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Transvaginal Bladder Neck Closure With Posterior Urethral Flap for Devastated Urethra

      Objectives

      To present a modified transvaginal bladder neck closure (TV BNC) technique using a posterior urethral flap to minimize the potential risk of ureteral injury and fistula formation. Urethral and bladder neck destruction owing to chronic indwelling urethral catheters in female neurogenic patients is a devastating complication.

      Methods

      A retrospective review was performed of all patients undergoing TV BNC at a single institution during a 3-year period. All patients had had a nonfunctional or destroyed urethra because of a long-term indwelling urethral catheter. In brief, the devastated outlet was closed using the dorsally bivalved urethra as a flap that was rotated cephalad onto the incised anterior bladder wall for closure, thereby rotating the suture line high into the retropubic space. A postoperative cystogram was obtained at 2-3 weeks.

      Results

      A total of 11 consecutive female patients with a devastated outlet underwent TV BNC, as described, with placement of a suprapubic tube. One patient experienced failure at 6 weeks postoperatively. The mean follow-up for the entire cohort was 9.6 months (range 1-36). Serial upper tract imaging at the last follow-up visit revealed no new hydroureteronephrosis.

      Conclusions

      The results of our study have shown that TV BNC with a posterior urethral flap provides satisfactory early results. This technique creates a suture line far removed from the ureteral orifices, minimizing the risk of upper tract injury during closure. Also, the rotation of the posterior urethra onto the anterior bladder wall secures the suture line high into the retropubic space, minimizing the risk of failure and postoperative fistula formation.
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      Linked Article

      • Editorial Comment
        UrologyVol. 78Issue 1
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          The authors describe a modification (the use of the posterior urethra as an advancement flap) to a well-known and described transvaginal technique to close the open, incompetent urethra, first described in 1985 by Zimmern et al.1 Although bladder neck necrosis is a rare condition, this is an important patient population and an important option for treatment. Women with destroyed urethras from chronic indwelling Foley catheter management present with a reconstructive challenge. Additionally, in more recent years, women have also been developing severe urethral incompetence from multiple failed anti-incontinence procedures and complications from mesh placement.
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