Bladder neck closure (BNC) is an uncommon procedure that has traditionally been reserved as a final alternative for the management of the female patient with neurogenically induced intractable incontinence arising from long-term Foley catheter drainage. It has also been used in the treatment of nonneuropathic conditions such as traumatic urethral destruction or recalcitrant fistula. BNC in the male is usually reserved for patients with neurogenic bladder or a history of incontinence secondary to trauma or urethrocutaneous fistula failing multiple prior attempts at surgical correction or artificial sphincter placement.

With the many other options that exist for the treatment of these complex conditions, there is a limited but distinct role for BNC. Though initially fraught with a high failure rate,7 patient selection and technical refinements have allowed some authors to achieve a success rate of nearly 100%. This chapter will focus on the technique of both abdominal and vaginal bladder neck closure in the female and abdominal bladder neck closure in the male with emphasis on the principles necessary to achieve both successful and durable results.

DIAGNOSIS

Preoperative evaluation and patient selection is extremely important to the success of BNC. A careful history should include special attention to prior abdominal or pelvic surgeries including prior reconstructive flaps or grafts. During the physical exam it is important to carefully assess the presence of lower extremity contractures that may limit access to the vagina, perineal skin integrity or presence of decubiti, and the potential for intermittent catheterization to be carried out successfully. In the patient with adequate manual dexterity or a reliable caregiver, a catheterizable efferent limb from the bladder may be chosen for postoperative drainage. When intermittent catheterization is not feasible, options for postoperative bladder drainage primarily consist of suprapubic tube or incontinent ileovesicostomy.

Study of the upper urinary tract by either ultrasonography or intravenous pyelography is important to exclude hydronephrosis or ureteral obstruction as often the same processes responsible for the patient’s incontinence may promote upper tract deterioration. When upper tract deterioration is noted, strong consideration must be given to supravesical diversion or preserving the bladder and lowering intravesical pressures by augmentation cystoplasty. A static or voiding cystogram assists in detecting bladder diverticula, vesicoureteral reflux, and calculi. In the case of urethral fistula or stricture, a retrograde urethrogram or fistulogram can document the nature and extent of the patient’s underlying disease.

Cystoscopy with biopsy to exclude malignancy is essential for the patient who has been managed for an extended period with an indwelling catheter. The extent of urodynamic evaluation is tailored to the choice of postoperative bladder management. In the patient who desires continent, catheterizable access to the bladder, preoperative urodynamic evaluation of bladder storage parameters such as compliance and detrusor instability (hyperreflexia) must be documented to determine the need for concomitant augmentation cystoplasty. When the bladder outlet is patulous, occlusion of the outlet during urodynamic evaluation can be readily accomplished using gentle traction on an inflated Foley catheter.

A sterile urine culture should be documented preoperatively. When it is impossible to completely sterilize the urine, culture-specific preoperative parenteral antibiotics must be administered to ensure adequate tissue levels at the time of surgery.

INDICATIONS FOR SURGERY

Female

The indications for bladder neck closure in the nonneurogenic patient are urethral destruction, severe intrinsic sphincteric deficiency that is not amenable to conventional treatment, and urethrovaginal fistula failing prior attempts at repair. Patients suffering from neurogenic incontinence often have intractable leakage from urethral destruction due to the long-term effects of an indwelling urethral catheter. A common indication is the patient with advanced multiple sclerosis with urethral destruction from chronic Foley catheter drainage who is not a candidate for aggressive reconstruction. Though control of incontinence has been achieved by some using a pubovaginal sling, many patients with urethral destruction and reduced urethral length are not suitable candidates for this procedure. Likewise, for the female patient who has failed attempts at urethrovaginal fistula closure, BNC with a continent catheterizable efferent channel, incontinent vesicostomy, or suprapubic tube may represent a viable option for management.

The vaginal approach is favored in the patient without history of prior radiation who desires suprapubic tube drainage. An abdominal approach is desirable for the patient with a history of radiation in whom vaginal tissues may be poorly vascularized and in whom omental interposition between the bladder neck and vagina is desirable. It is also the approach of choice in the patient who elects for a continent catheterizable efferent limb (made of bowel or appendix), incontinent ileovesicostomy, or has failed a prior attempt at vaginal closure of the bladder neck.

Male

The role of BNC in the male resides in the management of refractory urethrocutaneous or urethrorectal fistulas, and in cases of severe neurogenic or postoperative incontinence (with low outlet resistance) when the artificial sphincter is not an option. It may also be used in the treatment of recalcitrant urethral strictures when reconstruction is impossible or undesired.

ALTERNATIVE THERAPY

Options for local reconstruction in females with severe incontinence or fistula are limited. Though urethral reconstruction with vaginal wall or bowel is an available option, maintaining a urethral outlet that is both patent and continent can prove extremely challenging. Continence following these reconstructive procedures may be provided by autologous or synthetic sling materials, injectable bulking agents (collagen or fat), artificial urinary sphincter, or bladder neck reconstruction (Young-Dees). In the male with refractory incontinence or fistula, the artificial urinary sphincter and formal fistula closure are other viable alternatives.

Historically, supravesical diversion and ureterosigmoidostomy (nonneurogenic patients) have been advocated for treatment of patients with this severity of incontinence. However, it is our opinion that BNC should be considered before embarking on these more extensive surgical options. BNC not only preserves the bladder but preserves the integrity of the ureterovesical junction, thereby protecting the upper tracts.

SURGICAL TECHNIQUE

The goals of the procedure are the same for both male and female patients regardless of the approach utilized, i.e., wide mobilization of the bladder neck to allow for tension-free closure, multilayer closure of the outlet without overlapping suture lines thereby reducing the opportunity for fistula, interposition of vascularized tissue between the vesical outlet and urethral stump or vagina, and adequate postoperative bladder drainage with a large-bore catheter.

Vaginal Approach (Female)

The vaginal approach is preferred in the female who desires suprapubic tube drainage, has no history of prior radiation, and is not undergoing a concomitant abdominal procedure. Preoperative preparation includes antibiotics, vaginal douching, enema, and deep venous thrombosis prophylaxis. The patient is placed in high lithotomy position with careful attention to padding of all pressure points and extremities. A Lonestar ring retractor (Houston, TX) is suggested along with a weighted vaginal speculum and headlight to provide maximal vaginal exposure. In the case of a small contracted bladder, the curved Lowsley retractor is employed to place a suprapubic tube. The patient is placed in deep Trendelenburg position to displace bowel contents and the curved retractor is introduced through the urethra and directed to the anterior abdominal wall 1 to 2 cm above the symphysis pubis. A small suprapubic incision is made over the tip of the Lowsley, which can be palpated beneath the fascia. The tip of the retractor is then pushed out through the skin incision and a 20-Fr Foley catheter is grasped between the open jaws and delivered back into the bladder. Its intravesical position can be confirmed with cystoscopy or irrigation with normal saline.

A waterproof surgical ink pen marks the proposed inverted U-shaped vaginal wall incision. A dilute solution of vasopressin 60 U/100 cm3 is injected into the periurethral tissues and anterior vaginal wall to facilitate dissection of both the urethra and anterior vaginal flap and reduce local bleeding.

After a circumscribing incision has been made around the urethral meatus, the broad-based vaginal flap is elevated using sharp scissors dissection. This flap not only aids in the exposure of the remainder of the urethral dissection but serves as an advancement flap to close over the amputated vesical outlet and interposed labial fat pad. When dissecting in the proper plane, the vaginal wall exhibits a distinctly recognizable white glistening surface. Significant venous bleeding may be encountered when the dissection is carried out too deep and into the venous sinuses of the bladder wall. Sharp dissection is then used to free the urethra from its lateral and anterior fascial attachments. To achieve a tensionfree closure, the bladder neck must be completely detached from its surrounding (mostly anterior) attachments. The pubourethral ligaments are sharply transected and the endopelvic fascia is perforated bilaterally using blunt or sharp dissection. After entering the retropubic space, blunt dissection is used to free the lateral and anterior aspects of the bladder neck. Indigo carmine is given intravenously to aid in visualizing the ureteral orifices and the urethral edges may be trimmed to expose fresh healthy tissues for formal closure.

The bladder neck is first closed in a vertical fashion with absorbable 3-0 polyglycolic acid (PGA) suture. The integrity of the closure is checked by filling the bladder by gravity through the suprapubic tube. A second horizontal layer of interrupted 2-0 PGA serves to both imbricate the first layer and transfer the closed bladder outlet to a position high behind the symphysis pubis, thus rotating it into a nondependent position. This technique not only avoids a dependent closure but also directs the force of bladder spasms away from the vagina, thereby reducing the likelihood of secondary vesicovaginal fistula.

The use of a Martius flap is recommended to reinforce the bladder neck closure and reduce the risk of fistula. The technique relies on a well-vascularized fibrofatty labial pad (from the labia majora) that is based posteriorly on a labial branch of the internal pudendal artery.8 The Martius flap is tunneled beneath the vaginal wall and fixed in place over the bladder neck closure with 3-0 PGA sutures. The vertical labial incision can be closed with absorbable suture over a small suction drain. The vaginal flap is trimmed and advanced to close the vaginal incision with running 3-0 PGA suture. The suprapubic tube is then irrigated to ensure patency and the vagina is packed for 24 hours with an antibiotic-soaked pack.

Abdominal Approach Female

The patient is placed in low lithotomy position to provide continuous access to the vagina. Alternatively, if lower extremity contractures prohibit lithotomy position, supine position may be appropriate. A urethral Foley catheter is placed and an infra-umbilical midline incision made. This incision not only provides excellent exposure but also can be extended for omental harvest or use of bowel for an efferent catheterizable limb. A Pfannenstiel incision may be considered if a chronic suprapubic tube is chosen for postoperative bladder management. The rectus muscles are retracted laterally and the prevesical space (Retzius) is developed bluntly. The peritoneum is retracted superiorly, and a self-retaining retractor (Balfour or Bookwalter) provides exposure of the retropubic space.

With the aid of the Foley catheter and its balloon, the bladder neck and urethra are identified. A 2-0 PGA figure-of-8 suture is placed through the distal most aspect of the deep dorsal vein of the clitoris and the proximal urethra. Using electrocautery or sharp dissection, the anterior bladder neck is amputated from the pelvic inlet over the most distal aspect of the Foley catheter. The anterior bladder neck is grasped with traction sutures or Allis clamps and the Foley catheter is identified and delivered into the surgical field. After intravenous administration of indigo carmine, open-ended ureteral catheters may be placed to assist in a safe dissection of the posterior bladder neck. A hand in the vagina can help to identify and maintain the appropriate plane between the posterior bladder neck and the vaginal wall. Using electrocautery or sharp dissection, the posterior bladder neck is freed from the anterior vaginal wall. This division continues until the bladder neck is rolled up and out of a dependent position. The edges of the bladder neck are trimmed to allow approximation of healthy tissues and the ureteral stents are removed. When an incontinent vesicostomy or catheterizable efferent limb is selected for postoperative bladder drainage they may be fashioned at this time. Otherwise, a large-bore (24-Fr) Malecot or Foley catheter is placed through a stab wound in the bladder dome. The bladder neck is then closed in two layers as described for vaginal closure.

Approach in the Male

The technique of bladder neck closure in the male differs from the female in several distinct ways: (a) lack of direct perineal access to the bladder neck; (b) options for vascularized tissue are more limited; and (c) the prostatic anatomy poses a challenge to both intraoperative closure and postoperative care.

Perineal Access

Perineal approach to BNC, though conceptually and technically feasible, is not considered to be the procedure of choice in the male. Perineal access to the bladder neck necessitates either a concomitant prostatectomy with its own inherent morbidity or closure of the infraprostatic urethra, a procedure associated with a high rate of spontaneous fistulization. Infraprostatic closure of the urethra, though easily performed, is not desirable:

1. The surgical closure continues to remain in a dependent position.

1. With the exception of a gracilis or gluteal flap, there is little opportunity for interposition of a large healthy segment of vascularized tissue.

1. Prostate secretions can only drain in a retrograde fashion into the bladder or, in dyssynergic patients, remained trapped in the prostatic fossa. This results in a high rate of fistulization.

1. Perineal closure does not preserve antegrade ejaculation and compromises future fertility.

Abdominal Closure in the Male

The abdominal approach to bladder neck closure has two distinct advantages over perineal closure: (a) the bladder neck can be rotated anteriorly and out of a dependent position and (b) the choices for vascularized interposition are abundant (omentum, rectus flap, and peritoneal flap). Two techniques have historically been employed for abdominal closure of the bladder neck: supraprostatic and infraprostatic closure. Supraprostatic bladder neck closure has been our choice as it offers several distinct advantages over infra-prostatic closure. It is technically easier and does not involve deep pelvic dissection or transection of the dorsal venous complex. It allows for a better mobilization of the bladder neck, resulting in a tension-free closure. Lastly, it provides opportunity for future fertility as an antegrade flow of ejaculate is preserved.

After supine or low lithotomy positioning, the patient is prepped and a catheter placed sterilely. An infraumbilical vertical midline incision is performed and the retropubic space is accessed as described earlier. The bladder neck is identified and absorbable suture is used to ligate the superficial dorsal venous complex at the prostatovesical junction. The prostate and vesical neck are grasped and electrocautery or sharp dissection is then used to amputate the anterior vesical neck from the prostate. Once the bladder neck mucosa is entered, the Foley balloon may be deflated and removed to permit visualization of the posterior vesical neck. Indigo carmine and ureteral catheters are used as previously described. The posterior bladder wall is transected and the plane between the bladder and the rectum identified. Mobilization of the posterior bladder neck from Denonvillier’s fascia and rectum should continue until the vesical outlet has reached an anterior, nondependent position. Excessive mobilization should be avoided to prevent injury to the ureters or vascular pedicles of the bladder. A large-bore (22- to 24-Fr Malecot or Foley) suprapubic tube is then placed through a separate stab incision. If an alternative bladder drainage method is desired (incontinent vesicostomy, catheterizable efferent limb), it may be constructed at this time.

Depending on its size, bladder neck closure can be performed by one of two methods. In the patient with a small bladder neck, a series of two absorbable purse-string sutures of 3-0 PGA may be used to invert the outlet similar to the inversion of an appendiceal stump. For a larger bladder neck, or where closure is more difficult, the outlet is closed in two layers as described above. Placement of a well-vascularized flap of omentum, rectus muscle, or peritoneum in the fossa between the bladder neck closure and prostate is performed to not only facilitate healing but to help prevent fistulization. Concomitant prostatectomy is generally not indicated unless a strictured urethra or prostatorectal fistula poses a problem to postoperative prostatic drainage.

Vascularized Interposition

Following the BNC it is highly advisable to interpose vascularized tissue between the bladder neck and the pelvic outlet to reduce the risk of secondary fistula. Choices for interposition include omentum, a flap of adjacent peritoneum, or a rectus flap. We prefer omentum because of its size, reliable blood supply, and abundant lymphatic drainage. In patients with a generous omentum, a tongue may be easily mobilized with only limited dissection.8 If, however, the patient is extremely thin, or has had radiation or prior intraabdominal surgery, a more extended incision may be needed and the omentum may be mobilized on a pedicle supplied by the right gastroepiploic artery. The right side is preferred due to its more dependent position in the abdomen and its more generous blood supply. The omentum is positioned between the BNC and the pelvic outlet, and sutured in place with absorbable sutures. When a rectus flap is selected, it may be mobilized and based on an inferior epigastric vascular pedicle with careful attention to tie all lateral vascular collaterals. The mobilized rectus flap is then rotated downward and positioned as described above for omentum. Alternatively, a paravesical peritoneal flap may be interposed; however, its vascular supply may not be as reliable as omentum or rectus flap.8 A suction drain is left in the pelvis and brought out through a separate stab wound along with the suprapubic catheter.

Postoperative Care

Postoperative antibiotics are used for 3 to 5 days after which patients are placed on daily oral antibiotic suppression. The suction drain is usually left for 1 to 2 days. In our experience a nasogastric tube is not usually necessary. The suprapubic tube is carefully secured to avoid kinking or dislodgement. Patients are kept on either oral or rectal anticholinergic medication (oxybutynin with or without imipramine or belladonna and opium suppositories) to prevent bladder spasms. A cystogram is obtained at 2 to 3 weeks to document the integrity of bladder neck closure. If there is no evidence of leak or fistula, the suprapubic tube may be changed or removed if a catheterizable stoma was chosen for bladder drainage.

OUTCOMES

Complications

The primary complication of bladder neck closure is postoperative fistula. Such a fistula may occur as early as 1 week postoperatively or as late as 1 year. Prevention of fistula formation is accomplished by careful debridement of the bladder neck edges, use of two nonoverlapping suture lines, nondependent positioning of the bladder neck, interposition of well-vascularized tissue, interposition over the closure, and avoidance of postoperative bladder spasms. When a fistula is suspected, the patient should undergo a cystogram with a mixture of 30% iodinated contrast and methylene blue dye. The site of leakage (vagina or perineum) should then be assessed both visually and radiographically. If a small fistula is encountered early in the postoperative period, bilateral percutaneous nephrostomies may be used to divert the urine away from the fistulous site. Reoperation is a more complex but reliable method of dealing with postoperative fistula. When the initial procedure was performed from a vaginal or perineal approach, reoperation should be performed suprapubically to allow extensive bladder mobilization and allow for interposition of a large, well-vascularized omental flap. Supravesical diversion is reserved for patients in whom all other attempts at repair have failed.

Loss of access to the bladder may also represent a source of postoperative morbidity. Loss of a suprapubic tube and closure of its tract is an underreported but not uncommon complication. Access may be reestablished by using a flexible cystoscope or ureteroscope and may require fluoroscopy to negotiate the tract and pass a flexible wire down to the bladder. If this procedure fails, the patient may be given a fluid bolus and the bladder may be percutaneously accessed under sonographic guidance. Once access has been established, the tract may be dilated and a council catheter passed over the wire. Inability to catheterize a continent efferent limb may be treated similarly and endoscopic negotiation of the conduit usually suffices to reestablish access.

Results

Though a number of authors have reported their results with BNC, most series have been small, retrospective, and with a great deal of variability in technique.2,3,6,10 Consequently, long-term outcomes and overall success rates are difficult to judge. In series where the bladder neck is anteriorly mobilized and appropriate vascularized interposition is utilized, long-term continence rates range from 86% to 100% with a 7% to 8% reoperation rate.2,3,10 In series where these principles have not been employed, fistula formation and reoperation rate approach 30% and 25%, respectively.7 Upper tract deterioration has been noted in a single series (11%) and has been causally related to use of a continent catheterizable efferent channel in patients with persistent bladder dysfunction.3

Though closure of the bladder neck is not the procedure of choice for control of fistula or severe incontinence due to urethral loss, it nonetheless represents a viable treatment option in selected patients with advanced neurologic diseases or comorbidities precluding a more aggressive option. It may also be a useful alternative to supravesical urinary diversion in patients who have failed prior reconstructive lower urinary tract procedures. Decisions regarding surgical approach and postoperative bladder management should be individualized to meet each patient’s needs. Essential techniques for closure include wide mobilization of the bladder neck out of a dependent position; multilayer, nonoverlapping, tension-free closure; and interposition of a well-vascularized flap between the closed bladder neck and the pelvic outlet. Following these principles should yield a high level of success with acceptable risks and postoperative morbidity.

Posted in Urethra Tagged: Bladder neck closure, BNC ]]> http://urologysurgery.wordpress.com/2009/06/07/closure-of-bladder-neck-in-the-male-and-female/feed/ 0 urologysurgery http://urologysurgery.wordpress.com/2009/05/23/vaginal-repair-of-vesicovaginal-fistula/ http://urologysurgery.wordpress.com/2009/05/23/vaginal-repair-of-vesicovaginal-fistula/#comments Sat, 23 May 2009 09:57:39 +0000 urologysurgery http://urologysurgery.wordpress.com/?p=157 ]]>

There are numerous causes for the formation of a fistula tract between the bladder and the vagina. In developing countries the primary etiology is prolonged and obstructed labor, but in more developed countries the cause of approximately 90% of vesicovaginal fistula (VVF) is surgical trauma following gynecologic procedures. Total abdominal hysterectomy for benign disease accounts for the majority offistulae secondary to gynecologic surgery. Common nonsurgical causes include advanced local carcinoma (cervical, vaginal, endometrial) and radiation therapy. Risk factors for VVF formation include prior uterine surgery (Cesarean section), endometriosis, infection, diabetes, arteriosclerosis, pelvic inflammatory disease, and prior radiation therapy.

As the primary cause of vesicovaginal fistulae is iatrogenic, prevention should always be the surgeon’s chief goal. Bladder injuries during hysterectomy are 3 times more common with an abdominal versus a vaginal approach.8 Such injuries can often be avoided with sharp dissection in the appropriate plane and the use of an indwelling catheter during dissection. All attempts should be made to diagnose and repair suspected damage to the bladder at the time of surgical injury. The bladder may be filled to check for leakage or methylene blue or indigo carmine can be administered intravenously to identify a potential site of fistula formation. All identified sites of injury should be appropriately repaired after adequate mobilization of tissues. An important maxim with these injuries is that the first operation to repair a vesicovaginal fistula has the best chance of success.

DIAGNOSIS

The classic presentation of a VVF is continuous daytime and nighttime urinary leakage following a pelvic operation. A patient with a small fistula should still normally void a significant quantity of her urine; larger fistulae do not permit adequate collection of urine in the bladder to permit voiding. Approximately two-thirds of VVF secondary to pelvic surgery are clinically evident within 10 days following the initial injury; radiation-induced fistulae may occur as late as 20 years following therapy.

Physical examination, with the aid of a speculum, may determine the source of leakage and can help differentiate a urinary fistula from urinary incontinence of other causes. A fistula site may be identified if pelvic exam is negative by placing a Foley catheter, introducing a methylene blue–tinted solution into the bladder and inspecting the vagina for leakage. If blue-tinged leakage is not apparent and the diagnosis of VVF is in doubt, the sensitivity of this test is increased by placing a vaginal packing and ambulating the patient for a short period. If the vaginal packing remains dye-free with this maneuver, then a ureterovaginal fistula should be ruled out with the use of a clean vaginal packing and intravenous indigo carmine. A modified double dye has also been described to distinguish various vaginal fistulas. Phenazopyridine is systemically administered, blue dye is placed intravesically, and a tampon is placed. After 5 minutes the tampon is examined; an orange stain at the top is consistent with a ureterovaginal fistula, blue in the midportion suggests VVF, and blue at the tip is indicative of urethral leakage, likely due to stress incontinence.

