Teresa L. Danforth1 and David A. Ginsberg2
(1)
Department of Urology, State University of New York at Buffalo, Buffalo, NY, USA
(2)
Department of Urology, University of Southern California, Los Angeles, CA, USA
Teresa L. Danforth
Email: danforth@buffalo.edu
David A. Ginsberg (Corresponding author)
Email: ginsberg@med.usc.edu
Abbreviations
CIC
Clean intermittent catheterization
BNC
Bladder neck closure
SPT
Suprapubic catheter
TPN
Total parenteral nutrition
SBO
Small bowel obstruction
TV
Transvaginal
TP
Transperineal
Background
Transvaginal closure of the bladder neck in the female patient is indicated for those with a devastated outlet, usually caused by chronic indwelling urethral catheter placement. Many of these patients have a neurogenic etiology for either urinary retention or urinary incontinence. Chronic catheterization leads to urethral erosion and destruction, ultimately resulting in a patulous urethra that cannot be maintained in the bladder. Management is limited as many of these patients are debilitated due to their comorbid conditions. There is often an inadequate amount of residual urethra to allow for placement of a pubovaginal sling, and many of these patients are unwilling or unable to undergo urinary tract reconstruction. Therefore, the best option is often bladder neck closure with suprapubic tube (SPT) placement. Transvaginal closure is an outstanding option that does not require an abdominal incision, making it a viable minimally invasive option; however, vaginal techniques can be technically challenging for inexperienced vaginal surgeons. Primary complications include fistula formation, bladder stones, SPT site leakage or stenosis, and wound infection. Transvaginal closure of the bladder neck carries less morbidity but may require more than one procedure to achieve continence.
Indications for Transvaginal Closure of the Bladder Neck
Transvaginal closure of the bladder neck in a female patient is indicated for the devastated bladder outlet, usually caused by chronic indwelling urethral catheter placement. Chronic urethral catheters are placed for a variety of indications, including urinary incontinence refractory to other treatments and urinary retention. Many patients with indwelling urethral catheters have a neurogenic etiology (i.e., multiple sclerosis, spinal cord injury, spinal dysraphism, or stroke) as the cause of their lower urinary tract dysfunction. However, as the population ages and treatment of incontinence in the debilitated aging patient continues to be a challenge, chronic indwelling catheter usage may be seen with increasing frequency in this patient population as well.
The typical clinical situation would be one in which a patient undergoes placement of a urethral catheter as she is unwilling or not medically able to undergo any more invasive form of treatment for urinary incontinence or retention. These patients are generally not optimal candidates for clean intermittent catheterization (CIC) for reasons such as physical debilitation, poor hand function, or simply unwillingness to catheterize. In addition, most skilled nursing facilities are unable to maintain patients on a regular CIC program; indwelling catheter placement is a much easier initial option for both the patient and the nursing staff. Male patients with urinary incontinence have the option of using a condom catheter; unfortunately, there is not a similar alternative for female patients. Chronic indwelling catheters are known to have complications including urinary tract infections, urinary tract calculi, catheter plugging, cellular toxicity, and malignancy [1]. Furthermore, pressure from the catheter, balloon, and poor management of catheter by the patient or ancillary staff all contribute to urethral erosion and destruction (Fig. 15.1) [2]. With urethral erosion, further leakage around the catheter can occur which frequently leads to upsizing of the catheter or the balloon, resulting in even further damage to the urethra over time. The urethra become patulous and catheters are frequently pulled out or cannot be maintained in the bladder leading to a decreased bladder capacity, as the bladder can no longer fill and cycle. The damage can lead to traumatic hypospadias and/or anterior urethral erosion to the level of the pubic symphysis.
Fig. 15.1
Urethral erosion as demonstrated by a wide, patulous urethra
Management options for these patients are limited. Unfortunately many of these patients are debilitated secondary to their medical comorbidities and poor nutritional status. The use of pads or diapers can be problematic for management of pressure ulcers and wounds, which are commonplace in this subset of patients. Suprapubic catheters have been successfully used in some patients; however, many patients will still have significant leakage per urethra due to the damage caused by the initial indwelling urethral catheter. Transvaginally placed slings, although theoretically are useful as they allow for continued access to the bladder through the native urethra, do not usually give enough support to achieve continence. In addition, there may not be an adequate amount of residual urethral length to allow for sling placement if the urethral damage is severe enough.
