Bladder Edge Research Articles

Early approach for the iatrogenic vesico-vaginal fistula repair: a video case report.

Vesico-vaginal fistula (VVF) is a rare but debilitating condition, characterised by an abnormal connection between the bladder and vagina. While obstetric-related cases prevail in developing countries, iatrogenic fistulas are more common in industrialised ones, often resulting from pelvic surgeries. The optimal timing for surgical correction of VVF remains debated, often leaning towards delayed intervention. Here we report a successful early laparoscopic repair of an iatrogenic VVF following hysterectomy. The patient, a 54-year-old woman, presented with VVF after a hysterectomy. The laparoscopic repair was performed promptly upon diagnosis. To assess the feasibility and effectiveness of an early repair of a gynaecological-related VVF. First, cystoscopy identified the bladder edge of the VVF. Second, laparoscopy was performed and the vesico-vaginal dissection was carried out. The excision of the previous stitches and of the fibrotic tissue was undertaken to create free flaps for suturing. The bladder was repaired in a double layer, and a single layer was applied to the vagina. Finally, the omentoplasty was done. The patient was discharged on postoperative day 5. No complications occurred. This successful case demonstrates the feasibility and safety of early laparoscopic repair for gynaecological surgery-related vesico-vaginal fistulae. While acknowledging the need for further studies to standardise techniques, this report contributes to the evolving understanding of optimal management for this complex condition.

65: Robotic assisted approach to Burch urethropexy

The goal of this video is to demonstrate our robotic assisted approach to the Burch urethropexy. Stress urinary incontinence (SUI) affects nearly one in three women in the United States. The Burch urethropexy, originally described as an open procedure in 1961, was long considered the standard surgical option for treating SUI. Though the Burch procedure fell out of favor in recent decades due to the ease of placing mid-urethral slings, it is regaining popularity as a safe and effective mesh-free surgical option for the treatment of SUI. It is also an option for patients who have undergone a failed mesh procedure. The many advantages of mastering the robotic assisted approach to the Burch procedure are illustrated in this video, including improved visualization and dissection of the bladder edge, retropubic space, and surrounding vessels, as well as the superior range of motion of the robotic instruments over their laparoscopic counterparts. The Burch urethropexy is a safe and effective option for treating SUI. The robotic assisted approach demonstrated in this video increases the ease and safety of the procedure, solidifying its place in the toolbox of the modern gynecologist.

Validation of the physiological background correction method for the suppression of the spill-in effect near highly radioactive regions in positron emission tomography

BackgroundPositron emission tomography (PET) imaging has a wide applicability in oncology, cardiology and neurology. However, a major drawback when imaging very active regions such as the bladder is the spill-in effect, leading to inaccurate quantification and obscured visualisation of nearby lesions. Therefore, this study aims at investigating and correcting for the spill-in effect from high-activity regions to the surroundings as a function of activity in the hot region, lesion size and location, system resolution and application of post-filtering using a recently proposed background correction technique. This study involves analytical simulations for the digital XCAT2 phantom and validation acquiring NEMA phantom and patient data with the GE Signa PET/MR scanner. Reconstructions were done using the ordered subset expectation maximisation (OSEM) algorithm. Dedicated point-spread function (OSEM+PSF) and a recently proposed background correction (OSEM+PSF+BC) were incorporated into the reconstruction for spill-in correction. The standardised uptake values (SUV) were compared for all reconstruction algorithms.ResultsThe simulation study revealed that lesions within 15–20 mm from the hot region were predominantly affected by the spill-in effect, leading to an increased bias and impaired lesion visualisation within the region. For OSEM, lesion SUVmax converged to the true value at low bladder activity, but as activity increased, there was an overestimation as much as 19% for proximal lesions (distance around 15–20 mm from the bladder edge) and 2–4% for distant lesions (distance larger than 20 mm from the bladder edge). As bladder SUV increases, the % SUV change for proximal lesions is about 31% and 6% for SUVmax and SUVmean, respectively, showing that the spill-in effect is more evident for the SUVmax than the SUVmean. Also, the application of post-filtering resulted in up to 65% increment in the spill-in effect around the bladder edges. For proximal lesions, PSF has no major improvement over OSEM because of the spill-in effect, coupled with the blurring effect by post-filtering. Within two voxels around the bladder, the spill-in effect in OSEM is 42% (32%), while for OSEM+PSF, it is 31% (19%), with (and without) post-filtering, respectively. But with OSEM+PSF+BC, the spill-in contribution from the bladder was relatively low (below 5%, either with or without post-filtering). These results were further validated using the NEMA phantom and patient data for which OSEM+PSF+BC showed about 70–80% spill-in reduction around the bladder edges and increased contrast-to-noise ratio up to 36% compared to OSEM and OSEM+PSF reconstructions without post-filtering.ConclusionThe spill-in effect is dependent on the activity in the hot region, lesion size and location, as well as post-filtering; and this is more evident in SUVmax than SUVmean. However, the recently proposed background correction method facilitates stability in quantification and enhances the contrast in lesions with low uptake.