Cystoscopy, voiding cystourethrography (VCUG), and an upper tract study should be performed in patients evaluated for a urinary fistula. During cystoscopy the fistula size, the presence of collateral fistulas, and the bladder capacity are assessed; the location of the ureteral orifices in relation to the fistula are noted; and a biopsy of the fistula is done if there is a history of previous pelvic malignancy. VCUG may demonstrate the extent of the fistula as well as associated pelvic prolapse, stress incontinence, or vesicoureteral reflux that may require concomitant repair. Finally, upper tract evaluation with intravenous pyelography or computerized tomographic urography can rule out concomitant ureteral obstruction, suggestive of a ureterovaginal fistula.

INDICATIONS FOR SURGERY

Surgical repair of a VVF is indicated when conservative measures fail. Approximately 10% of posthysterectomy fistula will close with bladder drainage and antibiotics. Greatest success with this treatment option has come with fistulas only a few millimeters in diameter. Fistulous tracts that remain open 3 weeks after adequate Foley drainage are unlikely to resolve without surgical intervention.

ALTERNATIVE THERAPY

Cystoscopy with superficial bladder fulguration of the fistula is an option in patients with small, solitary, uncomplicated fistulous tracts. If the tract is not free of infection or the vesicovaginal septum is too thin at the time of fulguration, the surgeon risks increasing the diameter of the fistula with this procedure.

An alternative to the vaginal repair of VVF is an abdominal approach. Advantages of the vaginal repair of VVF include no abdominal incision, decreased morbidity, a quicker recovery, and avoidance of bivalving of the bladder. We use the abdominal approach when there is associated intraabdominal pathology such as ureteral fistula or obstruction or the need for concomitant augmentation cystoplasty (often seen in patients with radiation cystitis).

SURGICAL TECHNIQUE

There are numerous techniques describing repair of a VVF in the literature. This section discusses the technical aspects of our vaginal approach to a single, uncomplicated VVF as well as modifications for a complicated or radiation-induced fistula. Several techniques for interposing tissue and flaps that can be incorporated into the repair are also described.

The timing of VVF repair is somewhat controversial. The classic teaching is to perform fistula repair 3 to 6 months after the initial injury to allow maximum healing and resolution of inflammatory reaction. This is especially important if the repair is to be done through an abdominal approach. However, we routinely perform our repair through a vaginal approach 2 to 3 weeks after the initial injury if conservative therapy fails (i.e., the patient remains wet with a Foley catheter in place and with adequate drainage of the bladder provided) and the patient is in good general health. Retrospective review of the results have not shown a difference when comparing early transvaginal repair with delayed abdominal and vaginal repair.9 Early repair is contraindicated in patients with infection of the vaginal cuff or pelvis, and prolonged antibiotic therapy is required before reconstruction can be attempted in these patients.

Estrogen replacement is begun immediately after a VVF is diagnosed and continued up to the surgery date. Broad-spectrum intravenous antibiotics to cover anaerobes, gram-negative bacilli, and group D enterococcus are administered preoperatively.

Vaginal Approach (Basic Technique)

Positioning/Preparation/Retraction

The patient is placed in the dorsal lithotomy position, a rectal packing is placed (to aid in identification of the rectum if peritoneal flap is to be done in conjunction with the fistula repair), and the lower abdomen and perineum are prepped and draped in the usual standard fashion. Any concomitant anti-incontinence or other vaginal surgery that is to be done simultaneous with VVF repair should be done prior to reconstruction so as not to disturb the repair once completed. A suprapubic tube is placed with the use of the Lowsley retractor through a puncture wound and ureteral catheters are cystoscopically placed if the fistula tract is close to the ureteral orifices. Single-J stents can be used for difficult repairs in an attempt to keep the bladder (and the repair) dry during the early postoperative period. Appropriate exposure is maintained with use of a posterior vaginal weighted speculum, silk labial retraction sutures, and a ring retractor with hooks.

Incision

The fistula tract is initially dilated with metal sounds until a small catheter can be inserted which can be used for retraction later during the dissection. Saline is then injected into the anterior vaginal wall surrounding the fistulous tract. An inverted J-shaped incision that circumscribes the fistula tract is made with the long end of the J extending to the apex of the vagina. The asymmetric nature of this incision allows for creation of a vaginal wall flap that can be advanced and rotated over the fistula repair. This helps avoid vaginal shortening as well as overlapping suture lines during reconstruction. If the fistula is high in the vaginal cuff the incision should be inverted, placing the base of the flap distally, facing the urethral meatus.

Creation of Vaginal Wall Flaps

The vaginal wall flaps are created by dissecting in a proximal, distal, and lateral direction away from the incision. Each flap is mobilized 2 to 4 cm from the fistulous tract, exposing the perivesical fascia. The ring of vaginal tissue where the initial incision circumscribed the fistula opening is left intact; thus, flap creation is done in healthy tissue, avoiding dissection of the actual fistulous tract. This technique facilitates dissection in proper tissue planes, avoids bleeding edges at the resected fistula tract (which may require fulguration and the possible conversion of a small fistula defect into a larger defect with use of the electrocautery), ensures that closure of the fistula is done with healthy tissue (vaginal wall flaps), and decreases the risk of potential bladder perforation. In addition, adequate mobilization of the bladder allows for easier construction of a tension-free closure.

Fistula Closure

Closure of the fistulous opening is now done. The intrafistula catheter is removed and the first layer of the repair is placed with closure of the fistula tract with interrupted 2-0 polyglycolic acid sutures placed in a transverse fashion. These sutures incorporate bladder wall and the fistulous tract itself, starting in healthy tissue approximately 2 to 3 mm away from the margin of the fistula. Inclusion of the fistulous tract in the repair (and not resecting the fistula) provides a strong anchor of supporting tissue for the first layer of the repair. The second layer of the repair is placed with interrupted 2-0 polyglycolic acid sutures. These sutures are placed to invert the previous layer by imbricating the perivesical fascia and the deep musculature of the bladder over the first layer/fistula tract. The sutures should be applied at least 3 to 5 mm from the prior suture line, free of tension, and at a right angle from the first suture line to minimize overlapping of the two lines of repair. The integrity of the repair is confirmed by filling the bladder with indigo carmine.

Advancement and Closure of Vaginal Wall Flap

The final and third layer of closure is done with the vaginal wall flaps that were previously created. The redundant, excess anterior (distal) vaginal flap is excised and the posterior (proximal) vaginal flap is advanced beyond the fistula closure. This covers the fistula site with fresh, healthy vaginal tissue, which helps avoid overlapping of suture lines. The flap is advanced at least 3 cm beyond the fistula closure  and the vaginal wall is closed with a running, locking 2-0 polyglycolic acid suture.

An antibiotic-impregnated vaginal packing is placed for 24 hours postoperatively. The urethral Foley and suprapubic catheters are left to drain for 10 to 14 days. Anticholinergics are given to decrease bladder spasms and oral antibiotics are continued until the catheters are removed. A cystogram is done prior to catheter removal to document the integrity of the repair. Sexual intercourse is avoided for 3 months postoperatively.

Adjuvant Techniques for Interposition of Tissue

The interposition of healthy tissue during reconstruction is advised when repairing fistulas that are recurrent, located high in the vaginal vault, related to previous radiotherapy, ischemic (obstetric), large, associated with a difficult or doubtful closure, and when there is poor tissue quality secondary to a lack of estrogens or atrophic vaginitis. A flap of peritoneum or a Martius graft can be used when repairing a complex VVF via a vaginal approach; these two techniques are described below. The peritoneal flap is the method we prefer and is what we have primarily used for graft interposition over the past 5 years. Other procedures include gluteal skin flaps and myocutaneous gracilis muscle flaps, which are particularly useful for postirradiation fistulas, in the presence of vaginal atrophy and when no other viable skin source is available. Any one of these techniques enhances the quality of the repair by providing an additional layer of healthy tissue during closure of a complex fistula.

Martius Graft

The Martius graft, or fibrofatty labial flap, consists of adipose tissue and is the preferential graft for fistulas involving the trigone, bladder neck, and urethra. The blood supply to the graft is provided inferiorly by the posterior labial vessels (off the internal pudendal), superiorly by the external pudendal artery, and laterally by the obturator artery. The lateral blood supply is sacrificed during mobilization of the graft; the graft may be divided at either its most superior or most inferior margin (basing the blood supply on the inferior or superior vascular pedicle, respectively), depending on where the graft will be transferred.

Following the closure of the vesical portion of the fistula, the previously placed labial retraction suture is removed on the side where the flap is to be harvested and the ring retractor repositioned to eliminate tension from the labium. A vertical incision is made over the labia majora. The borders of dissection include the labiocrural fold laterally, the labia minora, and the bulbocavernosus muscle medially and Colles’ fascia covering the urogenital diaphragm posteriorly. Graft harvest is accomplished in a lateral-to-medial fashion. Dissecting down to the adductor muscles laterally before coming around the width of the Martius graft facilitates the harvest of a thick, fatty segment for graft placement. The entire thickness of the fibrofatty flap is included in a small Penrose drain and gentle downward traction is applied to aid in dissection superiorly. The main vascular supply to the graft is located at the base of the labia majora. The anterior segment is clamped and transected interior to the pubic symphysis. The free segment of the graft is dissected from the underlying structure down to the posterior based vascular pedicle.

Dissection is carried out from the site of the repair, between the vaginal wall and the perivaginal tissue, to create a tunnel to transfer the graft to the area of the fistula. A hemostat is used to transfer the fibrofatty pad from the harvest site through the tunnel to the vaginal area. The graft is placed over the fistula repair and secured with interrupted absorbable sutures in a tension-free manner.

The vaginal wall flap is advanced over the Martius graft and closed as previously described. A small Jackson-Pratt may be left in the labial incision if the operative field is not completely dry. The labial incision is closed and a pressure dressing may be applied to the labial skin incision.

Peritoneal Flap

The use of a peritoneal flap during repair of a complex VVF is a simple procedure that does not require extravaginal harvesting of the graft as does a Martius flap. This technique is primarily used in conjunction with repair of a high-lying VVF. Following formation of the vaginal flaps, dissection of the posterior (proximal) vaginal flap is continued into the cul-de-sac. The peritoneum and preperitoneal fat is identified, isolated, and mobilized using sharp dissection.

The first two layers of the fistula are closed as described above. At this point the peritoneal flap is advanced over the fistula repair and secured with interrupted absorbable sutures in a tension-free manner. If a peritoneotomy is made the defect can be closed as the flap is secured to the perivesical fascia over the fistula repair. The vaginal flap is then advanced and closed as previously described, providing a fourth layer of closure.

Radiation-Induced Fistula

The pathologic changes that lead to formation of a VVF after radiation also result in different strategies when a radiation-induced fistula is repaired. Radiation damage leads to obliterative endarteritis and results in poorly vascularized tissue along the fistula site and the surrounding tissue. Therefore, spontaneous healing of this kind of defect is unlikely. Radiation-induced VVFs are typically found in the trigone. This area of the bladder is fixed and more susceptible to the effects of radiation.

Primary repair of a radiation-induced fistula is difficult because the surrounding tissue is often fixed, easy to slough, and nonpliable. Extensive dissection of the fistulous tract combined with augmentation cystoplasty is a successful option, especially in the bladder that is contracted from previous radiation. We prefer to use ileum for augmentation; however, virtually all segments of bowel have been used by various authors for bladder augmentation. Whatever segment is used, the bowel should be nonirradiated, minimizing any compromise to the blood supply that could lead to suture line breakdown and failure of the reconstruction. Finally, inter-position of healthy tissue (such as omentum or a Martius graft) between the repair is performed, eliminating the possibility of an overlapping suture line and decreasing the risk of recurrent fistula.

OUTCOMES

Complications

Early postoperative complications include vaginal infection, bladder spasms, and bleeding. Bladder spasms should be treated with anticholinergics and vaginal bleeding is treated with bed rest and vaginal packing.

Late complications include vaginal shortening or stenosis, unrecognized ureteral injury, and recurrence of the fistula. Excessive resection of the vaginal wall causes vaginal shortening or stenosis, and is treated with vaginoplasty. Ureteral injuries are initially managed with a percutaneous nephrostomy drainage; retrograde pyelography and ureteroscopy should be avoided in the early postoperative period as they may result in disruption of the fistula repair. Recurrent fistula may be repaired again through a vaginal approach. This should be done no sooner than 3 months after the previous repair to allow for resolution of postoperative inflammation and is often done in conjunction with adjuvant measures such as a Martius or peritoneal flap.

More female urethral diverticula are now being diagnosed than ever before because of a higher index of clinical suspicion and improved diagnostic techniques such as voiding cystourethrogram (VCUG) and transvaginal ultrasound. Because of the complexity and variability of diverticula, thorough evaluation is required to completely assess important pretreatment facors and plan appropriate management. With proper pretreatment evaluation, surgical treatment is generally associated with an excellent outcome.

The true incidence of urethral diverticulum is unknown. The reported incidence varies from 1.4% to 5% depending on the population studied. Although diverticula are reported in all age groups, they most commonly present in the third through fifth decades, and 15% to 20% of women with diverticula are nulliparous. Though they are reported to be more common in the black population, the authors have not found any racial predilection.3 Female urethral diverticulum arises from the wall of urethra and consists mainly of fibrous tissue lined with epithelium. In many cases the epithelial lining may be absent because of chronic inflammation, and the diverticulum may be adherent to the neighboring structures including the periurethral fascia and anterior vaginal wall.

Although the exact mechanism of diverticular formation is unknown, the most commonly accepted theory implicates the periurethral glands. Obstruction of the periurethral gland duct is associated with infection in the occluded gland, which results in abscess formation. The abscess subsequently ruptures into the urethral lumen, either as the result of trauma or progression of the infection, forming the diverticulum.

The complications of female urethral diverticulum include infection (either acute or chronic), stone formation, and malignancy (adenocarcinoma in 61%, transitional cell carcinoma in 27%, and squamous cell carcinoma in 12% of reported cases).

DIAGNOSIS

The presenting symptoms of urethral diverticulum vary considerably and include the three Ds (dysuria, postvoid dribbling, and dyspareunia), urinary frequency/urgency, recurrent infection, urinary incontinence (stress and urge), hematuria, anterior vaginal pain, and swelling (particularly after voiding). The symptoms of urethral diverticulum may mimic those of simple or chronic bacterial cystitis, interstitial cystitis, pelvic inflammatory disease, endometriosis, nonspecific or gonococcal urethritis, carcinoma in situ of the bladder, detrusor instability, and bladder outlet obstruction. The symptoms are related to neither the size nor the number of diverticula, but more likely, the symptoms are dictated by the size and patency of the diverticular opening and the recurrent urinary tract infections associated with the diverticula. Two percent to 11% of urethral diverticula are asymptomatic and found incidentally on routine pelvic examination, radiography such as a postvoid view of an intravenous urography (IVU) for hematuria, or VCUG performed for vesicoureteric reflux, cystocele, or recurrent urinary tract infection.

A high index of suspicion for the possibility of urethral diverticulum is essential in making the diagnosis. One should always consider the possibility of a urethral diverticulum in a woman with persistent or recurrent lower urinary tract symptoms that fail to respond to routine treatment. Physical examination of the urethra should be routinely performed by compressing the anterior vaginal wall beneath the urethra and looking for tenderness, mass, or external urethral meatus discharge. In the authors’ experience, all urethral diverticula of significant size (>1 cm×1 cm) have been suspected by demonstrating a periurethral mass on pelvic examination.

However, all periurethral masses do not represent urethral diverticula; thus, the differential diagnosis of an anterior vaginal wall mass must be considered before the physician assumes thepresence of urethral diverticulum.2 The differential diagnosis of a periurethral mass includes Skene’s gland abscess (located lateral to the urethral meatus), Gartner’s duct cyst (located in the anterior lateral vaginal wall), ectopic ureterocele (located beneath the distal urethra and filled with clear fluid), vaginal wall inclusion cyst (spontaneous or after vaginal surgery), urethral carcinoma, periurethral or vaginal fibroma or myoma, hemangioma, urethral varices, endometriosis of the urethra, sarcoma botryoides, and vaginal wall metastasis.

Compression of the mass (which is usually tender) may result in pus, blood, or urine extruding from the external urethral meatus. Anterior vaginal wall tenderness may be noticed on palpation (even without obvious swelling), and point tenderness along the urethra may indicate the presence of urethral diverticulum.

Induration or hardness in the area of diverticulum suggests the possibility of malignancy or stone. During pelvic examination, other findings such as urethral hypermobility and vaginal prolapse are also considered in order to plan appropriate investigation and treatment.

A properly performed VCUG is the best radiographic test to confirm the presence, extent, size, number, and configuration of a urethral diverticulum. In the authors’ experience, 60 of 63 diverticula were adequately demonstrated on VCUG. The VCUG should be performed under fluoroscopic control in the standing position to clearly document all the characteristics of the diverticulum. Sometimes, an “air–fluid level” may be seen within the diverticulum because of partial filling, suggesting that the diverticulum is much larger than the portion of the diverticulum seen on the x-ray. Filling defects seen within a diverticulum may suggest the possibility of stone, tumor, or inflammatory mass. The lateral straining views also provide information regarding urethral support and hypermobility, and the presence of stress incontinence with loss of contrast across the bladder neck during coughing or straining.

Occasionally, the diverticulum may be demonstrated on the postvoid film of a standard IVU. However, the area below the pubic symphysis is frequently excluded on the postvoid film. The authors perform an IVU before diverticulectomy to identify an ectopic ureterocele presenting as a periurethral mass because excision of such an unrecognized lesion would result in total incontinence. Retrograde positive-pressure urethrography is used in the investigation of urethral diverticulum in selected cases, when there is a strong suspicion of diverticulum not demonstrated by other methods. Practically, retrograde urethrography is a difficult, time-consuming, and unsatisfactory procedure.

Ultrasound examination (vaginal, perineal, translabial, transrectal, suprapubic, or urethral endoluminal1) has been increasingly used in the investigation of urethral diverticulum. Ultrasound examination not only identifies the contents of the diverticulum but may also show multiloculation within a diverticulum  or the presence of a second diverticulum that might otherwise have been missed at operation. The ultrasound also helps to differentiate urethral diverticulum from other periurethral masses, and commonly the diverticular orifice can also be visualized. Given the quality of the ultrasound images, this study should replace positive-pressure urethrography in cases with a normal VCUG when a urethral diverticulum is suspected. Ultrasound is also commonly used to confirm or augment the findings of VCUG. Although they are interesting from a research perspective, the authors do not find CT or MRI scans of the urethra to be either clinically useful or necessary in the investigation of urethral diverticulum.

In addition to radiographic and ultrasound studies, complete cystourethroscopy with a 20-Fr female “short beaked” urethroscope is performed with a 0- and 30-degree lens. The regular cystoscope will not expand the urethral wall properly because of its long beak, making diagnosis more difficult. Palpation of the suburethral mass over the instrument allows a better appreciation of the location, size, and consistency of the diverticulum. Also, endoscopic observation of the urethral lumen while the mass is compressed will frequently demonstrate the site of communication as purulent material extrudes into the urethra. Even without the ability to extrude the diverticular contents into the urethra, the communication site usually can be identified with careful observation. It is important to identify the communication site before surgery to completely excise the diverticulum and to prevent recurrence. Another essential aspect of preoperative urethroscopy is to evaluate the competence of the bladder neck and the degree of urethral hypermobility with stress. This endoscopic information is extremely useful to determine whether a suspension procedure should be combined with diverticulectomy.

Urodynamic evaluation should be considered before diverticulectomy if the patient has a history of stress or urge urinary incontinence, symptoms of bladder dysfunction such as urinary urgency or frequency, or urethral hypermobility. The presence of stress incontinence requires a simultaneous bladder neck suspension along with diverticulectomy. The presence of detrusor instability may necessitate prolonged postoperative anticholinergic therapy to prevent “breakdown” of the urethral reconstruction site secondary to high intravesical pressures and to avoid persistent irritative symptoms such as frequency, urgency, and urgency incontinence in the postoperative period. Fluoroscopic examination, if available, should be used along with urodynamic evaluation (videourodynamic studies) to differentiate “paradoxic or spurious stress incontinence” (leakage of contrast from the diverticulum with coughing or straining without any leakage across the bladder neck) from genuine stress urinary incontinence (GSUI). When videourodynamic studies are not available, one must rely on the VCUG to confirm contrast loss across the bladder neck with stress. The urethral pressure profile (UPP) is of only historical interest and has no role in the diagnosis of urethral diverticulum and stress urinary incontinence.

INDICATIONS FOR SURGERY

The authors recommend urethral diverticulectomy if the patient is symptomatic and/or the diverticulum is of significant size (more than 0.5 cm in diameter). The authors prefer transvaginal excision of diverticula with a vaginal flap technique, which provides excellent exposure and complete excision of the diverticulum with minimal risk of recurrence. A three-layer closure is performed, and overlapping sutures are avoided to minimize the risk of urethrovaginal fistula or recurrent diverticulum.

A Martius labial fat pad graft interposition is also used between the urethra and vaginal wall during wound closure after diverticulectomy in selected cases.5 The indications for the Martius graft include fibrotic and scarred tissues, history of radiation treatment, absent or tenuous periurethral fascia for the second layer of closure, and recurrent diverticula.

Along with the vaginal flap technique, simultaneous bladder neck suspension can be performed  without fear of infection spreading into the retropubic space. To prevent infection, preoperative antibiotics are given, the transvaginal needle suspension is performed before the diverticulum is manipulated, and manual compression of the diverticulum is avoided during surgery. The indications for concomitant bladder neck suspension are documented GSUI, urethral hypermobility, and large proximal urethral diverticulum (which may make the placement of the bladder neck suspension sutures in the anterior vaginal wall difficult without entering the diverticulum).

