Indications
Female vesical neck closure is an uncommon procedure often reserved for those with severe urethral incompetence. There are a number of conditions in which vesical neck closure is indicated; the most common is in patients with neurogenic voiding dysfunction who have been managed with chronic indwelling urethral catheters. Frequently, these patients have been subjected to an increase in catheter and retention balloon sizes or escalating doses of anticholinergic medications for symptomatic control. Some may also have had repeated trials of chemodenervation. It may also go unrecognized that long-term catheterization has led to urethral dilation, resulting in complete loss of the continence mechanism. In the most severe cases, pressure necrosis may lead to traumatic hypospadias posteriorly, or there may be complete anterior loss of the urethra with exposure of the underlying pubic symphysis. This can lead to osteitis pubis and osteomyelitis. Vesical neck closure may also be indicated in patients with urethral loss related to failed anti-incontinence procedures, failed urethrovaginal fistula repairs, and complications related to the use of synthetic suburethral mesh. In these patients, the urethra may be beyond repair.
Regardless of the indication, vesical neck closure requires a concomitant low-pressure urinary diversion such as a suprapubic cystostomy, an ileovesicostomy, or augmentation cystoplasty with a continent catheterizable stoma. The type of urinary diversion chosen depends on the patient’s functional status, nutritional status, level of support from family and other caregivers, prior surgical history, and surgeon experience. It is imperative that both the patient and family are aware that vesical neck closure is a permanent and irreversible procedure.
Preoperative Evaluation
Physical examination may reveal skin changes to the perineum caused by chronic wetness. The urethra will be patulous. Often an examining finger is able to cannulate the meatus. If a Foley catheter is in place, there is a significant gap between the urethral mucosa and the catheter itself, allowing incontinence around the Foley catheter to occur ( ).
Preoperative evaluation may include ancillary studies such as cystoscopy and urodynamics. If the patient has had a long-term indwelling Foley catheter, cystoscopy should be done to rule out bladder malignancy. Additionally, many patients considering vesical neck closure have bladders of small capacity or poor compliance. Preoperative urodynamics will allow assessment of capacity and compliance and aid the surgeon’s decision to perform augmentation cystoplasy at the time of vesical neck closure (VNC), especially if combined with a catheterizable stoma. Severe vesicoureteral reflux warrants an augmentation cystoplasty at the time of bladder neck closure if being combined with a catheterizable channel. Many long-term studies have shown that there has been no de novo or worsening hydronephrosis after vesical neck closure and suprapubic tube insertion.
The patient’s nutritional status should be assessed if bowel segments are to be incorporated into the urinary system (i.e., catheterizable channel, augmentation cystoplasty, and ileovesicostomy). It is common for patients with neurologic conditions considering this procedure to be nutritionally depleted, placing them at risk for anastomotic leaks and wound complications. If concomitant bowel surgery is to be performed, the appropriate bowel preparation should be done. This is not usually necessary if the small bowel will be used; however, if using the colon, the surgeon should prepare the bowel, especially if the patient has a neurogenic bowel. Deep vein thrombosis prophylaxis is also essential. In all patients, begin with a clean urinalysis and urine culture. This may be difficult to achieve if there have been longstanding catheters. In that case, the patient should receive culture appropriate perioperative antibiotics, and the bladder should be irrigated with several liters of normal saline or sterile water at the beginning of the procedure.
Preoperative Evaluation
Physical examination may reveal skin changes to the perineum caused by chronic wetness. The urethra will be patulous. Often an examining finger is able to cannulate the meatus. If a Foley catheter is in place, there is a significant gap between the urethral mucosa and the catheter itself, allowing incontinence around the Foley catheter to occur ( ).
Preoperative evaluation may include ancillary studies such as cystoscopy and urodynamics. If the patient has had a long-term indwelling Foley catheter, cystoscopy should be done to rule out bladder malignancy. Additionally, many patients considering vesical neck closure have bladders of small capacity or poor compliance. Preoperative urodynamics will allow assessment of capacity and compliance and aid the surgeon’s decision to perform augmentation cystoplasy at the time of vesical neck closure (VNC), especially if combined with a catheterizable stoma. Severe vesicoureteral reflux warrants an augmentation cystoplasty at the time of bladder neck closure if being combined with a catheterizable channel. Many long-term studies have shown that there has been no de novo or worsening hydronephrosis after vesical neck closure and suprapubic tube insertion.
The patient’s nutritional status should be assessed if bowel segments are to be incorporated into the urinary system (i.e., catheterizable channel, augmentation cystoplasty, and ileovesicostomy). It is common for patients with neurologic conditions considering this procedure to be nutritionally depleted, placing them at risk for anastomotic leaks and wound complications. If concomitant bowel surgery is to be performed, the appropriate bowel preparation should be done. This is not usually necessary if the small bowel will be used; however, if using the colon, the surgeon should prepare the bowel, especially if the patient has a neurogenic bowel. Deep vein thrombosis prophylaxis is also essential. In all patients, begin with a clean urinalysis and urine culture. This may be difficult to achieve if there have been longstanding catheters. In that case, the patient should receive culture appropriate perioperative antibiotics, and the bladder should be irrigated with several liters of normal saline or sterile water at the beginning of the procedure.
Abdominal Approach
Place the patient in the low lithotomy position. After an appropriate antibiotic skin and vaginal prep, drape the patient so that the vagina is accessible. Place a Foley catheter at this time. The procedure can be done through either a low midline or transverse (Pfannenstiel) incision. After entering the abdomen, bluntly dissect the space of Retzius. Do this as widely as possible to ensure greatest mobility and working space. Take care not to avulse the dorsal venous complex. Next, enter the endopelvic fascia and ligate the dorsal venous complex with 0 synthetic absorbable suture (SAS) ties. Dissect the borders of the urethra as extensively as possible. The pubourethral ligaments should be transected. This can be accomplished with suture ligatures, a harmonic scalpel, or a LigaSure device. This will allow complete urethral mobility.
