INTRODUCTION

The primary bladder neck obstruction (PBNO) has been recognized in 41-45% of young men suffering from a chronic lower urinary tract symptoms (LUTS) [1,2]. It was described in 1933 for the first time by Marion [3] who distinguished congenital from acquired type through its histopathologic features, at the time of clinical manifestation. The precise cause of primary vesical obstruction has not been clearly elucidated. Theories as to its etiology include structural changes at the bladder neck such as sclerosis, hypertrophy smooth muscle and sub cervical glands of prostatic urethra and bladder neck [3] and inefficient bladder neck opening resulting from abnormal morphological arrangement of the detrusor/trigonal muscle [4] or dysfunction of sympathetic nervous system [5]. Mid-term use of alfa 1 blockers was beneficial in 54% of patient, but few long term effects could be observed [6]. The transurethral incision of the bladder neck is the most effective treatment of PBNO. Few studies are published in Literature about the use of laser devices in the surgical treatment of PBNO[7] and none about the use of Thulium Laser. The aim of our study is to report the results of our follow up in the endoscopic treatment of PBNO with Thulium Laser 

 

MATERIALS AND METHODS    

From January 2012 to January 2015 we treated 214 patients using Thulium laser (Cyber Tm) for primary bladder neck sclerosis. All patients had symptoms suggestive of LUTS or prostatism: filling or irritative symptoms (increased frequency of urination, increased urgency of urination, painful urination) and voiding or obstructive symptoms (poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence occurs in chronic retention). The preoperative assessment included evaluation of prostate specific antigen (PSA), urinalysis, spermioculture, urinary flow studies, suprapubic ultrasound and the post-voiding residual urine (PVR), imaging (voiding cystography) and/or cystoscopy, International Prostate Symptom Score (IPSS) was used to gauge the symptoms, along with physician examination, Quality of Life (QoL) and  International Index of Erectile Function (IIEF) was evaluated. After diagnosis the patients were treated with α-blockers and only in case of failure of medical treatment or interruption of therapy for adverse events, as retrograde ejaculation or hypotension, PVR > 50 mL, IPSS 8 or greater, QoL index > 3, Qmax rate less than 15 mL/s with an IIEF of at least 26 or greater there was the indication for endoscopic treatment.

All procedures were performed by two experienced surgeons to minimize the effects of the learning curve on the surgical outcome. All patients received preoperative antibiotic prophylaxis. Spinal or general anaesthesia was performed. TUIL (transurethral incision laser) was performed using a 24 F continuous-flow laser resectoscope, frontal fiber 600 μm, a 90-100 Watt, continuous saline irrigation and a video system [Fig. 1]. In 157 patients the incision was performed unilaterally at 7 o’clock of the bladder neck along ideal line that starts to the right ureteral meatus extending to about 1 cm proximal and lateral to verumontanum. Thus part of the supramontanal prostate was preserved. The incision is usually carried to a depth that allows complete division of the bladder neck and at least exposes the bladder neck capsular fibers [Fig. 2]. In 57 cases was performed bilateral incision at 5 and 7 o’ clock without vaporizing the tissue between the two incision. We chose to make the incision bilaterally in cases where a single incision was not enough to solve the obstruction from the bladder neck and prevent a recurrence.  Bladder irrigation was used overnight in all cases, and the catheter was removed after 12 hours.

 

 

RESULTS

196 patients enrolled completed 1 year follow-up: 157 patients underwent to unilaterally incision and 39 to bilateral incision. Mean age of the patients at time of surgery was 42 years (range 21-45 years). Mean operative time was 12 min (range 8-15 min.). Mean catheterization time was 1,2 days (range 1-2 days) and the mean hospital stay was 2 days (range 2-3 days). No intra-operative bleeding or post-operative urinary retention were reported, no one required blood transfusion or immediate re-intervention (grade I of Clavien-Dindo Classification of Surgical Complications) and no irritative syndrome was observed. For pain control 150 mg Diclofenac per os was administered. Relief of obstruction was confirmed by post-operative normalization of urinary flow. Mean peak flow rate (Qmax) increased from 8,3 mL/s (range 4,8 – 12,2 mL/s) preoperatively to 24 mL/s (range 22- 27 mL/s ) at 6, 12, 24 months. In 179 cases (91,3%) there was unchanged antegrade ejaculation, while reduced semen volume was reported by 14 men (7,1 %) and retrograde ejaculation by only 3 (1,5%) but these patients underwent to bilateral incision. The quality of orgasm and sexual satisfaction were not permanently changed by the operation. IPSS score improve from 25 preoperative to 7 postoperatively and IIFE was 24.

