V12-13: URETHROLYSIS FOR SYNTHETIC PERI-URETHRAL BULKING AGENT COLLECTION
VideoIntroductions and Objectives
Although urethral bulking therapy (UBT) is a minimally invasive procedure for stress incontinence, it nevertheless carries risks and potential for complications. We present the case of a 63 year old female with a history of hysterectomy and stress incontinence who failed sling placement and a subsequent peri-urethral Durasphere ® injection and presented with incontinence, bladder spasms and sharp, throbbing pain. An MRI 6 months after her UBT revealed a periurethral submucosal soft tissue mass. transvaginal ultrasonography revealed a 1 cm spherical periurethral collection at the bladder neck. Cystoscopy revealed a spherical bulge in the proximal urethral wall and retroflexion revealed a spherical bulge at the bladder neck. We present a video demonstrating the surgical technique utilized to perform a transvaginal urethrolysis and removal of peri-urethral Durasphere ® collection.
A circumferencial incision was made around the urethral meatus. Sharp and blunt dissection was then carried out to mobilize the urethra from the meatus to the bladder neck. The pubo-urethralis muscle was then divided, and circumferential urethrolysis was carried out proximally. The urethro-pelvic ligament was also incised. Urethrolysis was carried out to the bladder neck with care taken not to injure the urethral wall. The peri-urethral collection was dissected and the collection of Durasphere (R) with exudate was identified. The collection sac was then thoroughly examined using the flexible cystoscope and no communications was found with the urethral lumen. Intra-operative flexible cystoscopy was repeated and revelead a resolution of the previously noted spherical bulge at the bladder neck. The urethra was then plicated bilaterally on the lateral walls using 4.0 vicryl interrupted sutures and the the urethra was wrapped with a strip of Interseed mesh to guide the healing process. 4.0 vicryl sutures were used to stabilize the Interseed mesh and to prevent its migration and the peri-meatal incision was closed.
There were no complications and the patient was discharged home the following day with an indwelling foley catheter which was removed 10 days following the procedure. Two weeks postoperatively the patient had complete resolution of her pain as well as incontinence.
Transvaginal urethrolysis can correct complications associated with paraurethral Durasphere ® injections. When combined with a urethral and bladder neck plication, this technique can also lead to resolution of the original incontinence symptoms.