Good Morning All I was not going to say anything but I feel that you guy's need to know what is going on. This is about the Urolift and adding procedure to it at the same time. I have been thinking about this for a couple of days. Like I said I was not going to say anything but I would not like any other men to go through what these other men are going through. I have not heard about any of these procedure being done in the US. It is being done in the UK and Australia by a couple of doctors. What these doctors are doing is wrong. The Urolift is a procedure that stands alone. I have all ready sent two letter's to the company and they told me they sent them to the internal team. There are 2 ways of doing what these doctors are doing. One is after they put the clips on the prostate they do a laser lesser bladder neck incision. This one may be better but the patient is not informed of the added healing time. There is one guy on here now that had it done. The healing time for the Urolift is 2 to 4 weeks. With the lesser incision it will be 12 weeks or more. The patient was not told anything else of the risk or side effects. The doctor also had a additude when the patient ask if he could do the Urolift only for now With adding the BNI the Urolift was not giving a chance to work on it's own. It would have taking the pressure of the bladder neck and he would have been able to pee but we will never know. A year ago I was informed that a doctor was doing a 4D Urolift in the UK. I found out what it was and I wrote the company. At that time they said that they would handle it and got back to me saying that it was up to the doctor and patient as long as the doctor tells the patient of any side effect or problem. So in a way they are not doing nothing. About a week later I got a PM message from a man in the UK that had it done. This is what he told me. I was just going in to have the procedure when the surgeon stop me. He said that he just saw a video on a new pattern for placing the clips by a Australia doctor. All he told me was that I was going to be his first solo patient.. I did not think it would matter( Did not do research ) so I listen to him he was a consultant in the first Urolift trails. There was no mention of the possibility of retro, higher risk of incontinence or any other side effects. It was just suppose to make it better. When I woke up from the surgery I was in a lot of pain. The doctor was surprised. He never told me what he did. Never saw me after surgery. Every movement hurt. I was able to see him 4 weeks later. At 3 month's still leaking and pain. Even when I stand I leak. After looking this up. This is not the recovery profile of a Urolift procedure this is more on the order of a TURP or a Holep. The clips are put in to high and put on the bladder neck to keep it open. I never had a bladder neck problem my prostate was small just a little tight. This is also what the patient told me. The company should be watching it's back and start putting it patients first and stop these doctors from trying to make a name for them self. And stop them from using there patients has guinea pigs I talk with my doctor and he said that they could cut the strings to relax the bladder neck. When he ask his doctor he told him that can't be done that the only way to fix it was to do a TURP. He told him no and got up and walked out of the office. It is over a year and I got a e-mail from him at the start of the week that he is seeing 2 new Urologist to see if they can help him. He is still wearing pads for the leaking. Still in pain. He is not the only one. There are about 10 men that had this done. He also heard that the doctor in Australia is having some problems with the patients he has done. Now my main concern is that these doctor are doing this and there is no data on the procedures at all. They do not know the healing time or side effects or if it really does help. They are doing this without any research or trails. With all the procedure we have today they were all in trails for 1 or 2 years so we would have the information on them. If this is not stopped we will have no procedure to save a man ejaculation which some of us still are concerned about. Urolift is the only procedure that save a man sex life and ejaculation 100 %. Again I am sorry that this is so long but it has to be said.Take care allKen
hello ken,
i know nothing about BNI or urolift.
are u saying that BNI or UROLIFT when doing it alone, is OK , but when doing both at the same time will create complications that neither one would create when doing it alone?
In mild BPH, when the bladder neck is constricted, BNI seems to be the right treatment.
the urolift clips are placed away from the bladder neck. if the bladder neck is constricted, I suspect the clips won't be effective in pulling the bladder neck apart. in this case combining urolift and BNI would ne more effective.
i had watched a youtube video in which uroloft was done together with BNI (i believed by chen of australia)
BNI is known to have low incidence of RE.
not sure if u agree.
ken,
i agree that the doctor has a duty to explain what he wants to do on the patient to the patients.
below is info for RE from BNI.
