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Urology/residual tissue after turp &boo difficulties in self catheterisation.


QUESTION: Respected doctor,
Hope this letter find yu in good health and fine spirits. iam patient with hypo tonic urinary bladder with the possible etiology of bladder out let obstruction and narrowing of internal splincter and moderately enlarged prostate.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 these months though there are some contractions and i can void about 200 ml in standing posture with moderate abdominal pressure.
 About 5 months after surgery i felt difficulty in insertion of cathter, painful catheterisation , recurrent infections. i am forced to drop to Nelton cathetr No10 from No 14 F and no 12 F as both are almost immpossible to insert even with best possible care and lubrication.
 At this point you advised me to go in for cystoscopy suspecting a stricture( during May 2013) but my urologist is not available and and cytoscopy was performed on 26 june 2013, the findings are as follows.
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 and at bladder neck are seen..
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
4) The scope could inserted in to bladder cavity only after exerting downward pressure and readjesting.
5) bladder wall is smooth and no abnormalities were  found.
advice - repeat surgery to remove the tissue that is obstructing the bladder neck  to facilitate easy self catheterisation.
My doubts are -
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) 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.
3) what could be the complication s of repeat surgery in terms of recovery and is that as painful and distressing as as earlier surgery.
4) Can this operation cause complications like incontinence and impotency.
5)I could able to insert catheter normally up to 4-5 months after surgery and the problem of difficulty in insertion developed later. if the tissue that is obstructing the smooth passage of catheter why insertion is normal in the initial months after surgery.
on the basis of the cytoscopic evaluation can i opt for repeat surgery to facilitate easy self catheterisation in future.
         Awaiting for your reply

ANSWER: Ramakrishna:

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.

---------- FOLLOW-UP ----------

QUESTION: Dear doctor ,
thanks a million for the reassuring and prompt response.Fortunately i could be able to contact my urologisrt who said that the residual tissue at the bladder neck is actually hanging and if it is scar tissue rigid cystoscope canot be passed . As per your advice iam tryuing to contact a senorior urologist for second opinion.

Can i normally  self catheterize after second TURP surgery( if advised after repeated consultations with narrowest possible catheter of n0 10 Nelton) after removal of urine bag as the eye of the catheter can injure the raw incised area and cause pain and other complications.What is the safest surgical procedure in my case.

Can two cystoscopies be performed with in a gap of 10-15 days.
         truly yours


There should not be a problem with self catheterization after the second TURP procedure, but you may have to wait a short period as we usually leave a catheter in place right after surgery.

The eyelet of the catheter is not likely to cause much irritation to the surgical site.  Besides, there is really no alternative.

Safest surgical procedure could be a laser to vaporize the tissue with minimal bleeding.  You may or may not have access to such a laser.


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Stephen W. Leslie, MD


Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.


Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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