Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

15. Complications of Transvaginal Bladder Neck Closure

David A. Ginsberg 

(1)

Department of Urology, Keck School of Medicine of USC, USC Institute of Urology, 1441 Eastlake Avenue, NOR 7416, Los Angeles, CA 90033-9178, USA

David A. Ginsberg

Email: rovnere@musc.edu

Abstract

The indication for an adult woman to undergo a transvaginal BNC is an eroded and destroyed bladder neck/urethra secondary to a chronic, indwelling catheter. While the indication for the initial catheter placement may be varied, the chain of events leading to this scenario is usually quite similar. The catheter is usually placed for refractory urinary incontinence or retention, usually of neurogenic etiology but not necessarily.

Indications

The indication for an adult woman to undergo a transvaginal BNC is an eroded and destroyed bladder neck/urethra secondary to a chronic, indwelling catheter. While the indication for the initial catheter placement may be varied, the chain of events leading to this scenario is usually quite similar. The catheter is usually placed for refractory urinary incontinence or retention, usually of neurogenic etiology but not necessarily.

The common clinical scenario that results in an incompetent, eroded urethra is initiated with the simple decision to manage a patient with an indwelling catheter. With long-term catheter use, female patients may experience urethral erosion, which often leads to urinary leakage around the catheter. This erosive reaction is often further exacerbated by the caregivers’ decision to use a larger catheter size and inflate the balloon with larger volumes of water. The hope is that this will minimize leakage around the catheter; however, this often results in further urethral erosion. Erosion can be so severe that catheters cannot be maintained in the bladder and spontaneously fall out. In addition, a poorly secured catheter that is traumatically pulled out over and over can also contribute to urethral injury. If severe enough, the urethra becomes overly patulous and a urethral indwelling catheter cannot be maintained. The urethra can be wide enough and short enough that one or two fingers can be inserted directly into the bladder [1]. In addition, the erosion can be severe enough that when a finger is inserted into the urethra, the undersurface of the pubic symphysis is directly palpated as there is no remaining urethral tissue anteriorly. Because of the length of the urethra, this is rarely an issue in the male patient; the analogous reaction in the male to long-term catheter usage would be a traumatic hypospadias.

For these women there are few options besides use of pads/diapers. There is no female version of a condom catheter and many of these patients are not interested in or physically unable to undergo lower urinary reconstruction due to their disability. Placement of a suprapubic catheter (SP) is a nice option for these patients, and by itself, may be sufficient to control leakage of urine per the eroded urethra [2]. However, depending on the degree of the erosion and damage, leakage may still occur per the urethra despite continuous drainage per the SP tube. For these patients, options include placement of an obstructing sling or BNC. Sling placement is nice in that it does not permanently close the bladder neck; however, these outlets are often so damaged that there is not an adequate amount of urethral damage to allow for sling placement. Approaches for BNC include transvaginal and transabdominal. The transabdominal approach is often done in conjunction with some type of LUT reconstruction, is more invasive than a vaginal procedure, and has been reported to have lower rate of post-op leak/fistula formation. The alternative is a transvaginal approach which is often done in conjunction with SP tube placement; it is less invasive but may be a more challenging procedure for surgeons less experienced with vaginal surgery [3].

Complications

There is essentially one primary complication associated with BNC which is continued leakage and formation of a vesicovaginal fistula (VVF) between the attempted closure site and anterior vaginal wall. The fistula rate after the initial surgery ranges between 0 and 100% and is summarized in Table 15.1. The various surgical techniques described are fairly similar and are based on several essential principals: (1) complete mobilization of the urethra/bladder neck off the supporting pelvic ligaments; (2) resection of necrotic tissue down to healthy, viable tissue before closure is attempted: (3) multilayered closure; (4) mobilization of a large anterior vaginal wall flap to advance over the BNC.