Реконструкция мочевого пузыря с использованием свободного реваскуляризированного кожно-мышечного торакодорсального аутотрансплантата

The article presents a rare case of urinary bladder reconstruction using thoracodorsal revascularized autograft in a patient with a bladder injury resulting from a road traffic accident. The area and size of the thoracodorsal flap (2215 cm) were determined using a 500 ml latex model of the bladder. The autograft was revascularized through external iliac vessels. From the thoracodorsal autograft, the dome was formed with the dermal part inward, which was fixed along its circumference to the bladder edges with 3/0 prolene sutures. The muscular part of the thoracodorsal flap was fixed along the perimeter to the remaining aponeurosis and covered by a free expanded cutaneous autograft. The surgery resulted in a newly constructed neobladder of sufficient volume (250-300 ml) with elements of the patients own bladder (posterior wall and neck) while sparing the patient from a cystostomy and improving his quality of life.

Robot-Assisted Simple Prostatectomy.

Benign prostatic obstruction is the leading cause of lower urinary tract symptoms in older males. The management strategies include medical management and surgical therapy. However when the prostate becomes very enlarged medical therapy can be ineffective and transurethral resection may not be feasible. Open simple prostatectomy has been the mainstay of therapy however robot techniques can replicate the efficacy of the open operation while reducing convalescence. We describe our technique of robot simple prostatectomy including indications, patient preparation and surgical procedures step by step. This technique approaches the prostate in a similar fashion to a robot-assisted radical prostatectomy thereby lending familiarity to this simple prostatectomy approach. Robotic-assisted simple prostatectomy is a feasible surgical approach for patients with a very enlarged prostate. Anastomosis of the bladder edge to the distal apical prostate margin can greatly reduce postoperative hematuria.

SU‐G‐JeP3‐05: Geometry Based Transperineal Ultrasound Probe Positioning for Image Guided Radiotherapy

Purpose:The use of ultrasound (US) imaging in radiotherapy is not widespread, primarily due to the need for skilled operators performing the scans. Automation of probe positioning has the potential to remove this need and minimize operator dependence. We introduce an algorithm for obtaining a US probe position that allows good anatomical structure visualization based on clinical requirements. The first application is on 4D transperineal US images of prostate cancer patients.Methods:The algorithm calculates the probe position and orientation using anatomical information provided by a reference CT scan, always available in radiotherapy workflows. As initial test, we apply the algorithm on a CIRS pelvic US phantom to obtain a set of possible probe positions. Subsequently, five of these positions are randomly chosen and used to acquire actual US volumes of the phantom. Visual inspection of these volumes reveal if the whole prostate, and adjacent edges of bladder and rectum are fully visualized, as clinically required. In addition, structure positions on the acquired US volumes are compared to predictions of the algorithm.Results:All acquired volumes fulfill the clinical requirements as specified in the previous section. Preliminary quantitative evaluation was performed on thirty consecutive slices of two volumes, on which the structures are easily recognizable. The mean absolute distances (MAD) between actual anatomical structure positions and positions predicted by the algorithm were calculated. This resulted in MAD of 2.4±0.4 mm for prostate, 3.2±0.9 mm for bladder and 3.3±1.3 mm for rectum.Conclusion:Visual inspection and quantitative evaluation show that the algorithm is able to propose probe positions that fulfill all clinical requirements. The obtained MAD is on average 2.9 mm. However, during evaluation we assumed no errors in structure segmentation and probe positioning. In future steps, accurate estimation of these errors will allow for better evaluation of the achieved accuracy.