Pubovaginal sling procedures have also been performed along with diverticulectomy when the patients had either type II or type III stress urinary incontinence.9 The authors believe that it is risky to use a fascial sling over a delicate urethral closure site for fear of urethral erosion, especially in the absence of type III stress urinary incontinence or intrinsic sphincteric deficiency (ISD). In addition, the sling procedure is associated with postoperative urinary retention, and the authors are concerned regarding the potential need for self-catheterization through the “reconstructed urethra.”

Occasionally, a female urethral diverticulum presents as a large periurethral abscess that may not respond to antibiotics. The abscess may be initially drained with incision, and diverticulectomy is performed later, after satisfactory treatment of infection.

ALTERNATIVE THERAPY

Endoscopic Procedures

Lapides transurethrally “saucerized” the diverticula by opening the diverticula into the urethral lumen with a knife electrode, especially in women who had previous surgical intervention with multiple recurrent diverticula. The authors have successfully performed the saucerization technique in two distal recurrent diverticula. Other techniques include using a 10-Fr pediatric resectoscope and Collins knife or Pott scissors. Endoscopic procedures are useful mainly in diverticula situated in the distal urethra, creating a wide-mouthed diverticulum that is expected to drain freely. When these are used for mid- or proximal diverticula, the risk of urinary incontinence is greater. Endoscopic procedures do not address the need for concomitant treatment of stress urinary incontinence when a combined problem exists.

Marsupialization

Spence and Duckett described the technique of marsupialization of distal diverticula. It is basically an incision of the urethral floor through the diverticulum to the diverticular orifice. The diverticulum should be inspected thoroughly, and a biopsy should be taken from any suspicious area to exclude malignancy. The epithelium of the vagina and urethra are then co-opted by running an absorbable suture and keeping vaginal packing for 24 hours and a Foley catheter for 2 or 3 days. Though the reported incidence of stress incontinence after marsupialization of a distal diverticulum in experienced hands is as low as 0.3%, this technique should not be considered with proximal or midurethral diverticula. Other complications of this procedure include recurrent diverticula, vaginal voiding, and spraying of urine with micturition.

Miscellaneous Techniques

Ellick treated diverticulum with incision and packing of the diverticular cavity with oxidized cellulose (oxycel) or Gelfoam. Problems were encountered with a multiloculated diverticulum because the entire diverticulum was not obliterated. Tancer et al. described a partial ablation technique by transvaginally opening the diverticulum and using the sac as a second layer after closing the orifice. Periurethral injection of Polytef paste adjacent to the diverticulum was employed by Mizraki and Bitterman to collapse the diverticulum. Most diverticula contain infected material, and so, the risk of infection and abscess formation with the synthetic material is considerable.

There are several other techniques of diverticulectomy, including (a) a vertical vaginal incision, excision of the diverticulum, and closure of the periurethral fascia in vest-over-pants fashion; (b) a two-layer vaginal flap technique; (c) closure of the urethral defect, retaining a portion of the sac and marsupializing it to the vaginal mucosa to prevent extensive subtrigonal dissection; and (d) excision of the urethral floor from the external urinary meatus to the distal diverticulum and closing of the urethra in layers. The authors prefer a three-layer closure with the closures oriented in different directions to avoid overlapping sutures, which could result in urethrovaginal fistula formation.

Several techniques have also been described in the literature to define the diverticulum during surgery, including sounds, gauze packing, Foley or Fogarty balloon catheters, ureteral catheters, injecting methylene blue, coagulated cryoprecipitate, or a silicone and rubber mixture, and urethral endoluminal ultrasound. Kohom and Glickman have introduced a 7-Fr Foley catheter (with its tip cut off) through the defect of a diverticulum inadvertently opened during diverticulectomy and then inflated its balloon with saline to distend the diverticulum and facilitate continuation of dissection. In the experience of the authors, these diverticulum-defining procedures are rarely required during operation, as a thorough preoperative evaluation almost always reveals satisfactorily the diverticulum location, extent, and communication site.

SURGICAL TECHNIQUE

Preparation

At the time of preoperative consent, the patient is informed about the procedure and postoperative management in detail. Possible complications of diverticulectomy such as infection, bleeding, recurrent diverticulum, urethrovaginal fistula, and urinary incontinence are discussed. Vaginal douches and lower abdominal scrubbing are performed by the patient the night before and the morning of operation. Because most diverticula are filled with infected purulent material, perioperative parenteral antibiotics are given the morning of surgery, usually preceded by 1 week of oral suppressive antibiotic therapy. Patients are admitted the morning of surgery.

Diverticulectomy

After induction of general or spinal anesthesia, the patient is placed in the modified dorsolithotomy position after application of intermittent pneumatic calf compression. The vagina and lower abdomen are prepared and draped with isolation of the rectum from the operative field. The bladder is filled, and a 22-Fr suprapubic Foley catheter is placed as a “safety valve” for bladder drainage using a modified curved Lowsley tractor. Cystourethroscopy is performed to check the position of the suprapubic catheter and to reconfirm the site of urethral communication of the diverticulum. A 14-Fr Foley catheter is inserted transurethrally. Saline is infiltrated in the anterior vaginal wall along the site of incision, which is made in a U-shaped manner with the apex distal to the diverticulum. If a bladder neck suspension is being performed concomitantly, the suspension sutures are placed at this point.

The anterior vaginal flap is reflected toward the bladder neck with sharp, spreading dissection using scissors in the correct plane on the shiny white surface of the vaginal wall. Dissection in the wrong tissue plane (usually too deeply) results in entry into either the periurethral fascia or the diverticulum itself. Premature entry into either structure makes the remainder of the dissection more difficult. Preservation of the periurethral fascia is important to provide a second layer of closure between the urethra and the vaginal wall.

The urethral diverticulum is usually quite obvious once the vaginal flap is dissected inferiorly. Next, the periurethral fascia is incised transversely to allow subsequent exposure of the diverticulum beneath this fascial layer. The plane between the periurethral fascia and the diverticulum is defined using sharp dissection, away from the midline, with care taken not to dissect too deeply to enter into the diverticulum at this stage. Once the dissection is completed, the periurethral fascia can be opened like “leaves of a book” to completely expose the underlying diverticulum. The diverticulum is carefully dissected around until its communication with the urethra can be defined. Rarely, when there is any difficulty identifying the diverticulum or its communication site to the urethra during the operation, urethroscopy is performed, and a probe or curved pediatric sound is passed under visual control from the urethral lumen into the diverticulum for vaginal palpation. The diverticulum is then excised in its entirety with its communication with the urethra and the adjacent urethral wall, thus creating a large urethral defect. When the diverticulum is multiloculated, the diverticulum should be opened and inspected to ensure that all intercommunicating pockets are identified and removed. It is very important that all abnormal, weak, and attenuated tissue at the urethral communication site be excised to reduce the risk of recurrent diverticular formation. On the other hand, care must be exercised not to remove an excessive amount of urethral wall, or urethral closure over a 14-Fr catheter without tension may be difficult.

The urethral defect is closed vertically without tension, using a running locking 4-0 Vicryl suture starting at the proximal margin. Care is taken to incorporate both the muscular and mucosal layers of the urethral wall into the closure. A watertight closure is essential to reduce the risk of postoperative extravasation. Next, meticulous hemostasis is obtained to prevent hematoma formation and disruption of the suture lines. The periurethral fascia is closed transversely with a running 3-0 Vicryl suture. Care is taken to space the sutures to obliterate any “dead space” beneath the periurethral fascia. When indicated, a Martius labial fat pad graft is harvested and placed between the periurethral fascia and the anterior vaginal wall closure. The anterior vaginal wall is closed with a running 2-0 Vicryl suture. The wound closure is thus completed in three layers: the urethral wall vertically, the periurethral fascia horizontally, and the overlying vaginal wall flap, which covers the underlying suture lines.

The bladder neck suspension sutures, if placed, are then tied with minimal tension before the suprapubic incision is closed. At the end of the procedure, an antibiotic-soaked vaginal packing is placed, and both the suprapubic and urethral catheters are placed on gravity drainage.

Bladder Neck Suspension (Optional)

When indicated, a bladder neck suspension is performed after the initial vaginal wall incision. The bladder neck is identified by palpating the urethral Foley catheter balloon under traction. The plane between the vaginal wall and endopelvic fascia is developed laterally at the level of the bladder neck toward the pubic bone. The dissection must be in the correct plane between the vaginal wall and the medial reflection of the endopelvic fascia to avoid excessive bleeding or bladder injury. After the bladder is emptied, the endopelvic fascia is sharply or bluntly perforated laterally, entering the retropubic space. Blunt dissection is carried out with a wiping motion on the posterior aspect of the pubic bone and continued inferiorly to the level of the ischial tuberosity on each side. Blunt dissection is also continued anteriorly on each side to facilitate passage of the ligature carrier.

Number-one polypropylene sutures (Ethicon D-6731) are placed in a helical fashion incorporating the vaginal wall as the anchoring tissue at the level of bladder neck. Care is taken not to enter into the diverticulum at this point to avoid spillage of infected material from the diverticulum into the retropubic space. When a very large proximal diverticulum is present, placement of these helical sutures may be impossible without entering the diverticulum. In this situation, bladder neck suspension is deferred.

A 3- to 4-cm transverse suprapubic incision is made just above the symphysis pubis, and the anterior rectus fascia is exposed. After the bladder has been emptied, the modified Pereyra ligature carrier is transferred under finger guidance from the suprapubic area, through the retropubic space, into the vagina. Each suspension suture is threaded into the eye of the ligature carrier and pulled to the suprapubic position. Cystourethroscopy is performed to confirm the absence of bladder perforation or suture material inside the bladder, satisfactory ureteral efflux of previously injected intravenous indigo carmine, and adequate elevation of bladder neck with minimal traction on the suprapubic suspension sutures. When the bone fixation technique is used to anchor the bladder neck suspension sutures, the sutures should be passed through the pubic tubercle before the diverticulectomy is performed in order to reduce the risk of infection. In order to facilitate diverticulectomy and closure of the vaginal flap, the suspension sutures are not tied until the end of the operation.

Postoperative Care

Perioperative parenteral antibiotics are continued for 24 hours, followed by oral antibiotics until the catheters are removed. Belladonna and opium suppositories are given postoperatively until the patient can tolerate oral anticholinergics (oxybutynin and imipramine hydrochloride) to prevent bladder spasm. The vaginal packing is removed on the first postoperative day. Seven to 10 days postoperatively, after a vaginal examination has demonstrated an intact vaginal flap and suture lines, and following discontinuation of anticholinergics for 24 hours, a VCUG is performed. During the VCUG the urethral catheter is removed, and the bladder is filled with contrast through the suprapubic tube. The urethra is carefully observed fluoroscopically during voiding. Should any extravasation occur (as noted in approximately 50% of patients), the patient is asked to stop voiding, and the bladder is left on drainage via the suprapubic catheter. The urethral catheter is not replaced, and anticholinergics are restarted. The VCUG is repeated 7 to 10 days later. When there is no extravasation on the initial VCUG, the patient is allowed to empty her bladder, and if the postvoid residual urine volume is less than 100 ml, the suprapubic catheter is removed. The suprapubic catheter is removed only after satisfactory bladder emptying is established (postvoided residual urine consistently less than 100 ml). Intermittent self-catheterization is avoided for fear of disrupting the urethral reconstruction site.

OUTCOMES

Complications

The urethral diverticulum may recur as a result of incomplete excision of the diverticulum and its urethral communication site. Preoperative evaluation should identify the presence of multiple diverticula and/or communication sites for complete excision during operation. All pockets of a multiloculated diverticulum should also be removed. Care should also be taken to completely close the urethral defect after excision of the diverticulum to prevent formation of a pseudodiverticulum between the layers of closure. The VCUG should be performed postoperatively to rule out extravasation from the urethral closure site before the patient resumes voiding. Recurrence of a diverticulum is generally suggested by the presence of persistent or recurrent symptoms, periurethral mass, tenderness along the urethra, or recurrent urinary tract infection. Care should be taken in evaluating a patient with VCUG after diverticulectomy, as ballooning or irregularity of the urethra may be seen at the site of diverticulectomy and should not be mistaken for recurrence. Recurrent diverticulum may be managed with a second excision procedure with Martius fat interposition. A small distal recurrent diverticulum may also be satisfactorily treated with transurethral “saucerization” or Spence marsupialization procedure.

Urethrovaginal fistula is also a well-described complication of urethral diverticulectomy. In the authors’ experience the fistula is usually seen when a vertical vaginal incision is used for diverticulectomy with overlapping suture lines. The use of three-layer technique that avoids overlapping closures greatly minimizes the chance of fistula formation. Also, the urethral defect should be closed watertight, with care taken to avoid any tension on the suture line. Use of Martius fat interposition in selected cases (as described before) further reduces the risk of fistula. Urethrovaginal fistula can be repaired transvaginally without excising the fistula, using the three-layer anterior vaginal wall flap technique and interposition of Martius labial fat pad graft.

Bladder injury can also occur during dissection of a large proximal urethral diverticulum extending beneath the trigone, resulting in the formation of vesicovaginal fistula. Instillation of indigo carmine into the bladder and/or cystoscopy should be performed in such cases to rule out bladder injury.

Urethral diverticulectomy may be followed by urinary incontinence as the result of persisting GSUI (if simultaneous stress incontinence surgery is not performed), de novo GSUI, recurrent diverticulum with paradoxical loss with stress, urethrovaginal fistula, and/or postoperative de novo detrusor instability. Genuine SUI may develop after diverticulectomy from periurethral dis-section, further compromising the urethral support. Genuine SUI is also common after excision of a large proximal diverticulum extending beneath the proximal urethra and bladder neck area because of the extensive dissection required to remove the diverticulum. Preoperative evaluation is essential to identify individuals who may develop postoperative stress incontinence, which may be prevented with a concomitant bladder neck suspension when diverticulectomy is performed (see indications). Postoperative stress incontinence is evaluated and appropriately treated.

Irritative symptoms may be caused by urinary tract infection or bladder dysfunction. Urinary tract infection is treated with appropriate antibiotics. Preoperative evaluations including urodynamic studies are essential to identify candidates likely to develop postoperative irritative symptoms. In our recently published series, 12 women had preoperative detrusor instability during urodynamic studies, and it persisted in four women (33%) after diverticulectomy.3 Persistent detrusor instability is treated with anticholinergic medications, and postoperative de novo bladder dysfunction requires further evaluation.

Narrowing of the urethra is avoided by not excising too much of the urethral wall during excision of diverticular communication site. Sufficient urethral wall is preserved to close over a 14-Fr Foley catheter. Urethral stricture after diverticulectomy may require reconstruction of urethra.

The complications of concomitant bladder neck suspensions include bladder injury, ureteral injury, bleeding, nerve injury (secondary to patient positioning or nerve entrapment from lateral fixation of suspension sutures), acute and chronic urinary retention, immediate and late urinary incontinence, detrusor instability, and infection.

Results

In our series, urethral diverticulum was diagnosed in 63 women, and urethral diverticulectomy was performed in 56 women (88.9%), including concomitant bladder neck suspension in 27 women (48.2%). With a mean follow-up of 70 months (range 6 to 136 months), 48 women (85.7%) had relief of their presenting symptoms. Two recurrent diverticula (noted at the distal urethral closure site) were documented by periurethral mass and/or tenderness on follow-up vaginal examination. Both diverticula were managed satisfactorily with transurethral “saucerization.” Suprapubic tenderness occurred in one woman in relation to the bladder neck suspension sutures secured suprapubically. This pain resolved with conservative treatment within 6 months of the procedure. Early urinary tract infections were identified and treated satisfactorily in six women, and none of these patients developed recurrent urinary tract infections. Four women who had persistent detrusor instability after surgery noted significant urgency symptoms. No patient developed a retropubic or postoperative wound infection or urethral stricture.

In this series, the authors did not find any patient with intrinsic sphincteric deficiency (ISD) and did not use a sling procedure with diverticulectomy. The overall continence status in the treatment group of 56 women with a mean follow-up of 70 months  may be summarized as follows: totally continent or minimal incontinence (dry or no pad for protection), 45 (80.4%) women; moderate incontinence (1 or 2 minipads/day for protection), ten (17.9%) women, and severe incontinence (several pads/day for protection) in one woman (1.8%) because of detrusor hyperreflexia secondary to cerebellar degeneration.

Three of 27 patients who had diverticulectomy alone developed postoperative GSUI. Two of them had no GSUI before diverticulectomy, and the other one, as noted before, had preoperative GSUI, but simultaneous bladder neck suspension could not be performed because of the extremely large size of the diverticulum. All three women subsequently underwent bladder neck suspension with a satisfactory outcome. Six women developed recurrent GSUI after diverticulectomy and bladder neck suspension, but none had ISD. One woman in this group had a subsequent Burch colposuspension during hysterectomy, and the other five did not desire further treatment because their incontinence was significantly improved.

Female urethral diverticula are more common than previously thought, and the suspicion should always be high in the clinician’s mind. It is most important to be aware of this clinical entity in women with recurrent lower urinary tract symptoms such as urinary frequency, urgency, dysuria, postvoid dribbling, hematuria or dyspareunia, and/or urinary tract infections, with or without periurethral mass. An appropriate history coupled with vaginal examination, VCUG, endoscopic examination, and urodynamic studies will facilitate the diagnosis. With the use of the L/N/S/C3 classification all preoperative factors are easily addressed. The three layer vaginal flap technique of diverticulectomy is associated with an excellent success rate and minimal complications. Thus, the authors recommend this procedure as the treatment of choice for female urethral diverticula. In appropriate patients, diverticulectomy can be safely combined with bladder neck suspension without any significant additional risk and with a satisfactory outcome.

In the United States hysterectomy is the second most commonly performed operation on women following cesarean section. It may be indicated for a variety of gynecologic conditions including symptomatic uterine leiomyomas, endometriosis, carcinoma of the female genital tract, endometrial hyperplasia, and uterine prolapse. Many of these conditions have confounding diagnostic and therapeutic implications outside the realm of urology; thus, in this chapter the discussion is limited to vaginal hysterectomy only as it pertains to the surgical treatment of uterine prolapse. Uterine prolapse is particularly well suited to vaginal hysterectomy as the laxity of the ligamentous support of the uterus resulting in the prolapse allows excellent operative exposure transvaginally.

Uterine prolapse may be classified anatomically into four stages based on the position of the cervix relative to the vaginal outlet. It is rarely an isolated condition and is more commonly associated with the other manifestations of generalized pelvic relaxation, which may include cystocele, rectocele, enterocele, perineal laxity, and/or urethral hypermobility.

Multiple etiologic factors contribute to uterine prolapse, including congenital, neurologic, racial, social, and coexisting medical factors; however, the most important factor is parity.1 Stretching of the various paravaginal, parauterine, and paracervical supports during parturition causes significant trauma. Most patients recover from this initial insult; however, with advancing age and loss of estrogens postmenopausally, the effects of the multiparity may manifest as uterine prolapse.

Normal uterine support is provided primarily by the sacrouterine and cardinal ligaments. The cardinal ligaments extend from the upper vagina and cervix laterally to the pelvic sidewall in the base of the broad ligament. The sacrouterine ligaments extend from the posterolateral aspect of the cervix and extend below the peritoneal folds in the pouch of Douglas on either side of the rectum to insert onto the periosteum of the sacrum. These ligaments tether the cervix posteriorly such that the corpus of the uterus lies over the levator plate in its normal anteverted position. Increased intra-abdominal pressure is thus exerted on the posterior surface of the uterus, further assisting in the maintenance of uterine anteversion as the uterus is compressed into the levator plate. The round ligaments provide little support to the uterus but do assist in maintaining the uterus in its anteverted position. Other structures also assisting in support of the uterus include the bony pelvis and the urogenital diaphragm including the central tendon of the perineum.

Uterine prolapse results from weakening and laxity of its anatomic supports, including the sacrouterine and cardinal ligaments. With weakness of the sacrouterine ligaments the cervix may shift anteriorly over the levator plate. This may result in a change in the uterine axis as the corpus of the uterus swings backward. In addition, the predominant intra-abdominal forces may now be exerted on the anterior surface of the uterus, resulting in a tendency toward retroversion and further prolapse. Weakness of the cardinal ligaments allows further loss of support over the levator plate, and uterine prolapse results.

DIAGNOSIS

Uterine prolapse may present as an isolated mass or a bulge in the vagina. It also may be found when the patient is assessed for other urologic complaints such as irritative or obstructive voiding symptoms, urinary incontinence, or retention. A history of pelvic pain, back pain, dyspareunia, or recurrent urinary tract infections may be present. Classically, back pain caused by uterine prolapse is aggravated by standing as the uterus prolapses further through the introitus and is relieved by resuming a recumbent position.

The diagnosis is confirmed by physical examination, which reveals significant uterine descent. During pelvic examination, the prolapsed uterus should be assessed for mobility, size, and ligamentous laxity. Associated manifestations of pelvic relaxation, including cystocele, rectocele, and enterocele, should be noted and included in a comprehensive pelvic reconstruction plan when discussed with the patient. Sometimes significant uterine prolapse is not detected by physical examination, and it is not until examination under anesthesia before repair for other associated pelvic prolapse that the degree of uterine prolapse is fully appreciated. For example, in some patients presenting for repair of grade IV cystocele, the full extent of uterine prolapse may not be appreciated in the preoperative office evaluation. It is only when the patient is under anesthesia and fully relaxed that the degree of uterine prolapse becomes evident. Thus, patients who present for repair of grade IV cystocele should be advised of the strong association with uterine prolapse and the potential need for vaginal hysterectomy.

With complete uterine prolapse (procidentia), the upper tracts should be assessed for hydronephrosis, as ureteral obstruction can be insidious in onset and yet quite severe. Patients may present with recurrent pyelonephritis, upper tract calculi, or renal failure. This is usually reversible if the hydronephrosis has not progressed to complete renal parenchymal destruction.

Ultrasonography of the pelvis may be helpful in patients suspected of having large uterine leiomyomas, as their size may preclude vaginal hysterectomy because of size disproportion.

INDICATIONS FOR SURGERY

The decision to perform vaginal hysterectomy is based on the patient’s symptoms, the degree of uterine prolapse, the associated manifestations of pelvic relaxation requiring repair, and the patient’s desire to remain fertile.

