V2-08: Transvaginal Bladder Neck Closure for the Devastated Female Urethra
Management of female urinary retention or incontinence with a chronically indwelling urethral catheter inevitably leads to urethral destruction over time. Incontinence from an eroded or patulous urethra not only worsens quality of life but also may result in skin breakdown and non-healing decubitus ulcers particularly in neurologically injured patients. Management of the destroyed urethra is especially difficult as pubovaginal slings are rendered impossible and abdominal approaches to bladder neck closure can be morbid in the debilitated patient. Herein we present our video of transvaginal (TV) bladder neck closure with posterior urethral flap for treatment of the devastated female urethra as described by Rovner et al. (Urology 2011)
Our patient is a 63 year old, obese, diabetic, paraplegic female with chronic neurogenic bladder after a prior spinal cord stroke. She is unable to self catheterize and had been managed for years with an indwelling urethral foley. This eventually lead to destruction of her urethra, total urinary incontinence and chronic non-healing decubitus ulcers. Insertion of a suprapubic tube and three prior attempts at bladder neck closure were unsuccessful in resolving her leakage. She was referred to our institution where we performed a multi-layered TV bladder neck closure with Martius flap interposition.
The operation was uneventful. Operative time was 3.5 hours. EBL was 650 cc. The patient had her vaginal packing and labial penrose drain removed on POD#1 prior to discharge. She was seen in follow up at 3 months and her SPT was draining well, she had no vaginal leakage and her decubuti were steadily healing.
TV bladder neck closure is an effective, minimally invasive means of resolving the difficulties presented by the devastated female urethra, avoiding the risks associated with a transabdominal approach especially in the neurologically injured patient. Utilization of a posteriorly based urethral flap mitigates the risk of ureteral injury, while allowing the closure line to lie high in the retropubic space minimizing the risk of fistula formation.