Scand J Urol Nephrol. 1986;20(3):187-92. Bladder neck incision or transurethral electroresection for the treatment of urinary obstruction caused by a small benign prostate? A randomized urodynamic study.
Hellström P, Lukkarinen O, Kontturi M. Abstract Transurethral electroresection of the prostate (TURP) was compared with bladder neck incision (BNI) in the treatment of 24 patients with urinary obstruction caused by a small benign prostate. An evaluation of the urodynamic findings and subjective symptoms was undertaken before the operation and 6 months afterwards. Thirteen patients underwent TURP and 11 BNI. All patients except one in the BNI group subjectively considered the result good. The urodynamic evaluation showed that the detrusor pressure at maximum flow rate decreased more in the TURP group than in the BNI group and the urethral pressure profile was shorter after the operation. The maximum flow rates after the operation were similar in both groups. Retrograde ejaculation developed in 62% of the patients after TURP but none after BNI. BNI is recommended for men under 60 years with minimal prostatic hypertrophy and with an active sexual life.
Br J Urol. 1985 Apr;57(2):164-7. Ejaculation and sexual function after endoscopic bladder neck incision.
Hedlund H, Ek A. Abstract Endoscopic incision of the bladder neck, performed to relieve outflow obstruction, was evaluated as regards effects on ejaculation and orgasm in 61 men (mean age 48 years) by analyses of seminal fluid and a questionnaire. Relief of obstruction was confirmed by post-operative normalisation of urinary flow. In 47 cases there was unchanged antegrade ejaculation, while reduced semen volume was reported by 11 men and retrograde ejaculation by only 3. The quality of orgasm and sexual satisfaction were not permanently changed by the operation. Post-operative analysis of seminal fluid was performed in 27 patients, with normal results in 26. In 16 men who provided specimens both before and after bladder neck incision, no consistent change was found in the semen. An incision completely splitting the bladder neck but not extending distal to the verumontanum will relieve outlet obstruction. Maintenance of antegrade ejaculation can be expected in most patients undergoing this operation.
Kenneth,
Your post was very interesting and lead me to research the issue of bladder neck obstruction. Many men on this forum (myself included) have had various procedures that have not worked to improve their urinary symptoms (nocturia, frequency, urgency, low flow, retention). From what I have been reading, these symptoms might be a result of bladder neck obstruction issues (PBNO) and not BPH. My own uro did a cystoscope on me and told me that he didn't believe another operative procure would help me. He did not specifically mention bladder neck obstruction, but based on my research I believe that was what he was concerned about.
In your case, the addition of a BNI to a Urolift should have been thoroughly discussed prior to any treatment, including healing time. If urinary issues are being caused by the bladder neck rather than the prostate, then why do anything to the prostate when a simple BNI would help voiding issues? There must have been a reason why your uro did the BNI and not just a basic Urolift. Perhaps bladder neck obstruction was shown on a video urodynamics test.
I am hoping others here on the forum can add something to this very important topic. I had a PAE last year, but my issues continue with little relief. If my issues were and are being caused by bladder neck obstruction, then any BPH procedure that I would have done last year would have been for nothing.
So, now that you have had both the Urolift and BNI once the healing period is over you should well on your way to symptom relief.
Thank you for bringing up this topic...
My best,
Tom
Hello
Being that these are 2 different procedure and they can be done on there own. You have to give each one it's own time to do it's job. If you do the urolift and pin it down it will take the pressure they have see that in the trails
The doctor that you mentions has been doing them but BNI has a 35% chance depending where and how much is cut. I have read where they only do one cut and it does not cause retro.
PS I watch the same video. Some doctor were commenting on the cause of retro
Ken
Like I said before it depend how it is done and how much. The other procedure were they clip the bladder neck open all men ended up with retro because the bladder neck does not close. That is also why they leak
Ken
Tom
Thank you for your reply.
I did not have the Urolift and BNI. This is being done in the UK. One of the men sent me a e-mail to see if I can help. ( 10 Men ) I only had a Urolift and I have be good for over 3 years.