Vaginal hysterectomy is indicated in symptomatic patients with significant discomfort and/or dyspareunia as a result of the prolapsed uterus as well as asymptomatic patients with severe prolapse and urinary obstruction. Patients with moderate or severe prolapse and significant associated cystocele or enterocele should undergo simultaneous hysterectomy and repair of the associated pelvic pathology.

Vaginal hysterectomy should not be performed in the presence of significant size disproportion (i.e., large uterus or leiomyomata with stenotic vagina), adnexal or uterine malignant tumor, acute or subacute pelvic inflammatory disease, extensive endometriosis, and/or known obliteration of the cul-de-sac. Confounding factors such as uterine or cervical dysplasia or dysfunctional bleeding should be addressed before vaginal hysterectomy is done, as these situations may mitigate against a vaginal approach. Finally, in patients who desire continued fertility, uterus-preserving procedures should be considered.

Vaginal hysterectomy is not indicated in patients with stress incontinence and adequate uterine and pelvic support. Isolated removal of the uterus in these patients will have no impact on continence.

ALTERNATIVE THERAPY

Asymptomatic or mildly symptomatic patients with uterine prolapse may not require any therapy. Minimal degrees of uterine prolapse may respond to Kegel exercises or hormonal therapy. The primary nonsurgical alternative to hysterectomy for significant uterine prolapse involves the use of a pessary, which may be used in patients who are unable or unwilling to undergo surgery. This device is inserted transvaginally and requires suitable perineal support for efficacy. Unfortunately, many of the patients with uterine prolapse have significant perineal laxity, and thus, a pessary may not be effective.

Many uterus-sparing procedures have been described as alternatives to vaginal hysterectomy. These include both transabdominal and transvaginal procedures. The uterus may be fixed to the sacrospinous ligament either transvaginally (sacrospinous fixation) or abdominally (abdominal sacral colpopexy). Many other operations have been devised in the past to be expeditious and low risk in order to avoid hysterectomy and its historically high morbidity in the elderly population. These include the Manchester–Fothergill operation and the LeFort procedure. These operations are rarely employed now, as the technique of vaginal hysterectomy has evolved into a simpler operation with low associated morbidity. The Manchester–Fothergill operation involved amputation of the cervix, anterior and posterior colporrhaphy, combined with plication and suturing of the cardinal ligaments to the anterior surface of amputated cervix for uterine support. The LeFort procedure essentially involved excision of rectangular strips of vaginal wall on the anterior and posterior vaginal walls with reapproximation of the denuded areas over the cervix. This procedure was quite expeditious but left the patient with a very shallow vagina that was usually too short for coitus.

SURGICAL TECHNIQUE

Many techniques of vaginal hysterectomy exist. This chapter focuses on the technique that we have utilized with success for many years.

Preparation

Antibiotics are administered parenterally 1 hour before incision. General anesthesia is preferentially used in all our vaginal surgery unless medically contraindicated.

The patient is brought to the operating room and placed in the dorsal lithotomy position with candy-cane stirrups. The buttocks are placed just off the end of the operating room table. All pressure points are padded, and care is taken to ensure that no lower extremity joint is flexed more than 90 degrees. The lower abdomen and perineum are shaved. A povidone/iodine vaginal scrub and painting are performed. A povidone/iodine-soaked pediatric lap sponge is packed into the rectum, and the anus is draped out of the field with a self-adherent clear plastic drape. The remaining drapes are secured with silk suture across the perineum to ensure separation of the fecal and urinary streams. A weighted vaginal speculum is placed, and labial retraction sutures of 3-0 silk are used for maximal exposure. A ring retractor with hooks can be utilized to assist in retraction. If a cystocele repair or bladder neck suspension is planned, a suprapubic tube is placed at this time. A Foley catheter is placed per urethra to empty the bladder.

Incision

A tenaculum is used to grasp the cervix and evert it through the vaginal introitus. Mobility of the uterus should be confirmed by this maneuver. Normal saline is injected circumferentially around the cervix in order to facilitate dissection. A circumferential incision is performed 1 cm proximal to the cervix, and the anterior dissection is begun.

Anterior Dissection

Sharp dissection with Metzenbaum scissors is performed from the cervical incision anteriorly in the midline, developing a plane beneath the vaginal wall. Dissection is continued over the cervix, separating it from the posterior bladder wall and perivesical fascia. Care is taken not to dissect laterally. The point of the scissors should remain angled toward the uterus to avoid entry into the bladder. This dissection is aided by gently retracting the anterior vaginal wall and bladder cephalad with a Heaney retractor, especially when a significant cystocele is present. Dissection continues until the vesicouterine peritoneal fold (anterior cul-de-sac) is reached.

Posterior Dissection

Similar dissection is now carried out posteriorly from the cervical incision in the midline, separating the vaginal wall from the posterior fascia of the uterine cervix. Again, a Heaney retractor may assist in visualization of the critical anatomic structures by retracting the vaginal wall and rectum downward. Dissection is continued until the posterior peritoneal fold (posterior cul-de-sac or pouch of Douglas) is identified. If difficulty is encountered in locating the posterior peritoneum, the hysterectomy is begun in an extraperitoneal fashion. The cardinal and uterosacral ligaments can be divided first, thus enabling more mobility of the uterus and easier identification of the posterior peritoneal fold.

Opening the Peritoneum

The posterior cul-de-sac is entered sharply through a small peritoneotomy. The posterior peritoneum is gently explored digitally for adhesions and masses. A retractor is placed into the peritoneal cavity elevating the cervix and uterus anteriorly. Adhesions in the posterior cul-de-sac are sharply divided. The peritoneum may be tagged at this point for later identification during closure.

Division of the Cardinal and Sacrouterine Ligaments

The cervix is retracted through the vaginal introitus and slightly laterally to one side. The tip of a large right-angle clamp is placed into the cul-de-sac with the tips directed anteriorly 1 to 2 cm from the cervix. The ligaments are bluntly dissected out and isolated at their point of attachment to the cervix as the right-angle tip is brought from posterior to anterior against the uterus. The ligaments are individually clamped, divided, and ligated 1 to 2 cm lateral to the cervix using a figure-of-eight suture ligature. The suture ends are left long and are anchored laterally to one of the grooves of the ring retractor. The cervix is now retracted slightly to the other side, and the opposite ligaments are taken in the same fashion.

Division of the Uterine Vascular Pedicle

The right angle is then passed again in the same direction slightly higher along the uterus isolating the uterine vascular pedicle on one side. The vascular pedicle is isolated, clamped, divided, and ligated in a similar manner as the ligaments. The sutures are left long and anchored to the ring retractor. The opposite vascular pedicle is taken in the same fashion. It should be noted that any traction on the cardinal ligaments implies traction on the uterine vessels. This traction will bring the ureters closer to the operative field.

At this point the uterus should be markedly mobile. If the uterus is somewhat fixed, confounding factors should be considered such as ventral fixation, endometriosis, adhesions, carcinoma, and size disproportion.

Incision of the Anterior Peritoneum

The fundus of the uterus is now rotated and everted through the posterior peritoneotomy and out through the vaginal introitus. A finger is passed over the fundus of the uterus to identify the anterior peritoneal reflection. The anterior peritoneum is then entered safely and sharply by incising the peritoneum tented up by the fingertip. Thin peritoneal attachments to the fundus of the uterus are identified by gentle upward retraction on the bladder and divided.

Division of the Broad Ligament

A Heaney retractor is placed into the anterior peritoneal space and is used to retract the bladder cephalad. At this point, only the broad ligament and its enclosed structures hold the uterus in place. The uterus is retracted laterally to better expose the broad ligament on one side. A large right-angle clamp is placed across the entire broad ligament next to its insertion into the uterus. Within this clamp lie the utero-ovarian ligament, the fallopian tube, and the round ligament in succession. The broad ligament and its enclosed structures are then divided and suture ligated. The opposite broad ligament is divided similarly. The sutures are again left long. The uterus is now removed.

Three pedicles are identified bilaterally: the anterior pedicle is the divided broad ligament; the middle pedicle is the uterine vessels; and the posterior pedicle is the sacrouterine and cardinal ligaments.

Vaginal Vault Fixation, Closure of the Cul-de-Sac, and Peritoneal Closure

Modified McCall culdoplasty sutures are used to support the vaginal vault and close the cul-de-sac. A #1 synthetic absorbable suture (SAS) is placed through the vaginal wall starting from within the vagina as high as possible on the lateral fornix. The suture is then passed successively through the area of the sacrouterine and cardinal ligament pedicle on the same side and then the prerectal fascia and the sacrouterine and cardinal ligament pedicle on the opposite side. The suture is brought back to the original side, traversing the same structures in reverse order, and finally exiting the vaginal wall 1 cm from the site of entry. An identical suture is placed in the other direction from the opposite fornix. These sutures are not tied down at this time.

The peritoneal cavity is closed with two pursestring sutures of #1 SAS incorporating the prerectal fascia, the prevesical fascia, the posterior peritoneal surface of the bladder, and the sacrouterine cardinal pedicle. High placement of the McCall and peritoneal closure sutures ensures adequate vaginal depth on closure.

Closure

The broad ligament pedicles are tied to each other across the midline. The sutures on the uterine pedicles are trimmed. Next, the peritoneal pursestring sutures are tied down snugly. If no other vaginal surgery is planned (i.e., cystocele repair, vaginal wall sling, etc.), then the McCall sutures are now cinched down and tied. The vaginal mucosa is trimmed and closed with a running interlocking 2-0 SAS. The vagina is packed with an antibiotic-impregnated gauze.

Patients are admitted for 24 to 48 hours postoperatively or until they are able to ambulate and are tolerating a regular diet.

OUTCOMES

Complications

Potential complications at the time of surgery include ureteral or bladder injury, bleeding, and rectal or other bowel injury. Injury to the urinary tract may be heralded by the sudden appearance of hematuria in the urinary drainage bag or a sudden gush of clear fluid into the wound. If an injury to the urinary tract is suspected intraoperatively cystoscopy may be performed or, alternatively, the bladder may be filled retrograde through the Foley catheter with indigo carmine and saline until the laceration or injury is seen. If these maneuvers fail to demonstrate the injury, then intravenous indigo carmine is given, and the ureteric orifices are observed cystoscopically for blue efflux.

Ureteral injury is much less common after vaginal hysterectomy than after abdominal hysterectomy. This may be because of superior retraction of the anterior vesicoperitoneal fold and thus a higher displacement of the ureters during dissection.2 Nonetheless, the ureters are most likely to be injured during the case at two distinct junctures: while the uterine vessels are being clamped and divided (the ureters lie just below and lateral to the vascular pedicle) or during pursestring closure of the peritoneal cavity. To avoid ureteral injury during clamping and division of the uterine pedicle, these vessels should be taken very close to the cervix and as distal as possible. During closure of the peritoneum, the ureters lie anterolaterally at the 2- and 10-o’clock positions; thus, the pursestring suture should not incorporate any tissue in the anterolateral peritoneal folds and should be placed rather shallow on the posterior peritoneal surface of the bladder in the midline. Many times, ureteral injury may not become evident until the postoperative period when anuria, fever, flank pain, and/or tenderness may manifest. A high degree of suspicion for ureteral injury should be maintained in this setting with the early use of adjunctive diagnostic studies and operative repair when necessary.

Bladder injury may result from retractor injury or from dissection misadventure during the development of the anterior peritoneal fold. This should be repaired at the time of hysterectomy with a multiple layer closure and maximal urinary drainage to prevent the formation of a vesicovaginal fistula. Significant bleeding may result from a laceration of a branch of the uterine artery. This should be controlled carefully with pinpoint accuracy as indiscriminate cautery may result in ureteral injury, tissue devitalization, and potential fistula. Bowel or rectal injury is rare if the uterus is freely mobile and there are minimal intraperitoneal adhesions in the pelvis. Careful, controlled dissection and peritoneal entry as described is the best way to avoid this unfortunate complication.

Late postoperative complications include urinary fistulas, vaginal stenosis or shortening, and the appearance of vaginal vault prolapse. A small, asymptomatic vault prolapse is common after hysterectomy and requires no further therapy, as this is usually self-limited. However, significant vault prolapse may indicate that an enterocele was missed at the time of hysterectomy and requires repair.

An enterocele is a hernia of the peritoneal pouch of Douglas extending caudally between the vagina and rectum. It usually contains small bowel with or without omentum. Nichols described four types of enterocele:

• Congenital enterocele, the least common, occurs when the anterior and posterior peritoneal folds fail to fuse during fetal development.
• Pulsion enterocele is caused by a chronic increase in intra-abdominal pressure.
• Traction enterocele occurs when a pelvic organ, for example the uterus, bladder, or rectum, prolapses and causes traction on the vaginal vault and peritoneum.
• Iatrogenic enterocele occurs after hysterectomy, when excess peritoneum remains or the pouch of Douglas is not adequately closed. It may also occur after any procedure that alters the vaginal axis.

The two types of enterocele that urologists most often encounter are traction enterocele associated with anterior vaginal wall prolapse such as cystocele and iatrogenic enterocele that follows surgery on the anterior vaginal wall. Traction enteroceles often present with a concomitant cystocele and stress incontinence in any patient who has previously had a hysterectomy. It may be part of a total vaginal eversion. Iatrogenic enterocele is not uncommon after surgery for stress incontinence and has been reported in 3% to 17% of cases.

In order to understand the pathophysiology of an enterocele, one must first consider normal pelvic anatomy. The levator plate provides the primary support for the pelvic organs and directly supports the rectum and vagina. The distal vagina forms an approximately 45-degree angle with the vertical line while the proximal vagina forms a 110-degree angle and sits almost horizontally over the levator plate. The distal vagina is supported primarily by perivaginal or pubocervical fascia (which is a portion of the levator fascia) and its attachment to the tendinous arch. This proximal portion of the vagina is also anchored along with the cervix over the levator plate by the cardinal and uterosacral ligarnents, which are attached to the tendinous arch and sacrum, respectively. When there is an alteration in this support, commonly seen after hysterectomy, enterocele may occur.

DIAGNOSIS

An enterocele usually appears as a mass bulging from the vagina. If the uterus is in place, the enterocele will appear posterior to the cervix. However, more commonly it is seen as a bulge from the apex of the vagina after hysterectomy. Larger enteroceles can be seen bulging out of the vagina introitus. A systematic examination of the vagina and pelvis is the first step in the proper diagnosis of an enterocele. The major differential diagnosis is cystocele and high rectocele. An enterocele may exist independently or in combination with these other forms of pelvic prolapse. It is also important to ascertain if the vaginal vault is prolapsed, as this will affect the type of enterocele repair performed.

The extent of prolapse is first evaluated with the patient in the lithotomy position. The posterior blade of a vaginal speculum may be used to retract the posterior vaginal wall to view the anterior vaginal wall. At this time, the presence of urethral hypermobility, stress incontinence, and cystocele may be assessed. The patient should be instructed to cough and strain during these maneuvers. Next, the blade of the vaginal speculum is rotated to retract the anterior vaginal wall. The posterior wall and vaginal vault are inspected. Prolapse of the posterior vaginal wall can be observed readily with the bladder retracted out of the way. If the patient has not undergone a hysterectomy, the uterus can be evaluated for prolapse and movement. In posthysterectomy patients, support of the vaginal vault must be assessed. A rather large enterocele can occur posterior to the well-supported vault, or the entire vagina may be everted.

Although large enteroceles are often obvious, smaller ones associated with rectocele may appear as a high continuation of the rectocele bulge in the posterior vaginal wall. An enterocele may distinguished from a high rectocele by bimanual examination. A finger may be placed in the patient’s rectum, and she is instructed to cough or bear down. The impulse of the enterocele may be felt against the fingertip as it would during the examination an inguinal hemia. With the index finger in the rectum and the thumb in the vagina, an increased thickness in the rectal vaginal septum may be felt as the enterocele is trapped between the two fingers. This maneuver can be repeated in the standing position (with one foot elevated on a stool) if there is any doubt about the diagnosis. Standing the patient provides a true impression of the degree of prolapse experienced during daily activity. When there is difficulty in distinguishing between cystocele and enterocele, a cystogram with anterior–posterior, oblique, and lateral resting and straining views can be done to help delineate the bladder. Sometimes it is difficult to determine the degree of cystocele and enterocele strictly by physical examination, and this may not be sorted out until the time of surgery.

INDICATIONS FOR SURGERY

Generally, the degree of an enterocele and the amount of discomfort it causes are the indications for surgery. Small enteroceles are often asymptomatic and need not be treated. However, there is a tendency for enteroceles to increase in size over time if left untreated. Larger enteroceles that prolapse outside the vaginal introitus are usually quite uncomfortable. Generally, treatment is driven by patient’s symptoms of discomfort, incontinence, obstructive voiding, and constipation. In cases of severe vaginal prolapse, erosion and ulceration of the vaginal wall may occur, causing a great deal of discomfort. When other pelvic surgery is being performed, e.g., stress incontinence surgery, an enterocele of any size should be repaired at the same time, as they are likely to worsen postoperatively.

When surgery is contemplated, it is important to consider all of the anatomic abnormalities including vaginal vault prolapse, cystocele, urethral hypermobility with or without stress incontinence, rectocele, and the presence of a uterus. Also, the patient’s degree of sexual activity will play a role in the type of surgical procedure performed. Age may also influence the type of procedure being performed. Finally, if the patient might undergo a laparotomy for other pathology, this may influence the type of surgery performed, as a transabdoniinal procedure may be elected.

ALTERNATIVE THERAPY

A nonsurgical alternative for treatment of enterocele and pelvic prolapse is the use of a pessary. Pessaries come in a variety of shapes and sizes and are fit on a trial-and-error basis. Some patients with severe pelvic prolapse are unable to hold the pessary. In others, pessaries are found to be uncomfortable or to cause vaginal infections. A pessary can be used as a temporizing measure until surgery can be performed or as a chronic management of enterocele and pelvic prolapse in patients who do not wish surgical intervention. The type of pessary used is based on the degree of enterocele, presence of a uterus, and other coexisting pathology.

Another surgical alternative for enterocele treatment is colpocleisis, in which the entire vaginal canal is closed. This may be elected in the very elderly or in patients who have failed multiple attempts at repair.

SURGICAL TECHNIQUE

Presurgical Preparations

Once the patient has elected to have surgery, preoperative preparation is simple and consists of a modified bowel prep, which can be performed at home. The day before surgery the patient can begin on a clear liquid diet and also should take an oral laxative such as citrate of magnesia. The evening before surgery the patient should take a self-administered enema. As in all vaginal procedures, the patient receives broad-spectrum antibiotic prophylaxis perioperatively. We prefer to use gentamicin and ampicillin, or vancomycin in patients who are penicillin allergic. Doses of antibiotics are given just before the procedure and are continued for 24 hours after the procedure. At this time, the patient is switched to a broad-spectrum oral antibiotic for 10 days.

Surgical Approach

The choice of the specific type of enterocele repair will depend on several factors. We always prefer a transvaginal repair when possible, as this will reduce morbidity and recovery time. In cases in which laparotomy is being performed for another reason, an abdominal approach is preferred. In selecting the type of transvaginal repair, it is important to note the type and extent of the enterocele. If the vaginal vault is prolapsed, this will require a suspension or fixation of the vaginal vault in addition to the repair of the enterocele. This takes into consideration whether vault prolapse exists and also the degree of anterior vaginal wall prolapse or cystocele. If there is no vault prolapse and no cystocele, a simple repair can be performed. In cases in which there is vault prolapse and cystocele, a vaginal vault suspension is chosen. In cases of vault prolapse with no significant cystocele, a sacrospinous ligament fixation is performed. The sacrospinous ligament fixation can also be used in cases of vault prolapse with cystocele; however, we have found the vault suspension technique to be easier and to yield equal or better results in properly selected patients.

Transvaginal Enterocele Repair

All four variations start with the technique of simple enterocele repair, and other procedures may be performed after this if necessary. The patient is placed in the dorsal lithotomy position and prepped, with attention to adequately scrub the inside of the vagina in preparation for surgery. We usually place an iodoform-soaked pediatric laparotomy pad into the rectum so that it can be easily identified by palpation of the posterior vaginal wall. This is especially helpful when a concomitant rectocele repair is to be performed.

The labia are retracted with silk sutures. If a cystocele repair is to be performed, we usually place a suprapubic tube at the beginning of surgery either by the Lowsley tractor technique or percutaneously. A Scott ring retractor (Lone Star Medical Corporation) is very useful in helping to expose the operative field.

The first step is to isolate, repair, and remove the enterocele sac. This is begun by grasping the enterocele with two Allis clamps and bringing it outside of the vaginal introitus. The vaginal wall is then infiltrated with normal saline to facilitate dissection and separation of tissue planes. A longitudinal incision is made in the vaginal wall along the entire length of the enterocele. The vaginal wall is then carefully dissected away from the underlying pubocervical fascia and enterocele sac. In the initial dissection, care must be taken to stay very superficial and develop the proper plane. This is best accomplished by placing the curve of the Metzenbaum scissors against the vaginal wall. A finger can be placed on the outside of the vaginal wall to stabilize the initial dissection. Once the proper plane is entered, it is usually quite easy to dissect the vaginal wall away from the underlying enterocele sac. Care taken here will prevent early entry into the peritoneal cavity. The dissection of the enterocele is continued all the way to the neck of the enterocele sac. After the enterocele has been completely isolated, the sac is opened, and the peritoneal cavity is entered. At this time, one may see small bowel, omentum, or ovary and fallopian tube in cases where previous hysterectomy without oophorectomy has been performed.