Neonatal closure of bladder exstrophy

The ureteric orifices are identified and stented. Large mucosal polyps are excised and mucosa is repaired. A midline incision is made, starting above the umbilical cord, encircling it and extending on each side on the mucosal edge of the bladder up to the level of the verumontanum. The edge of bladder is partially mobilised and bladder closure is started from the dome with interrupted inverting sutures. A stent is placed across the bladder neck and secured before the closure of the bladder. The abdominal muscles are mobilised off the skin and apposed with interrupted horizontal mattress sutures starting from the upper part of the wound. In the lower part of the wound, the sutures are applied and put on crossover traction to stretch the pelvic ligaments, and tied in turn while maintaining traction to approximate the pelvis. The skin and subcutaneous tissue are approximated. Epidural analgesia and enteral nutrition are key to postoperative pain management and healing.

Generic method for automatic bladder segmentation on cone beam CT using a patient‐specific bladder shape model

The aim of this study is to develop and validate a generic method for automatic bladder segmentation on cone beam computed tomography (CBCT), independent of gender and treatment position (prone or supine), using only pretreatment imaging data. Data of 20 patients, treated for tumors in the pelvic region with the entire bladder visible on CT and CBCT, were divided into four equally sized groups based on gender and treatment position. The full and empty bladder contour, that can be acquired with pretreatment CT imaging, were used to generate a patient-specific bladder shape model. This model was used to guide the segmentation process on CBCT. To obtain the bladder segmentation, the reference bladder contour was deformed iteratively by maximizing the cross-correlation between directional grey value gradients over the reference and CBCT bladder edge. To overcome incorrect segmentations caused by CBCT image artifacts, automatic adaptations were implemented. Moreover, locally incorrect segmentations could be adapted manually. After each adapted segmentation, the bladder shape model was expanded and new shape patterns were calculated for following segmentations. All available CBCTs were used to validate the segmentation algorithm. The bladder segmentations were validated by comparison with the manual delineations and the segmentation performance was quantified using the Dice similarity coefficient (DSC), surface distance error (SDE) and SD of contour-to-contour distances. Also, bladder volumes obtained by manual delineations and segmentations were compared using a Bland-Altman error analysis. The mean DSC, mean SDE, and mean SD of contour-to-contour distances between segmentations and manual delineations were 0.87, 0.27 cm and 0.22 cm (female, prone), 0.85, 0.28 cm and 0.22 cm (female, supine), 0.89, 0.21 cm and 0.17 cm (male, supine) and 0.88, 0.23 cm and 0.17 cm (male, prone), respectively. Manual local adaptations improved the segmentation results significantly (p < 0.01) based on DSC (6.72%) and SD of contour-to-contour distances (0.08 cm) and decreased the 95% confidence intervals of the bladder volume differences. Moreover, expanding the shape model improved the segmentation results significantly (p < 0.01) based on DSC and SD of contour-to-contour distances. This patient-specific shape model based automatic bladder segmentation method on CBCT is accurate and generic. Our segmentation method only needs two pretreatment imaging data sets as prior knowledge, is independent of patient gender and patient treatment position and has the possibility to manually adapt the segmentation locally.