Reconstruction of the lower urinary with various methods have been described but many patients are not willing or medically appropriate to undergo such procedures. In patients who are willing and able to undergo urinary tract reconstruction, closure of the bladder neck is usually achieved transabdominally at the same time as their reconstruction. This type of closure is more invasive but has been reported to have lower rates of fistula formation postoperatively compared to transvaginal repair.
Transvaginal bladder neck closure (BNC) with SPT placement is reserved for those patients whom are not candidates for more invasive reconstruction. The primary concern with this procedure is fistula formation between the closed bladder neck and the vagina and may be more technically challenging for inexperienced pelvic surgeons.
Preoperative Evaluation
Preoperatively the most important decision is which approach to take in managing the patient’s incontinence. Andrews et al. described a series of 57 patients with long-term indwelling catheters of which 39 were managed successfully with SPT alone [1]. Similarly, Eckford et al. reported that 11 of 50 women with multiple sclerosis managed with indwelling catheters were happy with an SPT alone even with a small degree of intermittent leakage from the urethra [3]. It is important to recognize that some patients, depending on the degree of urethral destruction, may have enough improvement in their incontinence with an SPT alone that they may not need further surgical intervention. If this fails due to a poor outlet, then treatment will likely focus on an obstructing sling vs. bladder neck closure. Wantanabe et al. reported that candidates for pubovaginal sling must have an intact bladder neck with 1 cm of proximal urethral tissue in order to obtain effective compression of the urethra, which may or may not be the case in patients with a chronic indwelling catheter [4]. If bladder neck closure is to be done, then the decision between transvaginal versus transabdominal approach needs to be resolved.
When considering abdominal versus vaginal approaches, various factors must be considered: morbidity of the procedure, planned concomitant procedures, prior surgeries, surgeon experience [1, 5]. Certainly avoiding an abdominal incision allows for decreased morbidity, but the transvaginal approach is associated with higher rates of fistula and/or failure [1, 2, 5]. A discussion with the patient regarding the lower morbidity but higher risk of failure and potential need for reoperation must take place to set appropriate expectations. Surgeon experience should also be taken into account, as less experienced vaginal surgeons may not fare as well with this approach. Levy et al. reported on a series of 12 patients, 4 of whom underwent transvaginal closure of the bladder neck alone with a 50 % success rate [5]. The two patients who failed and the subsequent 8 patients underwent combined abdominal and transvaginal approach with 100 % success. Levy suggests that surgeons without significant experience operating vaginally should consider an abdominal approach to achieve higher success. Ginger et al. also reported an 11 % leakage rate in 26 patients undergoing abdominal BNC as opposed to a 100 % leakage rate in 2 patients who underwent transvaginal approach [2].
As already discussed, patients with chronic indwelling catheters are often debilitated and malnourished. Poor preoperative nutrition status is associated with poor wound healing, increased infection rate, higher pulmonary complication rate, prolonged hospitalization, and higher mortality rates [6]. Hebbar et al. reviewed studies looking at the use of total parenteral nutrition (TPN) or enteral feeds preoperatively and the rates of complications. From the VA TPN Cooperative Study which used 7–15 days of preoperative TPN, patients with severe malnourishment were found to have a dramatic drop in complication rate from 42.9 to 5.3 % with the use of TPN; however, pooled data of all patients did not show any significant difference. There was no difference between the use of TPN vs. enteral feeds. Therefore, one could consider using preoperative nutrition in the severely malnourished patient.
Procedure
Various techniques have been described to perform a transvaginal closure of the bladder neck [1–3, 7–10]. The patient is placed in dorsal lithotomy position with adequate exposure to the anterior vaginal wall using labial retraction sutures and/or a self-retaining retractor, with or without a posterior weighted speculum. If an SPT is not already present, one can be placed with various techniques. Eckford et al. describe a two stage technique in which an SPT is placed during the first procedure (percutaneously or open) followed by a second procedure for transvaginal BNC if the patient continues to leak [3]. A Lowsley suprapubic tractor may be used to aid in SPT placement if desired [7].
