Bladder Neck Incision: A Surgical Technique for Urinary Obstruction Relief

Introduction

A bladder neck incision is a surgery that is commonly done in conditions such as bladder outlet obstruction (BOO). This medical condition is characterized by a blockage at the base of the bladder, thereby preventing the flow of urine from the bladder into the urethra. It can lead to various urinary symptoms, such as difficulty in urination, frequent urination, weak stream, and a feeling of incomplete bladder emptying. Therefore, to treat this bladder, neck incision surgery has to be done at the neck of the urinary bladder to restore the proper urine flow.

What Is the Associated Anatomy With Bladder Neck Incision?

• The bladder neck is the junction of the urinary bladder, the urethra, and the tubular structure through which the urine flows out.

• The urinary bladder is a hollow organ that acts as the temporary storage reservoir for the urine and the urethra is the tube that carries the urine from the bladder for excretion.

• This junction contains muscle fibers that are arranged in three layers that act as an internal sphincter and prevent constant dribbling of urine.

• The internal sphincter is under involuntary control (actions that are not under an individual's conscious control), and the external sphincter encircles the urethra and is under voluntary control (actions that are under an individual's conscious control).

• The process of urination takes place due to the contraction of the urinary bladder and simultaneous loosening of the bladder neck and the external urethral sphincter.

What Is a Bladder Neck Incision?

A bladder neck incision (BNI) is a surgical procedure that aims at widening the bladder neck and improving urine flow. This is most commonly done in males as well as rarely in females. The objective of this procedure is to alleviate the obstruction and improve the flow of urine from the bladder. BNI is most commonly performed in males, as they are more prone to bladder outlet obstruction due to conditions like benign prostatic hyperplasia (BPH), prostate cancer, or other anatomical abnormalities.

What Are the Indications for Bladder Neck Incision?

Bladder neck incision is considered when other non-surgical and minimally invasive treatments for bladder outlet obstruction have not provided sufficient relief or when the obstruction is severe enough for surgical intervention. The following are common indications for bladder neck incision -

• Benign Prostatic Hyperplasia (BPH) - This is a non-cancerous condition leading to the enlargement of the prostate gland that can lead to compression of the urethra, leading to bladder outlet obstruction.

• Prostate Cancer - In some cases, prostate cancer can cause urinary obstruction by either directly obstructing the bladder neck or compressing the urethra.

• Bladder Neck Contracture - This is a condition in which scar tissue formation and narrowing of the bladder neck can occur due to previous surgery, radiation therapy, or inflammation, resulting in obstruction.

• Neurogenic Bladder - Neurological conditions like spinal cord injury or multiple sclerosis (an autoimmune condition affecting the immune system of the body) can affect bladder function and lead to bladder outlet obstruction.

• Recurrent Bladder Neck Obstruction - If the obstruction recurs after any previous treatments, a bladder neck incision may be considered.

• Failed Medical Management: When medications and other conservative treatments fail to alleviate the symptoms of bladder outlet obstruction, bladder neck incision may be an appropriate option.

How to Prepare for Bladder Neck Incision Surgery?

Before undergoing a bladder neck incision surgery, the patient will undergo a comprehensive evaluation by a urologist. This evaluation may include a medical history review, physical examination, urine tests, imaging studies (such as ultrasound or cystoscopy), and urodynamic studies to assess bladder function.

The tests include -

• Uroflowmetry Test - In this test, the patient is asked to pass the urine in a special container, which measures the speed and volume of the urine excreted by the patient. This helps in finding any obstruction in the urine flow, as in bladder neck obstruction, the flow is slow and prolonged. In some cases, there may be some residual urine left after the completion of voiding, which may be checked by using an ultrasound probe.

• Video Urodynamic Test - This test helps in evaluating the storage and voiding function of the lower urinary system. In this test, the bladder is first filled with water or contrast, and then the images are taken using an X-ray or ultrasound as the bladder is emptied. The patient with bladder neck obstruction may show an incomplete emptying of the bladder, with some residual urine in the bladder. The test may show the bladder neck fails to open when the bladder pressure goes up to void.

