Benign prostate hyperplasia (BPH) is a common disease among the elderly (1), which is the major cause of lower urinary tract symptoms. Surgical treatment is often the most effective intervention for such a disease. It has been reported that in transurethral resection of prostate (TURP), different energy laser sources and prostatic tissue ablation, such as photoselective vaporization of the prostate (PVP) with a green light laser, holmium laser enucleation or ablation of the prostate, and thulium vapoenucleation laser, are widely used in the clinical setting (2). However, complications of urethral stricture and BNC occur postoperation, which cause poor quality of life in patients. The reported incidence range of BNC is from 0.3% to 9.6% (3–6). Risk factors of BNC include a low adenoma volume, excessive electrocoagulation, resection of the bladder neck, and long operative time (7–9). Bladder neck incision (BNI), laser vaporization, balloon dilatation, and stent placement are applied for the treatment of BNC with overall high recurrence rates (10).

In recent years, new techniques such as T-plasty, a modified YV-plasty, and robot-assisted laparoscopic YV plasty have been performed in the treatment of BNC and have achieved satisfactory outcomes with a success rate of 83.3%–90% (11, 12). However, transurethral endoscopic treatment is still widely accepted as the initial treatment of BNC because of little trauma, low complications, and quick recovery. The present study aims to perform TUIBN at three points with a needle-type electrode for the treatment of bladder neck contracture and evaluate the efficacy of the procedure.

The patients’ baseline characteristics and perioperative results are shown in Table 1. The previous mean prostate volume was 30.05 (24.95, 37.18) mL. Of the 53 patients, 44 underwent TURP once or PVP before the development of BNC, 3 underwent TURP twice, and 6 underwent suprapubic prostatectomy once. All surgeries went smoothly, with the time of TUIBN varying from 15 to 70 min, 35.00 (25.00, 45.00) min. There was little intraoperative bleeding (less than 50 mL). The excised mean weight of redundant scar tissue of the bladder neck and prostatic tissue was 2.10 (0.65, 8.35) g. The mean time of postoperative bladder irrigation was 18.00 (14.00, 21.00) h. The postoperative hospital stay ranged from 2 to 8 days, mean 3.50 (3.00, 5.00) days. During perioperation, no patients had serious bleeding. Three cases of venous sinus hemorrhage were resolved by continuous balloon compression with catheterization. One patient was with hydroabdomen. One case of dysuria following the catheter removal 4 days after surgery, however, resolved completely in the further course of catheterization. Another case of dysuria was due to the presence of a large bladder diverticulum, but there was no recurrent BNC by the cystoscopic view at a follow-up of 18 months (Figure 1). One case of urethral stricture was resolved by regular urethral dilation in 2 months. There were two cases of retrograde ejaculation.

All cases that underwent follow-up assessment (Table 2) at 3 and 6 months after the surgery showed significantly decreased IPSS and PVR and increased Qmax compared to preoperation (p ≤ 0.001). All cases that underwent follow-up assessment 3 months after the surgery showed no significantly decreased IPSS (p = 0.331) and PVR (p = 0.297) and increased Qmax (p = 0.373) compared to 6-month data. Of these 53 patients, there was no recurrence of BNC in severe BNC patients, but a total 5 of 53 (9.4%) BNC patients developed BNC again within 6 months and required repeat TUIBN. Thirty patients comprised five recurrent cases with a follow-up period of more than 1 year and five patients with a follow-up period of more than 2 years, and there was no recurrence of BNC. However, routine and periodic cystoscopy for each patient is not ethical and is unnecessary in clinical practice. So, only two patients followed by the view of cystoscopy. An example of a severe BNC patient, whose bladder neck contracted to a pinpoint-like hole preoperatively and obtained a persistent wide bladder neck at 18 months after TUIBN, is presented in Figure 1. According to the modified Clavien–Dindo classification, there are two postoperative complications to patients, which were graded as grade II. The rest of the postoperative complications to patients were graded as grade I.

