Transurethral Incision or Resection of the Bladder Neck (Tuibn) or (Turbn)

Definition

Transurethral = through or across the urethra (tube through which urine exits bladder)

Incision = making a cut in

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Resection = cutting away or removal (some people refer to it as a “scraping”)

Bladder Neck = the opening of the bladder where the urethra begins

This procedure is done to open up a BNC or bladder neck contracture (restricting scar tissue)at the neck of the bladder. The most common reasons to have a bladder neck contracture are:

• a history of transurethral resection of the prostate, referred to as a TURP (prostate scraping procedure) or transurethral resection of a bladder tumor
• a history of an open prostate operation such as radical prostatectomy (removal of the prostate for cancer treatment) or simple prostatectomy (removal of the center portion of a prostate that was too large for a TURP procedure)
• a history of radiation and/or radioactive seed implantation for prostate cancer treatment

The symptoms characteristic of a bladder neck contracture are those of obstructive urination pattern. The most common symptoms are:

• straining (need to push to begin urination)
• hesitancy (delayed onset of urination following the urge to urinate)
• slow or diminished force of stream
• intermittence (urine stream that starts and stops)
• sensation of incomplete emptying

Other symptoms that may be associated are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).

Preparation

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There is no particular preparation for this procedure. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. You will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”).

The most common of these medications are aspirin and all related pain reliever or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure usually takes less than one hour depending on whether the procedure is an incision (typically shorter) or are section. Very dense (hard) and tight strictures may add some minimal time to the procedure. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters called stirrups). A special scope (which may have continuous fluid running through it) is carefully inserted up to the area of the BNC. In certain instances, we will insert a small wire through the tiny, scarred opening and into the bladder to act as a guide. This ensures that we open the scar in the proper place. The most common tool used to open a BNC is a small knife with an electric current. Certain types of laser may be used as well. In the TUIBN, incisions are made in certain areas to allow the scar to relax open. In a TURBN (more commonly done when prior radiation is the cause) the tissue may be cut or scraped away. Any blood vessels that are oozing may be cauterized (burned) closed. Once the channel is sufficiently open, we advance the scope into the bladder and carefully examine the bladder to ensure that everything is within normal limits. At the end of the procedure, a catheter is placed into the bladder to allow proper healing of the newly opened bladder neck channel.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be discharged home. Less commonly, you may require admission to the hospital after this procedure. It is normal for you to feel a sense of urgency to urinate. This is from the procedure and from the presence of the catheter. In most patients, this resolves within a couple of hours, but could last until the catheter is removed. Some patients require medications to help relax the bladder while the catheter is in. Your catheter will be attached to a bag. The urine will either be clear or minimally tinged with blood. The bag can be strapped to your leg and easily concealed under your clothing. You will be shown how to empty the catheter bag. You will usually be given a larger bag for overnight urine collection while you are sleeping. We assure you that it is quite simple.

Expectations of Outcome

Most patients are very satisfied after the procedure. The improvements that are typically noted immediately after the operation are:

• Stronger force of stream
• Decreased standing around waiting for the urination to commence
• Decreased need to push
• Loss of intermittence (i.e. where the flow used to start and stop and start, etc.)
• Loss of the sensation that you are “not really emptying your bladder”

Sometimes, it may be difficult to control the urine for a couple of weeks. This is more common in patients who had scarring due to radical prostatectomy or radiation.

You may notice that you are still voiding frequently and with some urgency (sensation that forces you to get to the bathroom quickly). These symptoms can take a long time to disappear. In patients who were significantly obstructed for a prolonged period, these symptoms may never fully go away.

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Nocturia (getting up at night to urinate) is typically the last symptom to go away. In many instances, it may become less frequent, but never fully disappear. The reason is that nocturia can be due to dozens of other physiological issues and also because the night-time ritual becomes somewhat habitual.

Retrograde ejaculation is when the semen (during ejaculation) goes backward into the bladder instead of forward and out of the penis. This is expected to some degree in almost all patients. It may be that your semen volume is less, or absent altogether. *You will still have the sensation of orgasm, but you may not see the semen. In this regard, you may be considered sterile.

*Uncommonly, the BNC cannot be opened. The two most common reasons are that it is too dense or too irregular to safely cut (more common in radiation patients). In these cases it maybe risky to cut the scar “blindly.” If this were the case, we would need to place a suprapubic catheter in your bladder. A suprapubic catheter is a small tube that is inserted into the bladder through a tiny puncture hole in the lower abdomen. It would be attached to a drainage bag. The tube will remain in place until further management is discussed with you in the office. Please refer to the literature on suprapubic catheter placement.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Hematuria (Blood in the Urine): Typically, there is no bleeding from this procedure. In rare instances, a blood vessel may open. The bleeding is almost always minimal and self-limited. Rarely, the bleeding may form small clots that would need to be irrigated out through the catheter. Recurrent bleeding following removal of the catheter is very uncommon. If severe, it could require replacement of the catheter.
• Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection often presents with the urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may need a short hospitalization for intravenous antibiotics, fluids, and observation. This is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TUIBN/TURBN. However, in any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Recurrent Bladder Neck Contracture: A recurrence of the BNC can occur weeks, months, or even years after this sort of procedure. Each time the procedure is repeated, the incidence of recurrence is greater.
• Urinary Incontinence: If your bladder was obstructed for years, and possibly also by your prostate, it may have learned to over-compensate by squeezing with more force. The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In some cases, it may never completely go away. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel. This is more common in patients who have a BNC following radical prostatectomy or radiation treatment.
• Urinary Retention: Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If you presented with long-standing urinary retention (complete inability to urinate), this may not resolve following a TUIBN/TURBN procedure. Patients whose retention was more sudden and painful are quite likely to void after the procedure.
• Perforation: If the incision or cut is too deep, the bladder can be perforated. This finding may not change the course of the case. It heals within days over the catheter that is left in place. In this case, we may elect to leave the catheter in for a few extra days. Injuries to the ureteral orifices (holes where the kidney tubes come into the bladder) are exceedingly rare and are most often dealt with in the same fashion. Sometimes, we may need to place a temporary stent in place (a plastic tube that goes from the kidney to the bladder). It would be quite unusual to need an open operation(incision on the abdomen) or minimally invasive procedure to repair the bladder or ureteral orifices.
• Erectile Dysfunction: According to the literature, 1-2% of patients complain of some erectile dysfunction (impotence) after almost any endoscopic procedure. There is no known explanation for its occurrence.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.

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