Transvaginal Closure Research Articles

Management of urinary incontinence in girls with congenital pouch colon.

This study describes the management of urinary incontinence (UI) in eight girls with congenital pouch colon (CPC) associated with anorectal malformation (ARM). From 2013 to 2015, six girls with CPC and UI underwent bladder neck reconstruction (BNR). Four girls had complete UI (CUI) and two girls partial UI (PUI). From 2019 to 2023, four girls, including two with failed BNR, underwent bladder neck closure (BNC) and augmentation cystoplasty (AC) with a continent stoma. Subtypes of CPC were Complete CPC (n = 7) and Incomplete CPC (n = 1). All girls had a double vagina; short, wide urethra; and reduced bladder capacity with an open, incompetent bladder neck (BNI). During BNR, a neourethra was constructed from a 1.5-2cm-wide and 1.5-3-cm-long trigonal strip. During BNC, AC was performed using a 20cm ileal segment (n = 3) and by a colonic pouch segment, preserved during earlier colorraphy (n = 1). Continent stoma included a Monti's channel (n = 3) and appendicovesicostomy (n = 1). BNR produced moderate improvement of UI (n = 2), while UI was still very severe (n = 4). During BNC, intraoperative complications included iatrogenic vaginal tears (n = 4). Early complications included partial dehiscence of the ileocystoplasty (n = 1), partial adhesive small bowel obstruction (n = 1), and difficulty in stomal catheterization with prolonged drainage from the pelvic drain (n = 1). Late complications included unilateral grade II vesicoureteric reflux (n = 2) and vesicovaginal fistula (VVF) (n = 2) needing trans-vaginal closure in one girl. Urinary stones (n = 2) with stomal leakage of urine in one girl needed open cystolithotomy twice (n = 1), and endoscopic lithotripsy (n = 1). At follow-up, all patients have high overall satisfaction with the procedure and their continence status. BNC with AC and a catheterizable stoma satisfactorily achieves continence in girls with CPC and UI, vastly improving quality of life. If lower urinary tract (LUT) anatomy is favorable, BNR with/without AC can be the initial surgical procedure. BNC should be the primary procedure in girls with unfavorable LUT anatomy and for failed BNR. IV.

Laparscopic versus transvaginal closure of vaginal cuff in patients undergoing total laparoscopic hysterectomy: A randomized study

Laparscopic versus transvaginal closure of vaginal cuff in patients undergoing total laparoscopic hysterectomy: A randomized study

Over/under: examining the cost difference in vaginal vs. laparoscopic cuff closure following a laparoscopic hysterectomy

Vaginal cuff closure following a total laparoscopic hysterectomy (TLH) can be approached laparoscopically or transvaginally. Route of closure is primarily determined by surgeon preference and may also be influenced by clinical/patient characteristics. The objective of this study is to compare the proportion of laparoscopic (LSC) closure to the proportion of transvaginal (TV) closure of the vaginal cuff following a TLH. We also aim to compare the cost utility of both cuff closure approaches. This is a retrospective cross-sectional study of all TLH cases performed at our institution between June 2018 – May 2019. We collected patient demographics, surgery parameters (vaginal cuff closure method, necessity for X-ray), and time measurements between case milestones (case start-to-end, X-ray completed, patient out of room). Of note, our institution carries a unique protocol that may not be the standard across other institutions, which mandates an abdominal X-ray (AXR) to evaluate for retained foreign bodies in patients with a BMI ≥35 when a laparoscopic case includes a TV cuff closure. This protocol does not apply in LSC cuff closure following TLH. Exclusion criteria included conversion to open procedure and involvement of concomitant procedures. Based on review of existing literature, operating room (OR) costs have been estimated to range between $30 - $81 per minute and post-operative radiologic images cost about $168 per procedure. Data were analyzed with Chi-square test and two-tailed t-test (α = 0.05). During the study period, 120 qualifying TLH cases were performed. Eighty-seven patients (73%) underwent LSC closure and thirty-three patients (27%) underwent TV closure. Mean age and BMI did not significantly differ between LSC and TV closure groups. Fifteen patients in the LSC closure group and nineteen patients in the TV closure group had BMI > 35. Service type differs between the two groups (p<.001). For the LSC closure group, the mean case time was shorter by a mean difference of 66 minutes (133 minutes for LSC versus 199 minutes for TV; 95% CI = -84.1, -47.8). If all TV closures were done laparoscopically, this translates to a potential cost saving of $1,980 - $5,346 per case. The mean time difference between case end time and out of OR time was shorter by 15.75 minutes in cases that did not require AXR. Nineteen patients who had a TV closure after TLH also required AXR for BMI>35. Thus, 19 AXR would be potentially avoided if TV closures were replaced by LSC closures. With added OR time and cost of AXR, there is a potential saving of $12,169 - $27,431 per year if LSC closures were chosen. Compared to TV cuff closure, LSC vaginal cuff closure following a TLH may afford a cost benefit due to decreased operating room time. Given our institutional policy, further cost savings can be seen by avoiding additional AXR.

