Closure of Bladder Neck in the Male and Female

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.

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