The anterior vaginal wall is infiltrated with injectable saline to aid in the dissection of the vaginal wall from the urethra and bladder. Two incisions are made along the anterior vaginal wall: one circumferentially around the urethral meatus and the second as an inverted wide-based anterior vaginal wall flap beginning from the urethral meatus extending past the bladder neck (Fig. 15.2a–f) [9]. The urethra is dissected laterally over the periurethral fascia to the retropubic space and off of the urethropelvic ligaments followed by transection of the urethra off of the urethropelvic ligament dorsally to the inferior margin of the pubic symphysis. This allows for complete mobilization of the remaining urethra and bladder neck (Fig. 15.2b). The necrotic urethral tissue is then removed, which may in fact be the entire urethra, thus making bladder neck mobility extremely important. If there is viable urethral tissue, one can utilize a technique described by Rovner et al. in which the anterior urethra is divided toward the bladder neck and the bivalved urethra is rotated in an anterior and cephalad direction and secured to the anterior bladder wall with two layers of absorbable suture (Fig. 15.2d). This rotates the suture line anteriorly, toward the retropubic space and underneath the pubic symphysis, minimizing overlying suture lines during closure of the vaginal wall flap (Fig. 15.2e, f). In addition, if possible, we also try to then secure the sutures used to close the bladder neck to the undersurface of the pubic symphysis, further placing the bladder neck closure anteriorly. Mobilization of the closure upward should minimize the risk of postoperative fistula formation. The vaginal wall flap is closed with absorbable suture and packing is placed.
Fig. 15.2
(a–f) TV BNC with posterior urethral flap. (a) Vaginal wall flap developed and dorsal semilunar incision is made above the urethra. (b) Dissection continued above urethra into retropubic space. Pubourethral and urethropelvic ligaments taken down, mobilizing urethra and anterior bladder neck. (c) Dorsal urethra bivalved and incision carried onto anterior bladder neck for 2–3 cm. (d) Dorsally bivalved urethra then rotated cephalad toward anterior bladder wall incision. (e) Ventral urethral flap affixed high on anterior bladder wall, such that when bladder rotates into anatomic position, suture line rotates under symphysis pubis. (f) Vaginal wall closed as second layer with no overlapping suture lines (All: Used with permission from Rovner ES, Goudelocke CM, Gilchrist A, Lebed B. Transvaginal bladder neck closure with posterior urethral flap for devastated urethra. Urology 2011;78(1):208-212)
Nielson et al. describe a technique in which two chromic sutures are passed through the SPT site via the Lowsley tractor and used to tag the edges of the urethral closure [7]. These sutures are then later used to invaginate the urethral mucosa and pull the urethra away from the vaginal closure.
Flaps or graft placements are generally not necessary in primary repair. In cases where the perivesical tissues may be compromised or in patients with history of prior pelvic radiation, one can consider using a Martius flap for interposition [8]. In patients who have failed prior attempts, a combined abdominal and vaginal approach with omental, peritoneal, or Martius flaps have been described [3, 9].
Postoperative Management
Appropriate postoperative management is critical to success of abdominal or transvaginal closure of the bladder neck. Ginger et al. found an association with poor postoperative catheter care and leakage [2]. They found that 13 of 29 patients had documented poor catheter management by their caregivers which included poor securing of the SPT, inadequate catheter irrigation, clogging, kinking, and dislodgement. 7 of 8 patients with persistent leakage postoperatively (6 urethral and 2 around SPT) were associated with poor catheter care. This stresses that not only an adequate catheter size should be used but also that catheters need to be appropriately secured at all times and irrigated if necessary to ensure that it is draining appropriately.
Equally important to adequate catheter drainage is management of detrusor overactivity. Ginger et al. demonstrated detrusor overactivity in 12 of 23 patients preoperatively [2]. Stoffel et al. also showed that 10 of 12 neurogenic patients had poorly compliant bladders on fluorourodynamics prior to BNC with urinary diversion [10]. Although an SPT should allow for continuous bladder drainage, physiologically an open bladder neck prompts a bladder contraction. Higher pressures in the bladder put stress on the suture line, thus increasing the risk of postoperative fistula formation. Administration of anticholinergics will potentially decrease this risk and should be used postoperatively (or continued if patient is already on them) [11]. The use of onabotulinumtoxinA at the time of BNC has not yet been studied, but presumably would allow for lower bladder pressures and higher success rates.
There are various complications associated with transvaginal closure of the bladder neck, the most important of which is continued leakage of urine and development of a vesicovaginal fistula. A postoperative cystogram should be performed 2–3 weeks following the procedure to assess the integrity of the repair. If a leak is suspected but cannot be identified on cystogram, often it can be identified on examination. Methylene blue or indigo carmine irrigation in the bladder can be used to easily identify the site of leakage if it cannot be identified.
