Preparing for bladder neck contracture repair

Bladder neck contracture can make it hard for you to drain your bladder. This can cause a build-up of urine. Your doctor may refer to this build-up of urine as “elevated post-void residual.”

Some common symptoms of bladder neck contracture include:

• Painful urination
• A weak urinary stream
• Straining or pushing to pee
• Urinary retention (meaning you cannot pee at all)
• Urinary tract infection (UTI)
• Bladder stones

Blood in the urine

Bladder neck contracture can lead to hematuria, also known as blood in the urine. Sometimes you can see the blood in the toilet after you pee. In other cases, the blood in the urine can only be seen by a microscope.

Bladder pressure

Bladder neck contracture may cause more pressure on your bladder. After some time, this pressure can harm the bladder and your kidneys. This can lead to permanent kidney damage from backup of urine.

Bladder irritation

The bladder muscle becomes thick after it works at high pressures for a long time. This can make the bladder more irritable and cause:

• Increased urinary frequency
• Urgency (a feeling that you need to pee right away)
• Urinary incontinence (involuntary urine leaks)

Kidney problems

Blood tests can show whether bladder neck contracture is harming your kidneys. These tests measure the levels of normal waste products in your kidneys and the health of the filters in your kidneys that move waste products to your urine.

Trauma to your body causes scar tissue to build up at the site of the trauma.

Scar tissue that builds up in tubes, like the bladder neck and the urethra, makes those tubes narrower than normal, and that can affect how well they work.

Trauma in these areas sometimes happens during complex medical procedures. These procedures include:

Endoscopic surgery

In endoscopic surgery, small instruments are inserted through the bladder neck to treat conditions such as enlarged prostate, bladder cancer and bladder tumors, and kidney stones.

In rare cases, these surgeries can harm the bladder neck. This can cause scar tissue to form.

The most common procedure that causes this scarring is transurethral resection of the prostate, also known as TURP.

Scarring can happen with many other endoscopic procedures, especially those that take a long time or are performed on patients who have had radiation treatments to their pelvis for cancer in the prostate, cervix, or rectum. This increases the risk for poor healing after surgery.

Prostatectomy

When the prostate is removed because of cancer, the procedure is called a radical prostatectomy.

After the prostate is removed during a prostatectomy, the surgeon then uses stitches to rejoin the bladder to the urethra. If these stitches do not heal correctly, scar tissue can build up at the connection. This is called vesicourethral anastomotic stenosis.

Radiation therapy

Radiation is often given to patients to treat cancer of the prostate, bladder, and colon. Radiation often does a good job of treating the cancer, but sometimes it can also damage normal tissue near the tumor.

That damage leads to build-up of scar tissue. The tissue damage and scar tissue may happen many years after the radiation treatment.

Vesicourethral anastomotic stenosis is a condition that is similar to bladder neck contracture. Vesicourethral anastomotic stenosis is scarring in the bladder neck that has been caused by the removal of the prostate gland.

The prostate is shaped like a doughnut, and it surrounds the urethra. Surgery to remove the prostate sometimes causes scarring where the urethra connects to the bladder neck.

The symptoms and treatments for vesicourethral anastomotic stenosis are similar to those of bladder neck contracture, but there are some differences. If you have vesicourethral anastomotic stenosis, your urologist will explain those differences to you.

There are many choices for treating bladder neck conditions. Each person’s treatment plan is specific to their condition.

The goal of treatment is a safe bladder. A safe bladder is a bladder that:

• Stores urine at low and healthy pressure
• Empties fully
• Has slight symptoms

Bladder neck conditions can change over time. That means your care might also change.

Overview of bladder neck contracture treatment

Your treatment will involve a number of steps. The exact steps will depend on your condition and the decisions that you and your doctor make about what’s best for your health.

These steps can include:

• Diagnostic tests that help your doctor better understand the exact details of your case of bladder neck contracture and choose the right treatment for you
• General testing of your health to make sure that your body will be able to tolerate whatever treatment is used to treat your bladder neck contracture
• One or more procedures to treat your bladder neck contracture
• Your recovery after you’ve been treated

Diagnostic tests help your doctor choose the right treatment for bladder contracture.

