Analysis of the efficacy of transurethral resection of prostate combined with transurethral incision of bladder neck when treating patients with small volume benign prostatic hyperplasia

Abstract

Objective

This study aimed to evaluate the therapeutic effect of transurethral resection of the prostate (TURP) combined with transurethral incision of the bladder neck (TUIBN) compared to traditional TURP in treating benign prostatic hyperplasia (BPH), with a focus on minimizing bladder neck contracture.

Methods

This was a retrospective study analyzing data from 112 patients with small-volume BPH treated between December 2015 and May 2020, who were divided into a TURP group (control, N = 56) and a TURP + TUIBN group (observation, N = 56). The safety and effectiveness of the combined technique were assessed through perioperative complications, clinical symptoms (IPSS, QOL), urodynamics (Qmax, PVR, PV), and incidence of bladder neck contracture.

Results

No significant difference was found in perioperative complications (P > 0.05). While IPSS and QOL scores were similar at 3 months (P > 0.05), the TURP + TUIBN group exhibited better urodynamic outcomes (Qmax, PVR; P < 0.05) and a significantly lower incidence of bladder neck contracture at 12 months (3.6% vs. 14.3%; P = 0.04). The observation group showed greater improvement in IPSS (from 22.1 ± 3.5 to 4.5 ± 0.5 vs. control: 22.3 ± 3.2 to 6.8 ± 1.2; P < 0.01) and Qmax (from 7.3 ± 2.1 to 19.6 ± 3.5 mL/s vs. control: 7.5 ± 1.9 to 17.8 ± 1.4 mL/s; P < 0.05). At 3-month follow-up, urodynamic improvements remained significant in the observation group (P < 0.05). Bladder neck contracture incidence was significantly lower in the observation group.

Conclusion

Within the study’s limits, TURP + TUIBN is a viable alternative to TURP alone for small-volume BPH, particularly effective in reducing bladder neck contracture, with additional improvements in functional outcomes. Further studies are warranted to confirm these findings.

Introduction

Benign prostatic hyperplasia (BPH) is the most common cause of dysuria in middle-aged and elderly men [1]. In recent decades, transurethral resection of the prostate (TURP) has become a widely adopted and effective surgical treatment for this condition. However, some younger patients also present with severe lower urinary tract symptoms (LUTS) despite having prostate volumes below 30 mL, a condition classified as small-volume benign prostatic hyperplasia (SBPH) [2]. Studies have shown that SBPH is frequently associated with bladder neck fibrosis, which limits the efficacy of conventional TURP and can significantly impair quality of life if not properly managed [3].

SBPH presents a unique clinical challenge, as obstruction is driven more by fibrosis than glandular hyperplasia. Although TURP is considered the gold standard for larger prostates, its success in SBPH is often hindered by a higher risk of postoperative bladder neck contracture [4–6]. Glandular hyperplasia in these cases often reflects smooth muscle fibrosis rather than nodular overgrowth. Several contributing factors have been implicated, including chronic inflammation (e.g., cystitis glandularis), recurrent prostatitis, and prior prostate treatments—all of which may lead to fibrotic remodeling and bladder neck obstruction [7].

Although transurethral incision of the prostate (TUIP) is guideline-recommended for prostates < 30 mL, it may be suboptimal for SBPH patients with bladder neck fibrosis. TUIP addresses lateral lobe obstruction but not the fibrotic annular narrowing of the bladder neck, which is central to SBPH pathophysiology. To overcome this limitation, we implemented a combined approach: TURP to address glandular hyperplasia and transurethral incision of the bladder neck (TUIBN) to directly release fibrotic obstruction.

This combination (TURP + TUIBN) has shown promise in previous reports, reducing the incidence of bladder neck contracture more effectively than TUIP alone [8–10]. Histopathological evidence supports this approach, highlighting the predominance of smooth muscle fibrosis in SBPH and the need for targeted intervention at the bladder neck [7]. Given the shortcomings of TUIP in this setting, TURP + TUIBN offers a more anatomically and pathophysiologically tailored strategy.

In this study, we conducted a clinical case-control analysis to evaluate the safety and efficacy of TURP combined with TUIBN in treating SBPH. We aimed to determine whether this approach improves symptom scores, urodynamic outcomes, and reduces long-term complications such as bladder neck contracture.