The next step is closure of the enterocele defect or pouch of Douglas. Retraction of the peritoneal contents is best performed using a moist pediatric lap pad and a narrow Deaver retractor. This is assisted by placing the patient in Trendelenburg position so that abdominal organs fall slightly cephalad. The enterocele repair begins posteriorly while the abdominal contents are retracted anteriorly using the Deaver. A #1 PGA suture is first placed through the peritoneum and into the prerectal fascia that overlies the rectum. A circumferential closure of the defect is then performed by placing the pursestring suture laterally in the right in the uterosacral–cardinal ligament complex, anteriorly in the peritoneum, overlying the base of the bladder, laterally on the left in the uterosacral–cardinal ligament complex, and finally again posteriorly in the prerectal fascia. After this pursestring suture has been placed, a second one is placed in the identical structures in close proximity to the first. Care should be taken to place these sutures deep enough to ensure that adequate vaginal depth can be achieved. After the second pursestring suture has been placed, a third #1 PGA suture is placed from the right to the left uterosacral–cardinal ligament complex. This suture helps to reinforce the repair and also will be left tagged to help identify this complex later should it be necessary. After all sutures are placed, the assistant cinches down and places tension on one of the pursestrings while the surgeon ties the other. After this has been tied, the second pursestring is tied in a similar manner, followed by the uterosacral–cardinal ligament suture. The two pursestring sutures may now be cut while the third is left tagged. The excess enterocele sac may be excised, and the ends oversewn with a 2-0 PGA suture. If only a simple enterocele repair is performed, the tagged suture may now be cut. Excess vaginal wall is then excised, and the vaginal wall is closed with a running 2-0 PGA suture incorporating deep tissue to obliterate any dead space. An antibiotic-impregnated vaginal packing is placed for a period of 24 hours.

Enterocele Repair with Vault Suspension

The vault suspension procedure may be used when the vaginal vault has prolapsed and a cystocele is present. The size of the cystocele will determine the choice of vault suspension. For moderate cystocele (grades 2 and 3) with primarily lateral defects, the four-corner vault suspension and cystocele repair is the procedure of choice. When severe anterior vaginal wall prolapse is present with a grade 4 cystocele and a large central defect of the bladder through the pubocervical fascia, vault suspension with repair of grade 4 cystocele is used. These procedures incorporate techniques of two previously described repairs for moderate and severe cystocele.

Four-Corner Vault Suspension

After simple enterocele repair has been completed, the vaginal wall is left open, and the anterior vaginal wall is further infiltrated with normal saline. An inverted-U incision with the apex halfway between the bladder neck and the urethral meatus is made. The sides of the U are extended proximally to the level of the vaginal cuff and the uterosacral–cardinal ligament complex where the previous enterocele repair had been performed. The vaginal wall is then dissected laterally off the glistening surface of the periurethral fascia and out to the pubic bone in a manner identical to that performed for the Raz bladder neck suspension. Once the pubic bone is reached, the retropubic space is entered with sharp dissection, detaching the urethropelvic ligament from the tendinous arch using a curved Mayo scissors. A finger can then be placed in the retropubic space, and any adhesions bluntly lysed. Two #1 polypropylene suspension sutures are placed on each side. The distal sutures are identical to those for a Raz needle bladder neck suspension. They include two or three helical bites of full-thickness vaginal wall without its epithelium, pubocervical fascia, and urethropelvic ligament at the level of the bladder neck. The proximal sutures incorporate two to three helical bites of full-thickness vaginal wall without epithelium at the level of the vaginal cuff, pubocervical fascia, and the uterosacral–cardinal ligament complex. This complex can be identified by placing tension on the previously placed #1 PGA suture, which had been left tagged. After these sutures are placed, tension should be placed on them individually to make sure they are in strong tissue. The patient should be able to be moved on the table by pulling on each suture. The procedure is then repeated on the opposite side. Once these sutures have been placed, a stab incision is made in the anterior abdominal wall at the superior border of the symphasis pubis in the midline. A Pereyra–Raz double-pronged ligature carrier (Cook Urological) is placed in this incision and brought through the retropubic space under direct finger guidance. Each of the four suspension sutures is transferred to the anterior abdominal wall individually, as in other needle suspension procedures. Once these sutures have been transferred, gentle tension is placed to make certain that there is reduction of the cystocele.

Cystoscopy is performed to document that there has been no injury to the bladder and that the bladder neck and proximal urethra elevate and coapt nicely. Ureteral injury is ruled out by having the anesthesiologist give intravenous indigo carmine and observing for efflux of blue from each of the ureteral orifices.

The vaginal wall is closed with a running interlocking 2-0 PGA suture. After closure of the vaginal wall, the previously placed suspension sutures are tied with minimal tension. Antibiotic-soaked vaginal packing is placed, and the small suprapubic incision is closed with a subcuticular 4-0 PGA suture.

Vault Suspension with Grade 4 Cystocele Repair

A vertical midline incision is made in the entire anterior vaginal wall after it has been infiltrated with normal saline. This incision will extend from the midurethra all the way through the vaginal cuff and sometimes into the posterior vaginal wall. As described above, the vaginal wall is then dissected from the underlying cystocele, enterocele, and pubocervical fascia. In these cases, it is usually the bladder that is first encountered. The large cystocele is dissected out almost in its entirety. Once most of the posterior portion of the cystocele has been dissected, the enterocele sac is usually seen. After the enterocele sac is identified, its posterior margin can be dissected off of the vaginal wall. It is extremely important to completely separate the anterior margin of the enterocele sac from the bladder. If this plane is not obvious on initial dissection, it can be seen more easily after the enterocele has been opened. Adhesions of the enterocele sac to the bladder can safely be dissected with a finger inside the enterocele sac. Once the cystocele and enterocele have been completely separated, the retropubic space is entered by perforating the endopelvic fascia as described above for the four-corner vault suspension.

The bladder may be reduced and packed up in its normal position with a gauze sponge so that enterocele repair can be performed first. The enterocele sac is opened, and the peritoneal cavity entered. Once the enterocele sac has been mobilized all the way to its neck and the cystocele is adequately reduced, enterocele repair can be performed (as described above for simple enterocele repair). After completion of the enterocele repair, attention is turned to the cystocele. Anterior vaginal wall and vault suspension sutures of #1 polypropylene are placed. The distal sutures include the urethropelvic ligament, pubocervical fascia, and full thickness of vaginal wall without the epithelium at the level of the bladder neck. The proximal sutures are placed in the pubocervical fascia, uterosacral–cardinal ligament complex (again identified by the previously placed tagged suture), and the full thickness of the vaginal wall without the epithelium. These sutures are transferred to the anterior abdominal wall through a stab incision in the identical manner described for the four-corner vault suspension. Next, the central defect of the cystocele is closed, approximating the attenuated pubocervical fascia in the midline, using a 2-0 PGA suture. During the repair of the central defect, the bladder is kept reduced with either a gauze sponge, which is removed, or PGA mesh, which can be left in place. After completion of the cystocele repair, cystoscopy is performed as above. The excess anterior vaginal wall is closed with a running interlocking 2-0 PGA suture incorporating deep tissue to avoid any dead space. If present, the rectocele is repaired at this time. After closure of the vaginal wall, the suspension sutures are tied with minimal tension. Antibiotic-soaked vaginal packing is placed, and the suprapubic incision is closed with a 4-0 subcuticular PGA suture.

Sacrospinous Ligament Fixation

This technique is used to repair enterocele and vault prolapse in cases in which the anterior vaginal wall is well supported. This commonly occurs after bladder neck suspension or colposuspension. Certainly, one would not want to jeopardize the previous anterior vaginal wall repair by performing a vault suspension. In this case, vaginal depth and axis are restored by posterior fixation of the vaginal vault to the sacrospinous ligaments. The sacrospinous ligament stretches from the ischial spine to the sacrum and is covered by the coccygeus muscle. This procedure may also be used with cystocele repair, but we prefer the vault suspension in this instance.

After simple enterocele repair is completed, the posterior vaginal wall must be opened far enough distally to facilitate dissection to the sacrospinous ligament. When a simultaneous rectocele repair is to be performed, the entire posterior vaginal wall is opened through the perineum. After the posterior vaginal wall is incised in the midline, it is gently dissected laterally from the underlying prerectal fascia for a short distance. Next, the sacrospinous ligament must be identified. This is done by penetrating the right or left rectal pillar (pararectal fascia) sharply and entering the pararectal space. Blunt dissection of the pararectal space can be performed with a combination of finger dissection and the use of deep Breisky–Navratil retractors. This dissection is performed until the sacrospinous ligament is palpated and overlying coccygeus muscle is seen. The Breisky–Navratil refractors will help to expose the ligament. Once the ligament is identified, a #1 PGA suture is placed through the ligament and coccygeus muscle complex 2 cm medial to the ischial spine, which is also identified by palpation. It is important to place the suture in this position to avoid injury to the pudendal nerve and vessels, which run just below the ischial spine. It is also important to include the strong ligament in addition to the overlying coccygeus muscle. Tension should be placed on this suture to make certain that it is in the ligament. A second suture should be placed adjacent to the first. Each of these sutures is then placed through the full thickness of the vaginal wall at the level of the dome, approximately 1 cm apart, and left untied. If a rectocele is present, it is repaired at this time. The dome of the vagina can be directed under finger guidance to the deepest possible portion, where it will be fixed. The vaginal wall is then closed with a running interlocking 2-0 PGA suture, and then the previously placed sacrospinous ligament fixation sutures are individually tied. Antibiotic-impregnated vaginal packing is then placed.

An intra-abdominal approach to enterocele may also be performed. We usually reserve this for when laparotomy is being performed for other reasons. The abdominal approach described by Moschcowitz is similar to the simple enterocele repair that we use except that the approach is from above.1 In cases of vault prolapse, a colposacropexy can be performed using autologous rectus fascia or a synthetic mesh.

After completion of the surgical procedure, the antibiotic-soaked vaginal packing is left in the vagina until the next morning. Patients receive two to three postoperative doses of intravenous antibiotics before they are switched to broad-spectrum oral antibiotic. In the case of simple enterocele repair or sacrospinous fixation, when no suprapubic tube is used, the oral antibiotic is continued for 7 to 10 days. In cases where a suprapubic tube is left indwelling, antibiotics are usually continued until normal voiding resumes and all tubes are removed. Patients are usually hospitalized for 24 to 48 hours. They may resume light activity on discharge and only restrain from heavy lifting, strenuous exercise, and intercourse for 6 weeks.

OUTCOMES

Complications

When the algorithm described above was used for 83 patients, 14% experienced complications.5 Operative complications included one bladder and one ureteral injury. Most of the delayed complications were minor and included suprapubic wound infection (2.5%), cystocele (1.2%), rectocele (1.2%), flap of excess vaginal tissue requiring excision (1.2%), and chronic suprapubic pain (1.2%). In one patient in whom hysterectomy was not performed with enterocele, uterine prolapse developed, and vaginal hysterectomy was done. Other possible complications that did not occur in our series include small bowel or rectal injury, vaginal shortening limiting the ability to have intercourse, prolonged urinary retention, de novo stress or urge incontinence, and pelvic pain from pudendal nerve entrapment following sacrospinous ligament fixation.

Results

We used the above algorithm on 83 consecutive patients undergoing enterocele repair. Forty-nine (60%) underwent simple repair, 25 (31%) had vault suspension with enterocele repair (eight had four-corner and 17 had grade 4 cystocele repair), and seven (9%) had sacrospinous ligament fixation. Overall success (no recurrence) was 86%: 82% for simple repair, 96% for vault suspension, and 86% for sacrospinous ligament fixation. A total of 11 patients suffered recurrence at a mean of 11 months (range 4 to 32 months). Two of these occurred after further vaginal surgery, and one after pelvic trauma. Success for sacrospinous ligament fixation has previously been reported to be 62% to 97%.

A cystocele represents herniation of the urinary bladder through the weakened supportive fascia of the anterior vaginal compartment. Cystoceles range from involvement of only a small portion of the bladder base with a well-supported urethra to involving virtually the entire bladder and urethra. Cystocele is one of the manifestations of pelvic floor relaxation and prolapse. Within the context of pelvic floor relaxation, cystocele is commonly associated with other defects in the support of the superior and posterior compartments of the vagina as well. Loss of superior support (uterine prolapse, vault prolapse, and enterocele) and loss of posterior support (rectocele and perineal laxity) may coexist with defects of anterior compartment prolapse (cystocele and urethral hypermobility) and will require a coordinated approach and simultaneous repair.

Anatomically, a cystocele is the result of loss of pelvic floor support because of weakness of the levator fascia. The levator fascia has the principal role in the support of the anterior vaginal wall, urethra, and bladder. This fascial sheet covering the levator musculature of the pelvic floor inserts on the tendinous arch of the obturator muscle laterally and has a vaginal side and an abdominal side. The abdominal side is referred to as the endopelvic fascia. The vaginal side is called the periurethral fascia at the level of the urethra and the perivesical fascia at the level of the bladder. Together, the periurethral and perivesical fascia comprise the pubocervical fascia. The abdominal and vaginal sides fuse laterally as they insert onto the tendinous arch of the obturator. This fascia has several important condensations that provide lateral support to the bladder and urethra. The pubourethral ligaments support the midurethra to the inferior margin of the pubic bone. The urethropelvic ligaments suspend the urethra to the lateral pelvic sidewall from the bladder neck to the external meatus. The vesicopelvic ligament extends laterally to the pelvic sidewall, supporting the bladder, and finally, the cardinal ligaments extend from the cervix and upper vagina supporting these structures to the pelvic sidewall.

Anterior compartment weakness may involve the supporting structures of the urethra, the bladder, or both. Isolated defects in support of the urethra alone result in urethral hypermobility without cystocele. This may result in stress urinary incontinence and is discussed elsewhere in this text. Defects in the anatomic support of the bladder with or without coexisting involvement of the urethra result in cystocele. The cystocele defect may involve either the central or lateral support of the bladder and urethra, or it may be a result of weakening of both. Isolated central cystoceles are found when the fascia spanning the levator hiatus on the vaginal side (perivesical fascia) becomes attenuated without compromise of the lateral support (urethropelvic and vesicopelvic ligaments). Separation or attenuation of the cardinal ligaments in the midline usually contributes to the anatomic defect in central cystoceles, and reapproximation of these structures is critical to effect repair and prevent the onset of enterocele postoperatively. Isolated central cystoceles are a rare condition and comprise fewer than 10% of cystoceles. Isolated lateral cystoceles are more common and result from weakness or disruption of the lateral attachments of the vesicopelvic or anterior cardinal ligaments to the pelvic sidewall without significant weakness of the central support. Urethral hypermobility is commonly associated with lateral fascial defects. Combinations of central and lateral fascial defects are the most common presentation of cystocele and may result in severe degrees of prolapse.

DIAGNOSIS

Patients with cystoceles may be asymptomatic, may have associated stress urinary incontinence, or may complain of an introital bulge or a sensation of a mass in the vagina. Large cystoceles may cause kinking of the bladder neck and urethra, resulting in obstructive urinary symptoms, incomplete emptying, and, less commonly, frank urinary retention. Severe cystoceles may result in obstructive hydronephrosis and renal failure from urethral and ureteral obstruction. Rarely a cystocele may present as dyspareunia or incontinence during sexual intercourse. On physical examination, cystoceles appear as a midline mass in the vagina anterior to the cervix or vaginal cuff (if a hysterectomy has been performed). If significant pelvic relaxation is present, a cystocele may be present outside the vaginal introitus at rest or may bulge outside the introitus with Valsalva maneuver. It is important to differentiate cystocele from the other manifestations of pelvic prolapse that also may present with masses protruding from the vagina, including enterocele and rectocele. Examination with a half speculum will locate the vaginal cuff. Significant enteroceles and rectoceles will usually present posterior to the vaginal cuff or cervix. If there is doubt, cystography can be of assistance.

Lateral fascial defects causing cystoceles are identified in those patients with significant urethral and anterior vaginal wall hypermobility on stress maneuvers during physical examination. On examination with a half speculum directed posteriorly reducing any coexisting enterocele or rectocele, these patients have hypermobility of the entire anterior vaginal wall on stress with laxity of support for the anterolateral vaginal wall.

Isolated central fascial defects are rare and result from attenuation of the perivesical fascia in the midline and separation of the cardinal ligaments without evidence of lateral fascial weakness. Clinically these patients have a distinct anterior midline vaginal bulge without coexisting loss of support for the urethra and anterolateral vaginal wall. Typically there is no urethral hypermobility, as the lateral support of the urethra is unaffected.

Combined lateral and central defects are common and can result in urinary obstruction with or without incontinence when severe.

It is important to ascertain the level of sphincteric competence preoperatively in any patient undergoing cystocele repair. Clearly, if the patient is incontinent, some type of procedure to increase outlet resistance is needed in addition to cystocele repair. However, many patients presenting with cystoceles may not have associated symptoms of stress incontinence. In these patients sphincteric incompetence may be masked by the valvular effect of the cystocele. If the cystocele is repaired in isolation, the protective valvular effect of the cystocele on the urethra and outlet will be lost. In this case, despite adequate repair of the cystocele, the unsuspended urethra will remain in a low-lying unprotected position, and the patient will have a substantial risk of postoperative incontinence. Therefore, any degree of urethral hypermobility in the presence of a cystocele, with or without urinary incontinence preoperatively, should be repaired at the time of surgery by simultaneous suspension or sling.

Finally, a cystocele with a well-supported, nonmobile urethra from a previous suspension in combination with poor emptying ability may signal urethral obstruction. This may be caused by urethral obstruction (from the previous suspension or the cystocele or both) or detrusor hypocontractility. Patients with urethral obstruction from previous surgery may require urethrolysis and resuspension in addition to cystocele repair in order to avoid postoperative urinary retention. Patients with poor detrusor contractility should be alerted to the high risk of long-term intermittent catheterization postoperatively. Careful preoperative urodynamics with the cystocele reduced will help sort out these situations.

INDICATIONS FOR SURGERY

The repair of cystocele is based on several factors: the presence or absence of urinary incontinence, the grade of the cystocele, the inherent pathophysiological fascial weakness (central or lateral), emptying ability, and the associated vaginal or abdominal pathology to be repaired (uterine prolapse, enterocele, rectocele, etc.). Asymptomatic, small cystoceles with no evidence of stress urinary incontinence (SUI), urinary obstruction, and absence of other manifestations of pelvic prolapse do not require surgical repair. Small grade I and II cystoceles resulting from lateral fascial defects associated with SUI are usually adequately repaired using the Raz vaginal wall sling described in this text and elsewhere.

Cystoceles resulting from an isolated central fascial defect without concomitant SUI, urethral hypermobility, or demonstrated sphincteric incompetence with the cystocele reduced can undergo a central fascial defect repair alone. It should be noted that this is an uncommon presentation, and this procedure is rarely performed in isolation at our center.

In patients with a moderate cystocele resulting from a lateral fascial defect, we utilize a six-corner bladder suspension. This group of patients has, by definition, associated urethral hypermobility as a result of the associated anatomic fascial defect. The urethral hypermobility as well as the cystocele will be corrected by the six-corner suspension. This operation is a modification of our previously described four-corner suspension.3 This evolution came about from our improved understanding of the importance of the midurethral complex in the maintenance of continence in many women.

In patients with a severe cystocele (grade IV) and both a lateral and central fascial defect, a combined lateral and central fascial defect repair with mesh and vaginal wall sling will be performed. This is also a modification of a previously described procedure now redesigned to incorporate the midurethral complex into the repair.

ALTERNATIVE THERAPY

With rigorous physical therapy and intensive pelvic floor rehabilitation, some small cystoceles can be eliminated by strengthening the pelvic floor musculature. The addition of oral or topical estrogens may augment the response to nonsurgical therapy in those patients who are poorly estrogenized. Larger cystoceles without significant urinary obstruction but large enough to be bothersome to the patient can be reduced and treated with a pessary. This is also effective in those patients whose coexisting medical illness precludes surgery.

Commonly used surgical alternatives to the transvaginal procedures described below include various transabdominal procedures including the Richardson para-vaginal repair, the Burch colposuspension, and the Marshall–Marchetti–Krantz (MMK) repair. Transabdominal retropubic procedures such as the paravaginal repair and the colposuspension are indicated when the presence of other intra-abdominal pathology (large uterine leiomyomas requiring abdominal hysterectomy, ovarian pathology, etc.) requires concomitant surgical exploration. It should be noted that these procedures do not address central fascial defects and are useful only for repairing isolated lateral fascial defects. The use of retropubic procedures to repair cystoceles resulting from central defects may actually aggravate the condition, as the lateral tension placed on the suspending sutures may create increased midline fascial separation through additional shearing forces on the already weakened central fascia. The MMK should never be utilized for the repair of cystocele, as the sutures are placed too medially over the urethra to have a significant impact on the intrinsic fascial defect causing the cystocele. Simultaneous abdominal and vaginal approaches may be necessary in some cases with combined pathology.

Transvaginal approach to cystocele repair has several distinct advantages over the abdominal approach. Vaginal incision is associated with less postoperative pain and discomfort and a faster return to regular activities. Coexisting vaginal pathology such as rectocele, enterocele, and vault prolapse are easily repaired through the same or a slightly extended incision. Finally, both the lateral and central fascial defects resulting in the appearance of the cystocele are completely isolated and repaired under direct vision with a vaginal approach.

SURGICAL TECHNIQUE

Combined Repair of Lateral and Central Defects with Mesh and Vaginal Wall Sling

This procedure will repair the lateral and central fascial defects as well as the associated urethral hyper-mobility. The lateral fascial defect is repaired by non-absorbable sutures placed through the ligamentous supports of the bladder and urethra and then suspended to the anterior rectus fascia. The vaginal wall sling is accomplished by these same suspension sutures, thus repairing the urethral hypermobility. Finally, the central defect is repaired by reapproximating the cardinal ligaments in the midline and then placing several interrupted sutures plicating the perivesical fascia from the bladder neck to the level of the cardinal ligaments.

Preparation

Most vaginal surgery at our institution is performed on an outpatient basis. Antibiotics are administered parenterally 1 hour before incision. General anesthesia is preferentially used in all our vaginal surgery unless medically contraindicated.

The patient is brought to the operating room and placed in the dorsal lithotomy position with candy-cane stirrups. The buttocks are placed just off the end of the operating room table. All pressure points are padded, and care is taken to ensure that no lower extremity joint is flexed more than 90 degrees. The lower abdomen and perineum are shaved. A povidone/iodine vaginal scrub and painting are performed. The anus is draped out of the field with a self-adherent clear plastic drape. The remaining drapes are secured with silk suture across the perineum to ensure separation of the fecal and urinary streams. A weighted vaginal speculum is placed, and labial retraction sutures of 3-0 silk are used for maximal exposure.