Table 15.1

Bladder neck closure fistula rate

References

Patients

Fistula rate (%)

Zimmern et al. [1]

6

0

Nielsen and Bruskewitz [10]

5

20

Eckford et al. [11]

50

22

Levy et al. [3]

4

50

Andrews and Shah [2]

8

50

Stoffel and McGuire [12]

8

87.5

Ginger et al. [4]

2

100

Rovner et al. [5]

11

9

Depending on the degree of erosion, it is possible that BNC may occur close to the ureteral orifices. It is important that the ureteral orifices are identified prior to BNC to minimize risk of damage. Certainly there is a theoretical risk of ureteral injury at the time of BNC, though that has not been previously described in the literature.

The remainder of this chapter will focus on steps to minimize the risk of forming a fistula after transvaginal BNC peri-operatively as well as how to manage the problem if a fistula does occur.

Pre-op

There is unfortunately little that can be done preoperatively to enhance success postoperatively in these patients. One important decision the surgeon should make is whether or not to perform BNC at all, and if so, via which approach. Levy et al. reviewed their experience with 12 patients, all of whom underwent BNC for urethral injury secondary to long-term indwelling catheters [3]. The first four patients all underwent a primary transvaginal approach. Of those, two succeeded and the other two failed a total of five transvaginal attempts to close the bladder neck, resulting in a success rate of 50%. Both of these patients ultimately underwent successful BNC with a combined abdominal and vaginal approach. The next ten patients (eight new patients and the two that had failed the prior transvaginal attempts) underwent combined abdominal and vaginal approach with 100% success. The authors’ recommendation at the time was that a purely transvaginal approach may not be optimal if the operating surgeon does not have extensive experience performing transvaginal surgery. This manuscript was published in 1994 and one would hope that more urologic surgeons are comfortable with transvaginal surgery. However, if that is not the case, then use of an abdominal approach should be considered. There are few studies that evaluated outcomes using multiple approaches; however, a study by Ginger et al. revealed a 11% leakage rate in 26 patients undergoing a transabdominal BNC compared to a 100% leakage rate in the two patients in their study that underwent transvaginal BNC [4].

Poor nutrition is one issue that could be improved preoperatively. Rovner et al. correctly state that many of these patients often have multiple medical comorbidities and poor nutritional status at baseline [5]. Poor nutrition has been shown to impact wound healing, increase susceptibility to infection, and place the patient at increased risk for pulmonary complications, prolonged hospitalization, and mortality [6]. However, preoperative nutritional supplementation appears to only be valuable in severely malnourished patients; in all other patients, surgery does not need to be delayed [7].

Intra-op

To minimize risk of postoperative failure and leak, there are several surgical steps that should be emphasized. Initially, two incisions are made. One is made circumferentially around the external urethra meatus. The other incision, along the anterior vaginal wall, allows for the dissection of a wide, anterior vaginal wall flap when beginning the procedure. This flap is advanced once the BNC is complete past the area of repair, thus minimizing the presence of overlapping suture lines. Prior to closing the bladder neck, appropriate mobilization is necessary. This includes transection of the urethra completely off the pubourethral ligament dorsally and the urethropelvic ligaments and remaining attachments laterally. Optimal mobility of the bladder neck is extremely important. Without mobility the closure of the bladder neck itself is very challenging. Prior to closing the urethra/bladder neck, all necrotic tissue should be resected down to viable tissue. This often results in resecting all if not the entire urethra. Thus, mobility allows the surgeon to pull the bladder neck out towards you with stays; thus making the actual closure of the bladder neck less challenging. In addition, with adequate mobility of the closed bladder neck, it can be mobilized anteriorly away from the vaginal wall closure. After closing the bladder neck in two layers, I will tag the sutures. The needle attached to those BNC sutures can then be brought through the undersurface of the pubic symphysis or even the anterior abdominal wall. Without adequate mobility the surgeon is unable to get to this area and the closed bladder neck cannot be easily maneuvered upwards in the appropriate direction. If successful, the suture line of the BNC is essentially mobilized anteriorly, well away from the vaginal wall. Theoretically, this will help minimize formation of the fistula if the initial repair is not watertight.

