There are various approaches to the bladder neck:
1.The anterior initial approach – where the surgeon cuts directly to the catheter in the midline. Lateral spaces and circumferential dissection is performed before division.
2.The posterior initial approach (Montsouris) – where the surgeon “falls” into the open posterior space.
Some of the pitfalls of bladder neck dissection include:
1. Entry into incorrect plane too close to the prostate. This can result in:
a. Oncologic compromise if the tumor is at the base
b. Residual BPH can be left with benign PSA recurrence
2. Entry into incorrect plane too far from the prostate. This can result in:
a. Injury to the trigone or ureteral orifices
b. Retro-trigonal “buttonhole”
c. Wide bladder neck requiring reconstruction
3. Bladder neck too thin either laterally or posteriorly. This makes reconstruction and anastomosis more difficult. Furthermore, the sutures may pull through.
When performing bladder neck preservation, it is important, to begin with, lateral dissection to identify the bladder neck, as shown in figure 1. It is important to recognize the various shapes of the bladder neck and remember that not all bladder necks are created equal (Figure 2).
In a single center, blind, multi-surgeon randomized controlled trial comparing bladder neck preservation to standard technique, the postoperative continence rates were demonstrated to be better with bladder preservation, as shown in figure 31 Preserving the bladder neck improves 3 and six months urinary function outcomes. Reconstruction of bladder neck also improves early (3 months) urinary function outcomes. At 12 months, it was shown that there is no difference in urinary function outcomes in patients undergoing preservation/reconstruction compared to the standard technique.
Figure 1 – Bladder neck dissection:
Lee et al. J. Endourol 20142
Figure 2- The various shapes of bladder necks:
Figure 3 – Postoperative continence rate:
Reconstruction of a wide bladder neck is needed when the bladder neck is deemed too big to “parachute”. Additionally, when the tumor is at the base or there is seminal vesicle involvement, and there is concern about positive margins, wide bladder neck is also needed. Dr. Peabody emphasized that reconstruction of a “good” bladder neck requires doing the reconstruction before starting the anastomosis, to a size equal (or slightly bigger) to the urethra.
Dr. Peabody concluded his talk with some take-home messages. It is important to evaluate the anatomy before making the incision. It is important to understand the variability in anatomy and size of the bladder neck. It is important to use a detrusor apron and visualize the correct plane and adjust. The bladder needs to be grasped, elevated and moved to identify the detrusor apron. Dr. Peabody also believes that the bladder neck size should be preserved if possible, and it is better to make it wider than too close. Lastly, if the bladder neck is too wide, the surgeon should consider reconstruction.
Presented by: James O. Peabody, MD, a senior staff member of the Vattikuti Urology Institute (VUI) at Henry Ford Health System in Detroit, Michigan
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at 2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States
References:
1. Nyarangi-Dix JN, et al. Urologe A. 2010.
2. Lee YS et al. Laparoscopic ureteroureterostomy and transvaginal ureterectomy for complete duplicated ureters. J Endourol. 2014 Jul;28(7):825-30