A Lowsley retractor is placed per urethra and supported at the meatus. The tip of the Lowsley is directed anteriorly, and a suprapubic incision is performed approximately two fingerbreadths cephalad to the superior margin of the symphysis pubis in the midline. The incision is carried sharply down onto the tip of the Lowsley, and the Lowsley is extruded through the anterior abdominal wall. A 16-Fr Foley catheter is grasped and brought into the bladder and confirmed in good position by irrigation with a Toomey syringe. An additional 16-Fr Foley is placed per urethra. If indicated, a vaginal hysterectomy is now performed.

Goalpost Incision

A ring retractor is placed, and the hooks are used to expose the introitus. The anterior vaginal wall overlying the cystocele is grasped and everted through the introitus. Infiltration with injectable saline is performed along the anterior vaginal wall in the line of a goalpost-shaped incision. The limbs of the goalpost are slightly obliqued and are located on the anterior vaginal wall 1 cm from the reflection of the lateral walls of the vagina. The obliqued limbs of the goalpost extend from the midurethra to just beyond the bladder neck. The proximal extent of the paired oblique incisions are connected across the midline under the bladder neck, and then a single incision is carried to the level of the vaginal apex in the midline. The preserved island of tissue beneath the proximal urethra and bladder neck will be used for the placement of the sling sutures.

Development of the Vesicovaginal Space

The cut edges of the vaginal wall in the midline are grasped with Allis clamps to provide countertraction for the ensuing initial dissection. Sharp, shallow dissection is then carried out laterally, using Metzenbaum scissors, to develop the vesicovaginal space. This plane is avascular, and the vaginal wall should easily separate from the underlying periurethral and perivesical fascia. In reoperative cases, the vesicovaginal space may be difficult to define, and very shallow sharp dissection on the vaginal wall is imperative to avoid inadvertent entry into the bladder.

Lateral and anterior dissection toward the limbs of the goalpost incision is carried out first. Posterior dissection toward the vaginal cuff in patients who have had previous hysterectomy can be difficult, and extreme care should be taken to avoid inadvertent bladder injury. Initial mobilization of the anterior and lateral vaginal walls will make the difficult posterior dissection toward the vaginal cuff considerably less dangerous because the tissues can be reflected over the surgeon’s finger in order to facilitate dissection in the correct plane. Careful attention should be paid to the possible presence of a coexisting enterocele in the region of the vaginal cuff.

All dissection should be done under direct vision. The hooks of the ring retractor can be replaced onto the developing vaginal flaps to assist in exposure. Excessive bleeding during the early portion of the dissection indicates entry into an incorrect plane and may signal imminent bladder perforation. Sudden brisk bleeding in the posterior dissection toward the vaginal cuff may indicate severing of a branch of the uterine artery. This can be readily controlled under direct vision with forceps and cautery. However, cautery should be kept to a minimum to avoid tissue devitalization and subsequent development of vesicovaginal fistula.

The entire bladder base with attached fascia should be dissected free of the vaginal wall. Anteriorly, the periurethral fascia should be exposed toward the inferior pubic ramus and its attachment to the tendinous arc of the obturator muscle. Posteriorly, the dissection is carried to the level of the vaginal apex in the region of the cardinal ligaments.

Once the entire cystocele has been dissected from the anterior vaginal wall, a 2-0 synthetic absorbable suture (SAS) is placed through the area of the cardinal ligaments so that it will reapproximate both cardinal ligaments to the midline when tied. This stitch is not tied at this time, as it marks the proximal extent of the central defect repair.

Repair of the Lateral Fascial Defect

Attention is now turned to the suspension. The retropubic space is entered with Mayo scissors pointed at the ipsilateral shoulder, perforating the urethropelvic ligament at its insertion onto the tendinous arc of the obturator muscle. The urethropelvic ligament is released from its attachment to the tendinous arc. The adhesions in the retropubic space are lysed bilaterally, leaving the urethra freely mobile.

The four suspending sutures (two proximal and two distal sutures) of #1 polypropylene (Prolene) are now placed. The proximal suture individually incorporates three structures: the proximal edge of the released urethropelvic ligament at the bladder neck, the perivesical fascia at the reflection of the dissected vaginal wall midway between the bladder neck and the cardinal ligaments, and, finally, the area of the cardinal ligaments at the level of the vaginal cuff. Exposure of the proximal portion of the urethropelvic ligament is aided by placing blunt forceps into the retropubic space and retracting the urethra medially. The suture is then passed through all these structures again.

The distal polypropylene suture is passed with helical bites through the midurethral complex, urethropelvic ligament, and the periurethral fascia (anterior vaginal wall excluding epithelium). Exposure of the midurethral complex is facilitated by opening a forceps horizontally within the retropubic space and placing downward traction with the open forceps. This suture incorporates the midurethral complex, including the pubourethral ligament and levator entrance into the urethra, and the distal aspect of the freed urethropelvic ligament and finally is passed parallel to the anterior vaginal wall to include the periurethral fascia but exclude the vaginal epithelium. The identical two sutures are placed on the opposite side.

Transfer of Sutures

A 1-cm skin incision is performed at the upper margin of the symphysis pubis on the lower abdominal wall. Blunt dissection is carried down to the anterior abdominal wall fascia. A double-pronged ligature carrier is now passed from the suprapubic incision to the vaginal incision under fingertip guidance. The ligature carrier should scrape the posterior surface of the symphysis as it is passed to avoid inadvertent bladder or urethral injury. Piercing the abdominal wall fascia too cephalad off the superior margin of the pubis will result in mobility of the sutures and considerable postoperative pain and discomfort.

The ligature carrier is used to transfer the four sutures individually from the vagina to the abdominal incision. They are not tied at this time. These four sutures represent the repair of the lateral defect of the cystocele as well as the vaginal wall sling.

Repair of the Central Fascial Defect

Absorbable mesh (Dexon or Vicryl) is used to pack and reduce the cystocele cephalad in the midline. This is left in situ but is not sutured in place. Interrupted horizontal mattress sutures of 2-0 SAS are placed in the lateral edges of the perivesical fascia sequentially from the bladder neck to the area of the cardinal ligaments. These imbricating sutures are placed just medially to the suspending polypropylene sutures into the perivesical fascia but are not tied. Usually four or five sutures are required to close the defect.

Cystoscopy

The urethral Foley is removed, and cystoscopy is performed to ensure that a polypropylene suture has not been inadvertently placed through the bladder or urethra as well as to confirm efflux from both ureteric orifices. The suprapubic tube location should be confirmed as well. Gentle upward traction on the suspending sutures should elevate the bladder neck and proximal urethra as viewed through the cystoscope.

Up to this point the operation is completely reversible, as no sutures have been tied. Thus, if a misplaced suture or incidental cystotomy is detected on cystoscopy, it is easily remedied.

Closure of the Vaginal Wall

The cardinal ligament suture is now tied, thus reapproximating these structures toward the midline at the level of the vaginal apex or cuff. The sutures repairing the central defect are now tied.

The limbs of the goalpost incision are closed with a running interlocking 2-0 SAS. The excess vaginal wall is trimmed, and the remaining vaginal wall is closed with 2-0 SAS in a running interlocking fashion incorporating the underlying central defect repair, thus closing potential dead space. The vagina is packed with an antibiotic-impregnated gauze.

Completing the Suspension

The suprapubic sutures are tied with the knot laid down onto the anterior abdominal wall fascia under no tension. A cystoscope sheath should be placed per urethra at a 30-degree incline while the suspending sutures are tied down. In our experience, if the cystoscope sheath maintains elastic mobility after all the sutures are tied, then there is no undue tension on the suspending sutures. The suprapubic incision is irrigated with antibacterial solution and closed with a subcuticular 4-0 SAS.

Postoperative Care

The SP tube is placed on slight traction and left to gravity drainage. The vaginal pack is removed in 2 to 3 hours. The patient is allowed to void immediately postoperatively. Postvoid residuals are checked every 2 to 3 hours. The patient is discharged from the same-day surgery unit when ambulatory and able to tolerate a regular diet. She is taught suprapubic tube care and how to measure her own postvoid residuals. When the residual is less than 30 to 60 cc, the suprapubic tube is removed. Alternatively, when the postvoid residuals remain high, the patient is taught clean intermittent catheterization techniques, and the tube is removed at the end of 4 weeks.

The patient may resume all regular activities immediately postoperatively except heavy lifting, running, and sexual intercourse. These limitations are removed at 4 weeks at the time of the first postoperative office visit.

Repair of Lateral Defect (Six-Corner Bladder Suspension)

This procedure is best suited for those patients with moderate cystoceles (grade II or III) and primarily lateral fascial defects.

Preparation

The positioning, preparation, and placement of suprapubic tube are identical to those for the repair described above.

Incision

The anterior vaginal wall overlying the distal urethra is grasped with an Allis clamp and stretched cephalad. Two oblique vaginal incisions are performed 1 cm medial to the reflection of the lateral vaginal wall onto the anterior vaginal wall, from the midurethra to the region of the vaginal cuff (if a hysterectomy has been performed) or to the paracervical region if the uterus is to be preserved.

Exposure of Ligamentous Supports

Sharp dissection is carried laterally from both incisions using the Metzenbaum scissors. Proximally, dissection is performed to expose the area of the cardinal ligaments. Distally, lateral dissection is carried over the glistening periurethral fascia, exposing the insertion of the urethropelvic ligament onto the tendinous arch of the obturator muscle.

The retropubic space is entered with Mayo scissors pointed at the ipsilateral shoulder and perforating the urethropelvic ligament at its insertion onto the tendinous arc of the obturator muscle. The urethropelvic ligament is released from its attachment to the tendinous arch bluntly. The adhesions in the retropubic space are lysed bilaterally, leaving the urethra freely mobile.

Placement of Sutures to Repair the Lateral Fascial Defect

Three sutures of #1 polypropylene (Proline) are placed on each side. Each suture incorporates multiple passes through the tissue. The proximal suture is passed through the perivesical fascia parallel to the anterior vaginal wall, incorporating the area of the cardinal ligaments at the apex of the vagina but excluding the vaginal epithelium. If passed correctly, this suture should be anchored into very strong, supportive tissue.

The middle suture is first placed at the level of the bladder neck and is passed with helical bites through the perivesical fascia parallel to the anterior vaginal wall excluding the vaginal epithelium. The bladder neck is then held medially and the suture is placed through the freed proximal edge of the urethropelvic ligament in a helical fashion at the level of the bladder neck.

The third suture is placed at the level of the midurethral complex. Exposure of the midurethral complex is facilitated by opening a forceps horizontally within the retropubic space and placing downward traction with the open forceps. This suture incorporates the midurethral complex, including the pubourethral ligament and levator entrance into the urethra, and the distal aspect of the freed urethropelvic ligament and finally is passed parallel to the anterior vaginal wall including the periurethral fascia but excluding the vaginal epithelium.

Transfer of Sutures

A 1-cm skin incision is performed at the upper margin of the symphysis pubis on the lower abdominal wall. The ligature carrier is used to transfer the six sutures individually from the vagina to the abdominal incision in the same manner as described for the combined repair. They are not tied at this time.

Cystoscopy

The urethral Foley catheter is removed, and cystoscopy is carried out examining for intravesical or intraurethral suture as well as proper location of the suprapubic tube at the dome. Urinary efflux should be confirmed from both ureteral orifices.

Closure of the Vaginal Wall

The oblique incisions in the anterior vaginal wall are now closed with a running interlocking 2-0 SAS with care taken not to trap the polypropylene suspension sutures in the closure.

Completing the Suspension

The suprapubic sutures are tied under no tension as described previously, and the abdominal incision is irrigated and closed.

Postoperative Care

The vaginal packing is removed in 2 to 3 hours, and the patient is discharged home when ambulatory and able to tolerate a regular diet. The remaining postoperative care is identical to that previously described for the combined repair.

Repair of a Central Defect

This procedure is specifically indicated only for the repair of isolated central fascial defects with a well-supported, competent, nonobstructed sphincteric mechanism. This is an uncommonly performed procedure, as most central defects are accompanied by other manifestations of pelvic prolapse.

Preparation

The positioning, preparation, and placement of a suprapubic tube are identical to those for the repairs described above.

Incision and Dissection of the Anterior Vaginal Wall

The anterior vaginal wall is infiltrated with injectable saline in the midline from the bladder neck to the apex of the vagina. The anterior vaginal wall overlying the cystocele is then incised sharply with the knife. The cut edges of the vaginal wall are grasped with Allis clamps to provide countertraction for the ensuing initial dissection. Sharp dissection is then carried out laterally, using Metzenbaum scissors to expose the vesicovaginal space and the perivesical fascia. This plane is avascular, and the vaginal wall should easily separate from the underlying periurethral and perivesical fascia. Lateral flaps of vaginal wall are developed from the midurethra to the vaginal apex. A ring retractor can be placed to assist in the retraction of the developing flaps.

Lateral dissection is carried out until the weakened perivesical fascia found in the midline—the cause of the anatomic defect allowing for the formation of the cystocele—is no longer attenuated. This strong lateral aspect of the perivesical fascia will constitute the tissue for the subsequent central defect repair.

Proximal dissection toward the vaginal cuff in patients who have had previous hysterectomy can be difficult, and extreme care should be taken to avoid inadvertent bladder injury. Dissection should be carried proximally to the area of the cardinal ligaments.

Repair of the Central Defect

Repair commences with the reapproximation of the area of the cardinal ligaments in the midline with a 2-0 synthetic absorbable suture. Attention is now turned to the perivesical fascia lateral to the bladder neck on either side. A horizontal mattress stitch of 2-0 synthetic absorbable suture is used to plicate this fascia toward the midline. When tied, this stitch will draw the perivesical fascia beneath the bladder neck. The cystocele is reduced manually or, as we prefer, using absorbable Vicryl or Dexon (polyglycolic acid) mesh. The cystocele is thus packed cephalad, and the mesh is left in situ. The remaining perivesical fascia is then plicated from the level of the bladder neck to the cardinal ligaments with interrupted closely approximated horizontal mattress sutures of 2-0 synthetic absorbable suture. The sutures are not tied at this time.

Cystoscopy

The urethral Foley is removed and cystoscopy is performed to ensure that a suture has not been inadvertently placed through bladder or urethra as well as ensure efflux from both ureteric orifices.

Closure

The plicating sutures are now tied. The excess vaginal wall is trimmed, and the vaginal wall is reapproximated with a running 2-0 absorbable suture. An antibiotic impregnated vaginal packing is placed. In 4 to 6 hours the vaginal packing and Foley are removed.

OUTCOMES

Complications

Complications associated with cystocele repair can be avoided by careful attention to detail during dissection of the cystocele and passage of the ligature carrier. Incidental cystotomy occurs rarely and should be repaired intraoperatively. A multiple-layer closure with nonopposing suture lines and maximal urinary drainage should be performed to prevent late-onset vesicovaginal fistula.

Careful cystoscopic evaluation intraoperatively should alert the surgeon to many other potential complications. Ureteral obstruction is diagnosed by noting the lack of urinary efflux from the ureteral orifice. Removal and replacement of the offending stitch should suffice for repair. Internal ureteral stenting is considered only if there was extensive trauma to the ureter. Inadvertent intravesical or intraurethral placement of nonabsorbable suture will result in recurrent infections and stone formation. This should be recognized intraoperatively during careful cystoscope examination. Removal and replacement of the suture is easily performed if it has not yet been tied as described above.

Postoperative bladder instability is a well-documented complication of cystocele repair. Detrusor instability may result from three sources: continuation of preoperative instability, de novo bladder instability temporally related to cystocele repair, and finally, urethral obstruction as a result of tying the suspension sutures under tension. Preoperative detrusor instability is expected to resolve in over 70% of patients postoperatively. The remaining patients may be treated pharmacologically with anticholinergic agents. De novo instability is treated pharmacologically as well. Nonresolution of de novo instability in the presence of incomplete emptying may indicate urethral obstruction. Tying the sutures with a cystoscope sheath in the urethra under no tension as described is the best way to avoid this complication. Urethral obstruction may require formal urethrolysis or complete takedown of the suspension for resolution. In this situation, resolution of instability can be expected in over 90% of cases.8

Incomplete emptying and urinary retention may also result from poor detrusor contractility unrecognized preoperatively. Long-term clean intermittent catheterization is preferable to indwelling Foley catheterization in these unfortunate cases.

Persistent pain, infection, bleeding, recurrent incontinence, vaginal stenosis and/or shortening, vesicovaginal fistula, ureterovaginal fistula, and dyspareunia are also potential complications of cystocele repair.

Finally, enterocele may result months to years later from alteration of the pelvic axis and insufficient anatomic reapproximation of the cardinal ligaments to the midline during repair. Plication of the perivesical fascia without reapproximation of the cardinal ligaments during repair of central defects leaves a considerable anatomic defect in the region of the vaginal cuff, allowing for the formation of an enterocele.

Results

Because these procedures represent relatively new modifications of previous technique, we are still compiling data on the results. Previously we had reported on the four-corner bladder suspension for moderate cystocele, which is the forerunner of the six-corner bladder suspension described above. This procedure did not incorporate the midurethral complex in the form of the vaginal wall sling as it does now. Nonetheless, with the previous technique, 105 of 107 patients with moderate cystocele were successfully treated at a mean follow-up of 2 years.

We have also reported on a previous modification of the combined repair of central and lateral defects. Likewise, this procedure did not incorporate the midurethral complex in the repair. In this preliminary study, we reported a 96% success rate for grade 4 cystocele at a follow-up of 34 months. The current modifications were designed to address the midurethral complex and improve postoperative continence in this complex group of patients.

Type III stress urinary incontinence results from intrinsic dysfunction of the urethra and bladder neck incompetence. Effective repair must restore closure of the deficient urethra. Current surgical techniques include the use of fascial slings, vaginal island slings, artificial urinary sphincter, or periurethral injections. A variety of natural materials have been used for sling procedures, the most popular being fascia lata or rectus fascia. Synthetic materials are convenient but are more prone to problems of erosion or infection. The narrow dimensions of a traditional sling make it important that the surgeon position the sling accurately at the proximal urethra. A more distal location can produce outflow obstruction or problems with recurrent infection or voiding difficulty. The rectus muscle provides a broad platform of support for the bladder neck and urethra, and accurate placement seems to be less of a problem.

DIAGNOSIS

There is a clinical pattern of sacral neurogenic deficit that is characterized by flat feet and loss of intrinsic muscle function of the toes (inability to abduct the toes), and the lateral toes may be hypoplastic. On perineal examination, there is loss of two-point discrimination (4 cm) in the postanal (S5) or perianal (S4) dermatomes, and anal examination reveals loss of anal tone and anal grip that is weak and not sustained.

The severity of urinary leakage will give a clue to intrinsic urethral weakness. If the patient leaks with a flood in the supine position on the first or second cough, one should suspect type III stress urinary incontinence. Correction of bladder neck displacement with the examining finger will usually fail to correct the leakage. It is often difficult to assess urethral function in the presence of severe vaginal vault prolapse or procidentia because the prolapsing bladder base may obstruct the urethra. Surgical correction of the prolapse may reveal moderate or severe stress incontinence.

Objective urodynamic findings are essential to distinguish the patient who will require a sling procedure. Selection criteria for rectus muscle sling procedure were Valsalva leak-point pressures of less than 60 cm H2O and/or maximum urethral pressure (Brown and Wickam) of less than 20 cm H2O and/or a urethral length of less than 1.5 cm.

INDICATIONS FOR SURGERY

Traditional indications would reserve sling procedures for those who have failed a primary surgical repair. In contemporary practice, the sling is also used as a primary procedure for patients with severe stress urinary incontinence. Clinical features would include leakage with a flood that occurs instantly with the first cough in a supine position, in a patient with a comfortably full bladder, or leaks while standing without provocation.

Cystoscopic features include open bladder neck and short urethral length (<1.5 cm).

Patients who present with total vault prolapse with eversion of the vagina will also require a sling. It is my practice to identify and correct all of the pelvic support defects at the time of surgery.

ALTERNATIVE THERAPY

A variety of natural materials have been used for sling procedures, the most popular being fascia lata or rectus fascia. Synthetic materials are convenient but are more prone to problems of infection and erosion. The narrow dimensions of a traditional sling make it important that the surgeon position the sling accurately at the proximal urethra. A more distal location can produce outflow obstruction, problems with recurrent infection, or voiding difficulty. The artificial urinary sphincter or injection of periurethral bulking agents may be considered for the treatment of type III stress urinary incontinence.

SURGICAL TECHNIQUE

We have used a combined abdominal and vaginal approach. Venous compression pneumatic hose’s are applied and activated. The patient is placed in a modified dorsal lithotomy position with the lower limbs supported in the Sams modification of Allen stirrups. Independent grounding pads are placed for the abdominal and vaginal fields. Careful examination of the vagina and perineum confirms the presence or absence of fascial defects for repair. The most common defects are paravaginal, but anterior (pubocervical) or posterior (rectovaginal) fascial defects may also be present.

A midline incision is preferred, extending from the left of the umbilicus to the pubic crest. Alternatively, a transverse incision may be made, but this will require that the anterior rectus sheath be incised with a deep U incision and reflected upward to the level of the umbilicus. The rectus abdominis muscle is mobilized from the posterior aspect of the anterior rectus sheath, with care taken to preserve the epimysium, the outer fascial envelope that encloses the muscle bundles. This dissection progresses easily if the assistant elevates the fascial edge with Allis forceps and then Richardson retractors, and the surgeon works from the pubis toward the umbilicus. There are two small perforating vessels that pass anteriorly from the deep inferior epigastrics through the rectus abdominis muscle and the anterior rectus sheath to anastomose with the superficial epigastric vessels in the subcutaneous tissues. These perforators are coagulated and divided. At the lateral border of the rectus muscle, the segmental neurovascular bundles penetrate between the posterior and anterior layers of the rectus fascia; these bundles are coagulated, but the larger bundles may be ligated and divided.

Dissection to the lateral border of the muscle in the distal third allows the thin posterior fascia to be opened and the deep inferior epigastric pedicle to be palpated. If the pedicle has been ligated during an earlier procedure, the rectus muscle will be thin and not suitable, but the contralateral muscle can be used. If both pedicles have been ligated, the rectus muscle procedure would be abandoned, and a fascial sling substituted.