Vesico-Vaginal Fistula Repair by a Vaginal Approach

Introduction: The aim of this study is to determine the outcome of surgically treated vesico-vaginal fistulae (VVaFs) using a transvaginal approach with a Latzko technique. Methods: A retrospective chart study was conducted at the Department of Urology, Radboud University Medical Centre. Surgical approaches to repair VVaF, from 2014 to September 2020, were selected. Patients who underwent a transvaginal approach were included. The primary objective was fistula closure. Secondary objectives were predictive factors for the outcome of the surgical procedure, for example, patient characteristics, leakage on cystography 2 weeks postoperative, and surgery time. Results: Thirty-one patients had surgery for VVaF. Twenty-five procedures (81%) were performed transvaginally. Thirteen of these (52%) had successful transvaginal closure after the first attempt. Seven out of 12 had their second attempt at the time of analysis, of which 4 (57%) were successfully closed thereafter. After either 1 or 2 attempts with the transvaginal approach, 17 (68%) of the VVaFs were successfully closed, but 79% if patients who did not yet had a second attempt were taken into account with the current success extrapolated. Only few minor complications were observed. Conclusion: Transvaginal closure of VVaFs with a Latzko technique is successful in about 79% in either 1 or 2 attempts, with few minor complications. A second attempt in closing the fistula with a transvaginal approach is useful, and a previous transvaginal attempt is not a contraindication for a second transvaginal attempt in closing the VVaF surgically.

Transvaginal closure of urinary bladder opening and Mitrofanoff technique in a neurologically impaired female with chronic indwelling catheter: a case presentation

BackgroundChronic catheterization remains the only attractive option in specific circumstances, especially in neurologically impaired patients. Complications produced by the indwelling catheters, like patulous urethra and bladder neck destruction, usually lead to severe incontinence and significant nursing difficulties. Here, we describe a rare case, a urinary bladder opening representing massive and extensive destruction of the urethra and bladder sphincter due to an indwelling catheter.Case presentationWe present a 46-year-old paraplegic woman complaining of recurrent febrile urinary tract infections and severe urinary incontinence. She suffered from persistent malodorous urine and skin breakdowns from constant urine leakage. The vaginal examination revealed extensive destruction of the urethra and a 10 cm opening permitting the urinary bladder wall to prolapse into the vagina. The patient underwent a combined surgical approach; a transvaginal bladder closure with anterior colporrhaphy and a Mitrofanoff procedure to ensure a continent stoma for future clean intermittent self-catheterization (CISC). The patient is compliant with CISC and, remains continent twelve years after surgery.ConclusionThis case demonstrates that in the era of CISC, there are still neurologically impaired females suffering from rare but critical adverse effects of indwelling catheters. The urethra and bladder neck erosion represent a demanding treatment assignment. The Mitrofanoff procedure for continent stoma and the transvaginal closure of urinary bladder opening produced a lifesaving potential treatment.

