Urethral Closure

In those cases where the proximal margin of the urethral erosion is the anterior bladder neck, or even more proximal bladder, secure closure depends on mobilization

Ureter Reconstruction

□ Fig. 7.11. A Preoperative study in a 34-year-old myelodysplastic patient incontinent around a Foley catheter placed because she could not manage intermittent catheterization. B Postoperative study after a crossed sling and ileovesicostomy. The bladder neck is closed and the ileovesicostomy provides for low pressure drainage

□ Fig. 7.11. A Preoperative study in a 34-year-old myelodysplastic patient incontinent around a Foley catheter placed because she could not manage intermittent catheterization. B Postoperative study after a crossed sling and ileovesicostomy. The bladder neck is closed and the ileovesicostomy provides for low pressure drainage of the anterior bladder deep to the endopelvic fascia (O Fig. 7.12, 7.13A-D). Incisions are made anterior to the open bladder neck as close to the bone as possible, or rather as far away from the bladder neck margin as possible. Sharp dissection at 10-11 o'clock and at 1 and 2 o'clock provides a safe entry place into the retropubic space. From those vantage points, one can dissect, under vision, the anterior bladder wall off the pubis without damage to the dorsal venous complex. A generous free margin of mobile

□ Fig. 7.12. Typical appearance of anterior complete urethral erosion. Here the distal third of the posterior urethra is also eroded bladder is needed for effective closure. Continuing the dissection along both lateral aspects of the bladder neck allows further mobilization of the anterior bladder wall from the back of the pubis. At the 3 and 9o'clock positions lateral to the bladder neck, it is not necessary to dissect into the retropubic space, as there is sufficient tissue here to permit mobilization and closure. Across the posterior aspect of the open urethra, a vaginal incision is made to permit mobilization of a generous inverted U-shaped vaginal flap to provide coverage of the suture lines closing the bladder neck. The flap is based superiorly and enough should be raised so that there is no tension on the suture line when the flap is advanced forward to the tissue margin just under the symphysis where the operation began. The mobile open posterior margin of the urethra is then sutured to the anterior bladder mobilized and pulled down toward the center of the operative field. The bladder neck is closed with a transverse suture line, which is then imbricated with a second suture line. If possible, a Mar-tius flap should be placed over the closed bladder neck. The vaginal flap is then advanced to cover the entire area. Catheter drainage here is a two-edged sword since reflex bladder activity, which in these neurogenic conditions is accentuated by the catheter, tends to pull open the repair. A period of 5-7 days is enough to protect the closure. Catheters are the cause of the problem to begin with and a much better operative field results if all catheters are removed, despite the obvious consequences, 2 weeks or more prior to the operative procedure.

Egress from the ileovesicostomy if that procedure is used should occur at 10 cm or less detrusor pressure (O Fig. 7.14). Once the catheter is removed from the ileovesicostomy and low leak point pressures from the stoma established, these systems tend to be very stable

□ Fig. 7.12. Typical appearance of anterior complete urethral erosion. Here the distal third of the posterior urethra is also eroded

Bladder Closure Procedure

O Fig. 7.13. A Incision lines to circumscribe the opening. B Dissection in the retropubic space to mobilize the anterior bladder wall and define the anterior margin of the defect to be closed, and posterior to the urethra to raise a vaginal flap to cover the urethral closure. C Initial suture line closure. D Second reinforcing suture line

O Fig. 7.13. A Incision lines to circumscribe the opening. B Dissection in the retropubic space to mobilize the anterior bladder wall and define the anterior margin of the defect to be closed, and posterior to the urethra to raise a vaginal flap to cover the urethral closure. C Initial suture line closure. D Second reinforcing suture line

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