Patients and methods

General information

This retrospective study analyzed 112 patients with small-volume BPH treated at our institution from December 2015 to May 2020. Patients were rigorously selected based on cystoscopic/urodynamic confirmation of bladder neck fibrosis (BOOI > 40, annular rigidity) and exclusion of median lobe hyperplasia - a phenotype representing < 20% of BPH cases in our institution. This stringent selection ensured homogeneity but limited recruitment. To mitigate selection bias, we used propensity score matching (PSM) to balance baseline characteristics (age, prostate volume, IPSS, Qmax, PVR) between the TURP (control, n = 56) and TURP + TUIBN (observation, n = 56) groups. Post-hoc power analysis confirmed > 80% power to detect a 15% difference in bladder neck contracture rates (α = 0.05). Among them, 56 cases were cured with traditional transurethral resection (control group), and 56 cases were cured with transurethral resection and transurethral incision of bladder neck (observation group). The standard of voiding difficulty is as follows:

Inclusion criteria: (1) The patient is older than 45 years old and has obvious symptoms of urinary tract obstruction. (2) The patient still has obvious dysuria after drug treatment. (3) Prostate volume was measured via transrectal ultrasound using the prolate ellipsoid formula (length × width × height × π/6) by experienced radiologists, with patients in the lithotomy position. 3. Cystoscopic or urodynamic evidence of bladder neck fibrosis (e.g., elevated detrusor pressure, annular rigidity). (4) Absence of median lobe obstruction (confirmed by cystoscopy). (5) The digital rectal examination confirmed the presence of hyperplasia and ruled out suspicious prostate cancer. (6) Urodynamic examination confirmed bladder outlet obstruction (BOO). Exclusion criteria: (1) Exclude neurogenic bladder. (2) Postoperative cases were confirmed to be patients with prostate cancer. (3) Urethroscopic examination found abnormal conditions such as urinary tract stenosis and stone obstruction. (4) patients with radiologically confirmed median lobe hyperplasia (defined as ≥ 1 cm protrusion into the bladder on transrectal ultrasound or cystoscopy). (5) Those who failed to follow up in 3-, 6- and 12 -months follow-up time as scheduled. 5. Those with severe other systemic diseases (such as cardiovascular and cerebrovascular, lung) that lead to surgery intolerance. The study protocol was approved by the Ethics Committee of Deqing County Third People’s Hospital (Approval No. DPH202409212). All patients provided written informed consent after a detailed discussion of surgical options, including TUIP as an alternative. Given the predominance of bladder neck fibrosis in our cohort a pathology less responsive to TUIP the ethics committee endorsed TURP + TUIBN as the preferred approach, consistent with institutional protocols for refractory fibrotic obstruction. This decision was based on preoperative cystoscopic and urodynamic confirmation of fibrosis (e.g., BOOI > 40, annular rigidity), exclusion of median lobe hyperplasia, and waived strict adherence to EAU guidelines for TUIP due to the need for targeted TUIBN in fibrotic cases.

Although TUIP is recommended for prostates < 30 mL, it was not included as a control group because our cohort consisted of patients with confirmed bladder neck fibrosis (BOOI > 40, annular rigidity), a condition that typically responds poorly to TUIP alone. As such, TURP + TUIBN was favored over TUIP based on preoperative findings and institutional protocol.

All patients were counseled preoperatively by a senior urologist regarding the available surgical options. The discussion included the risks, benefits, and expected outcomes of TURP alone versus TURP combined with TUIBN. Specific emphasis was placed on anatomical findings such as bladder neck fibrosis and how they might influence surgical choice and postoperative outcomes. Patients were informed about the potential for bladder neck contracture and how TUIBN might reduce this risk. Final treatment decisions were made collaboratively, taking into account patient preferences, symptom severity, cystoscopic findings, and urodynamic parameters.

Surgical indications

Surgical intervention was considered for patients with small-volume BPH (< 30 mL) presenting with refractory LUTS despite at least three months of α-blocker therapy, accompanied by urodynamically confirmed bladder outlet obstruction (BOOI > 40). Eligible patients demonstrated either recurrent urinary retention (two or more episodes), persistent severe obstructive symptoms (IPSS > 19), or secondary complications including recurrent urinary tract infections or bladder stones.

The decision to perform TURP + TUIBN rather than standard TURP was based on preoperative cystoscopic identification of bladder neck fibrosis, characterized by annular rigidity and lack of distensibility, along with fixed narrowing observed during the voiding phase. Patients with median lobe obstruction were excluded from the TURP + TUIBN cohort. Group allocation was verified by two independent urologists blinded to subsequent outcome assessment.

