a 53-year - old male patient presented to our clinic with aggravation of straining to void and lower abdominal distention that had developed 1 month earlier . he had undergone a radical cystectomy and orthotopic ileal bladder substitution with afferent limb ( studer 's neobladder ) for invasive bladder cancer 13 months previously and had been periodically followed . until this visit , he voided spontaneously , about 300 - 400 ml per episode , by increasing the intravesical pressure through a vasalva maneuver and relaxation of the bladder outlet , with a little incontinence at nighttime only . a computed tomography ( ct ) scan showed no signs of tumor recurrence or hydronephrosis . cystoscopy ( 16 fr ) showed a pinpoint stricture at the neovesical - urethral anastomotic site , and the scope could not be passed through the stricture site ( fig . a grade iii neovesical - urethral anastomotic stricture was diagnosed , and a balloon dilation of the stricture site was planned . on cystoscopic inspection , a 0.038 inch ureteral guide wire was passed into the neobladder through the stricture site . a ureteral dilation balloon catheter ( cook , spencer , in , usa ) was then advanced through the prepositioned guide wire . after placing the balloon ( length : 6 cm ) precisely in the stricture site under cystoscopic inspection , thereafter , a 24 fr cystoscopic sheath was freely advanced into the neobladder without any resistance and a 22 fr indwelling urethral foley catheter was placed . the patient tolerated the procedure well under local anesthesia ( i m injection of 50 mg pethidine ) . after removal of the urethral foley catheter , the patient voided well in amounts of 300 - 400 ml per episode without hesitation and his pvr was 0 ml . at present , 24 months after the procedure , follow - up cystoscopy revealed a patent anastomotic site ( fig . the patient voided well except for slight incontinence at nighttime , and his pvr remained at zero . although orthotopic ileal neobladder is considered the gold standard after cystectomy , the most important factor affecting the quality of life of patients with orthotopic diversion is emptying failure of the reservoir . simon et al analyzed emptying failures in a single - center cohort of 655 male patients who received an ileal neobladder and reported that 11.1% of the patients had emptying failure during their follow - up period . various causes were involved , such as strictures of the neovesical - urethral anastomotic site ( 3.5% ) , dysfunctional voiding ( 3.5% ) , urethral strictures ( 1.7% ) , local tumor recurrence causing neobladder outlet obstruction ( 2.0% ) , and obstructive mucosal valves ( 0.5% ) . the reported incidence of anastomotic bncs after radical cystectomy is 2.7% to 8.8% [ 1,3 - 6 ] . the diagnosis of bnc should be confirmed by cystoscopy , which allows for direct visualization of the bladder neck and a quantitative assessment of the degree of anastomotic stricture . the degree of stricture is classified as grade i ( > 17 fr but < 22 fr ) , grade ii ( < 17 fr ) and grade iii ( pinhole ) . the risk factors for strictures at the neovesico - urethral anastomotic site in patients with continent diversion have not yet been determined . we believe that the mechanism and risk factors for developing strictures at the neovesicalurethral anastomotic site are similar to the formation of bnc after radical retropubic prostatectomy ( rrp ) . the mechanisms postulated for bnc after rrp include the disruption of healing at the neovesical- urethral anastomotic site , an inflammatory response from prolonged catheterization , and failure of apposition of the bladder neck mucosa to the urethral mucosa , which leads to poor healing and urinary extravasation soon after rrp . the treatment options for bnc after orthotopic neobladder vary from conservative management with clean intermittent catheterization ( cic ) or dilatation at the level of the bladder neck to transurethral resection ( tur ) or transurethral incision ( tui ) with a cold knife , electrocautery , or holmium laser . in the series reported by patel et al , interventions ( tui or dilation ) in the operating room under anesthesia were needed in 4/4 of grade i , 5/6 of grade ii , and all of grade iii bnc cases after neobladder substitution . no patients had a significant change in continence after treatment ; specifically , none developed de novo daytime or nighttime incontinence , and at the last follow - up , 9 of the 10 patients were undergoing cic irrespective of the success of treatment . we adopted balloon dilation using a commercially available ureteral dilation balloon catheter ( cook , spencer , usa ) as the primary treatment of grade iii neovesical - urethral anastomotic stricture after studer 's neobladder formation because we believe this procedure is less invasive . the procedure does not require the patient 's admission or general or regional anesthesia , in contrast with other surgical options such as tur or tui with a cold knife . although successful long - term results were achieved with balloon dilation of a high - grade neovesical - urethral anastomotic stricture , the best treatment for these patients is still unknown .
neovesical - urethral anastomotic stricture is a complication of orthotopic neobladder , with a reported incidence of 2.7% to 8.8% . 
 strictures of the neovesico - urethral anastomotic site can be treated with regular self - dilation , but high - grade strictures require a surgical procedure involving incision by electrocautery or cold knife . here 
 we describe a grade iii neovesical - urethral anastomotic stricture after an orthotopic bladder substitution that was successfully treated by use of a ureteral dilation balloon catheter .