These tests are used to get as much detail as possible about the condition of your urethra, your bladder, and your kidneys so that your doctor can choose the treatments that will work best for you.

These tests can include:

Retrograde urethrogram

Contrast agent (also sometimes called contrast dye) is put into the urethra, and then the surgeon takes X-rays. The contrast agent helps the X-ray images show the urethra in more detail.

This test is done in the clinic while you’re awake.

Cystoscopy

A tiny telescope in placed in the urethra to test the health of the urethral tissue and get information about the scar tissue.

This test is done in the clinic while you’re awake. Before the procedure, lidocaine jelly is put into the urethra to numb the tissue.

Uroflow study

You pee into a special machine that measures the amount of pee and the flow rate of your pee.

Bladder volume index or post-void residual

A small ultrasound probe is passed over your bladder after you pee. It uses sound waves to measure the urine left in your bladder.

After diagnosis of your bladder neck contracture, your surgeon will discuss your treatment options with you. Possible treatment options include:

• Observation: No procedure is necessary at this time.
• Catheterization: One of three types of catheter is used to drain the bladder.
• Endoscopic treatment: Scar tissue is removed using a minimally invasive surgical procedure.
• Bladder neck reconstruction: The bladder neck is rebuilt by a surgeon.
• Urinary diversion: All or part of the bladder is removed, and the flow of urine is diverted to a bag worn on the side of the body.

Observation

Some cases of bladder neck contracture do not need treatment. Your surgeon may decide that observation is the best option for you. That means that you and your surgeon will continue to watch for any changes in your symptoms.

This is often an option for people who have scar tissue and:

• Do not have any symptoms from their scar tissue
• Have normal kidney function
• Can empty their bladder without difficulty

Catheterization

A catheter can be used to manage your bladder neck contracture by helping you empty your bladder.

There are three types of catheterization that may be used:

Intermittent catheter: The patient puts a catheter into the penis/urethra each day, up to 6 times a day, to drain urine from the bladder. After the urine has been drained, the catheter can be removed.

This drains the bladder regularly and helps to keep the urethra and bladder neck open in the places where there is scar tissue.

Indwelling catheter: The catheter is put into the penis/urethra and into the bladder, and it stays in place for up to 3 or 4 weeks. The catheter connects to a bag that collects the urine.

Suprapubic tube: This is a catheter that is placed directly into the bladder through the lower abdomen.

This option is most often used for people who cannot tolerate an intermittent or an indwelling catheter or who are waiting to undergo endoscopic treatment for their bladder neck contracture.

For some people, a permanent suprapubic tube is an excellent option for the long-term management of their bladder neck contracture.

Endoscopic treatment

Endoscopic treatment is often the first choice of treatment for bladder neck conditions. Endoscopic treatment is done in an operating room while you are under anesthesia.

In an endoscopic procedure, your urologist moves a small camera and small medical instruments through the urethra to open the scar tissue. This lets the pee drain from the bladder.

This procedure is done from the inside of the urethra, so no cuts are made on the skin. Often a medication is injected into the bladder neck during the procedure to decrease scar build-up.

If your body’s urine control mechanisms are harmed, it’s possible that you may have urinary incontinence after you’ve had this treatment, because the scar tissue that was preventing the flow of urine will be gone.

After endoscopic treatment

Time in the hospital

Many patients do not need to stay overnight at the hospital, but you may need to stay the night after your surgery if your surgeon is worried about:

• Infection or fevers
• Bleeding or pain

Checking for returning symptoms

After your procedure, you and your doctor will continue to check for symptoms of bladder neck contracture. If symptoms return after treatment, that may mean that scar tissue has returned.

Your doctor may then decide to use a bladder ultrasound, a uroflow test, or a cystoscopy to check for new scar tissue.

Catheterization as part of endoscopic treatment

During the procedure you will have an indwelling catheter in place. That catheter will stay in place for 3 to 7 days after the procedure.

