Skip to main content

Transurethral Bladder Neck Resection (TURBN)

Transurethral bladder neck resection (TURBN) removes fibrotic bladder-neck tissue with a resectoscope loop. It is a first-line endoscopic option, with incision, for non-obliterative bladder neck contracture (BNC) after endoscopic surgery for benign prostatic obstruction.[1] EAU guidelines make a strong recommendation for transurethral resection or hot-knife incision as first-line treatment of non-obliterative bladder neck stenosis after surgery for benign prostatic obstruction.[1] AUA guidelines state that either incision or resection may be performed according to surgeon preference , with comparable outcomes expected.[5] Vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy is anatomically distinct. Visually controlled dilation or incision is the first-line option in non-obliterative cases . Complete obliteration should not undergo endoluminal treatment .[1]

See TUIBNC for the incision counterpart, BNC for the broader framework, and VUAS.

AUA 2023 guideline amendment​

AUA statement 27 allows dilation, bladder neck incision or transurethral resection for BNC after an endoscopic prostate procedure. The text notes that no studies compare these strategies and that repeat endoscopic treatment may be needed. Statement 28 allows dilation, vesicourethral incision or transurethral resection for post-prostatectomy VUAS. First-time VUAS treatment succeeds in about 50% to 80% of cases, with similar rates across techniques, and patients should be told about the risk of incontinence. Statement 29 allows robotic or open reconstruction for recalcitrant stenosis. The guideline cites robotic patency of 72.7% to 75%.[5]

Resection and incision​

FeatureResectionIncision
InstrumentElectrosurgical loopElectrocautery Collins knife, cold knife or laser
Tissue handlingRemoves selected scar tissueDivides the scar to open the lumen
SelectionScar configuration, safe access and surgeon experienceScar configuration, safe access and surgeon experience

No strong comparative evidence establishes superiority or equivalence of these methods. A 1979 retrospective study reported resection and incision equally effective.[10] In Rosenbaum's retrospective cohort of 60 patients after benign prostate surgery, 49 (82%) underwent resection and 11 (18%) incision. Treatment type did not influence outcome. VUAS patients were excluded.[2]

Operative principles​

  1. Obtain a preoperative urine culture and treat bacteriuria or active infection; give intraoperative antibiotic prophylaxis guided by local resistance patterns.[12] Define the stenosis, residual lumen, prior operation, radiation exposure, baseline continence and drainage needs. Identify the bladder and ureteral orifices when safely accessible.
  2. Resect scar under direct vision with controlled depth. Zhang and colleagues resected scar to the circular fibers of the bladder neck; the extent must be adapted to viable tissue and the patient's anatomy.[3]
  3. Protect the external sphincter distally, the ureteral orifices proximally, the rectum posteriorly and the pubic tissues anteriorly. For VUAS or radiation-induced bulbomembranous stenosis, avoid deep 6- and 12-o'clock DVIU incisions because of rectal injury and urosymphyseal fistula risk, particularly after radiotherapy.[1] Exposure of perivesical fat is not a universal operative endpoint.[1]
  4. Confirm hemostasis, outlet patency and an appropriate postoperative drainage plan. Counsel that relieving obstruction can unmask or worsen SUI.

Zhang's protocol added triamcinolone acetonide (2 mL of 40 mg/mL) at 8 sites at the incision, then repeated cystoscopic injections every 4 weeks for three doses. Comparative evidence for this adjunct is lacking.[3]

Evidence​

StudyPopulationResult and limitation
Rosenbaum 202160 post-BPH-surgery patients; 49 resection, 11 incision32/60 (53%) needed no further instrumentation; 28/60 required catheterization, dilation or another procedure. Median follow-up was 22 months (IQR 12–32), without standardized cystoscopic assessment. Earlier presentation after BPH surgery was associated with recurrence. The apparent difference between prior HoLEP (6 patients) and TURP (54 patients) should not guide procedure selection by itself.[2]
Zhang 202128 highly recurrent post-TURP contractures; resection plus intraoperative and serial postoperative triamcinolone92.9% reported treatment success at median 2.8 years; 25/28 had adequate voiding. No control group establishes the steroid's added benefit.[3]
Kranz 2017TUR in 87 patients with VUAS after radical prostatectomy and 60 with BNS after TURPRetreatment-defined success after one or more TUR procedures was 35/87 (40.2%) for VUAS and 35/60 (58.3%) for BNS at mean follow-up 27.1 months (range 1–98). De novo incontinence occurred in 12/87 (13.8%) and 1/60 (1.7%), respectively.[1][11]

Prior treatments, bladder dysfunction and radiation also affect patient selection and outcomes.[1]

Practice patterns​

In a survey of 84 German urologic departments, transurethral resection was the most common treatment for BNC after radical prostatectomy, followed by cold knife incision, hot knife incision and dilation. Among 56 institutions with a set algorithm, 33 different approaches were identified.[7]

Risk factors for failure​

  • Interval. Recurrence was associated with a shorter interval between the BPH operation and BNC: median 7.5 months in initially treated patients with recurrence and 12 months without (p = 0.01).[2]
  • Prior operation. Success was higher after HoLEP than after TURP (100% vs 48%; p = 0.026) in a small cohort.[2]
  • Prior endoscopic treatment. Two or more prior endoscopic BNC procedures were associated with failure in incision series.[4][6]
  • Smoking. More than 10 pack-years was associated with failure in one incision series (p = 0.039).[4]
  • Radiation in VUAS. AUA reports lower apparent endoscopic success after pelvic radiation for post-prostatectomy VUAS and notes that prospective comparisons of radiated and nonradiated patients are lacking.[5]

The last three come from TUIBNC series and are extrapolated to resection.

