Chapter 97 TRANSVAGINAL CLOSURE OF THE BLADDER NECK IN THE TREATMENT OF URINARY INCONTINENCE
The treatment of urinary complications in the female patient with advanced neurologic disease is a challenging problem. Unlike their male counterparts, reliable urinary collection devices do not exist, limiting the available options. Most of these patients are treated with a long-term indwelling Foley catheter, which frequently causes severe complications, including a small and contracted bladder, recurrent infections, bladder stones, and a destroyed urethra. The long-term indwelling catheter and Foley balloon may produce urethral erosion and bladder neck pressure necrosis, resulting in spontaneous urethral expulsion with bladder spasms. In many cases, after the problems of detrusor compliance and bladder storage have been addressed, the patient is left with a fixed, open, and severely damaged urethra. Many options have been proposed for treatment of the destroyed urethra, including transvaginal closure, transabdominal closure, combined transvaginal and transabdominal approaches, a tight pubovaginal sling, or an artificial urinary sphincter. For milder cases with a partially intact urethra, a sling procedure can adequately close the bladder neck of most incontinent patients, but for the more severe cases, a bladder neck closure and suprapubic diversion are often necessary. Bladder neck closure methods remain the therapy of last resort, but they must occasionally be used because not all patients can be successfully managed with minimally invasive therapies.
For urethras that are not totally destroyed, a pubovaginal sling has been used successfully to close the urethra. Chancellor and associates1 used a combined “tight” autologous pubovaginal sling and enterocystoplasty in 10 female patients with urethras destroyed by long-term Foley use. At 24 months, the investigators reported excellent results with minimal incontinence or other complications. They remarked that at least 1 cm of normal urethra was required for proper functioning of the sling and that the sling must be pulled tighter than normal. Mesh may not be applicable in this circumstance because the sling is purposely pulled very tight, possibly leading to a catastrophic erosion. Overall, this method is appealing because it reduces the fistula risk, allows a relief valve if the suprapubic diversion becomes obstructed, and allows alternative catheter access if needed.
There are few published reports on the techniques and outcomes of transvaginal bladder neck closure in female patients. Reid and colleagues2 described five female patients (three procedures were performed transabdominally, and two were performed transvaginally) with an overall 80% cure rate. Fenely3 reported 24 female patients with neurologic disease who underwent transvaginal bladder neck closure and suprapubic tube placement. A vesicovaginal fistula developed in four patients, resulting in persistent incontinence. Zimmern and colleagues4 described six female patients with closure of the bladder neck. At 21 months of follow-up, no fistulas or cases of incontinence had occurred. In 1994, Levy and associates5 reported a 40% success rate using a transvaginal bladder neck closure. They subsequently modified their approach by using a combined transvaginaltransabdominal approach and reported a 100% success rate at a mean of 16 months’ follow-up for their subsequent 10 patients. Shpall and Ginsberg6 reported 39 patients who underwent a combined transabdominal bladder neck closure and continent cutaneous diversion. At a mean of 37 months, six patients (15%) had developed fistulas, and four patients were successfully repaired.
As illustrated by this historical perspective, the risk of complications, specifically a vesicovaginal fistula, is real, and they are difficult to repair. A bladder neck closure is much different from simple closure of the bladder wall, and the risk of a fistula should not be underestimated. Several principles should be understood before performing a bladder neck closure. The bladder neck is usually hyperactive in patients with neurologic disease because most of them have detrusor hyperreflexia, and every voiding reflex includes active opening of the bladder neck. Active opening and closing of the bladder neck therefore forcibly attempts to destroy the bladder neck closure. To reduce this risk, postoperative suppression of the voiding reflex using prolonged, continuous catheter drainage (3 weeks) and liberal use of anticholinergics is imperative.
For a fistula to form, leakage must occur. The repair must be watertight from the beginning, and this requires a precise mucosal closure using a running suture, with multiple additional layers above it to reinforce the strength of the repair. The urethral mucosa sutures lines and the vaginal epithelial suture lines should not overlap the bladder neck closure. For added protection, a drain should be placed through an abdominal incision.