In some cases an indwelling catheter is required for longer periods of time after the procedure. You will change the catheter each month.

After your indwelling catheter is removed, your urologist may ask you to use an intermittent catheter 1 to 2 times each day. An intermittent catheter is a catheter you insert and then remove after your bladder has drained. Using it after your endoscopic procedure can help to stop any scar tissue growth.

Using an indwelling catheter for a long period of time can have some risks. An indwelling catheter may cause:

• Urinary tract infection (UTI)
• Urethral erosion, which can cause tissue deterioration on the underside of the penis and cause it penis to split

Bladder neck reconstruction

If you have endoscopic treatment but it doesn’t cure your bladder neck contracture, your surgeon may choose bladder neck reconstruction as your next treatment.

This procedure is invasive, which means it is a more traditional type of surgery. The surgeon makes one or more cuts (also called incisions) in the abdomen to get inside your body to make the repairs needed.

There are a number different ways that this surgery can be performed. In some cases, it will be an open surgery. In other cases, the surgeon may use laparoscopy and may be assisted by a robot.

Laparoscopy is known as a minimally invasive surgery because the surgeon make small cuts and then inserts a tiny camera and tiny instruments through those cuts to make the repairs. The cuts are smaller than in an open surgery, and they usually heal faster.

In all cases, this procedure happens in an operating room while you are under anesthesia.

Most people stay in the hospital after this procedure for as many as 3 days.

After the surgery, you will have an indwelling catheter to drain your bladder, and a surgical drain will be in place to remove fluid from where the surgeon cut your skin.

Urinary diversion

Urinary diversion is a major operation to remove all or some of the bladder.

Because of this change in your body, the surgeon must also change the flow of urine so that it doesn’t go into the bladder anymore. Instead, urine will leave your body through an opening in the abdomen, where it can be collected in a bag that you wear under your clothing.

Urine normally travels to the bladder from the kidneys through tubes called ureters. In a urinary diversion procedure, the surgeon joins the ureters to a piece of bowel. After the procedure, urine drains from the kidneys, through the bowel, and into the bag, which can be drained often throughout the day.

This is a major surgery for patients with:

• Severe bladder neck conditions
• Fistulas, also called abnormal connections, from their urinary system and bowels
• Prior pelvic radiation therapy

Before urinary diversion surgery, you will see a wound ostomy nurse. The wound ostomy nurse will check your abdomen to help decide the most likely places to put the opening (also called the stoma) where urine will drain into the bag.

People often stay in the hospital for as many as 4 to 5 days after surgery.

Complications and risks

Urinary diversion is a major surgery, and as with any major surgery, there are possible complications and risks. It’s important for you to understand these complications and risks.

Complications

These are normal risks from surgery and include bleeding, infection, and harm to parts of your body that are near the place in your body that is being repaired.

Risks

Urine leak: The new links between the ureters and the bowel are held together with stitches. If these stitches fail and urine leaks, it can lead to problems. You may then need to have a temporary drain placed in your body to move urine from the leak and drain the kidney directly.

Ureteral stricture: If the ureter and bowel link does not heal the right way, scar tissue can form. This can cause backup of urine into the kidney. This may require another surgery to widen or fix the area.

Bowel leak: Any surgery that makes a new connection in the bowel may leak. This is rare, but it often requires more surgery to fix the leak.

Metabolic changes: The bowel piece interacts with the urine as it drains. This can cause changes with your electrolytes. You may need medications to address these changes.

Mucous production: Your bowels make mucous as part of their normal function. The small part of bowel used for the drain will continue to make mucous, and that can lead to infections and other issues.

Parastomal hernia: There can be a small hole in the connective tissue that the bowel comes from. Parts of the bowel, or fat found inside the belly, can squeeze through this hole. That can cause a bulge or swelling. If it becomes bothersome or causes backup of urine, another surgery may be necessary.

Fascia or stoma stenosis: Narrowing at the connective tissue of the abdomen or on the skin can cause problems and may prevent urine from draining properly. This may need to be repaired.