Adjuncts and complications​

Corticosteroid injection is an off-label adjunct with limited comparative evidence. Drug details are in the intralesional corticosteroid hub. EAU advises against mitomycin C for posterior stenosis outside a clinical trial, given uncertain benefit and reports of serious necrosis, osteitis and fistula.[1]

Discuss recurrence, bleeding, infection, extravasation, sphincteric incontinence and fistula. EAU reports that any endoluminal treatment may cause de novo incontinence (up to 25%) or worsen existing incontinence (up to 15%).[1] Baseline SUI is common in selected post-prostatectomy referral populations: 39 of 50 patients (78%) in Ramirez's incision series had it before treatment. Two-thirds of those men later had an AUS, placed about 2.9 months after TUIBNC, and more than 90% urethral patency was preserved.[4] EAU advises waiting three to four months after DVIU before incontinence surgery and excluding recurrence by cystoscopy first; it gives no TURBN-specific interval.[1]

Recurrent stenosis​

A further endoscopic procedure may be reasonable for selected non-obliterative recurrence .[1] No fixed two-failure threshold governs reconstruction; anatomy and bladder function guide the decision. Refractory or obliterative disease is referred for individualized open or robotic reconstruction assessment. Radiation injury, residual bladder function, continence goals and the feasibility of durable drainage are considered. Y-V plasty and reanastomosis address different anatomical problems. See also combined abdominoperineal repair.[1][5]

EAU advises against posterior urethral stents , citing patency of 47% to 60% and incontinence of 19% to 82%.[1] In a retrospective series of 25 men with severe recurrent post-prostatectomy BNC, one urethral wall stent stabilized the contracture in 13 (52%), and repeat stenting salvaged 6 more; median cohort follow-up was 2.9 years from the last stent insertion.[8] Delayed AUS placement followed, and 92% had severe SUI before stenting.[8] Continence surgery follows assessment of stable outlet patency. Urinary diversion is an option for selected devastated outlets or unsalvageable bladders. In Brede’s 63-patient referral series of recalcitrant post-prostatectomy BNC, 33 underwent AUS or sling during staged management and five (8%) ultimately required permanent diversion.[9]

References​

1. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.

2. Rosenbaum CM, Vetterlein MW, Fisch M, et al. Contemporary outcomes after transurethral procedures for bladder neck contracture following endoscopic treatment of benign prostatic hyperplasia. J Clin Med. 2021;10(13):2884. doi:10.3390/jcm10132884.

3. Zhang L, Liu S, Wu K, Mu X, Yang L. Management of highly recurrent bladder neck contractures via transurethral resection combined with intra- and post-operative triamcinolone acetonide injections. World J Urol. 2021;39(2):527-532. doi:10.1007/s00345-020-03224-w.

4. Ramirez D, Zhao LC, Bagrodia A, et al. Deep lateral transurethral incisions for recurrent bladder neck contracture: promising 5-year experience using a standardized approach. Urology. 2013;82(6):1430-5. doi:10.1016/j.urology.2013.08.018.

5. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

6. Nealon SW, Bhanvadia RR, Badkhshan S, et al. Transurethral incisions for bladder neck contracture: comparable results without intralesional injections. J Clin Med. 2022;11(15):4355. doi:10.3390/jcm11154355.

7. Pfalzgraf D, Siegel FP, Kriegmair MC, Wagener N. Bladder neck contracture after radical prostatectomy: what is the reality of care? J Endourol. 2017;31(1):50-56. doi:10.1089/end.2016.0509.

8. Magera JS, Inman BA, Elliott DS. Outcome analysis of urethral wall stent insertion with artificial urinary sphincter placement for severe recurrent bladder neck contracture following radical prostatectomy. J Urol. 2009;181(3):1236-41. doi:10.1016/j.juro.2008.11.011.

9. Brede C, Angermeier K, Wood H. Continence outcomes after treatment of recalcitrant postprostatectomy bladder neck contracture and review of the literature. Urology. 2014;83(3):648-52. doi:10.1016/j.urology.2013.10.042.

10. Woodhouse E, Barnes R, Hadley H, Rothman C. Fibrous contracture of bladder neck: cause, prevention, and treatment. Urology. 1979;13(4):393-4. doi:10.1016/0090-4295(79)90337-6.

11. Kranz J, Reiss PC, Salomon G, Steffens J, Fisch M, Rosenbaum CM. "Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis." Front Surg. 2017;4:44. doi:10.3389/fsurg.2017.00044

12. European Association of Urology. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery." 2026. Guideline.