Transurethral incision with transverse mucosal realignment (TUITMR) is a novel technique in the management of bladder neck contractures or vesicourethral anastomotic stricture after prostatectomy, providing a minimally invasive and effective reconstruction approach to resolve urinary obstruction.
Hi, I'm Laura Hoyisky. I'm a reconstructive urologist from the University of Miami, Deci at the Urology Institute. Today we're going to be performing a transurethral incision and mucosal realignment, which is a cystoscopic or minimally invasive procedure which allows me to reconstruct the bladder neck. The bladder neck can develop scar tissue after surgery, usually for enlarged. Prostate or when the prostate is removed. Traditional approaches were either cutting open the scar, which tend to have high rates of recurrence, or doing a complicated open or robotic reconstruction, which, while effective, carries increased risk of complications. This minimally invasive technique has been a great option for patients that are dealing with this issue. And has a very high success rate, about 89% success rate with a single procedure and nearly 100% with two of fixing this complicated issue. We can see this is his scar tissue here. We see the bladder neck. We see the view of the prostate, so this is right at the, where the bladder opens, and actually I can get in. So, we don't need to do the dilation. So, this is good. Take a quick look around the bladder. See the UOs, one there. All right. So, we have plenty of space. Where we're working toward the ureters connect. All right, good. So we'll come out here. So now I'm gonna open the scar and make a V in the tissue that will allow me to advance the bladder mucosa forward. I'm gonna look where the ureteral orifices are, make sure I'm away from them. No. We're gonna have a specimen which is prostate chips. And I want to look and see where this can becomes mobile. It's not mobile yet. Um, we probably won't need it. And we can see the bladder when it's um decompressed will be more have more mobility than when it's full. Also gonna work a little bit here. So we can see a little bit of mobility of the bladder mucosa, but not that much there. So since he has his prostate still in, we can do at 6 o'clock. If she had a prostatectomy, we would not. You know, we don't do as much here because the rectum is below, but he has a, he still has a prostate, so. We could do more. Let's see here. So I think The thing is here, I think I need to make this a little bit deeper so this tissue will advance better. So we can see this is nice and open now. The scar has been opened up and then we can do the reconstruction. Have a little bit of bleeding, a few areas, so we're just going to get that to stop. But. Before we go in with the urethroscope. All right, let's switch the um cystoscope for the urethroscope. Thank you. We'll kind of try to lock it just a smidge more. All right, great. Um, I will take one of the RD 180s. OK, perfect. All right, so now I'm gonna do the reconstruction. So we're gonna go in here. The suturing tool. We're gonna come out a little bit with this urethroscope, good. So I'm going to see the full tool here and then come back. Catheter tissue here. Mhm Reload. Here we go. This looks better. Coming in here. OK, it's good. Suture scissor. I Yeah. So, I'm going to show myself the suture, which is right there. I'm gonna pull here, give good tension. Should have released, there we go. So that's tied, good. Come out. So, let me do the other side. So, we want to work kind of from least tension to most tension. So, usually starting along the sides is good. Usually what you do. So here you can see a good bite and the tissues there. I, Oh wait, no, I'm just. I Yeah. Hm. All right, so let's deploy this right here. Tension on my suture. Cool, and then that ties on there. Good. No There we go, we can see a good bite. OK, good. All right, I'm gonna make them nice and even and nice and long. Here we go. All right, TK when you have it. It's a lot of passing things back and forth. It's It's a little, it's a little challenging. It takes some getting used to for sure. I think like being able to see the tissue move, and then seeing able to see your bites and reload the needle and like, kind of smoothly put everything together, it's just like, trying to get that smooth is like the hard part of the procedure. Thank you. There we go. We see tensioning. See it pushing. Good, so we are already seeing this is coming together, but we still need probably 1 or 2 more kind of in the middle there to reconstruct it, but it's looking a lot better. Yeah. All right, so looking at our repair. We have this kind of area right there. I'd like to get right behind the Vru. OK, so, I'm going to go in here. I'm going to come up like this. Watch the scope. Good. So, like, this will be good. OK. I'm trying not to get on, right on the Vero. So, let's see if I come. A little bit more like this. There we go, dig in. Mhm OK, thank you. So now, before I take this out and we lose pressure, we can see the final result, which is the scar tissue that was there has been resected. Actually, let's do one more up here. This one, there's some exposed scar. One more. Um, but we're, I think the other side is OK. I was, uh. A little bit there, yeah, maybe this one, yeah. Yeah, OK, we'll do 2 more. Well, we can see here that the scar that was opened is now has healthy bladder tissue. That tissue looks much better. So we're gonna put two more laterally and then call it a day. So, now we have finally closed up all of the scar. So that exposed surface isn't gonna react with urine and refibrosis. We have good tissue approximation. We see the viru here. Um, so this looks really good. So, we're gonna put in a Foley catheter now and then that'll be the end of the procedure. So, we're good on the, the saline. We can go ahead and, We'll take everything out. All right, here is this, and we'll take a 16 French. OK, so, um, this case went well. We can see there's a lot of fibrosis, but now that the bladder has been advanced and kind of closed up the scar, I think we'll hopefully have a very good result. We will look in with a camera in about 3 to 4 months to make sure those little metal clips have passed in the urine. They should just come. Um, if they haven't, they'll be able, we can brush them off with the camera, and then that's it. Um, so it was a good case, good team. Thank you.
