Transvaginal Bladder-neck Closure: A Step-by-step Video for Female Pelvic Surgeons - Beyond the Abstract

Bladder neck closure (BNC) is a definitive management option in women with patulous or severely shortened urethras, recurrent urethrovaginal fistulas, or irreparable urethral stricture disease. The two main techniques for performing BNC are the transvaginal approach and retropubic, or abdominal, approach. Surgeons often choose their approach based on their level of comfort with each technique, but both techniques are infrequently encountered in female pelvic surgery. 

The present video1 and accompanying manuscript describes a step by step approach for a transvaginal BNC. The transvaginal route is frequently chosen by surgeons to avoid morbidity from an abdominal entry in high-risk surgical patients, to achieve lower operative time, and to reduce the length of hospital stay. This option may also be ideal for patients in which a retropubic approach is challenging due to an obese patient body habitus, prior abdominal surgery, or history of radiation. The main challenge to the transvaginal BNC is the higher rate of vesicovaginal fistula. The first reported cohort study of transvaginal BNC by Feneley demonstrated fistula formation in 4 out of 24 women, but a later study by Zimmern et. al. in 6 women found no incidence of vesicovaginal fistula at an average follow-up period of 21 months.2,3 Subsequent studies demonstrated fistula formation in 9 to 50% of patients.4-7 In patients with recurrent failure after attempting a transvaginal revision, continence was achieved using an abdominal approach.4,5

The retropubic route for BNC has been described in both males and females and is preferable in instances where a simultaneous bladder augmentation or alternate urinary diversion technique is desired. Due to the potential for recurrent vesicovaginal fistula, the retropubic approach should also be considered after a failed transvaginal closure. In a recent comparison of transvaginal versus retropubic BNC, there was no significant difference incontinence rate after the first BNC procedure between the transvaginal and retropubic approach.8 While 14% of patients in the transvaginal group compared with 3% in the retropubic group developed a vesicovaginal fistula that required revision, there were significantly more short-term complications in the transabdominal group and no significant difference in long-term outcomes between the groups.

Proper technique and patient selection can help prevent the development of a vesicovaginal fistula after the transvaginal BNC approach. Careful and complete mobilization of the urethra and bladder outlet from their pubic bone attachments decreases tension on the closure and increases the distance between suture lines. Transposition of the closed bladder neck high behind the pubic bone using a second layer of closure will further reduce damage to the suture line from increases in intravesical pressure. Finally, the anterior vaginal flap should be closed so that the suture lines do not directly oppose those of the layers underneath, and an interposing Martius flap may be considered for additional protection. When performed correctly, the transvaginal BNC is an excellent and well-tolerated technique for achieving continence in female patients with a nonfunctional urethra.

Written by: Helen H. Sun, BS, University Hospitals Cleveland Medical Center, Center for Female Pelvic Medicine & Reproductive Surgery, Urology Institute, Cleveland, Ohio

References:
1. Petrikovets, A., Sun, H., Sheyn, D. et al. Int Urogynecol J (2018). https://doi.org/10.1007/s00192-018-3766-4
2. Feneley R. The Management of Female Incontinence by Suprapubic Catheterisation, with or without Urethral Closure. Br J Urol. 1983;55(2):203-207.
3. Zimmern P, Hadley H, Leach G, Raz S. Transvaginal Closure of the Bladder Neck and Placement of a Suprapubic Catheter for Destroyed Urethra After Long-Term Indwelling Catheterization. J Urol. 1985;134(3):554-556.
4. Levy J, Jacobs J, Wein A. Combined Abdominal and Vaginal Approach for Bladder Neck Closure and Permanent Suprapubic Tube: Urinary Diversion in the Neurologically Impaired Woman. J Urol. 1994;152(6):2081-2082.
5. Colli J, Lloyd L. Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder. J Spinal Cord Med. 2011;34(3):273-277.
6. Rovner E, Goudelocke C, Gilchrist A, Lebed B. Transvaginal Bladder Neck Closure With Posterior Urethral Flap for Devastated Urethra. Urology. 2011;78(1):208-212.
7. Kardos SV, Lopez JM, Foster HE Jr. Transvaginal Bladder Neck Closure Revisited: A Less Invasive Approach to the Management of a Destroyed Urethra. J Androl Gynaecol. 2013;1(1): 4.
8. Willis H, Safiano N, Lloyd L. Comparison of Transvaginal and Retropubic Bladder Neck Closure with Suprapubic Catheter in Women. J Urol. 2015;193(1):196-202.

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