Stoma appliance issues: The bag that collects urine from the body attaches to the skin with an adhesive. Some people can have trouble keeping it attached. This can cause urine to leak on the skin.

To make sure you’re ready for surgery, your health will be tested before you have your operation. Your tests may include:

Electrocardiogram (ECG/EKG): This is a test to make sure that your heart is healthy enough for surgery.

You may also need advanced heart testing, such as an echocardiogram, to get more information about your health that will be helpful for your primary care provider or your cardiologist.

Blood work: This will test organs like the kidney, liver, and intestine. It will make sure they are working the right way.

Blood work will also test your red blood cells by checking the levels of hemoglobin and hematocrit in your blood. These levels need to be high enough for you to be able to have surgery.

Chest X-ray: This will make sure that your lungs are healthy enough for surgery.

Medication review: A review of all of the medications you’re currently taking is also part of your preparation for surgery. This will help us to:

• Make sure that your blood pressure is controlled
• Let you know if you should stop taking any of your medications, such as medications that can lead to bleeding during surgery, like coumadin, aspirin, and clopidogrel

Along with these tests, you will need to stop using all tobacco products, including cigarettes, chewing tobacco, vaping products, and nicotine gum, before surgery. A urine test on the day of surgery will verify this.

Before your surgery date, you will get the information needed for your visit, including the details of where and when to check in at the hospital.

Two business days before your visit, you will get a phone call alerting you to the exact time that you should come to the hospital.

If you don’t get your phone call, or if you are unsure about any of the details of your surgery schedule, call 1-319-384-8008.

This depends on the type of surgery you are having.

Surgery time is most often less than 1 hour for:

• Urethral dilation
• Direct vision internal urethrotomy (DVIU)
• Suprapubic tube placement

Complex urethral reconstruction with buccal grafts can take as long as 4 hours. An extra hour is usually needed for:

• Anesthesia
• Surgical positioning
• Waking up

This depends on the type of procedure you are having. Some possible complications include:

Bleeding: It is common to see blood in the urine after the procedure. It is also common to see blood around the catheter.

There is usually a small amount of blood from the cut. There is also bruising in the scrotum and in the perineum, which is the area between the anus and the genitals.  

Infection: All people get antibiotics before their procedure. This will lower the risk of infection around the area of your surgery. Most infections only need antibiotics.

Recurrent bladder neck condition: Most first surgeries have a high success rate. But scar tissue can come back.

Scar tissue is more likely to come back if you:

• Already had urethral procedures
• Have had radiation
• Had problems after your first surgery

If scar tissue returns, some other procedure or surgery may be necessary. This will depend on where the scar tissue returns and how severe the scarring is.

Urinary incontinence: In people with a penis, 2 inside structures stop urine from leaking: the bladder neck and the external urinary sphincter, which is on the opposite side of the prostate from the bladder neck.

Urinary leaks can happen if:

• Both areas have been harmed.
• Both structures were removed with surgery
• The urethra is opened up from scar tissue.

The amount of leakage can vary. Some people will have an artificial urinary sphincter put in to help stop leakage.

Urine leak: When fixed in an open surgery, stitches hold the new link in place. If stitches do not hold, or if healing is not fast, urine can leak. Most urine leaks will heal on their own over time.

Fistula formation: An abnormal connection to the urethra can grow. This can cause a split urinary stream that moves down and away from the main urinary stream.

Neurologic injury or positioning injury: Pads are put on all body pressure points before surgery. Arms and legs are placed in a way that is meant to avoid nerve injury. But neurologic injuries can still happen.

Often injuries will go away in days and weeks after surgery. Some may need more intense rehab. Nearly 100 out of 100 will go away with time and rehab. Neurologic injuries are more common during long surgeries and in people who are obese.

With endoscopic surgery, you will go home the same day as the procedure.

For open bladder neck reconstruction or urinary diversion, most people will stay in the hospital for 3 to 6 days. Before they leave, they need to be able to:

• Eat solid food
• Have bowel function, such as a bowel movement and passing gas
• Be mobile
• Be able to control their pain with oral medications

If you had an epidural, that will be removed before you leave.

