Bladder Neck Incisions Versus Reconstructions

Surgical treatment of primary and secondary bladder neck obstruction after medical and conservative therapies such as CIC have been attempted, consists of transurethral bladder neck incision or bladder neck reconstructions. Whereas reported series of abdominal approaches for bladder neck reconstructions using anterior and posterior bladder flaps in women are restricted to small numbers from a few institutions because of the complexity of the technique, we prefer to use a transvaginal approach for performing the Tanagho anterior bladder neck reconstruction technique as described by Elkins and colleagues in 1992.2-3 This unique approach provides simultaneous exposure of both the bladder neck and orthotopic urethral reconstruc tions using a Martius fat pad and a fascial sling placement in an effort to reduce the morbidity of the procedure for the patient and to reduce the complexity of the procedure for the reconstructive specialist (Figure 10-2.2). Our added modification to this technique has been the use of the incision for obtaining the rectus fascia sling harvest as a means for providing finger access into the retropubic space for the anterior bladder neck mobilization required for the transvaginal Tanagho bladder neck reconstruction.

We generally reserve bladder neck reconstructions for cases in which the bladder neck is obliterated or nonfunctional and prefer to perform transurethral bladder neck incisions as a first-line procedure for functional bladder neck conditions based on the simplicity and efficaciousness of this minimally invasive endoscopic approach. Most specialists perform two incisions at a depth of 0.5 to 1.0 cm at the 5 and 7 o'clock position of the bladder neck, beginning midway between the urethral orifice and the bladder neck, and ending 1 to 2 cm distally. To avoid potential incontinence, one may elect to stage the intervention by performing only one incision at a time and elect to make a second or more extensive incision at a different session depending on the results achieved. Using a staged approach for transurethral bladder neck incisions, Gronbaek et al.4 reported a success rate of 76% at a mean follow-up of 55 months with only one case (3%) of developing interval incontinence.

As described above, the improvements in endoscopic technology and application of refinements in performing

Figure 10-2.2. Transvaginal view of a combined transvaginal bladder neck and urethral reconstruction using placement of a circumferential Martius fat pad around the neourethra before securing the fascial sling.

bladder neck incisions, transurethral incisions for mucosal strictures, or urethral and bladder neck reconstructions have largely replaced the anecdotal reports and use of traumatic urethral sphincterotomy in women with the attendant risk of urethral bleeding, stricture, or fistula formation. Although the use and indications for urethral stents have generally been restricted to males, the development of a removable, shorter urethral stent for females may have an expanding role in cases of bladder outlet obstruction in the near future.

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