Bladder Neck Contracture

01 April 2022

By Kalli Spencer 

Bladder neck contracture (BNC) is also known as bladder neck stenosis or alternatively a urethral stricture (which is not technically the correct term for this condition).

The cause of BNC

The prostate lies between the underneath surface of the bladder and the end of the urethra inside the pelvis. When the prostate is removed there is a gap between the opening of the bladder and the end of the urethra. The urological surgeon is able to reconnect the bladder to this “urethral stump” to ensure a waterproof outlet for urine to exit the body. However, in up to 7% of patients who have had conventional “open surgery” and 2% of patients who have had robotic prostate removal develop a BNC. It is thought to be due to scarring at the join between bladder and urethra which can result in narrowing of the new conduit resulting in difficulty and eventual failure to pass urine. 

Risk factors

These may be classified according to illnesses the patient already has or related to the original radical prostatectomy procedure itself.

Illness risk:

• Coronary artery/cardiovascular disease (blocked arteries that supply heart muscle)
• Hypertension
• Diabetes mellitus
• Peripheral vascular disease

All the above diseases have something in common and that is the reduction of blood flow through arteries supplying various organs in the body. This results in poor wound healing and scar formation.

Cigarette smoking also results in poor wound healing.

Procedure related risk:

• Suture technique
• Raised PSA after surgery or disease recurrence
• Blood in the urine after surgery (haematuria)
• Inability to urinate after surgery (urine retention)
• Urine leaks from the join after surgery
• Pelvic radiation prior to surgery

Presentation of BNC

Most patients that develop BNC do so within the first 6 months after surgery, but they can occur up to one year later or beyond. Patients may present to their doctor with progressively worsening urinary incontinence, difficulty passing urine and repeated urinary tract infections.

Diagnostic workup

If a BNC is suspected, then standard investigations which may be requested include submission of a urine culture to assess for infection; PSA test; camera check into the urethra and bladder (cystoscopy); measurement of postvoid residual urine volume (assessment of how much urine remains in the bladder after passing urine) and urine flow rate (uroflowmetry). Occasionally a urodynamic test is ordered to assess bladder function.

Treatment options

All options are performed under general anaesthetic in the operating theatre.

Dilation

This procedure involves the insertion of metal or balloon dilators into the urethra to stretch the scar tissue and improve the flow of urine. It has only shown a 60% success rate as the scarring can recur and the patient becomes symptomatic again.

Endoscopic incision

A scope (long metal tube) with a small camera on the end is passed through the tip of the penis through the urethra up to the site where the narrowing can be seen.

A specialised knife is used to cut through the scar tissue. An electrical current can also be passed through a specialised resecting instrument which uses heat to cut through the scar. A laser can also be used with the same effect.

This procedure has a similar success rate to dilation and 28% of patients may require more than two interventions.

Scar modulators

At the time of scar incision, a substance such as mitomycin C or a steroid such as triamcinolone can be injected into the scar tissue. They are able to reduce scar formation and improve treatment success.

Open bladder-neck reconstruction

Through an incision in the lower part of the abdomen the urologist is able to visualise the site of scar formation at the bladder neck and urethra. This scar tissue is removed, and the bladder and urethra are joined up again. There may be a risk of worsening incontinence after this surgery which can be managed with the insertion of an artificial urinary sphincter (see previous blog).

The bladder-neck reconstruction can also be done with the surgical robot but long-term outcomes for this approach are still pending.

Conclusion

With the increased use of the surgical robot for radical prostatectomies, BNC has become less common. Several factors have to be considered when treating this condition which include the patients existing illnesses, previous pelvic radiation, the stage of prostate cancer, the initial surgery to remove the prostate cancer and then the series of events and healing after this procedure. The BNC treatment journey can be long and complex but there are options available which can make a significant improvement to the patient’s quality of life.

References

^{Branche B, Crocerossa F, Carbonara U, Klausner AP, Roseman JT, Hampton LJ, Autorino R. Management of bladder neck contracture in the age of robotic prostatectomy: An evidence-based guide. Eur Urol Focus 2022; 8:297-301.}

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