Hypothesis / aims of study
We performed a retrospective analysis in our female population presenting primary bladder neck obstruction in the last five years describing the clinical findings, our method of diagnosis, and surgical approach with our results and complications in the management of this patients comparing it with the published data.
Study design, materials and methods
A retrospective analysys of our medical records was made, during period of time 2012 to 2017, in female patients who were diagnosed with primary bladder neck obstruction. All the patients underwent a physical examination and were asked for a laboratory with renal function, Urine culture, bladder diary, Validated pre-treatment questionnaires (IPSS and EVA), ultrasonography with voiding residual assessment, cistoscopy and pressure-flow study with X ray images or videourodynamics, according to availability. The postsurgical evaluation was performed with measurement of RPM, free uroflumetry, IPSS and EVA, with periodic controls being performed up to 5 years after the intervention.
A total of 25 patients were diagnosed with PBNO in our center. 3 cases (12%) the initial reason for consultation was acute urinary retention (RAO), in 1 case (4%) associated with bilateral uronephrosis and acute renal failure; the rest of the series, 21 patients (88%), reported filling phase symptoms (as frequency, urgency, nocturia) associated with voiding disorders ( decrease in the size of the voiding stream, post voiding dribbling). The initial treatment in all the patients was kinesics evaluation and alpha blockers. Of this 25 patients, 17 (68%) were refractory to initial treatment, and they progress to a surgical resolution. The bladder neck section was systematically performed in bladder neck at 5 and 7 hours, with subsequent periodic controls and a follow-up of up to 72 months (mean of 36 months). In our series, postoperative free flow doubled to preoperative one (mean 14.42 ml / sec), postsurgical IPSS decreased 83% (from 22 to 3.75) and EVA decreased 69.5% (from 6 to 1.83). 2 patients (11.7%) presented a recurrence of the PBNO, and were re-operated surgically, achieving a satisfactory desobstruction. 1 of these patients (5.8%) developed a cervicovaginal fistula, which required open surgical repair and other patient (5.8%) developed postoperative overactive bladder symptoms that initially improved with anticholinergics, subsequently yielding spontaneously.
Interpretation of results
The largest series with respect to PBNO in female patients, with a mean follow-up of 27.4 months, reported a clear symptomatic improvement and satisfaction rates in 84.5% of the patients who underwent surgery. Among the complications, they describe a rate of recurrence of 7.14% with re-intervention requirement, 3.6% of vesicovaginal fistula subsequently successfully repaired, 3.6% of urethral stricture requiring posterior urethral dilatations and 4.7% of urinary incontinence that needed a suburethral mesh. Our study is consistent with the international reports.
For all the above we can conclude that the female PBNO, is an uncommon condition in women but that should not be underestimated. Once the suspicion of female urinary outlet obstruction is established, the urodynamic evaluation is imposed under fluoroscopic guidance to confirm it and arrive at an accurate diagnosis. Once the conservative measures have been exhausted, in order to achieve a satisfactory response, the endoscopic section of the bladder neck can be used which in our experience proved to be a safe method with satisfactory results but which requires experience and, although as any medical procedure is not free of complications they can be resolved .