As dissection proceeds to the level of the umbilicus, a tendinous inscription will be noted where the anterior rectus fascia is adherent to the muscle. Above this level the direction of the fibers will change, and the muscle is mobilized for a further 2 cm cephalad to the tendinous inscription. The surgeon’s finger can now be passed from lateral to medial between the rectus muscle and the posterior rectus sheath. A large right-angle forceps is passed, and a heavy Vicryl ligature is carried around the muscle belly. As the ligature is tied, the muscle is divided, and the vascular pedicle is ligated. A second heavy ligature is tied, and the vessels are ligated and divided. Three holding sutures are placed through the tendon to facilitate the dissection and to be used later.

Dissection is continued until the muscle is free from all posterior attachments, and care is taken to clean all of the loose areolar tissue off the posterior rectus sheath to travel with the muscle; this will ensure that the vascular pedicle will be elevated with the muscle and preserved. The pubic insertion and the deep inferior epigastric vessels are not disturbed, but the muscle must be completely free from the overlying anterior rectus sheath and pyramidalis.

The muscle is held up by the holding sutures in the tendinous intersection and then folded along its longitudinal axis, by tying the lateral and medial holding sutures, to enclose and protect the vascular pedicle. The borders are approximated with two absorbable sutures in the middle third of the muscle.

The vaginal dissection is similar for other slings. The vaginal mucosa is elevated with injectable saline. We favor an inverted-U incision, but if access is narrow, a vertical incision is used. Dissection is carried out laterally to the pubic rami and forward under the bladder neck. The vaginal surgeon will elevate the endopelvic fascia, lateral and close to the pelvic side wall.

The abdominal surgeon will incise the endopelvic fascia and create an opening that will admit the passage of first one, and then two, fingers on the left side and then the right. The abdominal surgeon is usually able to guide the vaginal surgeon to avoid opening vaginal vessels, but on occasion the veins must be oversewn to control bleeding. Use of a spreading forceps (Knight Surgical Instrument Co.) allows the passage first of the holding sutures and then of the muscle belly through the ipsilateral defect to the vaginal surgeon. It is drawn downward to deliver the full length and then passed back into the pelvis through the other opening, while the spreading forceps within the pelvis hold open the defect in the endopelvic fascia. The tendinous inscription of the muscle is used to anchor the muscle sling to Cooper’s ligament with three or four nonabsorbable sutures. On occasion, the length of muscle will not reach up to Cooper’s ligament, and instead it will be secured to the internal obturator fascia.

The muscle belly fills the suburethral space and lies naturally without tension beneath the bladder neck and urethra. The suburethral muscle provides a broad support to the bladder neck and coaptation of the urethra. The vaginal wound is closed with interrupted absorbable sutures. If there are other support defects, the vaginal wound is closed first, before the colpopexy, and the paravaginal sutures from above (or the sacrocolpopexy fixation) are tied down.

Cystoscopy is done after intravenous injection of 5 ml of indigo carmine to confirm free efflux from the ureters. Cystoscopy is not used to adjust the sling but only to confirm the normal axis of the urethra and the closed appearance of the bladder neck. The bladder is drained with a urethral catheter. If there is a defect in the rectovaginal fascia or perineal body, this would be repaired after cystoscopy.

The abdominal wound is closed with interupted nylon sutures. Particular care is taken to close the fascia at the pubic crest.

The patient is mobilized on the first day. The catheter is drained to a bedside bag. It is removed when the patient has begun to pass flatus or had a bowel movement, usually on the third postoperative day. Voiding trials should begin at 3 hours, and after voiding efforts, straight catheterization should be done for residual volume. It is also necessary to drain the bladder one time in the course of the night in the first days. Most patients will require an interval of self-catheterization in the first 2 weeks, and some will use it for as long as 6 weeks. Preoperative teaching is done to encourage the transition through the interval of self-catheterization. When the catheterized volumes decrease to less than 60 ml, it can be tapered off. It is usually helpful to continue with the self-catheterization twice daily for a few days to be sure that emptying has been achieved.

OUTCOMES

Complication

Complications from this operation are few. Of 100 patients treated at our center since 1992, there was no mortality, and ten early complications included superficial wound infection (6), pelvic abscess (2), deep venous thrombosis (1), and fascial dehiscence (1). These complications all occurred early in the series, and some of these were related to the use of a suprapubic catheter. Special attention has been given to the surgical technique, including abandoning the use of suprapubic catheters, the introduction of antibiotic wound irrigation, and also the use of nonabsorbable sutures for the closure. There have been no wound problems in the last 26 cases.

There were 11 late complications including incisional hernia in nine. One patient had had multiple periurethral injections of Teflon, and the anterior vaginal wall was a solid indurated mass. After excision, the omentum was used to cover the muscle sling and repair the vaginal defect. This patient did well but developed prolapse of redundant omentum, which had to be trimmed after 6 months.

Results

One hundred patients have been treated for type III stress urinary incontinence with a rectus muscle sling since 1992. The medical record, patient interviews, and an independent questionnaire were used to evaluate the course and outcome of treatment. The interviews and questionnaires were done independently by a physician who was not a member of the surgical team. The mean age of the patients was 62 years, with a range of 24 to 83. The mean follow-up interval was 22 months, with a range of 3 to 47. Factors predisposing to incontinence included hysterectomy (79), lumbar stenosis (7), pelvic fractures (2), and traumatic paraplegia (1). Forty-nine patients had failed 86 previous surgical repairs, including MMK or bladder neck suspension (61), anterior repair (17), and periurethral collagen (8).

All patients had moderate or severe stress urinary incontinence, and all patients had preoperative videourodynamics. Selection criteria for rectus muscle sling procedure were Valsalva leak-point pressures of less than 60 cm H2O and/or maximum urethral pressure (Brown and Wickam) of less than 20 cm H2O and/or a urethral length of less than 1.5 cm.

Other anatomic defects were present in these patients, and other procedures were combined with the rectus muscle sling as needed. These procedures included sacrocolpopexy (34), paravaginal repair (31), and repair of urethrovaginal fistula (3).

The mean hospital stay was 6 days. On leaving hospital, 6% were already voiding to completion. Sixty-three were voiding but needed clean catheterization to empty, and 31% used a suprapubic catheter. After 2 months, 90% were voiding to completion, no patient had a suprapubic catheter, and only 10% used clean intermittent catheterization.

The pattern of voiding after a traditional sling may be slow or interrupted. It has been noticeable that voiding is quite normal for many of these patients after rectus muscle sling, and there are few complaints of irritative symptoms.

Of the 84 patients who responded to the independent questionnaire, 47% were dry and used no pads, and 33% were satisfied but were still using one or two pads a day. Twenty percent were not satisfied and still used 3 or more pads a day. Eighty-one percent of patients described themselves as improved or much improved after surgery.

This report represents a more complex group of patients than many series, because the majority had failed previous surgery, and no effort was made to exclude patients with risk factors of neuropathic disease, fistulas, or diabetes.

The rectus muscle flap is not difficult to develop, and the generous vascular pedicle is easy to protect during mobilization and transport of the flap. The muscle flap brings its own blood supply with it, providing excellent oxygenation for the healing tissues. This is an important consideration when dealing with complex problems of incontinence in patients who have had multiple surgical procedures or radiation therapy. This versatile flap may find many other applications in pelvic surgery.

A rectocele is secondary to a defect in the supporting fascia of the rectum that results in a herniation of the anterior rectal and posterior vaginal wall into the lumen of the vagina. The true incidence of rectoceles is unknown. Wells et al. reported a 12% incidence of rectoceles on physical examination when evaluating patients complaining of urinary incontinence.Concomitant rectocele or enterocele repair was performed in 35% of patients undergoing a Raz bladder neck suspension; however, 65% of patients who underwent repair of a grade IV cystocele required rectocele repair.

To understand the concepts underlying repair of pelvic floor relaxation, the anatomy of the normal pelvic floor support system should be briefly reviewed. The pelvic diaphragm is the superior shelf of the pelvic floor and consists of the levator ani and the coccygeus muscles. The urogenital diaphragm forms the second layer of the pelvic floor and consists of the bulbocavernosus, transverse perinei, and external anal sphincter muscles. These muscles join together with the anterior fibers of the levator ani to form the central tendon of the perineum.

The fascial support of the rectum consists of the prerectal fascia and the pararectal fascia. The prerectal fascia runs anterior to the rectum from the pouch of Douglas to the central tendon and prevents protrusion of the rectum into the vagina. A virtual space exists between the posterior vaginal wall and the prerectal fascia, which offers a convenient plane of dissection during rectocele repair. The pararectal fascia originates from the lateral pelvic sidewall and sweeps posteromedially to the rectum, splitting into anterior and posterior sheets and forming a fibrous envelope around the rectum.

The normal vaginal axis that is seen in the well-supported pelvic floor conveniently protects against rectocele formation and further pelvic prolapse. Two distinct areas of the vagina are seen if a normal vaginal axis is maintained. The proximal vagina lies at a 110- to 120-degree angle to the horizontal. The distal vagina, with the sling-like support provided by the levators, forms an angle of 45 degrees from the vertical. This results in a midvaginal angle of 110 to 130 degrees. In women with significant pelvic floor prolapse, levator plate laxity and widening of the levator hiatus result in a disappearance of the normal curvature of the vagina and a near-vertical vaginal axis, which facilitates rectocele formation.

The high incidence of concomitant rectocele and cystocele relates to the pathophysiology of pelvic floor weakness and subsequent rectocele formation. Childbirth results in several events that weaken the pelvic floor support system: (a) passage of the child’s head through the vagina stretches the prerectal and pararectal fascia and detaches the prerectal fascia from the perineal body; (b) the levator musculature and its fascia are weakened, which allows the levator hiatus to widen; (c) the normal narrowing of the vaginal opening is rendered ineffective secondary to widening of the anogenital hiatus and damage to the UG diaphragm.

The changes wrought by childbirth are further enhanced by aging, loss of estrogen stimulation, obesity, smoking, strenuous work/physical activity, and chronic abdominal straining, which is often seen in patients with chronic respiratory diseases and cough, constipation, and bladder outlet obstruction. Furthermore, loss of the normal vaginal axis, which is seen with pelvic floor relaxation (and may be accentuated after cystocele repair and/or anti-incontinence surgery), results in ineffective transmission of intra-abdominal pressures. This may lead to a worsening of preexisting pelvic prolapse and an increased risk of stress incontinence. Defects of the perineal body are often a result of injuries sustained during vaginal delivery or episiotomy.

DIAGNOSIS

The majority of rectoceles are asymptomatic. If symptomatic, rectocele-related complaints are often related to bowel dysfunction and include constipation, the need to digitalize the vagina to facilitate stool passage, a feeling of blockage at the outlet, and a sensation of stool pocketing. Interestingly, although problems with constipation are often correlated with a rectocele, many patients report continued difficulties with constipation after rectocele repair. Patients may also complain of dyspareunia and symptoms attributable to prolapse such as the feeling of a bulge or sitting on a ball. Defects of the perineal body are usually asymptomatic, but patients may complain of incontinence of liquid stool or flatus or loss of sensation during sexual intercourse secondary to a widened introitus.

The diagnosis of a posterior wall defect is made on physical examination. Examination of the posterior compartment is best accomplished using a Sims retractor or half of the vaginal speculum to displace the anterior vaginal wall anteriorly. Perineal body defects are associated with a widened introitus and a decreased distance between the anus and the posterior aspect of the vagina and are graded as follows: I, a tear in the hymenal ring; II, a tear involving the perineal body but not the anal sphincter; III, a tear involving the anal sphincter; IV, a tear extending into the anal mucosa. A rectocele will manifest as a bulge extending from the posterior wall of the vagina and is graded as follows: I, protrusion of the posterior vaginal wall at the level of the hymenal ring; II, protrusion at the level of the hiatus; III, protrusion beyond the introitus. Rectoceles may further be classified according to their position in the vagina as low, medium, or high. Rectovaginal examination will reveal attenuation of the fascia and helps rule out coincidental enterocele, which should be suspected in the patient with a high rectocele. With posterior wall defects, loss of the normal banana-like axis of the lower and upper vagina is seen, as the vagina will assume a straight orientation. Finally, defecography and dynamic rectal radiologic examinations are used by some authors in the diagnosis and classification of posterior vaginal vault defects.

INDICATIONS FOR SURGERY

Patients with symptomatic posterior vaginal wall defects should undergo surgical correction. The repair of asymptomatic defects coincident with other vaginal surgery is controversial. Arguments against repair of an asymptomatic rectocele include postoperative coital dysfunction and rectal injury. Jeffcoate described a 30% rate of discontinued coitus or dyspareunia after anterior and posterior repair3; however, recent reviews evaluating outcomes using present-day techniques describe a 0% to 9% incidence of coital dysfunction. Rectal injury has not been a concern with current surgical techniques.

Arguments favoring repair of asymptomatic pelvic floor relaxation during concomitant vaginal surgery include the risk of larger and symptomatic pelvic prolapse (i.e., rectocele, enterocele, uterine prolapse) if repair is not accomplished and the possibility that results of simultaneous anti-incontinence surgery are improved if repair is done. Anti-incontinence procedures orient the vagina in a vertical axis; however, pelvic floor relaxation repair helps restore the normal near-horizontal axis of the vagina. Restoration of this axis decreases the incidence of postoperative prolapse, results in more effective transmission of intraabdominal pressure to the pelvis, and should improve the results of anti-incontinence surgery by helping to provide a strong backboard against which the bladder neck and urethra (which are secondarily supported by the pelvic floor) can be compressed. These arguments, combined with the ability to accomplish this surgery without introducing significant perioperative morbidity, leads us to strongly favor simultaneous repair of even asymptomatic moderate pelvic floor weakness at the time of concurrent vaginal procedures.

ALTERNATIVE THERAPY

Alternatives to repair of pelvic floor relaxation include observation and intravaginal pessaries.

SURGICAL TECHNIQUE

The essential goals of rectocele repair include (a) plication of the prerectal and pararectal fascia, (a) narrowing of the levator hiatus by reapproximating the prerectal levator fibers;) repair of the perineal body.

Two days before surgery, the patient begins a clear liquid diet and begins oral laxatives. Broad-spectrum intravenous antibiotics to cover anaerobes, gram-negative bacilli, and group D enterococcus are administered preoperatively.

Positioning and Retraction

The patient is placed in the dorsal lithotomy position, and a Betadine-soaked rectal packing is placed to aid in identification of the rectum and to avoid rectal injury. The patient is draped (the rectal packing is isolated from the operative field with double draping), and a Foley catheter is placed. Anti-incontinence surgery, cystocele repair, enterocele repair, and vaginal hysterectomy, if indicated, are accomplished first. A ring retractor with hooks, applied to the perineum, aids in lateral exposure of the vaginal vault. The anterior vaginal wall is retracted upward with a Haney or right-angle retractor to improve visualization and help prevent excessive narrowing of the vagina.

Exposure of Perineal Body

The rectocele repair begins with the placement of two Allis clamps to the posterior margin of the introitus at the 5- and 7-o’clock positions. A V-shaped incision is made, and a triangular segment of perineal skin with the base of the triangle at the mucocutaneous junction is excised between the Allis clamps, exposing the attenuated perineal body.

Exposure of Distal Vaginal Defect

The Allis clamps are then placed in the midline of the posterior vaginal wall, grasping and elevating the rectocele at its midpoint. Saline is injected along the posterior vaginal wall to facilitate dissection. With the use of a scalpel, a second triangular incision is made in the posterior vaginal wall with the base of the triangle at the site of the previous incision and the apex of the triangle above the levator plate 2 to 3 inches inside the hymenal ring. This is a superficial incision through the vaginal wall only; a deeper dissection at this point risks injury to the rectum. Metzenbaum scissors are then used to sharply develop a plane from the lateral margins of the triangle, dissecting between the herniated rectal wall and the vaginal wall. Staying as close as possible to the vaginal wall to avoid injury to the rectum, the dissection extends laterally, exposing the attenuated prerectal fascia distally. The triangular island of posterior vaginal wall that was created by the inverted V-shaped incision is sharply excised off the prerectal levator fascia and fibers. This redundant skin is not discarded until the rectocele is entirely repaired; if the repair is accidentally too tight and/or excessively narrows the vagina, the excised piece of vaginal wall may be used as a free graft.

Exposure of Proximal Vaginal Defect

The prerectal fascia is exposed by sliding the Metzenbaum scissors under the posterior vaginal wall from the apex of the previous triangular incision to the cuff of the vagina. The posterior vaginal wall is then incised along the midline. This incision is made from the apex of the previous triangular incision to the vaginal cuff. An appropriately sized rectangular strip of posterior vaginal wall is excised (a greater severity of prolapse necessitates a wider resection of posterior vaginal wall), exposing the attenuated pararectal and prerectal fascia proximally. Use of a Haney or right-angle retractor on the anterior vaginal wall at this point helps prevent resection of an excessive amount of posterior vaginal wall, thus decreasing the risk of vaginal stenosis postoperatively. Inadequate resection of sufficient vaginal wall risks a weak repair and the formation of painful ridges during reconstruction.

Plication of Prerectal and Pararectal Fascia

At this point attention is turned toward repair of the rectocele. The anterior vaginal wall is retracted upward, and the distal rectum is retracted downward with a Haney or right-angle retractor. This protects the rectum, reduces the rectocele, and facilitates reapproximation of the pararectal and prerectal fascia. Reconstruction begins at the apex of the rectocele and is carried out to the level of the levator hiatus with a running, locking 2-0 polyglycolic acid suture. Each needle passage incorporates the edge of the vaginal wall and generous bites of the prerectal fascia and the pararectal fascia bilaterally. We attempt to reapproximate the sacrouterine/cardinal ligament complex with the initial bite of this portion of the repair to decrease the risk of subsequent enterocele formation.

Repair of the Levator Hiatus

Two or three interrupted figure-of-eight 2-0 polyglycolic acid sutures are placed, closing the distal posterior vaginal wall to the level of the perineum. This suture incorporates the same layers as previously described. As the reconstruction continues, each side of the vaginal wall should proportionally come together such that the most distal aspect of the repair, at the mucocutaneous junction, is reapproximated evenly. Reapproximation of the prerectal levator fascia at this level restores the normal axis of the vagina. Therefore, examination of the repair at this point should reveal a well-supported posterior vaginal wall with a concavity (corresponding to the normal midvaginal axis of 110 degrees) to the repair proximally. Finally, a smooth contour without ridges should be noted along the suture line.

Repair of the Perineal Body

Several vertical mattress sutures of 2-0 polyglycolic acid are used to approximate the bulbocavernosus, transverse perineal, and external anal sphincter muscles. This brings together the muscles of the UG diaphragm, reconstructing and providing support to the central tendon. The perineal skin is closed with a running 4-0 polyglycolic acid suture, and an antibiotic-impregnated vaginal packing is placed.

This procedure is performed as an outpatient surgery. The Foley catheter and vaginal packing are removed several hours after surgery, and patients are prepared for discharge within 6 to 20 hours postoperatively. Patients are sent home with oral antibiotics and are maintained on stool softeners for 1 month. Finally, patients are encouraged to resume early postoperative coitus to ensure normal resumption of sexual function.

OUTCOMES

Complications

Urinary retention is the most frequent complication of rectocele repair and occurs in 12.5% of patients. Retention in these patients is temporary and rarely lasts more than several days. Rectovaginal fistula was not seen in our series but has been reported in up to 5% of patients undergoing pelvic floor repair. Dyspareunia can be averted by not excessively narrowing the vagina, avoiding suture placement directly into the levators, and by not leaving uneven, painful ridges along the repair. Other complications of vaginal surgery include infection, bleeding, vaginal shortening, vaginal wall inclusion cyst formation, and fistula.

Results

Recurrent rectocele is very uncommon and has not occurred in any of the 95 patients we recently reviewed. However, recurrent pelvic prolapse can be expected in as many as 7.5% of patients postoperatively. Constipation is not resolved in up to 50% of patients undergoing rectocele repair for this complaint; this is likely a result of the multifactorial etiology of constipation in many patients.

In evaluating patients for the use of intraurethral injections as a treatment of urinary incontinence, it is essential to identify the cause(s) of incontinence in order to recommend appropriate therapy. Intraurethral injections benefit patients with incontinence occurring at the level of the bladder outlet. Incontinence occurring at this level may be caused by anatomic displacement of a normally functioning urethra (anatomic genuine stress urinary incontinence) in women or intrinsic incompetence of the urethral closure mechanism (intrinsic sphincteric dysfunction) in women or men. Patients with intrinsic sphincteric dysfunction (ISD) commonly have had a previous surgical procedure on or near the urethra, a sympathetic neurologic injury, or myelodysplasia. Female patients with genuine stress urinary incontinence have normal urethral function but hypermobility of the bladder neck and proximal urethra resulting from a deficiency in pelvic support. These patients benefit from bladder neck elevation and stabilization. Patients with ISD have poor urethral function and require procedures to increase outflow resistance. Patients with a fixed, well-supported urethra in association with ISD are excellent candidates for periurethral injection. In men this is most commonly encountered following radical prostatectomy, whereas in women the primary cause of ISD is a residual effect of multiple surgical resuspension procedures for genuine stress urinary incontinence.

DIAGNOSIS

Patients with ISD urodynamically display an open bladder outlet at rest in the absence of a detrusor contraction. However, standardization of a methodology to determine ISD has not yet been accepted. Because the incontinence of ISD is nonresistant (passive) urinary leakage, the goal of treatment should be only to coapt the urethra by passive occlusion. With respect to outlet function, maximum urethral closure pressure (UCPmax) obtained during urethral pressure profilometry has been the test used to determine the presence of ISD in women. Those women with UCPmax £ 20 cm H2O were said to have a “low-pressure urethra” or ISD, and these patients failed standard bladder neck suspension procedures.

