder to explain bladder neck obstruction. All patients had initial attempts at conventional treatment, including urethral dilatation, without success. Transurethral bladder neck incision was performed rather than bladder neck resection. The 26-inch resectoseope with hot knife was used, and incisions were full thickness at the 12:00 o'clock position, approximately 0.5 em in length and 0.5 cm in depth. The bladder neck was examined from the mid urethra during the procedure to be certain that it opened and dropped appropriately during surgery. Results Seven of the 10 patients treated with bladder neck incision had excellent clinical improvement. Of the 5 patients restudied, all had flow rates greater than 20 ec per second without residual urine. Two patients were not benefitted by surgery and did not have further therapy. One patient required a Y-V-plasty of the bladder neck, with good clinical resutts. Comment Bladder neck obstruction is an uncommon condition and can be difficult to diagnose. ~
VOLUME XXXV, NUMBER 2
109
Older techniques, such as urethral calibration, 3 voiding cystourethogram, and cystoscopy~'4 are not entirely reliable and urodynamies must be utilized. A flow rate greater than 20 cc per second usually rules out obstruction in the female, but complete studies are required to document obstruction. Video studies are necessary to localize the level of obstruction. Female bladder neck resection has had a bad reputation over the years related to complications and poor results. A modification, namely bladder neck incision, appears to be a safe and efficient procedure. Other authors have also documented good results with this technique.4,s Turner-VVarwick has demonstrated the value of bladder neck incision and has recommended incising at the 12:00 o'clock position because it avoids the possibility of vaginal injury and provides the easiest opportunity for full repair if this becomes necessary. 4 Bladder neck incision, does require considerable care as continence in women appears to be more dependent on closure of the bladder neck than the more distal mechanisms. One must be careful about caus-
110
ing recurrent urinary incontinence follow~ this type of surgery. Although other authors have treated postobstructive surgical patients with oth gical techniques, such as urethrolysis a n d ~ die resuspension procedures, with rep6~:~¢-good results, 6 bladder neck incision is a s procedure with similar results. ~;~ 4500 Oak $ ~ Vancouver, B.C. V6 Re~erences 1. Farrar DJ, et al: A urodynamic view of obstruction in the female, Br J Uro147:815 (19 2. Blaivas JG, and Norten LJ: Primary blade ton, World J Urol 2:191 (1984). 3. Tanagho EA, and MeCurry E: Pressure an lated to lumen caliber and entrance eorffiguratio~ (1971), 4. Turner-Warwick R: Impaired voiding effi~ tion, in Stanton SL (Ed): Clinics in Obstetrics Philadelphia, W.B. Saunders Co, vol. 5, 1978, ] 5. Axelrod SL, and Blaivas JG: Bladder n~ women, ] Urol 137:497 (1987). 6. Zhnmern PE, Hadley HR, Leach GE, and Raz S : : . I ~ urethral obstruction after Marshall-Marchetti-Krantz O ~ J Urol 138:517 (1987).
UROLOGY
/
FEBRUARY1990
/
VOLUME XXXV, N ~