A simple technique of vaginal cuff closure to prevent tumor cell spillage in laparoscopic radical hysterectomy for uterine cervical cancer.

The Laparoscopic Approach to Cervical Cancer (LACC) trial, a prospective randomized phase III clinical trial reported in 2018, unexpectedly showed inferior oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer compared with those in open surgery. It was proposed that the spillage of tumor cells into the peritoneal cavity might cause the inferiority of LRH. It has been suggested, based on retrospective studies, that transvaginal closure of the vaginal cuff before the colpotomy part of the surgery may prevent this. Before starting colpotomy, we closed the vaginal cuff transvaginally. After the assessment of the cutline of the vagina, the vaginal mucosa is pulled at the eight sites using the sutures. The four pairs of sutures on the diagonal line are ligated. A purse string suture is additionally placed on the vaginal mucosa to close the vaginal cuff completely. After that, we start the intracorporeal colpotomy using a vaginal pipe. Our technique is simple and quick. The blood loss during the transvaginal procedures is minimal. The use of the vaginal pipe helps keep the vaginal cuff closed during the colpotomy. Our technique may be an alternative to the conventional approach closing the vaginal cuff.

2972 Two-Port Laparoscopic Hysterectomy and Cuff Closure without the use of a Multiport Channel

Video Objective To demonstrate a novel technique for a two-port hysterectomy and laparoscopic cuff closure using an operative laparoscope. Setting The previously described port-reducing, single-port or two-port hysterectomy techniques fall into two broad categories. The first employs the use of a multiport channel, which requires a larger fascial defect and is associated with more postoperative pain and higher risks of postoperative hernia formation. The multiport channel is also technically limited by the loss of triangulation and instrument collision. The second technique for port-reducing hysterectomy uses two 5-10 mm ports and requires transvaginal cuff closure. The benefit of smaller incisions and better triangulation comes at the expense of higher rates of cuff dehiscence associated with transvaginal cuff closure. Interventions Two-port laparoscopic hysterectomy, salpingo-oophorectomy, and laparoscopic cuff closure using a 10 mm operative scope plus one additional 5 mm suprapubic port. Conclusion While we acknowledge that vaginal hysterectomy remains the most minimally invasive route of surgery; a two-port hysterectomy would better serve a number of patients with limited vaginal access, or whose indication for surgery is pelvic pain if the initial survey reveals limited pathology. The novel technique we describe combines the benefit of smaller incisions, better triangulation, and laparoscopic cuff closure. To our knowledge, our group is the first to describe that procedure.

Laparoscopic radical hysterectomy with transvaginal closure of vaginal cuff - a multicenter analysis.

Laparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy. Between August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator. A total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2-86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1-288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery. The combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire

Study ObjectiveThe effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. DesignSecondary analysis of a prospective randomized controlled trial. SettingThree academic research centers. PatientsWomen consenting to telephone interviews on their sexual life before and after undergoing TLH were included. InterventionsPatients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. Measurements and Main ResultsA validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010–7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966–180.5, respectively). ConclusionTransvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life.(Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.)

Transvaginal bladder-neck closure: a step-by-step video for female pelvic surgeons

Transvaginal bladder-neck closure is a definitive surgical option for urethral erosion due chronic bladder catheterization in patients with neurogenic bladder. Surgeons who perform female pelvic reconstructive surgery have limited exposure to this procedure in their training. The purpose of this video is to demonstrate a transvaginal bladder-neck closure due to urethral erosion in a patient with neurogenic bladder due to persistent neuropathy from Guillain-Barré syndrome managed with prolonged catheter drainage. We used a live-action surgical demonstration to describe transvaginal bladder-neck closure with urinary diversion. This video provides a step-by-step approach to transvaginal bladder-neck closure as treatment for urethral erosion from chronic catheterization. This video can be used to educate and train those performing female pelvic reconstructive surgery. Surgeons who perform female pelvic surgery should be familiar with the complications of chronic Foley catheterization and treatment options that include transvaginal bladder-neck closure. This video may be used to facilitate reproducibility and comprehension of this procedure.