One can infer that if urethral urinary loss can be induced by abdominal pressure, something must be wrong with the outlet. The abdominal leak-point pressure (LPPabd) is determined by direct measurement of the abdominal pressure required to overcome urethral resistance. This determination may be considered an indirect method of measuring the closure forces of the urethra during straining maneuvers. It is used primarily in women with stress urinary incontinence (SUI) to differentiate between anatomic displacement of a normal-functioning urethra (SUI caused by hypermobility) from poor outlet function (ISD). The leakage may be documented visually or fluoroscopically. At the point at which leakage occurs, LPPabd is recorded. Patients with ISD demonstrate minimal urethral resistance to straining, and therefore the urethral opening pressure is very low, whereas patients with an anatomic displacement of a normally functioning urethra have high urethral opening pressures, and therefore the LPPabd will be higher. However, no standardization of the technological methods to obtain LPPabd has been accepted. In summary, in evaluating leak-point pressures, until a universally accepted technique is established, a single mode with which the physician is comfortable should be used in the same manner on every patient whether for a preoperative evaluation or for the evaluation of a patient with an unsatisfactory result.

INDICATIONS FOR SURGERY

During the multicenter investigation of collagen in the treatment of ISD, the patients selected with anatomic (type II vesicourethral hypermobility) incontinence did not fare well. Therefore, the recommendation currently is to perform intraurethral or periurethral injections on patients with a poorly functioning urethra (ISD) and good anatomic support. However, recent data suggest that injectables may be used for selected female patients with anatomic stress urinary incontinence.

ALTERNATIVE THERAPY

The treatment of urinary incontinence related to the incompetent urethra has been a challenging problem and frequently involves surgical augmentation of intraurethral pressures by the use of slings made of autologous or synthetic materials, implantation of an artificial sphincter, or periurethral injection of bulk-enhancing agents.

SURGICAL TECHNIQUE

The technique of injection of material is not difficult; however, it is essential to perform precise placement of the material in order to ensure an optimal result. The equipment required for injection depends on the bulk-enhancing agent injected. The injection can be performed either suburothelially through a needle placed directly through a cystoscope (transurethral injection) or periurethrally with a needle inserted percutaneously and positioned in the urethral tissues in the suburothelial space, with the manipulation observed by cystourethroscopy. Men are injected predominantly by the transurethral approach, and women are injected by either technique. There is certainly a learning curve with any technique chosen, which ultimately results in using less injectable material to attain the desired result of continence. Injection techniques using glutaraldehyde-cross-linked collagen (Contigen) are presented, as this is currently the only injectable approved for incontinence.

Technique of Injection in the Male Patient

The patient is positioned in the semilithotomy position and prepped and draped in the usual fashion, and 10 ml of a 2% lidocaine jelly is placed intraurethrally and left in place 10 minutes before instrumentation. Cystourethroscopy with a zero-degree lens is employed. The injectable material is then delivered suburothelially by way of a transcystoscopic injection needle under direct vision. The needle is advanced under the mucosa with the beveled portion of the needle facing the lumen of the urethra. This is performed in a circumferential matter, employing four quadrant needle placements. The material is injected until a mucosal bleb is created in each quadrant. Gradually, after the circumferential injections, the urethral mucosa meets in the midline, although additional needle placements may be required for completion.

In cases of ISD following a radical prostatectomy, a short segment of urethra remains above the external sphincter. If visualization of this segment of the urethra is difficult, the needle may be placed at the level of the external sphincter and advanced to ensure deposition of the material proximal to the external sphincter. To be effective, any injectable material must be injected in the urethra superior to the external sphincter, even if this means injecting into the actual bladder neck on the proximal side of the anastomosis. It is important to note that the material should not be injected directly into the external sphincter, as this can cause pudendal nerve irritation with resultant sphincter spasm and discomfort. The depth of injection is also critical. The materials must deform the urethral mucosa so that it closes the urethral lumen. Too deep an injection site is a waste of the material and is not effective.

Injection is more difficult in patients with post-radical-prostatectomy incontinence resulting from the short segment of urethra above the level of the external sphincter and extensive scarring, which usually occurs in this area following surgery. This problem can be circumvented by using an antegrade approach. The technique is performed by passing a cystoscope with a 5-Fr working port through a small suprapubic cystotomy tract. The vesical neck and proximal urethra are then visualized, and subepithelial injections are performed until the bladder outlet is coapted. Frequently there is less scar tissue in this location, which results in better tissue coaptation. In early clinical trials, this technique seems to facilitate more precise injection of material, generating improved results with the use of less material.4 In the authors’ opinion this technique represents an exciting new method of implantation in male patients and should be considered in any postprostatectomy man not achieving adequate success by way of the standard transurethral approach. Post-radical-prostatectomy urothelium covers scar, and there is migration of any injectable substance distally along the urethra. Once this stops, there is a “wall” to abut the freshly injected material at the bladder neck. Therefore, this additional technique is not recommended as the primary method for an initial injection.

A small subset of patients continue to have some degree of incontinence after the placement of a bulbous urethral artificial urinary sphincter. To date the only options to address this problem have been to place a more distal second (tandem) cuff around the bulbous urethra or to place a higher-pressure regulating balloon. Injectable agents have generally been avoided in this setting because of fear of damaging the sphincter cuff. The antegrade approach can be used for this situation without fear of damaging the cuff, although it remains important to know the location of the pressure-regulating balloon before performing the punch cystotomy.

In cases of ISD following prostatic resection, a short segment of urethra remains below the veru montanum and yet is still proximal to the external sphincter. The injections should be made in this position circumferentially until urethral coaptation is visible. Extrusion of material into the urethral lumen from the needle holes may occur but can be minimized by not traversing the injected area with the distal end of the cystoscope once the material has been injected. In other words, do not enter the bladder.

Technique of Injection in the Female Patient

Women may be injected by way of a transcystoscopic technique, as described for the male patient, or by a periurethral approach. The patient is placed in the lithotomy position and prepped and draped in the usual fashion. The introitus and vestibule are anesthetized with 20% topical benzocaine, and the urethra is anesthetized with 10 ml of 2% lidocaine jelly. Following this, a local injection of 1% plain lidocaine is performed periurethrally at the 3- and 9-o’clock positions using 2 to 4 ml on each side. Panendoscopy is performed with a 0- or 30-degree lens, and the needle is positioned periurethrally at the 4- or 8-o’clock position with the bevel of the needle directed toward the lumen. The needle is then advanced into the urethral muscle into the lamina propria in an entirely suburothelial plane. Once the needle is positioned in the lamina propria, it usually advances with very little force. The needle may also be introduced between the urethral fascia and vaginal epithelium at the 6-o’clock position, and, again, needle placement is fully observed endoscopically. Bulging of the tip of the needle against the mucosa of the urethra is observed during advancement of the needle to ensure its proper placement. When the needle tip is properly positioned 0.5 cm below the bladder neck, the material is injected until swelling is visible on each side, creating the appearance of occlusion of the urethral lumen. Once the urethra is approximately 50% occluded, the needle is removed and reinserted on the opposite side, and additional material is injected until the urethral mucosa coapts in the midline, creating the endoscopic appearance of two lateral prostatic lobes.

Although urologists and urogynecologists are more familiar with transurethral than periurethral techniques, we prefer the periurethral approach, as this minimizes intraurethral bleeding and extravasation of the injectable substance. A useful “trick” described by Neal et al. is to add methylene blue to the injectable lidocaine to aid in the location of the needle tip before injecting the bulking agent.8 Once the needle is located at the bladder neck position, the syringe of anesthetic/methylene blue is removed, and the syringe containing the bulking agent is engaged. When the desired appearance of the coapted mucosa is attained, have the patient stand and cough to see if there is any leakage, and, if there is, reposition the patient and reinject.

Perioperative antibiotic coverage is continued for up to 3 days following the procedure. Most patients are able to void without difficulty following the procedure; however, if retention does develop, clean intermittent catheterization is begun with a 10- to 14-Fr catheter. An indwelling urethral catheter is to be avoided in patients, as this promotes molding of the material around the catheter. Although it is usually unnecessary, if longer-term catheterization is needed, suprapubic cystotomy should be performed in these patients.

Patients are contacted 2 weeks postprocedure in order to determine their continence status. Repeat injections are scheduled as necessary and at a time interval appropriate for the injectable substance.

OUTCOMES

Complications

The perioperative complications associated with periurethral injections are uncommon. In the multicenter clinical trial using Contigen injections, transient retention developed in approximately 15% of patients, but only 1% of patients experienced irritative voiding symptoms, and 5% developed a urinary tract infection. Hypersensitivity responses with Contigen are not a problem, as the possibility is assessed by skin testing (wheal and flare) with the more immunogenic and sensitizing non-cross-linked collagen prior to treatment. Those with a positive skin test are excluded from treatment. Regardless of the material, the use of periurethral injections has proven to be safe, eliciting only minor complications. All complications resolve rapidly, and a serious long-term complication from the use of periurethral injections has yet to be reported.

Results

There are no controlled, long-term reports available on any injectable. In fact, it is difficult to glean information in any group reported as to etiology of the incontinence. For example, in women results of injectables are reported without differentiating among patients with hypermobility, those with ISD, and those with both; and men with prostatic resection for benign disease are not separated from those having had a radical prostatectomy. Thus, results have been a combination of anecdotal reporting mixed with conjecture, speculation, and the hope that the truth is involved. Having stated this, it appears that injectables are helpful for some incontinent patients, especially selected women. There are two major disadvantages to the use of injectables: (a) the inability to determine the quantity of material needed for an individual patient and (b) the safety of nonautologous products for injection with respect to migration, foreign body reaction, and immunologic effects. At this point in time only Contigen has been approved as an injectable for incontinence in the United States, and results presented are confined to this approved substance.

Results of the North American Contigen Study Group of 134 postprostatectomy patients (17 postresection; 117 post-radical-prostatectomy) and 17 postradiation incontinent men demonstrated that only 22 men (16.5%) regained continence following injections of collagen, but 78.7% were dry or significantly improved at 1 year of follow-up, and 67% at 2 years following injections.2,7 Use of the antegrade injection technique in men failing the standard retrograde, cystoscopic approach increased the “cured” rate at 1 year by another 37.5%.

Results of the North American Contigen Study Group of 127 women demonstrated 46% dry and 34% socially continent (patients requiring a single minipad/day) with 77% remaining dry once continence had been attained. Worldwide independent studies have supported these findings. Patients with no anatomic hypermobility and ISD appear to be the most satisfactory candidates for intraurethral injections. In selected elderly and less mobile female patients with anatomic incontinence, recent data suggest that collagen may also be useful in this patient population.

Injectables are still in the developmental stages and their roles in the management of incontinence still need to be defined more precisely. Because the methods are less invasive and generally performed on an outpatient basis, medical costs should be reduced, and there should also be a more rapid return to the patient’s normal activities. The ideal material is still sought and should combine ease of administration with minimal tissue reaction, lack of migration, and persistence over time. The physician considering injectables for his or her patient should consider that there is a learning curve in patient selection as well as method of delivery of the bulking agents to attain optimal results.

The first urethral sling procedure was described by Von Giordano in 1907. However, even after numerous technical improvements and application of many different materials, the pubovaginal sling (PVS) was rarely used until repopularized by McGuire and Lytton in 1978. The pubovaginal sling has traditionally been used only when other incontinence procedures such as a bladder neck suspension or retropubic urethropexy have failed. In this regard, patients with type 3 stress urinary incontinence, also called intrinsic sphincter deficiency (ISD), have often been diagnosed by default. More recently, the preoperative diagnosis of ISD has been facilitated by use of the Valsalva or abdominal leak point pressure (ALPP) during incontinence evaluations. Accordingly, the diagnosis of ISD can be made before surgery and a PVS performed as the primary incontinence procedure.

Stress urinary incontinence in females is classified by the presence and degree of urethral mobility and functional status of the urethra. In types I and II stress urinary incontinence, the urethral sphincter functions normally; however, abdominal pressure can drive the sphincter to a position where it doesn’t function normally. Stress incontinence due to urethral hypermobility can be successfully treated by a procedure that immobilizes it, such as a retropubic urethropexy or needle suspension procedure. Type III stress urinary tract incontinence, or ISD, is usually characterized by a minimally mobile urethra and incompetence of the urethral sphincter during increases in abdominal pressure. A few patients have incontinence due to coexisting ISD and urethral hypermobility. All patients with ISD are effectively treated with a PVS.

DIAGNOSIS

The preoperative evaluation is directed to identifying ISD. The history can be helpful because patients with ISD usually have severe leakage with minimal activity or have a history of irradiation to the pelvis, a prior incontinence procedure, or are elderly (especially new onset in patients over 70 years old). The incidence of ISD increases after each failed incontinence procedure: 9% if no previous surgery, 25% after one failed procedure, and 75% after two failed procedures.

The physical exam is directed to demonstrating leakage, urethral hypermobility, and pelvic prolapse. Urinary leakage without significant hypermobility constitutes presumptive evidence of ISD. A careful evaluation for associated cystocele, rectocele, enterocele, and uterine prolapse is important for ALPP interpretation and in planning the appropriate operative procedures. Failure to repair associated pelvic prolapse conditions will put undue stress on any incontinence procedure, including a pubovaginal sling, which increases the failure rate.

After the postvoid residual is determined, a cystometrogram is performed to exclude poor detrusor compliance and overt detrusor instability. To diagnose ISD, an ALPP is indispensable. The bladder is filled to a standard volume of 200 ml (children to one-half functional bladder capacity) and a slow Valsalva maneuver is performed with the patient in the upright position until leakage is noted. Performing this several times and determining an average improves accuracy. If a well-performed Valsalva maneuver fails to induce leakage, vigorous coughing may be required. If the ALPP is below 60 cm H2O, then ISD is present. If the ALPP is greater than 90 cm H2O and minimal pelvic prolapse exists, pure urethral hypermobility is usually present. Patients with a significant pelvic prolapse condition may have a falsely elevated ALPP and reduction with a vaginal pack is helpful. ALPP values between 60 to 90 cm H2O form a gray area in which hypermobility and ISD usually coexist.

INDICATIONS FOR SURGERY

The most common indications for a PVS are urodynamically documented ISD with or without urethral hypermobility and a prior failed incontinence procedure. Additionally, because of the long-term success and durability of a pubovaginal sling, certain patients with stress urinary incontinence due to urethral hypermobility may be better served with a sling procedure. These include females who engage in vigorous athletic activities, are significantly obese, or who cough frequently due to pulmonary disease.

ALTERNATIVE THERAPY

In selected female patients with ISD and minimal urethral hypermobility, collagen can be injected at the bladder neck with a success rate of 63% using a mean of 9.1 ml and 1.5 treatments. The vaginal wall sling introduced by Raz uses the in situ vaginal wall as the sling with a reported 93% short-term cure rate in patients with ISD.

SURGICAL TECHNIQUE

Patients with atrophic vaginitis should be treated with topical estrogens for 2 weeks before the procedure. It is helpful to teach the patient clean intermittent catheterization before the procedure since incomplete emptying is common for a few days postoperatively. One dose of intravenous antibiotics should be given preoperatively. General or regional anesthesia may be used without particular advantage to either technique.

The procedure is performed in the low lithotomy position using Allen stirrups with feet squarely in the stirrups to avoid pressure on the calf areas. The legs should only be moderately flexed at the hips to allow simultaneous exposure to the vagina and the lower abdomen. A 16-Fr Foley catheter is placed and the balloon inflated with 5 mls to allow palpation of the bladder neck and urethra. A weighted vaginal speculum is placed. The labia may be sewn laterally if the view is obstructed.

The rectus fascia is usually harvested first to minimize vaginal bleeding. In adults, an 8- to 10-cm Pfannenstiel incision is made approximately 2 to 3 cm above the pubis. The subcutaneous tissue is cleared from the rectus fascia and a relatively scar-free area is selected. Even the most scarred and thickened rectus fascia is usually suitable as a sling. Incising parallel to the fibers, obtain a fascial sling approximately 8 to 10 cm in length with a center portion 1.5 to 2.0 cm wide, tapering the ends to 1 cm wide. Free the upper and lower fascial leaf from the rectus muscles superiorly and inferiorly for approximately 4 to 5 cm to allow a tension-free fascia closure. The sling sutures may be placed before or after transection. The size and type of suture used is a matter of personal preference but we currently use 1-0 polyglactin absorbable suture, which decreases postoperative suture pain and does not compromise durability. The sutures are placed perpendicular to the direction of the fibers approximately 0.5 cm from the ends incorporating all of the fibers in the bites.

The vaginal procedure begins by placing an Allis clamp midway between the bladder neck and the urethral meatus with traction placed superiorly. It is very important to maintain this traction throughout the vaginal procedure. Injectable saline is infiltrated beneath the vaginal epithelium over the proximal urethra to facilitate the dissection. A 3-cm midline incision is made over the proximal urethra and the initial vaginal dissection is performed with a scalpel or Church scissors, which allows one to quickly find the proper plane superficial to the white periurethral fascia. Damage to the underlying urethra and bladder is minimized when dissection proceeds in this plane. The dissection is facilitated by maintaining outward traction (toward the operator) on the developing vaginal flap and by maintaining the tips of the scissors on this flap at all times. Carry the dissection laterally and enter the retropubic space inferior to the ischium, at the level of the bladder neck, by perforating the endopelvic fascia using curved Metzenbaum scissors with tips pointed laterally and slightly superiorly. Blunt finger dissection should not be used to perforate the endopelvic fascia as bladder injury may occur. Once the endopelvic fascia is entered, gently advance the closed scissors laterally and slightly upward for 1 to 2 cm before opening widely. Gentle blunt finger dissection of the retropubic space superiorly to the rectus muscle is performed (Fig. 40-3). Through the abdominal incision, the lateral border of the rectus muscle is retracted medially to expose a defect just lateral to where the rectus muscle inserts onto the symphysis. Gentle dissection in this area allows safe and easy access into the retropubic space. If finger dissection of the retropubic space is difficult, as is sometimes the case after prior procedures, place the tips of Metzenbaum scissors directly on the posterior pubis and slowly advance them with constant pressure against the pubic periosteum. After this is completed, no tissue should be palpable between fingers inserted into the retropubic space from above and the vaginal incision below. If some intervening tissue is found at the level of the pelvic floor, penetration of that tissue is safe. If the tissue is higher than the pelvic floor, it is often the bladder attached to the posterior pubis. The bladder can be carefully dissected off the pubis by keeping the scissors on the back of the pubis at all times. A similar procedure is performed on the other side. Extensive retropubic space dissection is unnecessary and may lead to excessive bleeding or bladder injury. A Sarot or Crawford clamp is placed in the retropubic space from above and directed into the vaginal incision using manual guidance. The tip of the clamp should remain in contact with the pubic periosteum and under the vaginal operator’s finger at all times. After clamps have been passed bilaterally, cystoscopy is performed to ensure there has been no damage to the urethra or bladder. Each sling suture is pulled into the abdominal incision placing the sling under the urethra. Proper function and longevity of the sling does not depend on the sutures to hold tension indefinitely (since the sutures are absorbable) and thus it is critical that a good portion of the sling extend into the retropubic space to allow good fixation. One or two 3-0 absorbable sutures are placed through the edge of the sling and superficially through the periurethral fascia to secure it in place. The sling sutures are passed through the rectus fascia, directly above the retropubic “tunnel,” using a right angle clamp before the rectus fascia is closed. If a suprapubic tube needs to be placed (we do not recommend this), it is done under direct vision at this time. The vagina is closed with a running, locking 2-0 absorbable suture. The weighted speculum and all other instruments should be removed from the vagina. The sling sutures are gently pulled up to remove any slack and tied over the rectus. A shodded clamp can be used to hold tension on the untied sutures until the appropriate tension is obtained. The appropriate tension is the minimum amount required to stop urethral motion, which is tested by pulling on the urethral catheter. Also, one or two fingers should easily slide under the suture knot. If in doubt it is better to err on the side of too little tension. We do not place a vaginal pack before tying the sutures. We have not found it useful to judge how tight to pull the sling by visual assessment during cystoscopy nor by tightening the sling until leakage cannot be produced by compressing the bladder. In the situation where the patient does not void and permanent urinary retention is desired, increased tension can be applied. The skin is closed and a vaginal pack placed. When the abdominal and vaginal components are performed synchronously, the average operating time is 40 minutes with 50 ml average blood loss.

On postoperative day 1, the vaginal pack is removed; if the patient is ambulating well, the Foley catheter is removed. The patient performs clean intermittent catheterization after each void, or a minimum of every 4 hours if unable to void, until the postvoid residual is consistently under 60 ml. Patients are regularly discharged within 48 hours. Oral antibiotics are not routinely prescribed postoperatively. Patients should refrain from vigorous activities and sexual intercourse for 4 to 6 weeks to allow proper fixation of the sling.

OUTCOMES

Complications

When rectus fascia is used for the urethral sling, the most common complications include detrusor instability and urinary retention. Approximately 15% to 25% of patients will have residual urgency symptoms, with less than half demonstrating occasional urge incontinence. Less than 10% will develop new onset detrusor instability. In a recent report by O’Connell and colleagues, 26% of patients had residual urgency symptoms and less than half of this group had mild urge incontinence. In most cases, these symptoms are responsive to anticholinergic medications and will subside over a period of 3 to 6 months.

Persistent postoperative urinary retention, although believed to be a common complication, is not statistically more common after pubovaginal slings than after suspension procedures. In a recent series of 54 patients, no patient who could void preoperatively was in persistent retention postoperatively. McGuire and colleagues reported a 3% incidence of prolonged retention in one series.

Superficial wound infections occur in approximately 4% of patients and significant blood loss occurs in 1% to 2%. Wound infections have not resulted in sling failure. Although synthetic sling materials may be used, relatively high rates of infection and urethral erosion have been reported. Persistent postoperative pain is rare when absorbable suture is used. O’Connell and colleagues reported that no patient had to take analgesics chronically and no patient had a procedure to relieve pain.

Results

In a recent series, 82% of patients were totally dry and another 11% had rare incontinence (once a week or less) for an overall 93% cured or significantly improved. Other long-term series have documented a greater than 80% cure and over 90% significantly improved rate. Residual stress incontinence usually responds very well to injectable agents such as collagen.

The pubovaginal fascial sling is the procedure of choice for treatment of females with urinary incontinence due to ISD. Even patients who had prior surgical failures can obtain excellent results with minimal morbidity, but such results are contingent on an accurate preoperative evaluation and careful placement of the sling at the proximal urethra without undue tension.