Extraperitoneal Laparoscopic Modified Y-V Plasty for the Treatment of Refractory Bladder Neck Contracture

Summary

Here, we describe a modified surgical procedure for refractory bladder neck contracture that is associated with easy manipulation, optimum intraoperative exposure, and minimal invasiveness.

Abstract

Bladder neck contracture (BNC) is a rare, late complication of transurethral resection of the prostate (TURP). Although the endoscopic procedure is the primary treatment for BNC, the recurrence rate remains high. Y-V plasty offers excellent surgical results for those individuals with refractory and recurrent BNC. Traditional open operations usually fail to provide satisfactory exposure to the operating field and lead to greater invasiveness. Interrupted sutures lead to prolonged operative time and increased anastomotic leakage. Laparoscopic modified Y-V plasty is performed through extraperitoneal access to the pelvis, which provides adequate exposure to the surgical view and avoids intra-abdominal injury. After incising the anterior bladder wall neck in a Y-shaped fashion, anastomosis is performed using two absorbable barbed sutures. The mucosa and submucosa layer of the bladder is closed to both sides with consecutive sutures in a V-shape before suturing serosa, and tunica muscularis are sutured to reinforce. The aforementioned procedures reduce leakage from the anastomosis and decrease operative time and patient trauma. Extraperitoneal laparoscopic modified Y-V plasty offers significant advantages over the open approach in terms of post-surgical recovery and invasiveness, making it a feasible and safe surgical option for patients with refractory BNC.

Introduction

Transurethral resection of the prostate (TURP) remains the gold standard for the surgical treatment of benign prostatic hyperplasia (BPH)¹. Bladder neck contracture (BNC) is a common late complication of TURP, affecting 0.3% to 15.4% of patients^2,3. The mechanism and etiology of BNC occurrence are not yet fully understood. Risk factors include small glands, excessive resection of the bladder neck, robust fulguration, and hypertrophic scarring from extensive resection⁴. The endoscopic procedure is usually the treatment of choice for BNC; however, the failure rate is as high as 14%-28%⁴. Patients are considered refractory to BNC if stricture recurrence occurs after two or more failed endoscopic treatments⁵.

Reconstructive surgery of the bladder neck is considered an effective treatment for patients with refractory BNC. Young was the first to describe an open Y-V plasty of the bladder neck, which replaced the sclerotic bladder neck with a healthy bladder⁶. However, open surgery rarely provides satisfactory exposure to the operative field and causes greater invasiveness. The application of laparoscopy and robots reduces the difficulty and trauma of the procedure. Success rates of 87.5%, 92.6%, and 83.3%-100% are reported for open, laparoscopic, and robotic surgery, respectively^5,7,8,9.

In this study, we introduced an extraperitoneal laparoscopic modified Y-V plasty for the treatment of refractory BNC. The procedure is performed through an anterior extraperitoneal approach, and the bladder incision is closed with two continuously running barbed sutures. This new approach provides an adequate surgical field of view and reduces the invasiveness of the procedure compared to the conventional approach. In addition to that, the procedure can also reduce leakage from the anastomosis and decrease operative time.

Protocol

All the procedures in the following protocol were reviewed and approved by the Shandong Provincial Hospital ethics committee.

1. Patient selection and preparation

1. Inclusion criteria: Include patients having: lower urinary tract obstruction; urethrogram or cystoscopy suggestive of BNC; history of at least two unsuccessful transurethral procedures.
2. Exclusion criteria: Exclude patients with: suspected malignancy; acute systemic inflammation or pelvic inflammatory disease; severe coagulation disorders; any other contraindications for general anesthesia or laparoscopy.
3. Inform all patients about the surgical option with its expected outcomes and potential risks, and obtain written informed consent.
4. Perform the procedure under general endotracheal anesthesia. Administer prophylactic antibiotics intravenously 1 h before surgery.

2. Establish pneumoperitoneum

1. Place the patient in the recumbent position. Make a 3 cm vertical incision at the lower umbilicus edge.
2. Perform a blunt separation to reveal extraperitoneal space between rectus abdominis and posterior sheath of rectus abdominis. Then, perform balloon dilatation to improve operative field exposure.
3. Insert a 10 mm trocar into the vertical incision. Then, place the camera and establish pneumoperitoneum.
4. Place two 12 mm trocars on both sides 2 cm below the navel, and two 5 mm trocars on bilateral McBurney's point (Figure 1).

3. Modified Y-V plasty

1. Clear the fat around the surface of the bladder neck and prostate to expose their junction.
2. Make a Y-shaped incision at the anterior wall and neck of the bladder at the junction of prostate and bladder with an ultrasonic knife.
3. Then cut the narrow segment fully (i. e., cut the scar tissue completely until the normal bladder mucosa is observed) (Figure 2A).
4. Insert a 20F silicone catheter slowly, and check whether the urinary tract is probed for patency. If there is resistance when passing through the bladder neck, the narrow segment may need to be incised again (Figure 2B).
5. Perform a V-shaped anastomosis with two 2-0 absorbable barbed sutures. Suture the lowest point of bladder flap and normal mucosa.
6. Then, close the mucosa and submucosa layer with a tensionless continuous suture on the left side of the bladder. Perform the same procedure on the other side (Figure 2C).
7. Tighten both sutures simultaneously. Then, suture serosa and tunica muscularis for reinforcement (Figure 2D). Knot the two sutures at the 12 o'clock position.
8. Indwell a pelvic drainage tube and remove the trocars after the abdomen is deflated. Close the skin with an interrupted suture.

4. Postoperative management

1. Monitor the color and volume of urine and drainage fluid. Remove the drainage tube 1-2 days after surgery, and remove the urinary catheter 2 weeks after surgery.
2. Follow up postoperatively at 3 months, 6 months, 1 year, and annually thereafter. The follow-ups include the international prostate symptom score (IPSS), maximum urine flow rate (Qmax; mL/s), urethrography, urethroscopy, and ultrasound.

Results

Five patients were included in the study with a mean age of 66.2 years (range, 62-75 years) who had undergone at least two unsuccessful transurethral procedures. All patients completed the surgery successfully with no open surgeries. There were no significant intraoperative or postoperative complications. Preoperative Qmax was 5.48 mL/s (range, 3.7-4.9 mL/s) and the IPSS score was 22.6 (range, 17-29). The average operation time, blood loss, and postoperative stay were 104 min (range, 90-130 min), 74 mL (range, 60-100 mL)...

Discussion

BNC has long puzzled patients and urologists as a complication of prostate manipulation. The patient often presents varying degrees of symptoms of lower urinary tract obstruction or urinary retention⁵. Many patients who undergo initial treatment for BNC achieve early success, but a significant proportion of patients experience recurrent obstruction¹⁰. After exhausting endoscopic means and dilatation techniques to treat recalcitrant BNC, surgical repair is considered an effe...

Materials

Name	Company	Catalog Number	Comments
2-0 V-Loc 180	Covidien	A1F0606VY	2-0 absorbable barbed sutures
20F silicone catheter	CREATE MEDIC	D19111322	A disposable Foley Catheter
HARMONIC ACE Ultrasonic Surgical Devices	Johnson & Johnson	V95V2N	It is suitable for controlling bleeding and minimizing thermal damage as needed during soft tissue incision
Laparoscopic system	Olympus	20172220119	Provide HD images
Laproscopic trocar	Anhui Aofo Medical Equipment Tech Corporation	20202020172	Disposable laproscopic trocar