Detrusor underactivity (DU) is a common urologic problem. Our previous study revealed the transurethral incision of the bladder neck (TUI-BN) improves short-term voiding efficiency (VE) in female patients with DU. This study focused on the long-term outcomes and quality of life improvement of TUI-BN in women with DU refractory to medical treatment and demanded for spontaneous urination.

A total of 82 women with DU for whom medical treatment had failed underwent TUI-BN. The urodynamic parameters at baseline and follow-up were analysed. Surgical outcome was determined by comparing preoperative with postoperative urodynamic parameters and clinical presentation. We also analyzed subjective self-reported quality of life (QoL) changes by International Prostate Symptom Score quality of life (IPSS-QoL) and treatment improvement by global respond assessment index (GRA). Patients with VE of more than 50% and could void spontaneously with or without the aid of abdominal straining were considered to have satisfactory outcomes. The voiding status before and after TUI-BN were also compared.

The mean age of the patients was 60.8 ± 17.9 years (range 12-102). The median follow-up period was 5 years (ranged 1 to 12 years). Fifty-nine (72%) patients were diagnosed as neurogenic etiology and 23 (28%) as idiopathic DU. Sixty-two patients initially presented with chronic urinary retention, who required catheterization by clean intermittent catheterization (CIC) or indwelling catheter to empty bladder. Thirty-eight patients had difficult micturition with large post-void residual (PVR) (>200 mL) in 30 and small PVR in 8. During a mean follow-up period of 56.7 months, 9 patients expired and 5 lost to follow up, but the postoperative status could be traced from chart review. Among the overall 82 patients 40 (48.8 %) had satisfactory outcomes. The mean maximum flow rate (Qmax), voided volume (VV), PVR, VE, BOO index (BOOI), bladder contractility index (BCI) and IPSS-QoL significantly improved (Table 1). Among the patients, 50 (61%) patients could void spontaneously by abdominal straining and without catheterization. Indwelling catheter or CIC was needed in 62 (75.6%) patients before TUI-BN and in 33 (40.2%) postoperatively (p<0.01) (Table 2). The incidence of urinary tract infection was not significantly different before and after TUI-BN. In the patients who failed the initial TUI-BN 32 (39%) patients received addition procedures, including repeat TUI-BN and urethral botulinum toxin A urethral sphincter injection after the first TUI-BN. Among these 32 patients who received addition procedures 19 (59.4%) had satisfactory outcomes during follow up. After these procedures, 59 (72%) of the 82 patients had satisfactory outcome. Five (6.1%) patients developed immediate stress urinary incontinence after TUI-BN which was subsequently corrected by a suburethral sling procedure. Two (2.4%) patients developed vesicovaginal fistula during the TUI-BN procedure, and the fistula was repaired immediately without any urinary incontinence sequelae. Both of the patients received multiple TUI-BN (twice and four times, respectively). Twelve (14.6%) patients had mild urinary incontinence during follow up period.

TUI-BN is effective in relieving voiding difficulty, improving VE, increasing Qmax and VV, decreasing PVR, and restoring spontaneous voiding in women with neurogenic or non-neurogenic DU. Patients could void with or without abdominal straining and free of catheterization. Most of the patients had satisfactory outcomes after the TUI-BN or additional procedure for the initial failed TUI-BN surgery over the long-term follow up. Among them, 39% of the patients might need addition procedure such as repeat TUI-BN or urethral botulinum toxin A urethral sphincter injections to achieve a satisfactory outcome. Nevertheless, multiple TUI-BN procedures might increase the risk of vesicovaginal fistula.

TUI-BN is an effective procedure to reduce bladder outlet resistance, improve voiding efficiency, and quality of life. In women who demands spontaneous urination without catheterization, TUI-BN is valuable. In patients who failed the initial TUI-BN, repeat procedure or urethral botulinum toxin A injection may increase the satisfactory rate. The procedure is also durable with acceptable complication occurrence.