Case Series of Laparoscopic Retroperitoneal Hysterectomy: Outcomes, Cost and Patient Satisfaction [11D

INTRODUCTION: Laparoscopic Retroperitoneal Hysterectomy (LRH) is a minimally invasive hysterectomy approach incorporating retroperitoneal dissection to ligate the uterine arteries at the origin, lateralization of ureters, vaginal specimen extraction and transvaginal cuff closure. Our study evaluates LRH in terms of outcomes, cost, and patient satisfaction. METHODS: Retrospective chart review of 756 consecutive cases undergoing LRH for benign indications at a suburban hospital from 2011-2013. Data collected: patient characteristics and surgical outcomes. Direct hospital costs were estimated using a combination of micro- and gross-costing. Satisfaction surveys were mailed to the same patient population with a 12% response rate. RESULTS: Mean uterine size: 328.9g (SD 343.1), ranging from 20g to 9,314g. Mean operating time (OT): 61.8 min (SD 31.0). Average length of stay (LOS) 0.2 (SD 0.5) days with 88% discharged same day. Intraoperative and postoperative complication rates: 2.2% and 3.2%, respectively. Conversion to mini-laparotomy (&lt;5cm) = 1.2% (9 cases). Conversion to laparotomy (&gt;5cm) = 0.0%. Zero use of power morcellation. Average cost per case $4,061. Postoperative survey indicated 87.2% overall patient satisfaction rate. CONCLUSION: A distinguishing aspect of the LRH procedure is a standard retroperitoneal dissection with delineation of the ureter and control of the blood supply by uterine artery ligation at its origin. This technique is key to low complication rates, which minimizes OT, LOS, and costs, and contributes to patient satisfaction, and costs, and contributes to patient satisfaction. Further studies comparing LRH to the most widely performed minimally invasive hysterectomy approaches are warranted for this effective and cost-efficient procedure.

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy. After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P= .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P= .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

Treatment of Vaginal Cuff Evisceration

Vaginal cuff dehiscence is defined as partial or full separation of the vaginal cuff (vaginal incision), whereas evisceration refers to prolapse of intraperitoneal contents (usually ileum) through the cuff defect. Evisceration, a rare but potentially morbid complication of total hysterectomy, is a surgical emergency due to the potential for bowel injury and peritonitis. Minimally invasive hysterectomy techniques (robotic or laparoscopic- assisted) are associated with significantly higher rates of cuff dehiscence and evisceration than abdominal or vaginal hysterectomies. The frequency of vaginal cuff dehiscence and evisceration has increased in recent years largely due to the increased use of such minimally invasive procedures. Historically, urgent laparotomy was recommended for management of vaginal cuff evisceration, and it was believed that there was no role for transvaginal repair. Recently, successful outcomes have been reported in several case and retrospective studies using a less invasive vaginal or combined vaginal and laparoscopic approach. The aims of this article were to review an algorithm for transvaginal repair of vaginal cuff evisceration and to describe experience with this technique at a single institution. All women selected for transvaginal closure were medically stable and had no evidence of peritonitis or bowel injury. After administration of broad-spectrum antibiotics, the prolapsed bowel was copiously irrigated with warm saline solution and gently replaced into the abdomen through the vaginal cuff. After the cuff was sharply debrided of necrotic tissue, a full-thickness cuff closure was performed using a delayed absorbable monofilament suture. Between 2009 and 2014, 4 cases of vaginal cuff evisceration were successfully managed with a transvaginal approach. There were no intraoperative or postoperative complications. All 4 patients were discharged home on postoperative day 2 and did not require repeat surgery. These findings show that vaginal cuff dehiscence and evisceration can be managed by transvaginal bowel reduction and cuff closure in medically stable patients who have no evidence of peritonitis or bowel injury.