Transect the dorsal surface of the urethra at the level of the pelvic inlet (maximizing urethral length), exposing the Foley catheter ( Fig. 66.1 ). This can be done sharply or with cautery. Divide the catheter so that it may be drawn retrograde into the operative field, taking care not to let the balloon deflate. Clamp the catheter and place upward traction on the bladder neck. Transect the ventral aspect of the urethra. The distal urethra can be closed at this point in two layers using a running 3-0 polyglycolic acid (PGA) suture on the mucosa and an interrupted 2-0 PGA inverting layer. Or the distal urethral closure may be completed with 2-0 chromic sutures in a figure-of-8 fashion.
Open the bladder anteriorly down through the bladder neck. Next, identify the ureteral orifices. Note that the orifices may be closer to the level of urethral transection if there has been significant urethral loss. Ureteral catheters can be placed, or indigo carmine can be administered intravenously to aid in visualization of the ureteral orifices. Transect the bladder neck from the proximal urethra. Continue the dissection posterior to the bladder neck in the vesicovaginal space. Mobilize the bladder off the vaginal wall until it is rolled away from the inlet ( Fig. 66.2 ).
Place a cystostomy tube or construct a diversion at this time. If placing a cystostomy tube, a 20- to 22-Fr Foley catheter is desirable for adequate drainage.
Begin a two-layer closure of the bladder neck. The first layer should invert the mucosa and is placed in a vertical running fashion with 3-0 PGA ( Fig. 66.3, A ). The second layer should be done horizontally with 2-0 PGA suture. Exaggerate suture bites on the upper side so the closure rolls up and away from the dependent position and the closed distal urethra ( Fig. 66.3, B ). A watertight closure should be confirmed at this time by irrigating the bladder via the suprapubic tube with 200 to 300 cc of fluid. If possible, an omental or peritoneal flap can be placed over the closure for more security.
A perivesical drain is left in place and removed just before discharge if output is minimal.
Urethral Approach
This approach can be performed if an abdominal incision is to be avoided or is not desired. Start by placing the patient in the low lithotomy position. After adequate lower abdominal and vaginal skin prep, cystoscopy is performed, and a cystotomy is made along the anterior dome with the aid of curved Lowsley retractor, which elevates the bladder to the anterior abdominal wall. A 20- to 22-Fr catheter is desirable for adequate bladder drainage. A Malecot catheter should be avoided because they are easily dislodged. The suprapubic tube is secured to the skin with silk or nylon suture material. Retract the labia with sutures or a self-retaining ring retractor and place a weighted vaginal speculum.
An elliptical incision is made around the urethra. This should be full thickness through the surrounding vaginal mucosa ( Fig. 66.4 ).
Sharply dissect the urethra from the anterior vaginal wall. The plane anterior to the urethra is developed and dissection is carried up to the level of the pubic symphysis or bladder neck. Perforate the endopelvic fascia and free the bladder neck attachments in the retropubic space, including the pubourethral ligaments. These can be easily secured with suture ligatures, a harmonic scalpel, or a LigaSure device (the latter two may help avert troublesome bleeding). At this point, the urethra and the bladder neck should be free and mobile. If not, continue to mobilize any areas fixed on the vaginal side or in the retropubic space.
The distal urethra is trimmed. After excision of this portion, the remaining urethra is inverted. Begin by placing three 2-0 PGA mattress sutures so that the mucosal edge is rolled into the lumen of the urethra. This should exclude the mucosa from the operative field. Next, place a 2-0 PGA purse-string suture around the bladder neck. Invert the urethra into the bladder and tie down the purse-string ( Fig. 66.5 ). A watertight closure should be confirmed at this time by irrigating the bladder via the suprapubic tube with 200 to 300 cc of fluid.
Close the periurethral fascia over the bladder neck. Last, the urethral hiatus should be closed with interrupted 3-0 chromic cat gut suture. Place a vaginal pack coated with vaginal estrogen creme.
An alternate approach is illustrated in Fig. 66.6 . Here an elliptical incision is made around the urethra. The urethra is then dissected from the surrounding tissues and freed from the pubourethral ligaments. After it is isolated, the urethra is transected just distal to the bladder neck, and the bladder neck is closed in two layers using 2-0 polyglactin suture material. The vaginal mucosa is then closed using the same but in a simple interrupted fashion.
Vaginal Approach
This is another approach to closing the vesical neck that avoids entry into the abdomen. This approach is similar to that of the urethral approach, but because of its wider area of dissection, the urethra can be transected more proximally, and there is greater ability to roll the bladder neck anteriorly during the second layer closure. Start by placing the patient in the low lithotomy position. A suprapubic tube is placed in the same manner as described earlier in the urethral approach. Retract the labia with sutures or a self-retaining ring retractor and place a weighted vaginal speculum.
Begin with a wide inverted U -shaped incision on the anterior vaginal wall. If desired, the anterior vaginal wall can be injected with saline or a dilute lidocaine with epinephrine solution to hydrodissect the vesicovaginal space. Start the apex of the U incision close to the urethral meatus, and extend it proximally as far into the introitus as possible ( Fig. 66.7 ). The longer this flap can be made, the less tension there will be at the time of closure. Develop the anterior vaginal flap from this incision. The correct level of dissection should reveal the glistening white surface of the vaginal wall ( Fig. 66.8 ). If the flap is too thick, venous or detrusor bleeding will occur.