Fast volume measurement algorithm based on image edge detection

A volume measurement algorithm based on edge detection was introduced in this paper.The algorithm was applied to the portable system for measuring bladder volume.In the system,the three-dimensional ultrasound probe performed the scanning with the axial angle of 180 degree.Twelve axial sections of a bladder with the same scanning interval were obtained and used to edge extraction.The group of bladder edges formed a three-dimensional bladder body and the integral method of spatial volume was used to calculate the bladder volume.The average error of the algorithm in clinical diagnosis experiment was within 12%.

SU-F-BRA-04: Automatic Bladder Segmentation on CBCT for Online ART of Bladder Cancer

Purpose: Large day-to-day variations in bladder—filling hamper accurate radiotherapy of bladder cancer. To allow accurate ART for bladder cancer, automatic bladder segmentation in CBCT is required. However, image quality limitations make this a challenging task. Our aim is to develop an automatic bladder segmentation method using spherical harmonics. Methods: The method includes two steps: a statistical bladder model was built from training dataset (98 bladder contours from 8 patients) and this model was then applied to automatic bladder segmentation in an independent test dataset (110 CBCT scans from another 7 patients). 3D bladder contours were converted into parametric surface descriptions using spherical harmonic expansion. Principle component analysis (PCA) was applied in the spherical harmonic based shape parameter space to calculate the major variations of bladder shape. The number of PCA modes was chosen such that 90% variation in the training dataset was described. By changing the weight of each PCA mode, an initial contour (from the first CBCT of each patient) was deformed to obtain the best fit with the bladder edge in test image. The fit was achieved by optimizing a cost function based on the image gradient using a simplex optimizer. Results: Only 5 PCA modes were needed to represent 90% of the bladder shape variation. The mean and SD of the absolute residual error over all test dataset were 4.8mm and 3.5mm, respectively. The mean volume overlap was 76%. The agreement of plan selection between automatic and manual bladder segmentation was 71%, which was similar to human observer. Conclusions: PCA on spherical harmonics space efficiently describes bladder deformation. This segmentation approach is robust to relatively poor CBCT image quality and allows fast and automatic segmentation of bladder on CBCT with moderate accuracy. This method can potentially be used to select the appropriate plan for online ART of bladder cancer. The research was funded by Dutch Cancer Society. No conflict of interest.

Rectal and bladder deformation and displacement during preoperative radiotherapy for rectal cancer: Are current margin guidelines adequate for conformal therapy?

PurposeTo evaluate rectal motion and estimate an appropriate target volume for preoperative radiotherapy (RT) for rectal cancer. MethodsBetween January 2006 and December 2009, 17 rectal cancer patients undergoing preoperative RT underwent 39 cone-beam computed tomographic scans (CBCTs). CBCTs were fused to treatment planning CT scans by bony anatomy. The rectum and bladder were contoured on each scan. Margins of 2, 5, 10, and 15 mm were added to the rectum, and the volume and percent rectum on CBCT outside each of these margins were determined. The clinical target volume (CTV) was examined to determine the necessary margin beyond the posterior bladder edge to ensure coverage of the mesorectum at all time points. ResultsMedian percentage rectum on CBCT outside the planning rectum was 7.77% (range, 0.19%-42.91%). Two patients had 1 or more CBCT with 1% or greater rectum outside a 1.5 cm margin. Five patients had 1 or more CBCT with 1% or greater rectum outside a 1.0 cm margin. A CTV extending 1 cm into the posterior bladder edge (CTV1.0) was adequate at all time points for 79% of evaluable patients, and a CTV with a 1.5 cm anterior margin was adequate for 93% of patients. For 2 patients, the rectum extended outside the CTV1.0 on CBCT. ConclusionsWith a limited number of CBCT scans, we found that the rectum tended to remain within 1.5 cm of the initial location on treatment planning CT. However, an anterior margin of 1.5 cm beyond the posterior bladder edge provides better coverage of the mesorectum than 1 cm for the initial CTV.