Ken
hello ken,
Assume the urologist feels that BNI is needed for urolift.
in ur view, the best is to BNI first, let it heals and let the tissues settles, then do urolift. if BNI gives good results, then there is no reason to do urolift. yes?
It is my first time encounter bladder neck obstruction so just confused.
in ur view, BNO is a problem of its own and is not caused by adenoma or tissue overgrown at the bladder neck. in this view, BNO has no cure?
have time to explain?
DL
Yes that is one way to look at it. You can go the other way to. Have the Urolift first. Heal from that and if that work's there is no need from the BNI.
There is no need for 2 procedures If one will solve the problem. Less recovery time and less side effects
Have a great day.........Ken
DL
Yes it is it own problem. It can be helped with a-blockers or surgery
It can be treated by surgically with unilateral or bilateral transurethral incision of the bladder neck. The main concern with having a bladder neck incision is the development of postoperative retrograde ejaculation. Retrograde ejaculation is less likely to occur with unilateral incision as opposed to the bilateral but it does happen with both.
BNO can be case by many things not just the prostate but when they do a BNI they will remove some of the prostate tissue that is near the base of the bladder neck.
There is a lot more to read I have read a few of them and they tell you more things but it can happen in men and women and the treatment is the same.
Ken
ken,
i think BNI first would be better as it will give the tissues time to settle down, so when urolift clips are applied, they can be located at the optimal positions.
DL
I think it all depends on what you are concerned about. With Urolift 100 % no retro BNI you still have a chance
I also think that it would depend on the age of the man which one you would go with first. I man of 30 or 40 may have different concerns then a man of 60 or 70. Don'y you think so.
Take careKen
hello ken, i did some research. results are given below.
Below gives the cause for bladder neck obstruction as given by Mayo Clinic and I also present a paper in 2005 that discuss the etiology, diagnosis and treatment for BNO.
As u will see the major cause for BNO is BPH. Diagnosis for BNO is different than BPH because it has to prove that the obstruction comes from the bladder neck. Just like BPH, the first line of treatment is drug and the second line of treatment is surgery. the surgery is a single incision or a double incisions at the bladder neck towards the verumontanum. Details are given in the paper. This is the only paper that I could find.
1) Bladder outlet obstruction: Causes in men? From Mayo Clinic: My doctor says I might have bladder outlet obstruction. What does that mean?
Answer From Erik P. Castle, M.D. Bladder outlet obstruction in men is a blockage that slows or stops urine flow out of the bladder. Bladder outlet obstruction can cause urine to back up in your system, leading to difficulty urinating and other uncomfortable urinary symptoms.
Possible causes of bladder outlet obstruction might include:
Enlarged prostate, also known as benign prostatic hyperplasia (BPH) — this is the most common cause of bladder outlet obstruction in men Scarring of the urinary channel (urethra) or bladder neck, as a result of injury or surgery Use of certain medications, including antihistamines, decongestants or drugs to treat overactive bladder Bladder stones Prostate cancer Prompt diagnosis and treatment of bladder outlet obstruction is important to prevent serious problems caused by urine backing up into your system.
If you can't pass urine, emergency treatment includes insertion of a tube (catheter) through the tip of your penis and into your bladder. This tube helps urine drain from your bladder. If your condition doesn't require urgent care, your doctor might order tests to determine the underlying cause of your bladder outlet obstruction. Tests include imaging the bladder with sound waves (ultrasound) and viewing the bladder with a camera (cystoscopy). Treatment might include medications or surgery.
