Urology/hypotonic bladder advice for repeat turp
Respected doctor, ( this is a repeat question of 28 june 2013 as no anwer was received with the probabiity of non receiving of the original question due to technical errors. Please bear with me)
Hope this letter find yu in good health and fine spirits. iam a male patient, Indian , 52 years old with hypo tonic urinary bladder. The etiology is bladder out let obstruction due to unknown cause and narrowing of internal splincter with moderately enlarged prostate. Urodynamics indicated weak bladder and it was advised to get bladder outlet operated. with a hope to revive the bladder activity, at least partially, turp&boo were performed on 2 july 2012. The bladder has not responded positively during all these months though there are some contractions and i can void about 200 ml in standing posture with moderate abdominal pressure. Iam practicing ISC 5 times a day.
About 5 months after surgery i felt difficulty in insertion of cathter, painful catheterisation , painful ejaculation recurrent infections, i am forced to drop to Nelton cathetr No10 from No 14 F and no 12 F as both are very difficult to insert to insert even with best possible care and lubrication.Voiding by abdominal pressure is also became difficult which was quite easier few months after operation and saved me from cathing during journeys and ewmergencies.
After conservative therapy with antibiotics and due to poor response my urologist whoi is the second doctor,suspected a stricture( during May 2013) but my urologist and cytoscopy was performed on 26 june 2013 almost one year after TURP and BOO The following findings are recorded.
1) Scope can be inserted with ease and there are no evidence of stictures throughout the length of urethra.
2) Residual tissue from the roof of outlet and at bladder neck are seen suspecting inadequate removal of tissue during the surgery.
3) The residual tissue at urethral opening is at the level of bladder neck is flap like and causing obstruction and this possibly is hindering the the passage of catheter during CIC
4) The scope could be inserted in to bladder cavity only after exerting downward pressure and readjesting indicating repositioing of bladder and obstruction at outlet.
5) bladder wall is smooth and no abnormalities were found.
6) Alfuzosin& dutasteride (10mg +0.5mg) were prescribed.
advice - repeat surgery(TURP) to remove the tissue that is obstructing the bladder neck to facilitate easy self catheterisation. This may also reduce recurrent pain and related symptoms due to trumatic prostatis
My doubts are –
Is the surgery as recommended by urologist is benificial and needed. I could able to insert catheter normally up to 4-5 months after surgery and the problem of difficulty in insertion developed only later. if the tissue that is obstructing the smooth passage of catheter., Why the insertion is normal in the initial months after surgery.
1) Is repeat surgery is advised as my previous operation is a nightmare in terms of recovery which took more than 4 months with recurrent pain, burning sensation and spasms, post ejaculatoy stinging pain.
2) Can the surgery facilitate easy catheter insertion and urination with abdominal pressure in emergencies. Is it adviced at this stage.
3) Is removing the residual tissue that is obstructing the bladder opening like a flap means
total removal of remaining prostate amounting to radical prostate resection.
4) After my intial surgery adverse complications like incontinence , impotence etc are not
occur .Can repeat surgery cause them
5) on the basis of the cytoscopic evaluation can i opt for repeat surgery to facilitate easy self catheterisation in future.
Awaiting for your reply
The findings indicate no stricture, but some tissue in the area of the bladder neck that is thought to be obstructing.
Repeat surgery is advised as without it you will continue to have ongoing problems until cathteterization is no longer possible and a permanent catheter will be needed. Recovery may be difficult but that's less important.
Removal of the tissue described would not be equivalent to a radical prostatectomy or radical resection.
Complications of a repeat surgery are difficult to estimate, but all of the problems encountered with the original surgery are possible even though this would be a smaller procedure.
Incontinence and erection difficulties are possible complications.
It is unclear why catheterization was easy immediately after surgery and then only became difficult later. However, scar tissue does tend to harden and stiffen with time and this involve the bladder neck tissue.
The final decision on a repeat surgery is up to you and your surgeon. Consider getting a second opinion.