Obstetric vesico‐vaginal fistula repair: Should we trim the fistula edges? A randomized prospective study

To test the hypothesis that not trimming the edges of the vesico-vaginal fistula (VVF) during its surgical repair has an advantage in the outcome as compared to the classical teaching of trimming the fistula. Sixty-four females with obstetric VVF were randomized into two groups. Both groups were treated with vaginal anatomical closure in three layers with Martius flap inter-positioning. Fistulae of the first group were closed without trimming the edges of the bladder while the second group was subject to trimming of the bladder edges. There were no statistically significant differences between both groups regarding pre-operative patient demographics and fistula characteristics. Cure rates were 75% and 67.6% in the non-trimming and the trimming groups, respectively. This was not statistically different. When patients were stratified according to the number of previous repairs, 100% patients in both groups were cured in cases of primary repair of the fistula. Lower cure rates were shown with increasing number of previous repairs. Recurrent fistulae after our repair were not statistically different in site and number in both groups. Nevertheless, fistulae after trimming tends to get larger than the original ones as compared to the non-trimming group which tends to get smaller. This is statistically different. Although there is no statistically significant difference between both groups regarding the cure rate in both fresh cases or recurrent ones, there is an advantage of not trimming the fistula since trimmed fistula tends to get larger, should recurrence occur after trimming.

Laparoscopic Transvesical Vesicovaginal Fistula Repair

Background and Purpose: Transabdominal transvesical vesicovaginal fistula repair has become the standard treatment of difficult vesicovaginal fistulae. To decrease operative morbidity, transvaginal repairs were introduced, having success rates lower than that of open surgery. We describe a laparoscopic transvesical technique that duplicates the steps of the open operation while minimizing operative morbidity; this technique also minimizes operative morbidity while adhering to the principles of transabdominal repair as described by O'Conner. Technique: The patient is placed in the lithotomy position using Allen stirrups, and bilateral SF open-ended ureteral catheters are placed cystoscopically. Using four laparoscopic ports, the prevesical space is accessed. The bladder is bivalved down to the fistula, and stay sutures are placed at the bladder edges for exposure. The fistulous tract and adjacent fibrotic tissue are excised, and the bladder and vagina are closed separately with single layers of full-thickness interrupted 2-0 Vicryl sutures. An omental flap is interposed between suture lines in the bladder and vagina. The ureteral catheters are sequentially removed on the first and second postoperative days. A gravity cystogram is performed 3 weeks postoperatively; if it is normal, the urethral catheter is removed. Results: This procedure has been performed on two consecutive patients who had failed prior Latzko repairs. Both patients were discharged 2 days postoperatively without complications. At a follow-up of 41 months in the first patient and 39 months in the second, no fistula recurrence has been seen. Conclusions: Laparoscopic transvesical vesicovaginal fistula repair appears to be a safe and effective procedure that adheres to the principles of a transabdominal transvesical fistula repair while decreasing morbidity and improving cosmesis. Continued follow-up is required to determine its long-term efficacy compared with the accepted open transabdominal and transvaginal approaches. No competing financial interests exist. Runtime of video: 7 min 35 sec

Spontaneous bladder perforation: a rare complication of tuberculosis

Spontaneous bladder perforation secondary to tuberculosis (TB) is very rare. Only three cases have been reported so far in the literature. Due to its rarity, the diagnosis of spontaneous bladder perforation is often missed. Confirmation of TB via culture takes a long time and starting empirical treatment for TB is necessary. We relate our experience with a young woman who presented with clinical features of a perforated appendix and was only diagnosed with bladder perforation during laparotomy. She also had distal right ureteral stricture and left infundibular stenosis. The provisional diagnosis of TB was attained via typical histopathological features and a positive Mantoux test. She was started empirically on anti-TB treatment and recovered without any complications. Urine culture after 6 weeks confirmed the diagnosis of TB.