2) Primary Bladder Neck Obstruction in Men and Women (2005) by Victor W Nitti, MD
Abstract Primary bladder neck obstruction (PBNO) is a condition in which the bladder neck does not open appropriately or completely during voiding. Although the true prevalence of PBNO is difficult to ascertain, studies in both men and women with voiding dysfunction demonstrate a marked prevalence of the condition. Symptoms caused by PBNO include storage symptoms (frequency, urgency, urge incontinence, nocturia) and voiding symptoms (decreased force of stream, hesitancy, incomplete emptying). There are multiple theories as to the etiology of PBNO, including muscular and neurologic dysfunction and fibrosis. The diagnosis of PBNO can be made precisely with videourodynamics, urodynamic testing with simultaneous pressure-flow measurement, and visualization of the bladder neck during voiding. Treatments vary from watchful waiting to medical therapy to surgery, depending on the severity of symptoms, urodynamic findings, and response to therapy. This article reviews the current state of the art with respect to the prevalence, etiology, diagnosis, and treatment of PBNO.
Etiology The precise cause of PBNO has not been clearly elucidated. Theories as to the etiology of the condition are varied. Initial theories focused on structural changes at the bladder neck, such as a fibrous narrowing or hyperplasia, as initially proposed by Marion.1 Leadbetter and Leadbetter6 proposed that there is a fault of dissolution of mesenchyme at the bladder neck or inclusion of abnormal amounts of nonmuscular connective tissue, resulting in hypertrophic smooth muscle, fibrous contractures, and inflammatory changes. Similarly, Turner-Warwick and colleagues2 described inefficient bladder neck opening resulting from abnormal morphologic arrangement of the detrusor/trigonal musculature. A neurologic etiology for PBNO in the form of sympathetic nervous system dysfunction has also been suggested.7 Crowe and colleagues8 demonstrated an increase in the density of neuropeptide Y-immunoreactive nerves, part of the sympathetic contractile system of the bladder neck, in bladder neck tissue obtained from men with bladder neck dyssynergia.
Some cases of apparent bladder neck dysfunction may actually be the result of abnormalities of the striated urethral sphincter. It is widely accepted that the first event in volitional micturition is relaxation of the external striated sphincter.9–11 The recent work of Yalla and Resnick11 showed that, as the external sphincter relaxes (and pressure drops), the pressure in the bladder and at the bladder neck increases. However, the rate of increased pressure in the bladder is greater than that at the bladder neck. When vesical pressure exceeds vesical neck pressure, which occurs “within a few seconds,” voiding ensues. The authors also found that, in certain patients, the periurethral striated muscle can extend functionally to the bladder neck. In such patients, the pressure changes during the initiation of voiding may be slightly altered. In another study, Yalla and colleagues12 demonstrated that such extension of the functional external sphincter to the bladder neck occurred in 48% of men.
Diagnosis PBNO is a videourodynamic diagnosis, the hallmark of which is relative high-pressure, low-flow voiding with radiographic evidence of obstruction at the bladder neck with relaxation of the striated sphincter and no evidence of distal obstruction. In men, what constitutes high pressure and low flow in PBNO has not been universally defined. In various series on PBNO, detrusor pressure at maximum flow ranges from 20 cm H2O to 70 cm H2O with maximum flow rates (Qmax) of less than 15 mL/s.3,15,17 Nomograms used to classify obstruction in men with BPH do not necessarily apply to PBNO. Nitti and colleagues14 recently categorized PBNO into 3 distinct types: classic high-pressure, low-flow voiding (Figure 1); normal-pressure, low-flow voiding, with narrowing at the bladder neck (Figure 2); and delayed opening of the bladder neck. All 3 classifications represent vesical neck dysfunction causing obstruction. Alternatively, PBNO has been diagnosed by micturitional urethral pressure profile, in which a pressure drop between detrusor pressure and bladder neck pressure is seen.21
In women, the pressure/flow criteria for PBNO are even less defined. According to the videourodynamic criteria proposed by Nitti and colleagues,16 a detrusor contraction of any magnitude associated with radiographic evidence of obstruction at the bladder neck is adequate to diagnose PBNO. Chassange and colleagues22 proposed cut points for obstruction of 15 mL/s or less for Qmax and greater than 20 cm H2O for detrusor pressure at maximum flow. The Blaivas-Groutz nomogram has also been proposed to diagnose obstruction.23 However, if either of the latter 2 methods is used, a simultaneous radiographic study is still needed to localize the obstruction and make a definitive diagnosis (Figure 3).
