There is unfortunately little that can be done preoperatively to enhance the postoperative success 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 and colleagues 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 urologic surgeons have become more 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. Ginger and colleagues 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]. Willis and colleagues reviewed their experience with both approaches in 64 patients (35 transvaginal, 29 retropubic) and noted residual urethral leakage in five patients in both the transvaginal (5/35–14.3%) and retropubic (5/29–17.2%) cohorts [5].

Poor nutrition is one issue that can be addressed preoperatively. Rovner and colleagues correctly state that many of these patients often have multiple medical comorbidities and poor nutritional status at baseline [6]. 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 [7]. However, preoperative nutritional supplementation appears to only be valuable in severely malnourished patients; in all other patients, surgery does not need to be delayed [8].

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. Adequate mobility allows the surgeon to pull the bladder neck out with stays; thus making the actual closure of the bladder neck less challenging. In addition, with adequate mobility of the closed bladder neck, the repair itself can be mobilized anteriorly away from the vaginal wall closure. After closing the bladder neck in two layers, I will tag the sutures involved with the repair. The needle attached to those BNC sutures can then be brought through the undersurface of the pubic symphysis or even the anterior abdominal wall. This results in mobilization of the suture line of the BNC anterior, away from the vaginal wall closure. Theoretically, this will help minimize fistula formation if the initial repair is not watertight. This maneuver cannot be done if adequate mobility of the bladder neck has not been obtained.