Sclerosis of the bladder neck.

Sclerosis of the neck of the urinary bladder is the development of a connective tissue cicatricial process due to inflammation in the area of the neck of the urinary bladder with partial involvement of the organ wall in the process.

ICD-10 code

N32.0. Obstruction of the neck of the bladder. Stenosis of the neck of the bladder (acquired).

What causes bladder neck sclerosis?

The main role in the etiology belongs to the complicated course of the postoperative period after interventions (open and endoscopic) for prostate adenoma. Idiopathic sclerosis of the bladder neck, known in the literature as Marion's disease, is also encountered, having first described it.

The pathological condition may proceed as a stricture or complete obliteration of the bladder neck and is characterized by the progression of IVO up to complete urinary retention and the need for bladder drainage (cystostomy). In the latter case, the condition is accompanied by social maladjustment of the patient, the development of chronic pyelonephritis, chronic cystitis with possible bladder shrinkage.

The incidence of bladder neck sclerosis varies after different surgical interventions. Thus, after transvesical adenomectomy it is observed in 1.7-3.9% of patients, after TUR - in 2-10% of cases, after bipolar plasma kinetic resection - in 1.28% of patients, after TUR with holmium laser - in 0.5-3.8% of cases.

Classification of bladder neck sclerosis

According to the classification of N.A. Lopatkin (1999), there are three main groups of obstructive complications after operations for prostate adenoma.

Localized organic complications:

• stricture of the posterior wall of the urethra;
• stricture or obliteration of the bladder neck;
• pre-bubble.

Combined organic complications:

• prevesicle and urethral stricture;
• bladder neck stricture-prevesicle-urethral stricture.

False move (complication of a complication):

• prevesical-vesical false passage (Fig. 26-36)
• urethroprevesical, prevesical-vesical false passage;
• urethrovesical false passage (bypassing the forevesical).

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ]

Diagnosis of bladder neck sclerosis

Diagnosis of bladder neck sclerosis is based on the patient's complaints of difficulty urinating or the inability to empty the bladder naturally, information about a previous operation and a complicated course of the immediate postoperative period.

To determine the severity and localization of IVO, ascending contrast urethrography is used, and in the case of preserved urination, UFM and urethroscopy are used.

Transrectal echo-Dopplerography provides useful information.

Differential diagnostics are performed with other obstructive complications of previous surgeries: urethral stricture, false passages, "prebladder", and prostate sclerosis. Common symptoms for these conditions are difficulty urinating or complete retention of urination.

Diagnostics are performed using X-ray and endoscopic methods of examination. Thus, in case of sclerosis of the neck of the urinary bladder, ascending urethrograms determine the free patency of the urethra up to the neck of the urinary bladder; in case of stricture of the urethra, the narrowing is detected in the distal part of the urethra (in relation to the neck of the urinary bladder). In the presence of a "forebladder", an additional cavity between the stenotic neck of the urinary bladder and the narrowed section of the urethra is contrasted on urethrograms.

[ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ]

Treatment of bladder neck sclerosis

The goal of treatment of bladder neck sclerosis is to restore the patency of the vesicoureteral segment. The only method of treatment is surgery; only drug treatment with antibacterial drugs can be performed on an outpatient basis to reduce the activity of the infectious and inflammatory process in the organs of the urinary system. In the presence of a cystostomy, drainage is changed in a timely manner. Bladder lavage with antiseptic solutions.

An effective method for treating bladder neck sclerosis is transurethral electroresection of scar tissue. Indications for surgery are signs of IVO. If bladder neck sclerosis is accompanied by its stricture, the surgery is performed after inserting a guidewire into the narrowed area.

In case of total replacement of the bladder neck lumen with scar tissue, the scars are perforated under visual control with a cystoscope from the bladder neck and urethra and using TRUS control (to prevent rectal injury). A guidewire is inserted from the urethra, the position of which in the projection of the bladder neck is controlled with a cystoscope inserted through the cystostomy. Then, the scar tissue is dissected along the guidewire with a cold knife, after which the scars are resected and the bladder neck is formed in the form of a funnel. At the end of the operation, a balloon catheter is left in the urethra, through which the bladder is drained for 24-48 hours.

TUR of scars in case of recurrent sclerosis of the bladder neck can be completed by installing an intraprostatic stent.

In the postoperative period, broad-spectrum antibiotics and NSAIDs are prescribed to prevent infectious and inflammatory complications. Preference should be given to selective cyclooxygenase-2 inhibitors.

Despite the measures taken, urethritis, epididymitis, orchiepididymitis may develop after the operation, the occurrence of symptoms of which requires immediate removal of the balloon catheter, a change in antibacterial drugs and increased anti-infection treatment. In destructive epididymitis, epididymectomy is sometimes performed. After discharge from the hospital, it is recommended to continue treatment with antibacterial drugs under the control of a general urine test, bacteriological examination and determination of the sensitivity of the urine microflora to antibiotics. NSAIDs are continued for 3-4 weeks. If the urine stream weakens, UFM is indicated, and if the urine flow rate decreases, urethrography and urethroscopy are performed. In the case of recurrent sclerosis of the neck of the bladder, a repeated TUR of the scars is performed, which usually gives good results.

How to prevent bladder neck sclerosis?

Prevention of the development of bladder neck sclerosis after transvesical adenomectomy includes:

• gentle enucleation of adenomatous nodes;
• hemostasis using removable ligatures on the gland bed, brought out through the urethra;
• reduction of the time of drainage of the bladder through the urethra to 2-4 days (no more than 7 days);
• the fastest possible restoration of independent urination.

All these factors contribute to the favorable formation of the vesicourethral segment.

How to prevent bladder neck sclerosis after TUR:

• careful preparation of patients for surgery using antibacterial drugs;
• use of tools of the appropriate diameter;
• sufficient treatment of instruments with gel;
• minimization of aggressive coagulation and contact manipulations in the area of the bladder neck during surgery;
• limiting the reciprocating movements of the resectoscope tube in the neck area in favor of the movements of the strings and instruments located inside the tube.

Prognosis of bladder neck sclerosis

In case of sclerosis of the bladder neck and its narrowing, the prognosis is quite satisfactory. In case of obliteration of the neck, relapses often occur, sometimes - urinary incontinence. In case of complete urinary incontinence, an artificial sphincter is implanted or sling operations are performed using synthetic materials.