Surgical technique

Using a 24Fr resectoscope, resection began with the middle lobe tissue obstructing the bladder neck. This standardized approach ensured complete exposure of the bladder neck in all cases, including those with minimal middle lobe protrusion below the exclusion threshold. The lateral lobes were then systematically removed until the surgical capsule was visualized. Bladder neck incisions were made at 5 and 7 o’clock positions.

Standardization of bladder neck incision

The extent of bladder neck incision during TUIBN was standardized intraoperatively using consistent anatomical and functional criteria. Incisions were made bilaterally at the 3 and 9 o’clock positions, extending approximately 1–1.5 cm longitudinally. The depth of incision was guided by the appearance of dense fibrotic tissue and continued until visual release of annular fibers, improved bladder neck opening, and enhanced irrigation flow were achieved. These anatomical landmarks ensured consistency across procedures.

Operation methods

All procedures were performed by two senior urologists (QC and ZY) with > 10 years of TURP experience, using identical equipment and standardized resection protocols. The power of the mirror was the same in the two groups, 280 W and 120 W, epidural anesthesia and bladder lithotomy position. (1) The control group underwent traditional transurethral resection. According to the patient’s condition, after general anesthesia or sacral vertebrae, the patients were placed in the lithotomy position, and the urethral opening was checked for no abnormality. F26 continuous flushing resectoscope was placed in the urethra into the bladder, and the lobe of BPH was noticed with a 30° endoscopic optic visualization. The bladder wall was thoroughly inspected for pathological lesions (e.g., tumors or abnormal growths), with confirmation of patent ureteral orifices. Using a cutting power of 180 W and coagulation at 80 W, resection began with the middle lobe protruding into the bladder. The procedure progressed from the bladder neck to the verumontanum (identified by its anatomical landmarks: median ridge and ejaculatory duct openings), systematically removing lateral lobes and apical tissue until the surgical capsule was reached. Annular fibers at the bladder neck were incised as needed. After confirming hemostasis on the wound surface to ensure there was no bleeding in the surgical area, the bladder was cleaned with an irrigator. The excised prostate tissue was then aspirated and sent to the pathology department for biopsy. Select a suitable size three-way urinary catheter, inject 50 ml of normal saline into the balloon to fix it, and then continue to flush the bladder with irrigation fluid to keep the urine drainage smooth and remove blood clots in the bladder. (2) On the basis of the surgical technique of the control group, bladder neck incision is added. The bladder neck was identified by its characteristic pale, fibrous appearance, with the ureteral orifices serving as proximal landmarks. Using a Collins knife electrode at 120 W cutting current, full-thickness incisions were made at the 5 and 7 o’clock positions deliberately avoiding the 6 o’clock position to mitigate rectal injury until complete division of the circular fibers was achieved. Successful division was confirmed by: (1) visual separation of the incised edges, (2) loss of bladder neck rigidity on mechanical palpation, and (3) free flow of irrigate across the neck. The endpoint was reached when the resectoscope could pass freely through the bladder neck without resistance, exposing underlying adipose tissue while preserving detrusor muscle integrity. Intraoperative records documented the weight of resected prostate tissue (grams) for all patients. For the TURP + TUIBN group, the bladder neck incision dimensions (length at 3/9 o’clock positions and depth to annular fibers) were additionally measured using calibrated cystoscopic instruments. until the bladder neck is visibly loosened. All patients were routinely catheterized with three-lumen urinary catheter after operation, and flushed with normal saline until no obvious bloody fluid was seen. Postoperative infection prevention treatment was routinely given.

Effect basis and evaluation index

The International Prostate Symptom Score (IPSS) and Quality of Life (QOL) score were employed to understand the subjective symptoms and QOL of patients in each time period during postoperative hospitalization and 3 months after surgery. The perioperative complications were recorded, and the safety of the operation was evaluated. The effectiveness in enhancing urinary tract obstruction was understood by comparing the preoperative and postoperative urodynamic main indicators Qmax and PVR. The differences between the two procedures were assessed by comprehensive postoperative and 3-month postoperative urodynamic parameters (Qmax, PVR), clinical scores (IPSS, QOL), and the incidence of bladder neck contracture, a common complication.

The evaluation indicators are mainly the following four indicators: (1) IPSS. (2) QOL score: The subjective performance of the impact of LUTS symptoms on the patient’s future life, and the score quantification of the patient’s requirement to improve symptoms. Scores range from 0 to 6, with lower scores indicating lower levels of distress. (3) Residual urine volume (PVR). (4) The BOOI was calculated as detrusor pressure at Qmax − 2 × Qmax, with values > 40 indicating obstruction. (5) Maximum urinary flow rate (Qmax): normal voiding condition Qmax > 25mL Universe 10 < Qmax < 25mL/s indicates that micturition is slightly obstructed and there may be obstruction. If Qmax < 10mL/s, it indicates obvious voiding obstruction, indicating that there is a definite obstruction.

