ZANCLE technique for bladder neck obstruction

Short answer. ZANCLE (“Z” Anatomical Needle Cut Leads Ejaculation) is an endoscopic procedure, performed through the urethra with no external incisions, to treat primary bladder neck obstruction in men. It consists of a unilateral Z-shaped incision of the bladder neck and prostate, designed to relieve the obstruction while trying to preserve ejaculation. It was described by Dr. Alessandro Calarco and colleagues in three studies published between 2025 and 2026.

What primary bladder neck obstruction is

The bladder neck is where the bladder opens into the urethra. In some men, often young or middle-aged and with a prostate that is not enlarged, it does not open properly during urination. The result is a weak or intermittent stream, frequent urination including at night, a feeling of incomplete emptying and sometimes burning. These symptoms are often mistaken for chronic prostatitis.

Who it may suit

In the published studies the technique was offered to men with:

• primary bladder neck obstruction documented by tests;
• prostate volume below 30 mL;
• persistent symptoms despite alpha-blocker therapy;
• a wish to preserve ejaculation.

The indication is set only after a consultation and tests: usually uroflowmetry, measurement of post-void residual urine and ultrasound; in selected cases urodynamic study and urethrocystoscopy. With a larger prostate or other causes of obstruction, such as a urethral stricture, other treatments are considered.

How it is performed

The procedure is endoscopic: an instrument with a micro-camera is passed through the urethra and, with monopolar or bipolar energy, an incision is made on one side only of the bladder neck and prostate, following a “Z” path designed to spare the structures involved in ejaculation. In the first published study the median hospital stay was 1 day and the catheter was kept in place for a median of 3 days. The procedure is performed under spinal anaesthesia.

What the published studies report

Limits of the evidence

The studies concern selected patients, operated on by a single surgeon at a single centre, and have no comparison group with other techniques. Follow-up reaches 24 months. Comparative studies and longer follow-up are needed. The results described are not a guarantee of outcome for an individual patient.

Possible side effects and risks

Short answer. Like any endoscopic procedure on the bladder neck, the ZANCLE technique can have side effects. The most frequent appear in the first days or weeks and are usually temporary; serious complications are uncommon.

The list below summarises the general risks of this type of procedure described in guidelines and the literature. Each patient’s risks are discussed during the consultation and set out in the informed consent.

In the first days and weeks (frequent, usually temporary)

• burning on urination and a frequent or urgent need to urinate;
• blood in the urine (haematuria), sometimes with small clots;
• discomfort from the catheter while it is in place.

Less frequent

• urinary tract infection, sometimes with fever, requiring antibiotics;
• difficulty urinating after the catheter is removed, which may require it to be reinserted for a few days;
• more significant bleeding, which rarely may require bladder washouts, a further endoscopic procedure or a transfusion.

Later on

• scar narrowing of the bladder neck (bladder neck sclerosis) or of the urethra (urethral stricture);
• return of obstructive symptoms, possibly requiring further treatment;
• changes in ejaculation, such as reduced volume or retrograde ejaculation: the technique was designed to reduce this risk but cannot rule it out for an individual patient;
• very rarely, urinary leakage (incontinence).

Risks of spinal anaesthesia

The procedure is performed under spinal anaesthesia. Headache after the puncture, a drop in blood pressure and temporary difficulty urinating are possible; neurological complications are rare. The anaesthetist discusses these at the pre-operative assessment.

What the published studies report

In the largest and most recent published series (186 consecutive patients operated on at a single centre between December 2018 and September 2025, with follow-up of up to 24 months; Surgeries 2026), mean maximum urinary flow rose from 10.2 to 19.8 mL/s at 24 months, the IPSS symptom score fell from 16 to 6.5 and post-void residual from 125.5 to 31.2 mL. Minor complications (Clavien grades 1–2) were recorded in 2.7% of patients and no major complications; antegrade ejaculation was preserved in all patients. A further prospective study of 40 consecutive patients (Journal of Clinical Medicine 2026) assessed ejaculatory (MSHQ-EjD) and erectile (IIEF-5) function with validated questionnaires; both remained stable at 12 months. These are selected patients: the results cannot be transferred automatically to an individual case and are not a guarantee.

Where it is performed in Rome

Dr. Alessandro Calarco performs the ZANCLE procedure, under spinal anaesthesia, at Casa di Cura Nostra Signora della Mercede, Via Tagliamento 25, and at San Carlo di Nancy Hospital, Via Aurelia 275, Rome. Consultations can be booked on +39 366 6856844 or through the contact form. The procedure can be performed privately, under agreement with insurers or through the Italian National Health Service (SSN).

Frequently asked questions

References

• Calarco A, Viscuso P, Filippi B, Leonardi R, Mantica G, Magazzino C, Tufano A. “Z” Anatomical Needle Cut Leads Ejaculation (ZANCLE): Unilateral incision for bladder neck obstruction with ejaculation-sparing intent: A single-surgeon experience. Urologia Journal. 2025;92(3):466-469. doi:10.1177/03915603251334084 · PMID 40243909
• Calarco A, Leonardi R, Mantica G, Ambrosini F, Scornajenghi CM, Paolillo M, Morgia P, Viscuso P, Tufano A. “Z” Anatomical Needle Cut Leads Ejaculation (ZANCLE): Unilateral Incision for Primary Bladder Neck Obstruction with Ejaculation-Sparing Intent—An Extended Single-Surgeon Series with 24-Month Follow-Up. Surgeries. 2026;7(3):84. doi:10.3390/surgeries7030084
• Calarco A, Morgia P, Scornajenghi CM, Paolillo M, Viscuso P, Filippi B, Tufano A. Validated Assessment of Ejaculatory and Erectile Function After Unilateral “Z”-Shaped Bladder Neck Incision (ZANCLE): A Prospective Study Using the MSHQ-EjD Short Form and IIEF-5. Journal of Clinical Medicine. 2026;15(19):7699. doi:10.3390/jcm15197699 · PMID 42882160
• European Association of Urology (EAU). Guidelines on the Management of Non-neurogenic Male LUTS, section on transurethral incision of the bladder neck/prostate (TUIP).

Author and review: Dr. Alessandro Calarco, urologist, Director of the Unit of Robotic and Minimally Invasive Urology at San Carlo di Nancy Hospital · ORCID 0000-0001-6893-2179 · Last updated: 30 October 2026. For information only: this content does not replace a medical consultation. Any test or treatment is decided only after a visit.