Highly recurrent bladder neck contracture (BNC) following transurethral surgery of the prostate is rare but troublesome condition. Success rate declined considerably after repeated endoscopic treatment. With lack of standardized treatment; bladder neck reconstruction remains one of the most accepted therapeutic options for recurrent BNC. This study evaluates the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral surgery of the prostate.

We present medium-term results of 15 consecutive patients with refractory BNC who underwent open Y-V plasty at a tertiary care centre between May 2017 and January 2020.  All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments. Participant information was obtained including clinical evaluation, demographics, comorbidities, and prostate profile. Perioperative evaluation, operative data and postoperative outcome were analyzed. Postoperative complications were recorded and classified according to the Clavien classification. Functional and patient-reported outcomes were evaluated using standard uroflowmetry and validated self-reported questionnaires. The questionnaires included validated IPSS, IPSS-QoL, OAB-V8 and IIEF-5 survey items.

Fifteen patients underwent the open Y-V plasty procedure, most of whom developed refractory BNC secondary to TURP [n=11, (73%).] Mean age at surgery age (SD) was 66.9 (5.8) years. Mean follow-up was 16.1 (6.5) months. Success rate was 100% (Table 1). Post-operative Qmax improved significantly [pre-OP 6.47 (8.6) ml/s vs post-OP was 14.74 (7.8) ml/s, p = 0.001]. Mean post-void residual decreased significantly [pre-OP 174.92 (206.6) ml vs post-OP 48.92 (75.7) ml, p = 0.018)] (Table 2). Overactive bladder symptoms were the most common postoperative complication in 47% of subjects. Mean post-operative IPSS-score was 12.3 (range 3–22) and mean post-operative IPSS-QoL was 2.4 (range 0–5). Age at surgery (r = 0.52) and BMI (r = 0.52) were positively correlated with changes in OAB-V8 score p = <0.05.

Highly recurrent bladder neck contracture following transurethral surgery of the prostate is a rare but troublesome condition. With lack of standardized treatment; bladder neck reconstruction remains one of the most accepted therapeutic options for recurrent BNC. The rationale for YV-reconstruction of the bladder neck is to avoid recurrent scarring by transposition of a well-vascularized bladder wall flap enabling reconstruction of a wide bladder neck. Our results confirm these considerations true: Success rate, defined as no need for further instrumentation or surgery is great along with significant improvement in objective measures as Qmax and PVR as well as health related quality of life. The IPSS-QoL of mean 2.4 is favorable. Excellent and consistent rates of bladder neck patency can, therefore, be achieved for patients suffering of refractory BNC after transurethral surgery of the prostate.

Nearly half of our patients developed persistent or de novo overactive bladder (OAB) symptoms after bladder neck reconstruction. This leads to suboptimal treatment outcomes, reduced QoL, and are associated with substantial personal and societal costs.  The residual storage symptoms after treating bladder outlet obstruction is mostly attributable to underlying bladder dysfunction for instance detrusor overactivity. It is important to recognize the risk factors for persistent OAB symptoms in order to satisfactorily council the patient before surgery, to understand how to treat these symptoms and to develop an actual clinical practice guidelines

Y-V plasty represents a safe and viable treatment option with high success rates and favorable patient reported outcomes for refractory bladder neck contracture. Residual storage symptoms are usually attributable to underlying bladder dysfunction leading to a suboptimal treatment outcome.