Cone Beam CT Imaging Analysis of Daily Variations in Bladder Volume and Position during Radiotherapy for Bladder Cancer

Interfractional changes in target volume position and size are technical challenges to accurate radiotherapy (RT) delivery for bladder cancer. The purpose of this study is to quantify daily variations in bladder size and position occurring during bladder cancer RT. Ten bladder cancer patients receiving at least 20 RT fractions underwent daily cone beam CT (CBCT) bladder imaging in the treatment position. Bladder and PTV were defined on each CBCT and compared with pre-RT planning volumes for: bladder centre of mass shifts in the X, Y, and Z coordinates, position and size variance, changes in volume margin three dimensional positions, and common overlap and mutually exclusive regions occupied by planning and CBCT volumes. Images from five patients have been analyzed. Mean ratio of CBCT to planning bladder volume was 74.56% (SD 14.2%). Mean CBCT bladder volume outside the planning bladder volume was 33.04 cm3 (SD 38.3 cm3). Mean planning bladder volume outside of CBCT bladder volume was 60.42 cm3 (SD 20.34 cm3). Mean ratio of CBCT to planning PTV was 80.64% (SD 10.8%). Mean CBCT PTV outside the planning PTV was 36.49 cm3 (SD 21.1 cm3). Mean planning PTV outside the CBCT PTV was 126.62 cm3 (SD 50.9). Average CBCT bladder volume outside the planning PTV was 2.11 cm3 (SD 2.9 cm3). Mean bladder edge displacement was: superior -0.63 cm (SD 0.83 cm), inferior -0.55 cm (SD 0.93 cm), right lateral -0.78 cm (SD 0.54 cm), left lateral -0.78 (SD 0.67 cm), anterior -1.09 cm (SD 0.96 cm), posterior -0.85 cm (SD 0.74 cm). CBCT bladder and PTV volumes significantly differed from their planning counterparts (p < 0.043). Significant variations in bladder and PTV volume, size and position occurred in patients undergoing RT on this trial.

A new technique for dissecting the bladder laparoscopically

To evaluate a new technique designed to facilitate bladder dissection during laparoscopic-assisted vaginal hysterectomy (LAVH). Minimal access surgery unit, James Cook University Hospital. A retrospective review of 130 LAVHs in which the bladder was dissected laparoscopically. A metal catheter was used to facilitate identification of the bladder edge, and a sponge forceps was inserted vaginally to mark the site for anterior colpotomy. Then monopolar scissors were used to open the vagina. The hysterectomy was then completed vaginally. In this series there were 14 (10.8%) recorded complications with two (1.5%) major complications (95% confidence interval 0.2–5.5%). There was one bladder trauma (0.7%; 95% confidence interval 0.02–4.2%), which was recognised immediately and repaired with laparoscopic intracorporeal knots. One patient required additional vault sutures 6 h postsurgery because of vaginal bleeding. The mean operating time was 98.7 min, and the recorded mean hospital stay was 2.7 days, with a range of 2–5 days. The recorded estimated intraoperative blood loss ranged from 75 to 300 ml, with a mean loss of 195 ml, and four patients required blood transfusion. Dissection of the bladder laparoscopically adds 5–10 min to the operative time but significantly facilitates identifying the appropriate plane. It is an easy technique to learn and teach. It is associated with minimal complications, with no increased incidence of bladder injury or dysfunction.