Diagnosis of bladder neck contracture

Postoperative bladder neck contracture was diagnosed through combined cystoscopic and urodynamic evaluation. All patients underwent 12-month follow-up cystoscopy to visually confirm stenotic narrowing at the bladder neck, with concurrent urodynamic studies requiring both maximum flow rate (Qmax < 10 mL/s) and elevated detrusor pressure (> 40 cm H₂O) for diagnostic confirmation. In cases where differentiation from urethral stricture was clinically uncertain, retrograde urethrography was additionally performed to exclude distal urethral pathology, ensuring accurate localization of the obstructive site.

Histopathological protocol

All resected tissue specimens were fixed in 10% neutral buffered formalin, processed through standard histological protocols, and embedded in paraffin blocks. Sections were stained with both hematoxylin and eosin (H&E) for general histological assessment and Masson’s trichrome specifically for collagen fiber visualization. A board-certified genitourinary pathologist, blinded to patient treatment groups, performed all quantitative analyses including stromal-to-glandular ratio determination across multiple high-power fields, digital quantification of fibrosis area fraction using ImageJ software (National Institutes of Health), and semi-quantitative scoring of inflammatory infiltrates on a standardized 0–3 scale.

Statistical analysis

All statistical calculations use the SPSS22.0 version. Longitudinal data were analyzed using linear mixed-effects models to account for repeated measures across timepoints (baseline, 3-month, 12-month), with group × time interaction terms to evaluate treatment effects. Missing data (< 5% of observations) were handled via multiple imputation under the missing-at-random assumption. The counting data were presented in the form of mean ± standard deviation or quartile according to normal distribution, and T-test or Mann-Whitney U test was adopted for comparison between groups. The measurement data were presented as a percentage, and chi-square test or Fisher exact test. probability method was used for comparison between groups. To mitigate selection bias, we employed 1:1 PSM with a caliper width of 0.2 standard deviations, ensuring balanced covariates (age, prostate volume, IPSS). Standardized mean differences (SMDs) for all matched variables were < 0.1, confirming adequate balance. A post-hoc power analysis using GPower (v3.1) indicated that our sample size (N = 112) provided 82% power (α = 0.05, two-tailed) to detect a 15% absolute reduction in bladder neck contracture rates (14.3% vs. 3.6%), based on chi-square tests. This effect size was selected as clinically meaningful for surgical outcomes. Propensity scores were calculated using logistic regression with covariates including age, prostate volume, and preoperative symptom scores. Nearest-neighbor matching (1:1 ratio, caliper = 0.2) was applied. SMDs for all matched covariates were < 0.1, indicating adequate balance. Baseline characteristics prior to PSM are summarized in Table 1. Matching successfully balanced the groups across all covariates (Table 2). The difference exhibited statistically significant (P < 0.05).

Table 1.

Baseline characteristics before propensity score matching

Variable	TURP (n = 56)	TURP + TUIBN (n = 56)	P-value
Age (years)	63.4 ± 5.2	62.1 ± 4.8	0.18
IPSS	21.3 ± 2.5	22.1 ± 2.3	0.09
Qmax (mL/s)	7.6 ± 1.1	7.2 ± 1.3	0.12
PVR (mL)	61.5 ± 8.2	58.2 ± 7.9	0.15
Prostate volume (mL)	28.5 ± 2.3	27.9 ± 2.7	0.24
Hypertension (%)	21 (37.5%)	25 (44.6%)	0.41
Diabetes mellitus (%)	14 (25.0%)	12 (21.4%)	0.64

Values are presented as mean ± SD for continuous variables and n (%) for categorical variables

P values from independent t-test (continuous) or chi-square test (categorical)

Table 2.

Baseline characteristics and preoperative parameters of study groups

Parameter	TURP Group (N = 56)	TURP + TUIBN Group (N = 56)	P-value
Demographics
Age (years)	62.4 ± 5.8	61.9 ± 6.2	0.65
PSA (ng/mL)	2.8 ± 1.2	2.7 ± 1.1	0.72
Prostate volume (mL)	28.5 ± 3.1	27.9 ± 2.8	0.31
Preoperative Metrics
IPSS score	22.1 ± 3.5	21.8 ± 3.2	0.68
QOL score	4.8 ± 0.9	4.7 ± 1.0	0.56
Qmax (mL/s)	7.3 ± 2.1	7.5 ± 1.9	0.59
PVR (mL)	85.2 ± 12.4	83.7 ± 11.9	0.52
BOOI	42.3 ± 5.1	41.8 ± 4.9	0.61
Surgical Indications
BOO (n)	42	44	0.82*
Recurrent retention (n)	14	12	—

Data presented as mean ± standard deviation SD or number of patients n

Groups were balanced at baseline (all P > 0.05)

Chi-square test for categorical variables

BOOI Bladder Outlet Obstruction Index

Results

Before matching, baseline differences were noted between groups (Table 1). These differences were minimized after PSM, resulting in comparable groups (Table 2).