BNC is a relatively severe complication after endoscopic surgery for BPH. It usually develops within 60 days after transurethral resection (15). Lee (13) reported that the mean time to diagnose BNC after surgery was 18.5 months; however, half of patients developed BNC within in 6 months. If there is no significant improvement in dysuria after urethral dilation, a necessary cystoscopy can confirm the diagnosis due to the possibility of BNC. So far, the exact mechanisms of BNC after TURP remain unclear, and the proposed predisposing factors have been stated as extensive resection of the bladder neck, excessive fulguration at the bladder neck, or a large resecting loop that generates excessive heat to produce a hypertrophic scar in a small intraurethral adenoma (16). Treatment options for BNC remain controversial; urethral dilation 18F followed by a 3-month period of intermittent self-catheterization, cold knife incision, and transurethral resection have been proposed with varying success rates. Regular long-term urethral dilation contributes to a false urethral pathway, hemorrhage, infection, and poor quality of life. About 90% of patients may have to repeat urethral dilation within the first 2 years (17). Eltahawy et al. demonstrated a success rate of 83% after stricture site irrigation with triamcinolone following BNC ablation with a holmium laser (18). Redshaw et al. showed a success rate of 75% after mitomycin C (MMC) injection following a radial cold-knife incision of BNC. However, for MMC utilization, adverse events were described, such as anaphylaxis, extravasation, or bladder neck necrosis, that need to be noticed (19).

Patients with refractory BNC are advocated for more invasive procedures such as YV-plasty, TV-plasty, T-plasty (a modified YV-plasty) (11), and even robot-assisted laparoscopic Y-V plasty (RAYV) (12). The analysis of subjective satisfaction showed that patient satisfaction was very high, high, and undecided in 70%, 20%, and 10%, respectively, with the T-plasty procedure; however, the mean time of operation was 112 min, and the mean hospital stay was 13 days. Musch et al. presented a success rate of RAYV of more than 80%, with a median follow-up of 23.2 months. However, the surgical time ranged from 140 to 360 min, and the blood loss was more than 50 mL. Therefore, these complicated procedures are not accepted among BNC patients initially but for the refractory BNC.

It appeared that a prophylactic bladder neck incision could protect against the formation of bladder neck contracture and reduce the incidence of BNC (4, 20). According to these results, BNI may be beneficial for the treatment of BNC. Ramirez et al. reported a success rate of 72% at a mean follow-up of 12.9 months after Collings knife (the same as the needle-type electrode) incision of BNC at 3 and 9 O’clock positions, an overall success rate of 86% after two procedures (21). Rosenbaum et al. showed that the success rate after TUIBN at 4, 8, and 12 O’clock positions was 45%, and the risk factors associated with recurrent BNC were >10 pack/year history of smoking and patients who had undergone more than two previous TUIBN procedures (22). In the present study, the incision of BNC was carried out at 5, 7, and 12 O’clock positions, resulting in 48 (90.6%) successful cases.

Our present study showed scar tissue of prostatic urethra (Figure 2) formed in patients, which combined with BNC promoted dysuria. That is why we performed the incision not only at the bladder neck but also extended the incision from the bladder neck to the proximal verumontanum. The mechanism of TUIBN for the treatment of BNC may be lowering the pressure by destroying a part of the adrenergic receptors of the prostatic fascia (13). A greater degree of destruction of the sympathetic innervation can be obtained through deep trilateral incisions.

The needle-type electrode has the advantage of precise hemostasis and cutting to avoid urinary extravasation or incontinence. If venous sinus hemorrhage occurs, 1 h of compression by F22 catheterization with 45 mL water injection in a balloon was performed for hemostasis. In the present study, several cases of venous sinus hemorrhage were treated with this method efficiently, and the total blood loss was within 50 mL in each case. For those severe BNC cases, especially patients with false urethral pathways caused by incorrect urethral dilation, it is very difficult to find the right urethral pathway under a resectoscope. So, a guidewire should be used to identify a correct pathway under the ureteroscope through the urethra or bladder (14).

From our point of view, this approach brings more advantages compared to the previous endoscopic incision and reanastomosis for BNC. A short operative time, less blood loss, fewer complications, and a higher success rate (90.6%) were also presented. It is noteworthy that TUIBN seemed more likely to treat the severe BNC without recurrence of BNC in the present study. Specifically, this easy method will benefit the surgeon who holds the essential TURP skills for the treatment of BNC.

Limitations of this study are that it is a retrospective study and a relatively small number of patients for follow-up are included. Thus, the incidence of recurrent BNC could have been underestimated in this study.

This method was reported on TUIBN at three points with a needle-type electrode for BNC. As performed, the method was feasible for all patients and easy to perform. At the same time, no major intraoperative or postoperative complications were observed. Certainly, more clinical data with a longer follow-up are needed to reveal the actual efficacy and relevance of TUIBN for BNC.