Closure of the bladder neck with multiple layers is certainly an important step and several techniques have been described. Zimmern et al. used an initial vertical and anterior–posterior layer followed by a second layer placed transversely in perivesical fascia and detrusor muscle superficially [1]. Rovner et al. described a modification of this technique using a posterior urethral flap (Fig. 15.1). Once the bladder neck has been fully mobilized, the dorsal urethra is bivalved into the anterior bladder wall for 2–3 cm. The bivalved posterior urethral flap is then rotated cephalad and secured to the anterior bladder wall. That suture line is subsequently rotated upwards to the retropubic space, behind the pubic symphysis [5]. It should be noted that use of an adjuvant flap or graft placement is not usually required for primary repairs; these techniques are more commonly seen for patients requiring redo surgery for postoperative fistula after failure of primary BNC [4].

A213469_1_En_15_Fig1_HTML.gif

Fig. 15.1

(a) Incision made circumferentially around urethra with arms extending proximally to develop anterior vaginal wall flap. (b) Urethra is freed from its attachments as the urethropelvic and pubourethral ligaments are divided. (c) Dorsal urethra bivalved up to bladder neck. (d) Ventral urethra flap rotated up to edge of bivalved urethra. (e) Closure of bladder beck. With rotation of flap in a cephalad direction, the suture line rotates under the symphysis pubis. (f) Anterior vaginal wall advanced and vaginal wall closed with no overlapping suture lines

Post-op

Without appropriate postoperative management, even the best of repairs will break down, resulting in formation of a VVF. The importance of optimal drainage post-op in these patients cannot be overemphasized. Ginger et al. noted a significant association between poor post-op catheter care and persistent leakage [4]. A total of 29 patients in their series underwent retropubic BNC, with eight of these patients continuing to have persistent urinary leakage post-op. This was directly attributable to catheter mismanagement in seven of the eight patients. An appropriately sized suprapubic tube should be placed, secured, and optimally drained postoperatively to help ensure healing of the suture line along the closed bladder neck.

In addition to poor drainage, residual detrusor overactivity can negatively impact the healing process. Even with a catheter in place allowing for continuous bladder drainage, patients can have residual detrusor overactivity. The bladder’s natural response to a detrusor contraction is relaxation of the bladder neck and a spontaneous void. If the bladder neck has been surgically closed, this only leads to increased pressure on the suture line and greater risk of postoperative failure. Anticholinergics are thus an important part of the postoperative management of these patients and should be started immediately postoperatively. Theoretically, peri-operative injection of botulinum toxin A into the detrusor muscle could be used in the hopes of completely eliminating any postoperative detrusor overactivity [8]. The clinical uses of botulinum toxin A in urology continue to be explored and expanded; however, this actual use has yet to be documented.

Fistula Diagnosis

The diagnosis of a post-BNC fistula is fairly straightforward and can be done either radiographically or on examination. A leak at the closure site may be suggested at the postoperative visit if the patient complains of continued urinary leakage vaginally; however, a lack of leakage does not mean that the BNC has adequately healed. All patients should have a cystogram 2–3 weeks postoperatively to adequately assess the quality of the repair. If a residual leak is noted, then continued catheter drainage could be considered. The theory with a posthysterectomy VVF is that prolonged catheter drainage can be successful and lead to closure if the patient is dry with the catheter in place and is unlikely to succeed if the patient continues to leak per the fistula site despite continuous catheter drainage. This has not been evaluated in post-BNC leaks, but it is likely that the theory and healing process is similar—if urine continues to leak through a hole (i.e., the fistula site), then that hole will not heal.

If the cystogram is equivocal or if a patient returns complaining of leakage despite a previously noted negative cystogram, then direct examination may be helpful in identifying a fistula. As opposed to most posthysterectomy fistulae, which tend to be deep towards the vaginal vault and can be challenging to identify on examination, these fistulae are not deep in the vault and are often easy to see on examination. A simple technique to easily evaluate for a leak is to perform a pelvic examination while an assistant fills the bladder through the suprapubic tube with normal saline colored with a dye such as methylene blue or indigo carmine. If a leak is present, it will be readily apparent when the blue-tinged fluid is noted leaking through the fistula site in the vagina. If the patient is concerned a leak is present but cannot come to the office for immediate evaluation, another option would be for her to do a pyridium pad test at home. If her pad turns orange after taking pyridium post-BNC, then that is strongly suggestive that a fistula is present.