Incidence of complications

There was no statistically significant difference in perioperative complications (P > 0.05). All the data results are indicated in Table 2.

Intraoperative safety comparison

Intraoperative complications were comparable between the TURP and TURP + TUIBN groups. Bleeding requiring transfusion occurred in 2 patients (3.6%) in the TURP group and in 1 patient (1.8%) in the TURP + TUIBN group. Capsular perforation with mild irrigation extravasation was observed in one patient per group, with no need for additional intervention. Transient incontinence was not observed intraoperatively in either group. Postoperative urgency and dysuria common features of irritative LUTS occurred slightly more frequently in the TURP + TUIBN group (12.5%) versus the TURP group (10.7%), but symptoms resolved spontaneously within 1–2 weeks. No statistically significant differences were observed in overall intraoperative complication rates between the two groups (P > 0.05).

Resected tissue volume

The mean weight of resected prostate tissue was comparable between groups (TURP: 12.3 ± 2.1 g vs. TURP + TUIBN: 11.8 ± 1.9 g; P = 0.42). In the TURP + TUIBN group, the bladder neck incision extended 1–1.5 cm longitudinally at the 3 and 9 o’clock positions, with full-thickness incision confirmed cystoscopically.

Comparison of IPSS, QOL score, qmax, and PVR

While both groups showed comparable improvements in IPSS and QOL scores at 3 months (P > 0.05), the TURP + TUIBN group demonstrated superior urodynamic improvements across all measured timepoints. At 12-month follow-up, Qmax was significantly higher in the combined procedure group (19.6 ± 3.5 vs. 17.8 ± 1.4 mL/s, p < 0.01), while post-void residual volumes (PVR) were markedly lower (28.3 ± 10.1 vs. 42.5 ± 12.7 mL, p = 0.03). The BOOI showed greater reduction with TURP + TUIBN (38.2 ± 6.1 vs. 31.5 ± 5.8 points, p < 0.01). Symptom improvement patterns differed between groups – though both achieved similar IPSS scores by 12 months (4.5 ± 0.5 vs. 4.8 ± 0.7, p = 0.12), the TURP + TUIBN cohort reached clinically significant symptom relief faster (3-month IPSS: 6.5 ± 1.2 vs. 8.2 ± 1.5, p < 0.01). QOL scores improved comparably in both groups (1.2 ± 0.4 vs. 1.3 ± 0.5, p = 0.21), with stable postoperative prostate volumes (< 32 mL). the TURP + TUIBN group demonstrated superior urodynamic improvements across all measured timepoints. At 12-month follow-up, Qmax was significantly higher in the combined procedure group (19.6 ± 3.5 vs. 17.8 ± 1.4 mL/s, p < 0.01), while PVR were markedly lower (28.3 ± 10.1 vs. 42.5 ± 12.7 mL, p = 0.03). The BOOI showed greater reduction with TURP + TUIBN (38.2 ± 6.1 vs. 31.5 ± 5.8 points, p < 0.01). Symptom improvement patterns differed between groups – though both achieved similar IPSS scores by 12 months (4.5 ± 0.5 vs. 4.8 ± 0.7, p = 0.12), the TURP + TUIBN cohort reached clinically significant symptom relief faster (3-month IPSS: 6.5 ± 1.2 vs. 8.2 ± 1.5, p < 0.01). QOL scores improved comparably in both groups (1.2 ± 0.4 vs. 1.3 ± 0.5, p = 0.21), with stable postoperative prostate volumes (< 32 mL) Table 3.

Table 3.

