Sclerosis of the neck of the bladder

Sclerosis of the neck of the bladder - the development of connective tissue scar process due to inflammation in the neck of the bladder with a partial involvement in the process of the wall of the organ.

ICD-10 code

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

What causes sclerosis of the neck of the bladder?

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

The pathological condition can proceed as a stricture or complete obliteration of the neck of the bladder and is characterized by the progression of the IVO up to a complete delay in urination and the need for drainage of the bladder (cystostomy). In the latter case, the condition is accompanied by social disadaptation of the patient, the development of chronic pyelonephritis, chronic cystitis with possible wrinkling of the bladder.

The incidence of sclerosis of the neck of the bladder is not the same after different surgical interventions. So. After an 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 sclerosis of the neck of the bladder

According to N.A. Lopatkina (1999) distinguish three main groups of complications of obstructive nature after operations for prostate adenoma.

Localized organic complications:

• stricture of the posterior wall of the urethra;
• stricture or obliteration of the neck of the bladder;
• prebubble.

Combined organic complications:

• pre-bubble and stricture of the urethra;
• stricture of the neck of the bladder-pre-bubble-stricture of the urethra.

False course (complication of complication):

• pre-tubercular-vesical false course (Figure 26-36)
• uretroprispuzyrny, pre-bubble pseudo-course;
• uretropuzyrniy false course (bypassing the pre-bubble).

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

Diagnosis of sclerosis of the neck of the bladder

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

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

Useful information allows you to get transrectal echodopplerography.

Differential diagnostics is performed with other obstructive complications of the transferred operations: stricture of the urethra, false passages, "pre-tuberculosis", and also sclerosis of the prostate. Common symptoms for these conditions are difficulty urinating or full delay.

Diagnosis is carried out with the help of radial and endoscopic methods of investigation. So. When sclerosis of the neck of the bladder on the ascending urethrograms determine the free passage of the urethra to the neck of the bladder; with the stricture of the urethra, constriction is detected in the distal part of the urethra (relative to the neck of the bladder). If there is a "prebubble" on urethrograms, an additional cavity between the stenotic neck of the bladder and the narrowed part of the urethra is contrasted.

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

Treatment of sclerosis of the neck of the bladder

The goal of the treatment of sclerosis of the neck of the bladder is the restoration of the permeability of the vesicourethral segment. The only method of treatment - surgery on an outpatient basis can be conducted only drug treatment with antibacterial drugs to reduce the activity of the infectious and inflammatory process in the organs of the urinary system. In the presence of cystostomy, a timely change in drainage is ensured. Washing of the bladder with antiseptic solutions.

An effective method for the treatment of sclerosis of the neck of the bladder is transurethral electroresection of scar tissue. Indication for surgery - signs of IVO. If the sclerosis of the neck of the bladder is accompanied by its stricture, the operation is performed after inserting the conductor into the narrowed section.

When the lumen of the bladder neck is completely replaced by scar tissue under visual control by the cystoscope on the side of the neck of the bladder and the urethra and with the help of the TRUS-control (to prevent a rectal injury), scars are perforated. From the side of the urethra conduct a string-conductor, the position of which is monitored in the projection of the neck of the bladder by a cystoscope carried through the cystostomy. Then, the scar tissue is cut through the conductor with a cold knife, followed by the resection of scars and the formation of the neck of the bladder 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 scars with relapse of sclerosis of the neck of the bladder can be completed by installing an intraprostatic stent.

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

Despite the measures taken, after the operation, it is possible to develop urethritis, epididymitis, orcoepididymitis, the appearance of symptoms requiring immediate removal of the balloon catheter, changing antibacterial drugs and strengthening anti-infective treatment. With destructive epididymitis, epididymectomy is sometimes performed. After discharge from the hospital, it is recommended to continue treatment with antibacterial drugs under the control of general urinalysis, bacteriological examination and determination of the sensitivity of urine microflora to antibiotics. Within 3-4 weeks continue to receive NSAIDs. With the weakening of the urine stream, the UFM is shown, with a decrease in the flow rate of urine - urethrography and ureteroscopy. With the development of relapse of sclerosis of the neck of the bladder, a repeated TUR of scars is performed, which usually gives good results.

How to prevent sclerosis of the neck of the bladder?

Prevention of the occurrence of sclerosis of the neck of the bladder after a transgeneric adenomectomy includes:

• sparing removal of adenomatous nodes;
• hemostasis with the use of removable ligatures on the lining of the gland, output through the urethra;
• reduction of the duration of the bladder drainage by the urethra to 2-4 days (not more than 7 days);
• early recovery of independent urination.

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

How to prevent sclerosis of the neck of the bladder after performing TUR:

• careful preparation of patients for operation with the use of antibacterial drugs;
• the use of tools of proper diameter;
• sufficient treatment of tools with gel;
• minimization of aggressive coagulation and contact manipulation in the neck of the bladder during surgery;
• restriction of reciprocating motion of the resectoscope tube in the neck area in favor of movements of strings and instruments inside the tube.

Prognosis of sclerosis of the neck of the bladder

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