Our team at New York University compared urodynamic findings in men and women with PBNO using the 2 groups described above. Flow parameters were similar, with a mean Qmax of 10.6 mL/s for men and 8.0 mL/s for women (P = .101). However, detrusor pressure at maximum flow was significantly higher in men than in women: 52.5 cm H2O versus 38.5 cm H2O (P = .027). PVR was significantly higher in women: 180 mL versus 33 mL (P < .001).
Treatment of PBNO The treatment options for men and women with PBNO are the same and include watchful waiting, pharmacotherapy, and surgical intervention. Watchful waiting is an option for patients who are not bothered much by their symptoms and have no clinical or urodynamic evidence of upper and/or lower urinary tract decompensation. Unfortunately, the natural history of PBNO is not well characterized. It is not known how many men or women who elect watchful waiting have progressive symptoms, develop decompensation, or subsequently receive treatment. It is likely that, in some cases, older men with LUTS presumed to be caused by BPH who had the start of symptoms in their twenties or thirties actually have long-standing PBNO.
A review of the literature provides some reasonable guidelines for the treatment of PBNO in men, albeit without the benefit of randomized, controlled trials. For women, however, most treatment options are based on “expert opinion,” with only a few small series available for review.
Pharmacotherapy α-Blockers have been the mainstay of pharmacotherapy for PBNO. Although much of their effect is presumed to involve the smooth muscle of the bladder neck, α-blockers may also affect the bladder via local or central mechanisms, as is assumed to be the case in BPH treatment. However, unlike α-blocker therapy for BPH, only variable success has been reported for α-blocker therapy for PBNO. Most studies have been small, nonrandomized, and noncontrolled, with no consistency in type or dosage of drug. In addition, there are no reported placebo-controlled studies, and outcomes have been variable. Most studies report subjective results, with relative underdosing of medication, and no parameters have been consistently reported to predict success or failure. ............ ...........
Fifty percent of subjects responded to α-blockade with decreased symptoms, increased flow, and decreased PVR. Specifically, in responders, Qmax increased from 9.5 mL/s to 15.1 mL/s and PVR decreased from 277 mL to 27 mL. No validated symptom assessment was used to evaluate symptom response.
Surgery PBNO can be treated surgically with unilateral or bilateral transurethral incision of the bladder neck. The main concern with bladder neck incision is the development of postoperative retrograde ejaculation. Retrograde ejaculation is less likely to occur with unilateral incision as opposed to bilateral incision.17,24 Bladder neck incision is highly effective. In 1986, Norlen and Blaivas3 performed incision or resection in 18 of 23 men with PBNO. All patients experienced “symptomatic relief” (no objective parameters were used), and mean Qmax increased from 9.1 mL/s to 26.1 mL/s. In 1994, Kaplan and colleagues17 reported the results of unilateral incision in 31 men. Thirty men experienced a subjective improvement in symptoms, with mean Boyarsky symptom score decreasing from 16.4 to 6.4 and mean Qmax increasing from 9.2 mL/s to 15.7 mL/s. No retrograde ejaculation was reported in this series with unilateral incision. Unilateral bladder neck incision was also performed by Kochakarn and Lertsithichai26 in 35 men aged 36 to 46 years. Objective outcomes were measured with respect to IPSS, flow rate, and sperm count. Patients were evaluated at 3, 6, and 12 months postsurgery. Of note, there was continued improvement in IPSS and flow rates up to 1 year after surgery. At 1 year, there was a mean 55% decrease in IPSS and a mean 95% increase in flow rate. Postoperative sperm counts were decreased at 6 to 12 months (70% mean decrease from preoperative); however, the authors could not offer a satisfactory explanation for this decrease, because it did not appear to be related to ejaculatory volume. In a study by Trockman and colleagues,24 18 of 36 men diagnosed with PBNO underwent bilateral incision. A “successful” outcome was obtained in 16 (89%) of the men. Mean AUA symptom score decreased from 17.1 to 4.3, and mean Qmax increased from 8.2 mL/s to 26.7 mL/s. Antegrade ejaculation was maintained in 73% of subjects. Bladder neck incision and resection may also be used to treat PBNO in women. Axelrod and Blaivas5 performed bilateral incisions at 5 o’clock and 7 o’clock in 3 women with PBNO and reported success in all cases, with no subject developing incontinence. Gronbaek and colleagues19 performed a single incision initially and a second incision as needed in 38 women with PBNO. At a mean follow-up of 55 months, the success rate was 76%. One patient (3%) developed incontinence. Kumar and colleagues20 performed a single incision at 12 o’clock using a pediatric resectoscope in 6 women with PBNO who had failed α-blockade. Success was reported in all 6 subjects, with Qmax increasing from 8.5 mL/s to 15.5 mL/s and PVR decreasing from 256 mL to 40 mL. Mild stress urinary incontinence was reported in 2 (33%) of the women.