Laparoscopic Hysterectomy in Case of Uteri Weighing ≥1 Kilogram: A Series of 71 Cases and Review of the Literature

Study ObjectiveTo present our experience with laparoscopic hysterectomy (LH) for uteri weighing 1 kilogram or more and to provide a systematic review of the available English literature. DesignRetrospective analysis and review of the literature (Canadian Task Force Classification II-2). SettingDepartment of Obstetrics and Gynecology, University of Insubria, Varese, Italy. PatientsAll women in whom LH was attempted at the Department of Obstetrics and Gynecology, University of Insubria for uteri weighing ≥1 kg were included in the present study. Demographic characteristics and perioperative details of patients were prospectively recorded in our institutional surgical database. We also performed a systematic review of the English literature to identify studies including at least 1 case of LH for uteri weighing ≥1 kg. InterventionsHysterectomy for uteri ≥1 kg was performed through a total laparoscopic approach with vaginal morcellation of the uterus in the majority of patients and transvaginal closure of the vaginal vault in all cases. Measurements and Main ResultsLH was attempted in a total of 71 women. The median uterine weight was 1120 g (1000–2860 g). Three (4.2%) conversions to open surgery were needed. The median operative time and blood loss were 120 minutes (55–360 minutes) and 200 mL (10–1000 mL), respectively. No intraoperative and 2 (2.8%) postoperative complications occurred. Our review identified 6 studies reporting details of LH for uteri weighing ≥1 kg for a total of 62 patients; conversion to open surgery was necessary in 6 (9.7%) patients, and an additional 13 (21%) received a minilaparotomic incision to extract the uterus. The overall complication rate reported in the literature was 11.4%. ConclusionLH represents a possibility even in cases of uteri weighing ≥1 kg. In a dedicated setting with high endoscopic experience, conversion and complication rates appear acceptable.

V252 TRANSVAGINAL BLADDER NECK CLOSURE

You have accessJournal of UrologyFemale Voiding Dysfunction (Pelvic Reconstruction and Incontinence)1 Apr 2012V252 TRANSVAGINAL BLADDER NECK CLOSURE Dennis Lee, Kenneth Faber, Vannita Simma-Chiang, and David Ginsberg Dennis LeeDennis Lee Los Angeles, CA More articles by this author , Kenneth FaberKenneth Faber Los Angeles, CA More articles by this author , Vannita Simma-ChiangVannita Simma-Chiang Los Angeles, CA More articles by this author , and David GinsbergDavid Ginsberg Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.308AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transvaginal closure of the bladder neck is indicated in female patients with urethral destruction resulting from long-term use of chronic indwelling urethral catheters. The transvaginal approach avoids the morbidity associated with an abdominal incision and provides a viable option for the management of the incompetent urethra. METHODS This video shows our technique of transvaginal bladder neck closure. The patient is positioned in dorsal lithotomy position. After suprapubic catheter placement, a circumscribing incision is made around the urethra and an inverted U incision is made in the anterior vaginal wall to develop a vaginal flap. The urethra is mobilized down to the level of the bladder neck. This dissection includes the division of both the lateral (urethropelvic ligament) and anterior (pubourethral ligament) supporting structures of the urethra. The anterior urethra is then spatulated down to the bladder neck and the posterior urethra is mobilized upwards. The bladder neck is initially closed in two layers and an additional layer of closure is added with imbrication of the detrusor muscle. Lastly, the anterior vaginal flap is advanced to close the anterior vaginal wall to complete the repair. RESULTS The operative time was 2 hours and 15 minutes with an estimated blood loss of 760 cc. The patient was maintained on oxybutynin post-operatively to minimize post-operative detrusor overactivty. At 3 months postoperatively, she was doing well without evidence of urinary leakage. CONCLUSIONS Transvaginal bladder neck closure is a reasonable treatment option for patients with urethral destruction and avoids the morbidity of an abdominal incision. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e102 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dennis Lee Los Angeles, CA More articles by this author Kenneth Faber Los Angeles, CA More articles by this author Vannita Simma-Chiang Los Angeles, CA More articles by this author David Ginsberg Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Transvaginal closure of urethra and correction of uterovaginal prolapse in neurologically impaired patient with chronic indwelling catheter