With an endoscopic procedure, you will have no cuts on the skin.

For most open bladder neck repair or urinary diversion surgeries, there will often be a cut in the lower abdomen.

For some procedures, there is a single cut above or below the scrotum. That will depend on the location and the length of the scarring.

All stitches will dissolve on their own as your body heals.

You should expect to need a catheter after you come out of surgery for bladder neck contracture. The type of catheter you have, and any other tubes needed, will depend on which type of surgery you have.

Endoscopic surgery

You will have a catheter to drain the bladder. Most people will have a catheter in their repaired urethra.

People with a suprapubic catheter will have a catheter coming from their lower abdomen.

Bladder neck reconstruction

Foley catheter: This will drain your bladder. It will stay in place for 1 week. Most people will come back to the clinic to have it taken out.

Jackson-Pratt (JP) drain: This will drain fluid or blood around the area of repair. The drain will also find any urine leaking that has developed. Most JP drains are taken out before you go home.

Urinary diversion

Jackson-Pratt (JP) drain: This will drain fluid or blood around the area of repair. The drain will also find any urine leaking that has happened. Most JP drains come out before you go home.

Ureteral stents: This small flexible tube is put in at the time of surgery. It will allow the ureter and bowel connection to heal. It can lower the chance for urine to leak outside of the repair.

Stents often come out 2 weeks after surgery. This happens in the clinic.

Stoma appliance: The bowel stoma is on the skin of the abdomen or belly. It gets the urine that drains. It attaches to the skin with an adhesive. The stoma appliance will need to be changed every 3 to 4 days.

Before you leave the hospital, the stoma nurses will work with you and your caregivers to show you how to care for the stoma and change it.

Pain medications: Most people only need a few days of narcotics after they leave the hospital. These medicines are morphine-based.

Stool softeners: Anesthesia, pain, and pain medications can cause constipation. Stool softeners help keep routine bowel habits. They especially help when you are taking pain medications.

Bladder spasm medications: A Foley catheter can irritate the bladder. This can make the bladder contract and spasm.

Medications can help with this, but they can cause:

• Constipation
• Blurry sight
• Dry mouth
• Mental cloudiness

You will need to stop taking a bladder spasm medication 24 hours before your first follow-up visit. This will let the bladder empty well after the catheter is removed.

Antibiotics: Most people only need these at the time of surgery. They will not be given when you leave.

After your surgery, we will schedule a series of post-operative visits for you.

These visits help us check how well you’re doing after your surgery. We may also use tests, including some of the diagnostic tests you had before your surgery, to check how well you’re healing.

First post-op visit

For most procedures: You will come back 1 to 2 weeks after surgery to have the Foley catheter removed and to do a voiding test. A voiding test checks to see if you can drain your bladder before you leave clinic. 

If you had a urinary diversion, your ureteral stents and skin staples will be taken out.

Second post-op visit

For most procedures: You will come back 3 months after surgery. We will check how well you are peeing. We do this with a uroflow test, bladder volume index, and cystoscopy.

If you had a urinary diversion: Your second post-op visit will be 6 to 8 weeks after surgery for some tests and to make sure you are doing well with stoma appliance changes.

Other post-op visits

If you had an endoscopic procedure: A year after your first surgery, we will do a uroflow and bladder volume index to make sure your urethra is still open.

If you had a urinary diversion: We will see you after 3 to 4 months to make sure you are doing well.

You will have a normal schedule for post-op visits, but it’s important for you to call us if any of these happen between those visits:

• New or worsening symptoms
• Decreased urinary stream
• Urinary tract infection (UTI)
• Urinary retention
• Straining to urinate
• Not being able to drain your bladder

Our goal is for you to only need one repair, but some people have more scarring and will need more than one repair.

For most people who need more than one surgery, the scarring returns within the first year. The way you heal will give us an idea of your likely success over the long-term.

In some cases, bladder neck conditions can return many years after surgery. This happens more often if you have had radiation therapy. You should return to the clinic if symptoms come back years after surgery.