If there is a leak, continued catheter drainage can be attempted with the hopes of eventual closure. No study has looked at conservative management of leakage after an attempted transvaginal BNC. In uretero-ileal anastomosis or abdominal BNC with fistula, it has been suggested that conservative management with continued drainage for several weeks with frequent catheter irrigations and placement of bilateral percutaneous nephrostomy tubes may lead to resolution of a fistula [11]. If a patient has a leak on cystogram with bladder filling, but is clinically dry, these patients can usually be managed with regular SPT changes monthly and do not require further intervention unless the fistula progresses and becomes clinically relevant. For a matured fistula tract, repeat surgery may be considered. The choice of transvaginal versus transabdominal versus combined approach is at the discretion of the surgeon. Those surgeons with more vaginal experience may consider a repeat transvaginal approach with or without a Martius flap. Less experienced vaginal surgeons may consider an abdominal approach or combined abdominal and transvaginal approach. If the repair is not salvageable, more invasive measures for urinary diversion may be considered including cystectomy with continent or incontinent diversion.
Complications
Fistula rates for transvaginal BNC are variable, ranging from 0 to 100 % (Table 15.1) [1–3, 5, 7, 9–12]. After revision, fistula rates drop to 0–25 % [1, 3, 9–11]. Abdominal BNC fistula rates are notably lower with both primary repair (0–18 %) and after revision (0–6 %) [1, 2, 10, 11, 13, 14].
Table 15.1
Comparison of complication rates of transvaginal and transabdominal BNC
|
Author |
Approach (number of patients) |
Follow-up |
Complications |
Fistula rate |
|
Zimmern et al. [12] |
Transvaginal (6) |
TV 0 % |
||
|
Nielsen et al. [7] |
Transvaginal (5) |
35 months (10–78) |
SPT site stenosis 20 % |
TV 20 % |
|
Eckford et al. [3] |
Transvaginal (50) |
6.5 years (2–17)a |
Bladder stones 42 % Catheter blockage 79 % Redo SPT 11 % |
TV 22 % 8 % after 2nd revision |
|
Levy et al. [5] |
Transvaginal (4) Combined (10)b |
15.6 months (6–40) |
TV 50 % Combined 0 % |
|
|
Andrews et al. [1] |
SPT (39) Urethral Recon (6) Transvaginal (8) Abdominal with augment(4) |
4.6 years (0.5–9.5) |
Bladder stones 6 % SPT site leakage 6 % |
Urethral Recon 33 % TV 50 % 25 % after revision Abdominal 0 % |
|
Shpall et al. [11] |
Abdominal with augment (39) |
36.9 months (7–173) |
Stomal Dysfunction 15 % Wound Infection 3 % Retained sponge 3 % Stones 13 % |
Abdominal 15% 3 % after revisionc |
|
O’Connor et al. [14] |
Abdominal with SPT (15) Abdominal with Continent Stoma (12) Abdominal with Ileovesicostomy (5) |
78.6 months (12–164) |
Vesicocutaneous fistula 6 % Enterocutaneous fistula 3 % SBO 3 % Stomal stenosis 9 % Bladder stone 6 % |
Abdominal 17 % 6 % after revision |
|
Stoffel et al. [10] |
Transperineal (4)d Transvaginal (8)d |
20 months (9.2–27) |
Poor bladder compliance 8 % |
75 % (all patients 1 procedure) TV 12.5 % after revision TP 0 % after revision |
|
Spahn et al. [13] |
Abdominal with continent diversion (17) |
68 months (12–129) |
Vesico-intestino-cutaneous fistula 6 % Stomal Stenosis 24 % Stones 12 % |
Abdominal 18 % 0 % after revision |
|
Ginger et al. [2] |
Transvaginal (2) Abdominal (26) Perineal (1) |
38.2 months (0.9–104) |
SPT dysfunction 24 % Wound infection 21 % SPT leakage 3 % SBO 3 % Urosepsis 3 % Stones 10 % |
TV 100 % Abdominal 12 % Perineal 100 % |
|
Rovner et al. [9] |
Transvaginal (11) |
9.6 months (1–36) |
Cellulitis 9 % |
9 % 0 % after revision |
aOnly 19 patients had data for review
b2 patients were failed transvaginal BNC
cOne patient had spontaneous resolution of fistula
dPatients underwent concomitant bladder augmentation
Other complications of transvaginal BNC surgery include bladder stones, SPT site leakage, SPT site stenosis, leakage around SPT, and wound infection. If associated bladder augmentation procedures are performed, further complications can arise including intestinal fistulae, stomal stenosis, small bowel obstruction (SBO), and poor bladder compliance.
Summary
Overall, transvaginal closure of the bladder neck is well tolerated and carries less morbidity than an abdominal approach; however, patients may require more than one procedure to achieve continence.
References
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