• Retrograde Urethrogram and Voiding Cystourethrogram - In this test, the contrast medium is introduced into the urinary bladder through the urethra, and images are obtained, which may reveal the presence of scar tissue at the bladder neck.

• Electromyography (EMG) - This test records the electrical activity of the muscles of the urinary bladder and the sphincters to detect any functional problems. The sensors are placed on the skin near the urethra or rectum or introduced into the urethra or rectum through catheters. This test is often done in females who need to undergo a bladder neck incision.

Some other routine tests that may be done before the surgery may include -

• Blood tests like hemoglobin levels, blood group, and liver and kidney function tests.

• Urine infection should be ruled out prior to the procedure through a urine routine microscopic examination and a urine culture.

• Electrocardiogram (ECG) to study the electrical activity of the heart.

• Chest X-ray for the detailed assessment of the heart.

Additionally, the patient will receive specific instructions about fasting before the surgery and any medications that need to be adjusted or stopped prior to the procedure. It is essential to inform the medical team about any allergies, medications, or medical conditions the patient may have.

How Is the Bladder Neck Incision Procedure Done?

Bladder Neck Incision is typically performed under general or spinal anesthesia. The surgical steps involved in BNI are as follows -

1. Positioning - The patient is positioned on the operating table, and anesthesia is administered to ensure a painless procedure.

2. Cystoscopy - A cystoscope, which is a thin, flexible tube with a camera on its tip, is inserted into the urethra and advanced into the bladder. This allows the surgeon to visualize the bladder, neck, and urethra and identify the site of obstruction.

3. Incision - Using specialized surgical instruments, the surgeon makes an incision in the bladder neck. This incision widens the bladder neck and relieves the obstruction, allowing urine to flow more freely.

4. Closure - After the incision is made, the surgeon may use sutures to close the wound and allow the incision to heal, or in some cases, the incision is left like that to heal on its own naturally. However, the method of incision closure depends upon the surgeon's preference and the patient's condition.

5. Post-operative Care - Once the procedure is complete, the patient is monitored in the recovery room before being transferred to a regular hospital room. The patient will receive pain medications and a urinary catheter may be left in place temporarily to help drain the bladder and promote healing.

What Are the Benefits of Bladder Neck Incision Surgery?

bladder neck incision offers several advantages in the management of bladder outlet obstruction, which includes -

• Improved Urinary Flow - The primary benefit of a bladder neck incision is the improvement in urinary flow, allowing the patient to void more easily.

• Relief of Symptoms - Patients usually experience relief from symptoms such as frequent urination, weak stream, and difficulty starting or stopping urination.

• Minimally Invasive - Bladder neck incision is considered a minimally invasive procedure compared to more extensive surgeries like open prostatectomy. As a result, it typically involves a shorter hospital stay and a faster recovery.

• Preservation of Prostate Tissue - Unlike any other surgical approaches, such as transurethral resection of the prostate (TURP), bladder neck incision preserves more prostate tissue, which may be beneficial for patients with a smaller prostate gland.

• Lower Risk of Sexual Dysfunction - Bladder neck incision is associated with a lower risk of sexual side effects compared to more radical procedures like radical prostatectomy.

What Are the Possible Complications After Bladder Neck Incision?

The possible complications of bladder neck incision include the following -

• Burning while passing urine.

• Injury to the urethra.

• Infection of the urinary tract.

• Blood in the urine.

• Retrograde ejaculation is more commonly seen in bilateral surgery as compared to unilateral surgery.

• Urinary incontinence due to injury to the external urethral sphincter.

• Perforation of the vaginal wall may occur in females.

Conclusion

Bladder neck incision is a valuable surgical procedure for managing bladder outlet obstruction in men. With its potential to improve urinary flow and relieve bothersome symptoms, BNI has become a favorable treatment option for patients who have not found relief from non-surgical approaches. While the procedure carries some risks, its minimally invasive nature and shorter recovery time make it an appealing choice for many individuals. As with any medical decision, it is essential for patients to discuss their specific situation thoroughly with their urologist to determine the most appropriate treatment.