Comparison of postoperative functional outcomes between TURP and TURP + TUIBN groups

Parameter	TURP Group (n = 56)	TURP + TUIBN Group (n = 56)	p-value
IPSS
Baseline	22.1 ± 3.5	21.8 ± 3.2	0.68
3-month	8.2 ± 1.5	6.5 ± 1.2	< 0.01
12-month	4.8 ± 0.7	4.5 ± 0.5	0.12
Qmax (mL/s)
Baseline	7.3 ± 2.1	7.5 ± 1.9	0.59
12-month	17.8 ± 1.4	19.6 ± 3.5	< 0.01
PVR (mL)
Baseline	85.2 ± 12.4	83.7 ± 11.9	0.52
12-month	42.5 ± 12.7	28.3 ± 10.1	0.03
BOOI
Baseline	42.3 ± 5.1	41.8 ± 4.9	0.61
12-month change	−31.5 ± 5.8	−38.2 ± 6.1	< 0.01
QOL score
12-month	1.3 ± 0.5	1.2 ± 0.4	0.21
Prostate volume (mL)
12-month	29.1 ± 3.2	28.7 ± 2.9	0.45

Data presented as mean ± standard deviation

IPSS International Prostate Symptom Score (range 0–35, higher = worse symptoms), Qmax Maximum urinary flow rate (normal > 15 mL/s), PVR Post-void residual volume (normal < 50 mL), BOOI Bladder Outlet Obstruction Index (normal < 20)

 p values calculated using independent t-tests

Histopathological findings

Quantitative analysis of resected specimens revealed distinct tissue composition between groups. The TURP + TUIBN group exhibited significantly higher stromal-to-glandular ratios (2.1 ± 0.3 vs. 1.7 ± 0.2, p = 0.02) and greater collagen deposition (32.4% ± 5.1% vs. 25.8% ± 4.7% area fraction by Masson’s trichrome, p = 0.01), confirming more extensive fibrosis in these patients. Inflammatory infiltrates (predominantly lymphocytic) were comparable (Grade 1.3 ± 0.5 vs. 1.2 ± 0.4, p = 0.38). These findings align with cystoscopic observations of bladder neck fibrosis in the TURP + TUIBN cohort and provide pathological corroboration for their improved urodynamic outcomes.

Incidence of bladder neck contracture

At the 12-month follow-up, complication rates diverged significantly between groups (Fig. 1). Bladder neck contracture occurred in 8 TURP patients (14.3%) versus 2 TURP + TUIBN patients (3.6%) (p = 0.04), while urethral strictures were less frequent (TURP: 3/56, 5.4%; TURP + TUIBN: 1/56, 1.8%; p = 0.30). All cases were confirmed cystoscopically, with 3 requiring additional urethrography for localization. No other late complications showed significant intergroup difference (Table 4).

Fig. 1.

Bladder neck contracture rates (%) at 3, 6, and 12 months postoperatively in patients undergoing transurethral resection of the prostate (TURP) versus TURP combined with transurethral incision of the bladder neck (TUIBN). The TURP + TUIBN group demonstrated a consistently lower incidence of bladder neck contracture across all follow-up intervals. Data expressed as percentage of affected patients within each group (N = 56 per group)

Table 4.

Time-Stratified complication rates

Complication	3-month	6-month	12-month
Bladder Neck Contracture
TURP	2/56	5/56	8/56
TURP + TUIBN	0/56	1/56	2/56
Urethral Stricture
TURP	1/56	2/56	3/56
TURP + TUIBN	0/56	0/56	1/56

Three months after surgery, there was no significant difference in the incidence of bladder neck contracture (P > 0.05). However, during the full 12-month follow-up, the cumulative incidence of bladder neck contracture was significantly higher in the control group (P < 0.05). All summarized data are presented in Table 5.

Table 5.

Postoperative complication rates compared between TURP and TURP + TUIBN groups

Complication	TURP Group (n = 56)	TURP + TUIBN Group (n = 56)	p value
Bladder neck contracture	8 (14.3%)	2 (3.6%)	0.04
− 3-month	2 (3.6%)	0 (0%)	0.15
− 12-month	6 (10.7%)	2 (3.6%)	0.04
Urethral stricture	3 (5.4%)	1 (1.8%)	0.30
Transfusion required	1 (1.8%)	2 (3.6%)	0.56
Acute urinary retention	4 (7.1%)	3 (5.4%)	0.50

Data presented as number of cases (percentage)

p values calculated using Fisher’s exact test

TURP Transurethral resection of prostate, TUIBN  Transurethral incision of bladder neck