 

 

DISCUSSION

The understanding of the presentation, diagnosis, and treatment of PBNO has evolved over the last 20 years. PBNO is a condition in which the bladder neck fails to open adequately during voiding, resulting in increased striated sphincter activity or obstruction of urinary flow in the absence of another anatomic obstruction, such as that caused by benign prostatic enlargement. The precise prevalence of BPNO in men is unknow. Kaplan et al. reported that a 54% incidence of PBNO in a retrospective analysis of 137 men younger than 50 years with chronic voiding dysfunction and abnormal urodynamic assessment [1]. Nitti et al. observed that PBNO was the common diagnosis (47%) in 85 men younger than 45 years who underwent video-urodynamic study for chronic LUTS [8]. Although PBNO is a common disease in young men presenting with a long history of LUTS, many of these patients can be misdiagnosed. Many conditions are clinically similar to the PBNO as chronic prostatitis, neurogenic bladder dysfunction, psychogenic voiding dysfunction and pelvic pain. Thus, they are inappropriately treated with antibiotics and often treated for years until a definite diagnosis of PBNO is made. The main reason for misdiagnosis may be due to many urologists being unfamiliar with PBNO, who should pay more attention to this common disorder in young male patients with a long history of LUTS[9]. Medical or surgical treatment of PBNO can clearly give rise to adverse effects, first of all to retrograde ejaculation, both in the young and in elderly, occurs with great discomfort [10]. We continue to use α-blockers in selected patients with some success in clinical practice for one or two years. Nowadays, sexual function is accepted to be an important domain of Quality of Life and recent evidence has suggested a link between symptoms and sexual dysfunction in men both in the community and in those attending urology clinics, and so each treatment, prior to be performed, requires an appropriate diagnosis of the patient’s disease [11]. In our series the quality of orgasm and sexual satisfaction were not permanently changed by the operation. Furthermore the incision unilateral or bilateral with thulium laser is a minimally invasive technique safe and effective, with minimal bleeding, therefore also indicated in patients receiving anticoagulants and antiplatelet[12].  

 

CONCLUSION

In patients with PBNO it is possible to perform endoscopic treatment with Thulium laser that we think an effective and safe procedure, not affecting sexual functioning and particularly retrograde ejaculation.

 

 

 Fig. 1.Bladder neck sclerosis

 

 Fig. 2. Unilateral incision of bladder neck

   
   
   

 References
1. Kaplan SA, Ikeguchi EF, Santarosa RP, et al: Etiology of voiding dysfunction in men less than 50 years of age. Urology 1996;47(6):836-839
2. Wang CC, Yang SSD, Chen YT, Hsieh JH: Videourodynamics identifies the causes of young mes with lower urinary tract symptoms and low uroflow. Eur Urol 1933, 5: 351-53
3. Marion G: Surgery of the neck of the bladder. Br J Urol 1933, 5: 351-53
4. Turner-Warwick, R; Whiteside CG,Worth PHL, Milroy EJG and Bates CP: A urodynamic view of the clinical problems associated with bladder neck dysfunction and its treatment by endoscopic incision and transtrigonal posterior prostatectomy. Br J urol 1973 45: 44-47
5. Awad SA, Downie JW, Lywood DW, Young RA and Jarzylo SV: Sympathetic activity in the proximal urethra in patients with urinary obstruction. J Urol 1976 115: 545-548
6. Yang SSA, Wang CC, Hsieh JH, Chen YT. Alfa1 adrenergic blockers in young men with primary bladder neck obstruction. J Urol 2002; 168: 571-4
7. Yang SSA, Tsai YC, Chen JJ, Peng CH, Hsieh JH, Wang CC. Modified transurethral incision of the bladder neck treating primary bladder neck obstruction in young men: a method to improve voiding function and to preserve antegrade ejaculation. Urol Int. 2008; 80 (1): 26-30
8. Nitti VW, Lefkowitz G, Ficazzola M, et al. Lower urinary tract symptoms in young men: videourodynamic findings and correlation with noninvasive measures. J Urol.2002; 168(1):135-138
9. A. Del Rosso, S. Masciovecchio, P. Saldutto, G. Paradiso Galatioto, C. Vicentini. TURP in the young man: i siti possible to preserve the anterograde ejaculation?. Urologia 2013; 80(1):64-69
10. Mishriki SF, Grimsley SJ, Lam T, et al.TURP and sex: patient and partner prospective 12 years follow-up study. BJUI. 2001; 109:745-50
11. Brookes ST, Donovan JL, Peters TJ, et al. Sexual dysfunction in men after treatment for lower urinary tract symptoms: evidence from randomized controlled trial. BMJ. 2002;324:1059
12. S. Mattioli, A. Picinotti, A. Burgio. Thulium laser in patients with benign prostatic hyperplasia on anticoagulant and antiplatelet drugs. New Orleans, 31st World Congress of Endourology & SWL, October 22-26, 2013

 

 

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