Laparoscopic Transabdominal Transvesical Vesicovaginal Fistula Repair

Transabdominal transvesical repair has been the standard treatment for difficult vesicovaginal fistulae. We describe a laparoscopic transvesical technique that minimizes operative morbidity while adhering to the principles of transabdominal repair as described by O'Conner. The patient is placed in the lithotomy position using Allen stirrups, and bilateral 5F open-ended ureteral catheters are placed cystoscopically. Using four laparoscopic ports, the prevesical space is accessed. The bladder is bivalved down to the fistula, and stay sutures are placed at the bladder edges for exposure. The fistulous tract and adjacent fibrotic tissue are excised, and the bladder and vagina are closed separately with single layers of full-thickness interrupted 2-0 Vicryl sutures. An omental flap is interposed between suture lines in the bladder and vagina. The ureteral catheters are sequentially removed on the first and second postoperative days. A gravity cystogram is performed 3 weeks postoperatively; if it is normal, the urethral catheter is removed. This procedure has been performed on two consecutive patients who had failed prior Latzko repairs. Both patients were discharged 2 days postoperatively without complications. At a follow-up of 41 months in the first patient and 39 months in the second, no fistula recurrence has been seen. Laparoscopic transvesical vesicovaginal fistula repair appears to be a safe and effective procedure that adheres to the principles of a transabdominal transvesical fistula repair while decreasing morbidity and improving cosmesis. Continued follow-up is required to determine its long-term efficacy compared with the accepted open transabdominal and transvaginal approaches.

Supratrigonal VVF Repair by Modified O’Connor’s Technique: An Experience of 26 Cases

ObjectiveTo report the technical modifications of O’Connor’s procedure and their outcome in 26 supratrigonal vesico vaginal fistulae. Materials and methodsTwenty-six cases of supratrigonal VVF (17 primary, 9 recurrent) were operated using the described modifications. It consisted of approaching the bladder transperitoneally, without dissecting the retropubic space, making a short sagittal or parasagittal cystotomy in between stay sutures, liberal use of bladder rotation flaps instead of midline closure, using single layer, continuous, closely placed, interlocking stitches for bladder as well as vaginal approximation and universal use of vascularised tissue interposition. ResultsMean fistula size was 2.8cm (range 1.0 to 3.7). Mean operative time was 104 minutes, and blood loss was insignificant. Three patients required ureteroneocystostomy. All patients were dry after 2–3 weeks of suprapubic and per urethral catheter drainage. One patient persisted with stress urinary incontinence. No patient on follow up complained of features suggestive of prolonged ileus, peritonitis or adhesive intestinal obstruction. ConclusionModified O’Connor’s repair is safe and achieves excellent functional results. It requires a shorter cystotomy instead of bi-valving of the bladder, thus minimizes tissue trauma, intraoperative blood loss and operating time. It also gives option of tailoring the cystotomy in sagittal or parasagittal line, according to the site and size of the fistula, and thus permits closure of fistula by rotation of bladder flap into the defect without any lateral traction on the bladder edges. Retropubic dissection and drainage of the retropubic space is also not required.

Recognition of Occult Bladder Injury During the Tension-free Vaginal Tape Procedure

In Brief OBJECTIVE To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury. Water seepage through the tension-free vaginal tape plastic sleeve is indicative of occult bladder injury and requires repeat cystoscopic inspection of the bladder.

Recognition of occult bladder injury during the tension-free vaginal tape procedure

OBJECTIVE: To identify signs and the etiology of occult bladder injury during the tension-free vaginal tape sling procedure. METHOD: The charts of 140 women who underwent a tension-free vaginal tape procedure were reviewed, and complications were tabulated and analyzed. The tension-free vaginal tape procedure was performed in six fresh-frozen pelves to demonstrate the mechanism of the occult bladder injury. RESULTS: Occult bladder injury was suspected when cystoscopy instillation fluid flowed from the plastic sheath that covers the prolene tape after the extraction of the tension-free vaginal tape trocar. Three of six cases of intraoperative bladder injury had occult bladder injury identified on repeat cystoscopic inspection. The bladder injury caused by the rough edge at the point of attachment of the tension-free vaginal tape to the trocar was reproducible in three of 12 tension-free vaginal tape applications in fresh-frozen pelves. Traction on the tension-free vaginal tape reapproximates the injured bladder edges and potentially promotes spontaneous healing. CONCLUSION: Bladder injuries may go unrecognized during a tension-free vaginal tape procedure. Continuous seepage of water through the prolene plastic sleeve is suggestive of occult bladder injury and requires repeat cystoscopy to identify the potential site of injury.