Discussion

BPH is a common disease that plagues urination disorders in elderly men, with clinical manifestations of LUTS and BOO [1]. In severe cases, it can lead to urinary retention and affect renal function. In contrast, our cohort exhibited distinct features younger mean age (62 years) and a predominance of fibrotic pathology (SBPH) rather than glandular hyperplasia. For these patients, we performed TUIBN, a procedure involving endoscopic lateral incisions at the bladder neck to relieve obstruction caused by fibrosis. This pathological and technical distinction likely explains the disproportionate obstruction relative to prostate volume observed in our patients, as well as the limited efficacy of TUIBN as standalone therapy in advanced fibrotic cases. However, our cohort exhibited distinct features younger mean age (62 years) and a SBPH rather than glandular hyperplasia. This pathological divergence likely explains the disproportionate obstruction relative to prostate volume observed in our patients, as well as the inadequacy of TURP as standalone therapy. Unlike TURP, which primarily addresses glandular hyperplasia, TUIBN specifically targets the bladder neck’s annular fibers a structure typically spared in standard TURP due to its role in continence. Our technique’s efficacy was confirmed intraoperatively by anatomical landmarks (ureteral orifices, fibrous appearance) and functional endpoints (irrigation flow, mechanical compliance). This targeted approach explains the reduced bladder neck contracture observed in our TURP + TUIBN cohort, as it addresses the fibrotic component central to SBPH pathophysiology.

Since the clinical development of TURP, it has gradually replaced open surgery and has become the “gold standard” to treat BPH [11]. However, TURP still has many deficiencies: the absorption of too much irrigation fluid during the operation leads to blood volume expansion, which is easy to cause electrical resection syndrome (TURS). The incidence rate is about 2%, and with the increase of operation time, the risk of occurrence increases; Difficult to stop bleeding, easy to perforate the capsule, about 2–5% of patients require intraoperative blood transfusion; postoperative complications such as bladder spasm, urinary incontinence, urethral stricture, retrograde ejaculation dysfunction, etc [12].

According to the characteristics and pathogenesis of SBPH, the newly proposed addition of bladder neck incision (TURP + TUIBN) on the basis of TURP is undoubtedly a more targeted treatment, and it has been proved to have better therapeutic effect [13–15]. While the EAU guidelines advocate TUIP for small-volume BPH, our study highlights the need to tailor surgical approaches to underlying pathology. In patients with concomitant bladder neck fibrosis a feature poorly addressed by TUIP alone TURP + TUIBN demonstrated superior urodynamic outcomes and reduced long-term complications. This supports the rationale for combining resection with targeted incision in select cases, particularly where fibrosis is a dominant contributor to obstruction. These findings also confirm the safety of the TURP + TUIBN technique. Despite adding an incision step, complication rates including bleeding, capsular perforation, transient LUTS, and incontinence were not significantly different from standard TURP. The low incidence of adverse intraoperative events further supports TURP + TUIBN as a safe surgical option in patients with small-volume BPH and bladder neck fibrosis.

This study investigated the effectiveness of TURP + TUIBN in terms of perioperative complications, surgical evaluation, and improvement of patient symptoms. Although TURP + TUIBN added bladder neck incision on the basis of TURP, there exhibited no significant difference in the incidence of perioperative complications. Therefore, compared with the traditional TURP, there is no gap in the security of TURP + TUIBN [16–20]. Moreover, we re-evaluated IPSS and QOL for all patients during the postoperative hospital stay. TURP + TUIBN was equally effective, and TURP + TUIBN had the same effect on the QOL of patients in terms of QOL score comparison. The improvement seems to be better [21]. Due to the different processes and provocative factors of bladder neck contracture after surgery, we conducted a long-term follow-up, and performed statistics and monitored some urodynamic indicators, IPSS and QOL scores in 3 months [22]. The follow-up results indicated that during the three-month follow-up period, there was no significant difference in the subjective perception of the two groups of surgical patients, but the urodynamic examination began to show the difference, and the improvement of TURP + TUIBN was more obvious [19]. It fully shows that the TURP + TUIBN group is superior to TURP when treating SBPH patients in terms of postoperative patient experience, improvement of urodynamics, and reduction of bladder neck contracture [23].

Additionally, while this study assessed complications at 12 months, standardized symptom scores (IPSS, QOL) and urodynamic parameters (Qmax, PVR) were systematically collected only up to the 3-month follow-up. This limits our ability to evaluate longer-term functional durability of treatment. Future studies should incorporate scheduled 6- and 12-month assessments of both symptoms and urodynamics to provide a more comprehensive understanding of the sustained efficacy and quality-of-life impact of TURP + TUIBN compared to TURP alone.