Main Points Primary bladder neck obstruction (PBNO) is a condition in which the bladder neck fails to open adequately during voiding, resulting in increased striated sphincter activity or obstruction of urinary flow in the absence of another anatomic obstruction. PBNO can present with a variety of symptoms, including voiding symptoms (decreased force of stream, hesitancy, intermittent stream, incomplete emptying), storage symptoms (frequency, urgency, urge incontinence, nocturia), or a combination of both. PBNO is a videourodynamic diagnosis, the hallmark of which is relative high-pressure, low-flow voiding with radiographic evidence of obstruction at the bladder neck with relaxation of the striated sphincter and no evidence of distal obstruction. α-Blockers have been the mainstay of pharmacotherapy for PBNO. Although much of their effect is presumed to involve the smooth muscle of the bladder neck, α-blockers may also affect the bladder via local or central mechanisms. PBNO can be treated surgically with unilateral or bilateral transurethral incision of the bladder neck. Uniform diagnostic criteria for PBNO need to be developed to help
Dl,
Yes, it appears as if bladder neck obstructions are a separate issue from normal prostate enlargement issues. They both end up causing retention, nocturia, frequency and urgency. My concern is that many on this forum are being treated for prostate enlargement issues when the real problem is the bladder neck. That may have been what happened in my case. So, now we are learning something very important. When choosing a treatment for the above mentioned issues, it's really important to understand what the real problem is. This has been a big "eye opener" for me. Until now I was not aware of the possibility that my issues were being caused by a possible bladder neck obstruction. I still don't know if that's my issue, but before moving forward with any other procedure, I will definitely attempt to find out if my bladder is the issue, rather than my prostate.
Tom
Thank you. I read that one to. I think it all depends on how deep they cut the bladder neck. They do it at the 5 and 7 o'clock and they will removed so of the prostate at the bottom of the bladder neck.
It is very interesting. Doctor have to make sure what is the problem before they do a surgery. It can be the prostate or the bladder neck. Why do 2 when one would take care of the problem
Take care Ken
Good man Tomken
Hello tom,
i doubted any urologist would do a procedure without doing cystoscopy first.
cystoscopy can definitely identify if the patient who is complaining BPH symptoms has BPH or bladder neck contracture, or urethral stricture.
if surgery get rids of all the latter three items and if the BPH symtoms persist, then the next suspect could be the bladder. urodynamic can tell how much pressure the bladder is applying and whether it is within range. the urinary system is a simple system consisting: the bladder (an inflated balloon), the bladder neck or internal sphincter (a valve), the urethra(a tube), the external sphincter (a valve), the penis (a tube).
after BPH surgery, we know that the urethra should be wide opened. if there is still small or no urine flow, we know there is no pressure from the bladder or one or both of the valves are closed. but urodynamic directly inserts a tube into the bladder to measure its pressure. so we know the bladder is OK or not OK. i would imagine the urodynamic tube could be slightly withdraw to just below the bladder neck. if at the point , there is no urine flow, we know the problem could be the bladder neck. Next is to withdraw the urodynamic tube just beyond the external sphincter to check urine flow. By process of elimination, one can figure out where the blockage is. not sure if u agree.