We report the case of a 38-year-old neurologically impaired woman with continuous urinary incontinence as a result of a chronic indwelling catheter for neurogenic bladder. Long-term catheter resulted in dilatation of urethra and pressure necrosis of urethra, with subsequent incontinence despite the catheter. She also had a stage 3 uterovaginal prolapse. She underwent cystoscopy, closure of urethra and bladder neck by transvaginal route (Feneley procedure), insertion of a suprapubic catheter, sacrospinous fixation and posterior colporrhaphy with prolene mesh (Apogee). Vaginal hysterectomy was declined by the patient and her family. She remained dry at follow-up visit and is happy with the outcome.

Our experience with salvage genitourinary fistulae repair: technique and outcomes

The objectives are to present the long-term results of vaginal reconstructive operations using the labial fat pad flap (Martius flap) interposition. Eight women, 27-65 years old (mean 40), suffering from urinary fistulae (five urethrovaginal and three vesicovaginal) who failed primary repair underwent salvage vaginal reconstruction for damaged urethra or bladder. Urethral or bladder and vaginal defect was closed and a Martius fat flap was interposed between urethra or bladder and vaginal wall flap to secure a watertight separation of the structures. A Martius flap was also used successfully for salvage vaginal reconstruction in three more women, two with extensive injury of their urethra and bladder neck and one with vaginal leakage, after a rectosigmoid neobladder diversion following cystectomy. The repair was successful in all eight patients with urinary fistulae and in the one with rectovaginal leakage. The patient with the traumatically injured urethra and bladder neck developed an anastomotic stricture treated with urethral dilatations and internal urethrotomy. The older one developed a vesicovaginal fistula due to bladder neck closure, and this was repaired with a second transvaginal closure. Martius labial fat flap is an easy to prepare, well-vascularized tissue that can be most helpful in achieving a long-lasting favorable outcome in vaginal reconstructive surgery.

Outcome of urethral closure in patients with neurologic impairment and complete urethral destruction

The purpose of this study is to describe the problems associated with prolonged urethral catheterization in 12 patients with neurological problems and to report the results of surgical treatment. A retrospective study of patients with neurogenic bladder and urethral dysfunction treated with prolonged catheterization resulting in incontinence associated with loss of urethral tissue and or function selected 12 patients. All had video urodynamics. Twelve were continuously incontinent despite a catheter. Bladder compliance, where that could be measured, was low is 10, and there were multiple and serious co-morbidities including sepsis, hypoalbuminemia, skin breakdown, osteomyelitis, respiratory insuffiency, etc. There were 4 males and 8 females, 9 had a spinal cord injury and 3 progressive multiple sclerosis. Male patients underwent transperineal closure of the membranous urethra; females transvaginal closure of the urethra. All patients had a urinary diversion, either an ileovesicostomy, or an augmentation cystoplasty and construction of a neourethra. Continence was ultimately achieved in 11 of 12 patients at a median 20 months. Four patients had one additional procedure to gain continence, but five patients required 3.8 procedures/patient to achieve continence. Closure of the male urethra was more easily accomplished than closure of an extensively damaged eroded female urethra. Patients with urethral damage and erosion related to prolonged catheter present a formidable challenge in surgical reconstruction. Most have serious co-mobidities and a single operation does not usually solve all the problems. Persistence does almost always result in continence.

