Bladder neck closure for the devastated outlet

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who: the outlet that cannot be saved The devastated outlet is a urethra and bladder neck that have been destroyed rather than weakened: the woman with a neuropathic bladder and a long-term urethral catheter whose urethra has eroded to a patulous gutter, the pelvis after radiotherapy with a fistula or a fixed open neck, the man after multiple failed sphincters, slings and urethroplasties whose urethra is a scarred tube that leaks continuously. Sphincters, slings and bulking have failed or cannot be offered. The alternatives are laid out honestly: a long-term suprapubic catheter alone, a catheterisable channel, an ileal conduit, or cystectomy with diversion. Bladder capacity and compliance are measured beforehand, because a small high-pressure bladder closed at the neck needs augmentation as well or it will leak or harm the kidneys.
2. The plan: how the urine will leave The bladder neck is never closed until the route out has been decided and, where possible, built in the same operation. For most patients it is a suprapubic catheter for life, changed every twelve weeks, and the patient has lived with one for a trial period beforehand to see whether they can. For the patient with the hands and the will it is a continent catheterisable channel, a Mitrofanoff from the appendix or a Monti from ileum, with augmentation if the bladder is small. The stoma site is marked by the stoma nurse. The consent names recurrent leakage through the closure in about one in five, fistula, stones, infection, the catheter changes, and the possibility of a conduit later if the closure fails twice.
3. Incision and the retropubic space Lower midline or Pfannenstiel, the choice made by the previous scars and by whether bowel is needed. The rectus sheath is opened and the muscles separated in the midline; the transversalis fascia is divided and the retropubic space of Retzius entered with a finger sweeping the bladder off the back of the symphysis, staying extraperitoneal unless omentum or bowel is wanted. In the irradiated or many-times operated pelvis the space is obliterated and is taken sharply with scissors on the bone, the bladder held down with a Morris retractor. The endopelvic fascia is opened on each side of the neck so the lateral surfaces of the bladder base are seen. A urethral catheter with its balloon inflated identifies the bladder neck as the catheter is pulled and pushed.
   where it bites: in a scarred, irradiated pelvis the bladder is stuck to the bone and the plane is found sharply, not with a finger; a finger tears the bladder and enters the wrong plane.
4. Dissecting the neck and dividing the urethra With the balloon pulled down onto the neck the junction of bladder and urethra is dissected circumferentially: anteriorly the dorsal venous complex is divided between sutures or with the LigaSure, laterally the pillars of the bladder are taken with the bipolar, and posteriorly, the dangerous side, the plane between the bladder base and the vagina in a woman, or the prostate and rectum in a man, is developed with the diathermy on the bladder side. In a woman a finger in the vagina and in a man a finger in the rectum guide the posterior dissection. The catheter balloon is deflated and the urethra transected just below the neck. The ureteric orifices are looked for from inside and catheterised if they lie within a centimetre of the cut.
   where it bites: the ureteric orifices sit a centimetre or two behind the neck in a scarred trigone; they are identified and catheterised before the posterior wall of the neck is closed.
5. Closing the urethral stump The distal urethra is closed so it does not become a blind pocket that collects secretions or, in a woman, a sinus to the vagina. In a man the stump is oversewn with two or three interrupted 2-0 Vicryl sutures through its full thickness, taking care not to include the rectum behind it. In a woman the urethra is short and the stump is closed with interrupted sutures and buried with the periurethral tissue over it; some units excise the urethra to the meatus instead and close the vaginal side, which is the choice when the urethra has eroded to the vagina already. The closed stump is checked with a swab for bleeding and left alone.
6. Closing the bladder neck in two layers The neck is trimmed back to healthy bladder. The first layer is a running or interrupted 2-0 or 3-0 Vicryl or PDS through the full thickness of the neck, inverting the mucosa into the bladder so no mucosa faces the pelvis, tied without tension. The second layer is interrupted 2-0 Vicryl in the muscle and adventitia, imbricating the first so that it lies buried. The closure is then tested by filling the bladder with 100 to 150 millilitres through the suprapubic route and looking for a leak at the neck; any leak is closed with an interrupted suture and the fill repeated. The suture lines of the neck and the urethral stump are deliberately offset so they do not lie against each other.
   where it bites: tension and the wrong tissue are what open a neck closure; the edge is trimmed to healthy bladder and the two layers sit without pull, or the closure fails.
7. Omentum between the closure and the urethra The peritoneum is opened and the greater omentum brought down on its right gastroepiploic pedicle, mobilised off the transverse colon and lengthened if needed by dividing the left gastroepiploic and the short branches, until it reaches the pelvis without tension. It is laid between the closed neck and the closed urethral stump and around the neck closure, and sutured in place with a few 3-0 Vicryl sutures, so that the two suture lines never touch, the closure has a blood supply beside it, and any leak is absorbed rather than becoming a fistula. In a woman with a vaginal repair the omentum lies between bladder and vagina. Where omentum is absent a Martius labial fat flap or a rectus flap does the same work.
8. Suprapubic catheter, drain, the test fill A 16 to 20 French silicone suprapubic catheter is brought through the dome of the bladder, well away from the closed neck, and out through a separate stab in the abdominal wall, fixed with a purse-string in the bladder and a suture at the skin. If a catheterisable channel has been made it is catheterised and its own catheter left in. A tube drain is placed in the retropubic space. The bladder is filled once more through the suprapubic catheter and the neck watched; the drain and the wound must stay dry. The rectus sheath is closed with looped 1 PDS and the skin with staples or a subcuticular suture. The suprapubic catheter is the only route out for the next three weeks.
9. After: leakage, stones, the channel The suprapubic catheter stays for three weeks and a cystogram before it is changed shows the neck holding. Then the pattern for life: the suprapubic catheter changed every twelve weeks, or the channel catheterised by the clock. Leakage per urethra in the first weeks is a small fistula through the closure and is managed by keeping the bladder empty; leakage that persists after three months is a failed closure and is re-closed with a fresh interposition, or diverted. Stones form on the catheter balloon and in the bladder and are looked for with ultrasound; the kidneys are imaged for pressure and the bladder pressure remeasured if leakage or infection returns. The patient is told plainly that this is the last operation on the urethra.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance