Unroofed Midline Prostate Cyst Misled Into a Stricture With Obliterative Bladder Neck Contracture Following a Laser Prostatectomy
A 67-year-old man visited Severance Hospital due to persistent and aggravated lower urinary tract symptoms (LUTS) following a KTP laser PVP 3-month ago in another hospital. The International Prostate Symptom Score (IPSS) was 21, the QoL score was 5. Uroflowmetry showed that the peak flow rate was 1.8 mL/sec. Transrectal ultrasonography revealed prostate volume was approximately 35 mL (). A bladder neck contracture was considered, and transurethral incisions of the bladder neck and possible completion transurethral resection of the prostate (TURP) were planned.\nUnder the spinal anesthesia, patient was placed in the lithotomy position. Using a 24 Fr resectoscope (Karl Storz, Tuttlingen, Germany), cystoscopy revealed an elevated bladder neck with narrow opening. Transurethral resection at the narrow vesical neck was performed. On panendoscopy, vascular pattern with areas of prominent vessels of the bladder mucosa appeared unremarkable. However, other anatomic landmarks such as the trigone and ureteral orifices could not be identified despite giving intravenous indigo-carmine, and the bladder capacity was noted to be extremely small. So we suspected that this space, which was regarded as the bladder, might not be a true vesical space. A palpable suprapubic mass was noted on Crede maneuver, which was identified as a distended bladder on an intraoperative ultrasonography. A suprapubic cystostomy was performed to adequately drain the bladder and thus address the obstruction temporarily. Retrograde urethrography revealed severe bladder neck obstruction and a large midline cyst (). In retrospect, what we visualized by initial cystoscopy and assumed as the bladder neck, were actually the borders of an unroofed cyst from the previous PVP. Furthermore, the cyst wall seeming to appear like a bladder mucosa was what we assumed to be as the urinary bladder (). Under these thorough anatomical understanding, the severely obliterated bladder contracture ("true bladder opening") was identified through a repeat endoscopic evaluation. A straight urethrotome was advanced to create a channel at bladder neck, and more radical incisions made from the minute opening at the site of the contracture to create a larger opening. The area of the contracture was further resected to achieve visualization of the bladder and its entirety. This time the bladder trigone and ureteral orifices were identified, and no other abnormalities were seen. Resection of the prostatic cyst wall was done extending to the fibromuscular area of the prostate gland. A three-way Foley catheter was inserted after evacuation of the resected tissues. The patient was discharged with both Foley catheter and suprapubic catheter maintained. A week after the procedure, the patient's Foley catheter was removed and he was noted to have resolution of voiding symptoms. Removal of the clamped suprapubic catheter was done later when voiding problems were noted to be resolved since it can be used to drain the bladder should the patient have difficulty in voiding. A noninvasive procedure, uroflowmetry was repeated on follow up and showed a flow rate of 21.5 mL/sec and a residual volume of 8 mL (). IPSS was 7 and QoL was 2, 3 months after operation.