Symposium i‐2. pathophysiology and treatment of pressure ulcer Moderated by Hiroyuki Kuwano: Administration of Basic Fibroblast Growth Factor (bFGF) for Intractable Rectovesical Fistula — a Case Report

Case: 62‐year‐old female. Drainage of abscess and hysterectomy were performed for pelvic peritonitis. But stool‐like exudates was observed at postoperative 2 days. Transverse colostomy and drainage of the abscess were performed. Transvaginal closure of the vaginal stump was performed for rectovaginal fistula. After a while, intractable rectovesical fistula was newly observed.Clinical course: Because patient was contracted articular rheumatism, she wanted to avoid operation. Under sufficient informed consent, we started the treatment of injection with bFGF via the drainage tube to rectovesical fistula (50 μg/day). Narrowness of the fistula was checked by fistulography, and decrease of eduction of stool like exudates was observed. The fistula was closed after 2.5 months from beginning of the treatment.Summary: We reported a case that bFGF was available for intractable nontumorous enterogenic fistula.

THE ANTERIOR SAGITTAL TRANSRECTAL APPROACH FOR TRAUMATIC URETHROVAGINAL FISTULA CLOSURE

The anterior sagittal transrectal approach (ASTRA) de- rived from the posterior sagittal anorectoplasty introduced by deVries and Pena in 1982 and was primarily developed for the treatment of anorectal malformations.1 We report the management of a recurrent traumatic urethrovaginal fistula using this technique. CASE REPORT A 10-year-old girl presented with a recurrent posttrau- matic fistula after a mine explosion in Afghanistan. Follow- ing the injury primary closure was performed twice, initially via a combined abdominovaginal procedure, and a secondary transvaginal closure was performed. Two years after the reconstructions the patient presented with recurrent urinary tract infections in combination with urge incontinence and additional permanent urinary drib- bling. Voiding cystourethrogram showed a recurrent fistula between the proximal urethra and the proximal third of the vagina (fig. 1, A). Additional urodynamic investigation re- vealed a bladder capacity of 110 ml, unstable detrusor activ- ity with intravesical pressure to 80 cm H2O and complete bladder emptying. An unimpaired upper urinary tract was confirmed by ultrasonography and excretory urography. Ure- throcystoscopy demonstrated an intact distal and mid ure- thra, while a wide proximal fistula to the vagina close to the bladder neck was detected. In this portion the vagina ap- peared uninjured and a normal cervix uteri was identified. However, on vaginoscopy no cervix could be found, indicating a separation of the vagina by the previous trauma (fig. 2, A). Based on these endoscopic findings, the ASTRA procedure was selected for fistula closure. Standard mechanical bowel preparation was performed for 2 days preoperatively with senna. With the patient in the prone position a midline incision was made from the anus to the vaginal introitus. The anterior rectal and posterior vag- inal walls were incised in the midline to the level of the peritoneal reflection. Following exposure of the dorsal vagi- nal wall a cicatricial obliteration of the mid vaginal portion with separation of the vagina in 2 parts was observed (fig. 2, B). The fistula was located at the proximal third of the vagina, and, therefore, could not be identified on vagino- scopy. Excision of the fistula and lateral mobilization of the surrounding tissue were performed, and the urethra was longitudinally sutured over a 10Fr catheter with interrupted sutures. A subcutaneous Martius flap was prepared out of the right labium and used as a secondary layer to cover the urethra. The vagina was repaired posterior to the Martius flap. Following the procedure a 10Fr suprapubic tube cystos- tomy was used for 4 weeks. Neither drains nor a protective colostomy was needed. Perioperative antibiotic treatment in- cluded metronidazole and cefuroxime, and was continued for 9 days after surgery. After urinary drainage for 4 weeks voiding cystourethro- gram confirmed complete fistula closure (fig. 1, B). At 3-month followup the girl was continent and voided without residual urine. Persistent urgency is treated with anticholin- ergics. DISCUSSION Urethrovaginal fistula in childhood is a rare condition, and, therefore, an evolving field. Following trauma the fis- tula in girls mainly occurs in the proximal part of the urethra