Several limitations of this study should be acknowledged. First, while our mixed-effects models accounted for repeated measures and missing data, the single-center retrospective design may limit generalizability. Second, although we standardized urodynamic measurements (performed by two blinded technicians using identical equipment), inter-operator variability cannot be fully excluded. Third, the surgical outcomes may reflect surgeon-dependent variability, as all procedures were performed by our institutional team without external validation of technique standardization. While our sample size was sufficient to detect primary outcomes, we acknowledge that larger multicenter cohorts are needed to validate these findings, particularly for rare complications (e.g., urethral stricture). Future studies should prioritize prospective designs with standardized surgical protocols. Fourth, while we employed transrectal ultrasound for prostate volume measurement, the specific measurement protocol and operator details were not systematically recorded, which could introduce measurement variability. Fifth, although our histopathological analysis demonstrated greater fibrotic composition in the TURP + TUIBN specimens, this evaluation was necessarily limited to the resected prostatic tissue and could not include the incised bladder neck fibers themselves, suggesting future studies should incorporate direct sampling of this surgically modified region. These factors may affect the generalizability of our results. Future multicenter prospective studies with standardized surgical protocols and detailed imaging documentation would help validate these findings. The lack of a TUIP control group also warrants consideration. While TUIP is guideline-recommended for small-volume BPH, our patient population characterized by bladder neck fibrosis was less suitable for TUIP due to its limited efficacy in fibrotic cases. Future studies should include a TUIP arm to enable broader comparison across surgical modalities and better evaluate its role relative to TURP and TURP + TUIBN in patients with and without fibrosis.

Another limitation of this study is the absence of a TUIP control group. Although TUIP is guideline-recommended for prostates < 30 mL, our institutional approach prioritized TURP + TUIBN for patients with cystoscopically confirmed bladder neck fibrosis a pathology less responsive to TUIP alone. Nevertheless, to enable more comprehensive comparison across surgical modalities, future studies should include a TUIP group to directly evaluate its efficacy relative to TURP and TURP + TUIBN in small-volume BPH with or without fibrosis. The overall volume of resected tissue was recorded; however, the bladder neck portion removed during TUIBN was not separately quantified. This limits our ability to isolate and evaluate the specific impact of bladder neck tissue removal on surgical outcomes. Due to the fibrous and non-glandular nature of this region, precise intraoperative measurement proved technically difficult. To address this limitation, future studies should incorporate dedicated quantification methods such as intraoperative imaging, volumetric estimation, or pathology-based analysis to more accurately assess the relationship between bladder neck modification and postoperative function or complication rates. Although bladder neck incisions were standardized using visual cues and anatomical endpoints, objective quantification of incision depth or volume was not performed in this study. This represents a limitation in evaluating reproducibility and outcome correlation. Future studies should consider incorporating intraoperative quantification tools such as endoscopic ultrasound, calibrated depth instruments, or 3D imaging techniques to enable precise and reproducible assessment of incision extent and its impact on functional outcomes. While resected tissue volume was similar between groups, we acknowledge that precise quantification of bladder neck tissue removal during TUIBN was challenging due to its fibrous nature. Future studies may benefit from standardized histopathological analysis of resected bladder neck specimens. While this study assessed complications at 12 months, standardized urodynamic (Qmax) and symptom (IPSS) measurements were not systematically collected beyond the 3-month postoperative period. This represents a limitation in evaluating longer-term functional outcomes. Future studies should incorporate scheduled 6- and 12-month assessments to better characterize the durability of treatment effects. In addition, the PSM strengthened group comparability, the retrospective nature limits causal inferences. Future prospective randomized trials are warranted to validate our findings. Within the limits of our study, TURP + TUIBN appears to be a viable alternative to TURP alone for small-volume BPH, particularly in reducing long-term complications such as bladder neck contracture. Further multicenter studies are needed to validate its broader applicability.

Authors’ contributions

Conceptualization: Z.Y., Q.C.; Data Curation: Z.Y., C.Y., Q.C.; Formal Analysis: Z.Y., J.Y., Q.C.; Funding Acquisition: Q.C.; Investigation: Z.Y., C.Y., Q.C.; Methodology: Z.Y., Q.C.; Project Administration: Q.C.; Resources: Z.Y., Q.C.; Software: Z.Y., Q.C.; Supervision: Z.Y., C.Y., Q.C.; Validation: Z.Y., J.Y., Q.C.; Visualization: Z.Y., C.Y., Q.C.; Writing - Original Draft: Z.Y., C.Y.; Writing - Review & Editing: J.Y., Q.C.

Funding

This research received no external funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The current study was approved by the Ethics Committee of the Deqing County Third People’s Hospital (approval number DPH202409212). Written informed consents from all patients were obtained in any experimental work with humans.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.