Fistula Management

If a VVF develops between the vagina and bladder neck closure site despite appropriate surgical technique and peri-operative care, then several options are available. An attempt to maximize drainage with supravesical diversion using bilateral nephrostomy tubes could be attempted. This has primarily been used in the postoperative setting in patients with a urine leak at the ureteroileal anastamosis site after urinary diversion. With a mature fistula tract, it is unlikely this will allow for closure of the fistula, though this may theoretically help close a leak early in the postoperative period.

Once the fistula tract has matured, the patient is destined to undergo further surgery if repair is desired. For experienced vaginal surgeons, a second attempt at a transvaginal BNC could be considered. The technique is essentially the same as was attempted with the initial attempt at closure. However, use of an adjuvant flap or graft is highly recommended in a redo procedure, especially if one was not used in the initial procedure. If a graft/flap was used with the initial attempt at BNC, it is possible that it could be identified intra-operatively and reused if healthy.

For those surgeons not experienced with transvaginal surgery, an abdominal approach should be considered after a failed prior attempt at BNC. If an abdominal BNC is performed, an omental flap can be harvested and placed at the closure site to add an extra layer of repair [9]. If further evaluation finds that the bladder is not salvageable or the BNC cannot be done, then the surgeon and patient should also be prepared for possible cystectomy and either continent or incontinent diversion to the skin. This is certainly a much larger undertaking than BNC and, if it is thought that this might be a possibility, appropriate preoperative preparation is required including patient counseling, stoma site marking, and obtaining of an adequate informed consent.

References

1.

Zimmern PE, Hadley RH, Leach GE, et al. Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization. J Urol. 1985;134:554–6.PubMed

2.

Andrews HO, Shah PJR. Surgical management of urethral damage in neurologically impaired female patients with chronic indwelling catheters. Br J Urol. 1998;82:820–4.PubMedCrossRef

3.

Levy JB, Jacobs JA, Wein AJ. Combined abdominal and vaginal approach for bladder neck closure and permanent suprapubic tube: urinary diversion in the neurologically impaired woman. J Urol. 1994;152:2081–2.PubMed

4.

Ginger VA, Miller JL, Yang CC. Bladder neck closure and suprapubic tube placement in the debilitated patient population. Neurourol Urodyn. 2010;29:382–6.PubMed

5.

Rovner ES, Goudelocke CM, Gilchrist A, et al. Transvaginal bladder neck closure with posterior urethral flap for devastated urethra. Urology. 2011;78:208–12.PubMedCrossRef

6.

Detsky AS, Baker JP, O’Rourke K. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med. 1987;107:195–203.PubMed

7.

Hebbar R, Harte B. Do preoperative nutritional interventions improve outcomes in malnourished patients undergoing elective surgery? Cleve Clin J Med. 2007;74 Suppl 1:8–10.CrossRef

8.

Smith CP, Somogyi GT, Chancellor MB. Emerging role of botulinum toxin in the treatment of neurogenic and non-neurogenic voiding dysfunction. Curr Urol Rep. 2002;3:382–7.PubMedCrossRef

9.

Shpall AI, Ginsberg DA. Bladder neck closure with lower urinary tract reconstruction: technique and long-term followup. J Urol. 2004;172:2296–9.PubMedCrossRef

10.

Nielsen KT, Bruskewitz RC. Female urinary incontinence treated by transvaginal urethral closure and suprapubic tube. Int Urol Nephrol. 1989;21:603–8.PubMedCrossRef

11.

Eckford SB, Kohler-Ockmore J, Feneley RCL. Long-term follow-up of transvaginal urethral closure and suprapubic cystostomy for urinary incontinence in women with multiple sclerosis. Br J Urol. 1994;74: 319–21.PubMedCrossRef

12.

Stoffel JT, McGuire EJ. Outcome of urethral closure in patients with neurologic impairment and complete urethral destruction. Neurourol Urodyn. 2006;25: 19–22.PubMedCrossRef