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Complications of Marshall-Marchetti-Krantz urethropexy
COMPLICATIONS
OF MARSHALL-MARCHETI’I-KRANTZ
URETHROPEXY
LESTER KNUTE
PERSKY,
M.D.
GUERRIERE.
M.D.
From the Urological Service, Department Case Western Reserve University School Cleveland, Ohio
of Surgery, of Medicine,
ABSTRACT - The course of 2 patients with ureteral obstructions created during the MarshallMarchetti-Krantz procedure is described. The superior or most craniad stitches of the repair were placed inadvertently through the bladder wall obstructing the ureterovesical junction on each side. Awareness of the possibility of this complication should aid in avoiding this mishap. _
Complications may be seen after any operative procedure. Familiarity with their occurrence and nature affords the surgeon an opportunity to avoid them in his preoperative planning and during the execution of the procedure. The usual pitfalls of the Marshall-MarchettiKrantz’ urethropexy are well known, and care is taken to avoid trauma to the symphysis pubis, to avoid dilated vessels lying along and about the urethra, and to place sutures where the urethra itself will not be infringed on. An unusual, infrequently seen, and unexpected complication has recently been encountered in 2 patients which highlights the ever present need for constant surveillance even during the course of what at times appears to be the most mundane exercise. Case Reports
A fifty-five-year-old woman was admitted to Women’s Clinic of University Hospitals of Cleveland, Ohio, in August, 1973, with the complaint of stress incontinence, of increasing severity, of six months’ duration. Preoperative history, physical examination, and laboratory studies were all normal. At surgery an uneventful Marshall-Marchetti-Krantz operation was done seemingly without incident. Postoperatively the patient was left on constant drainage.
UKOLOGY
/ NOVEMBER
1976 / VOLUME
VIII,
FIGURE
dilatation
NUMBER 5
Case 1. Excretory urogram showing and poor visualization of upper tract.
1.
469
closed and a Marshall procedure done to correct the incontinence. In the postoperative period no urine flow was found. Cystoscopic study was undertaken. A preliminary urogram had suggested obstruction of the ureters at the level of the bladder with poor visualization. A cystogram indicated possible distortion of the base of the bladder at the ureterovesical junction, At endoscopy the usual cystoscopic landmarks were distorted and unrecognized. The incision was opened and the bladder entered. Again the offending agents leading to the ureteral blockage were the superior stitches of the urethropexy, which had also been placed through the anterior and posterior walls of the bladder catching and obstructing the ureters at that point. Relief of obstruction promptly attended removal of these stitches. Comment
FIGURE 2. Case 2. Cystographic phase of study showing filling defects due to dilatation of lower ureter.
It was noted after six hours that there was little or no urine flow. Excretory urograms were done on an emergency basis and showed poor excretion with minimal visualization (Fig. 1). The patient was returned to the surgical suite; the incision was reopened, a cystotomy was done, and the superior sutures which were placed seemingly at the bladder neck were found to be traversing the bladder and to have been placed Here they caught the through the trigone. ureters at their junction with the bladder and caused obstruction by a constricting mechanism. Both stitches were removed, and there was an instant copious flow of urine. The bladder was closed and the incision repaired. The patient’s hospitalization was subsequently uneventful. Case 2 A forty-five-year-old woman was admitted to Lake County Memorial Hospital West in March, 1974, for stress incontinence and a pelvic mass. Her preoperative studies revealed normal findings on physical examination; history and laboratory determinations were also in order. At the time of operation, a total hysterectomy was done for a fibroid uterus. After this had been carried out, the peritoneum was
470
The Marshall-Marchetti-Krantz procedure has afforded urologist and gynecologist a most effective approach to the relief of incontinence of the female. It can be utilized after previous repairs from above and below,’ has had modifications proposed by a variety of authors, but has in general varied little from the original description. It can be redone if initial efforts with it have failed and over-all is largely trouble free. Occasionally these patients will have bleeding from the torn varix; rarely will osteitis pubis develop, and infrequently a patient will continue to lose urine.3 The 2 patients described in this report present an unusual complication. Ordinarily there is no need for blood transfusions so that acute tubular necrosis would not be suspected when anuria is noted postoperatively. The operation is usually brief, poses no undue lengthy anesthetic time, and should not lead to hypotension or shock. Occasionally the placing of the sutures in the symphysis requires great force, or the actual use of drills, but this is not generally true. Anuria when it develops, therefore, must be due to a technical lapse and misadventure. In one of our patients cystoscopy was not done. In the second woman a hysterectomy had been part of the procedure and therefore the possibility of bilateral direct ureteral injury had to be entertained and investigated. In the main, we believe urography is worthwhile, takes little time, and is of relatively small risk. It was of great help in both cases, and in Case 2 there
UROLOGY
/ NOVEMBER1976
/ VOLUMEVIII.
NUMBER5
was even a suggestion of lower ureteral dilatation or filling defects at the ureterovesical junction (Fig. 2).
A period of delay to attempt a fluid push or the use of mannitol or other diuretics appears to be warranted in most instances of postoperative oliguria. However, when anuria is seen as a postoperative event after the Marshall-Marchetti repair, excretory urography we believe should be done first, followed by immediate surgical exploration and deligation. The need for ureteral catheters or stents post relief of obstruction has not been apparent in these 2 cases. Care in the placement of the most cranial sutures near the bladder neck must be exercised to avoid the complication discussed here (Fig. 3). Use of a large balloon catheter during surgery will facilitate recognition of the bladder neck, as well as the preliminary placement of a Babcock clamp at the urethrovesical junction. Awareness of the possibility of obstruction will make the complications seen in these 2 patients less likely. 2065 Adelbert Road Cleveland, Ohio 44106 (DR. PERSKY) References
MARSHALL, V. D., MARCHETTI, A. A., and KRANTZ,
FIGURE
offending
UROLOGY
Mechanism sutures.
3.
of ureteral
/ NOVEMBER1976
obstruction
/ VOLUMEVIII.
by
NUMBER5
K. E. : The correction of stress incontinence by simple vesicourethral suspension, Surg. Gynecol. Obstet. 88: 509 (1949). MARSHALL, V. F., et al. : Experience with suprapubic vesicourethral suspension after previous failures to correct stress incontinence in women, J. Urol. 100:647 (1968). EDRICH, M., et al. : The Marshall-Marchetti operation, Acta Urol. Belg. 42: 321 (1974).
471
OF MARSHALL-MARCHETI’I-KRANTZ
URETHROPEXY
LESTER KNUTE
PERSKY,
M.D.
GUERRIERE.
M.D.
From the Urological Service, Department Case Western Reserve University School Cleveland, Ohio
of Surgery, of Medicine,
ABSTRACT - The course of 2 patients with ureteral obstructions created during the MarshallMarchetti-Krantz procedure is described. The superior or most craniad stitches of the repair were placed inadvertently through the bladder wall obstructing the ureterovesical junction on each side. Awareness of the possibility of this complication should aid in avoiding this mishap. _
Complications may be seen after any operative procedure. Familiarity with their occurrence and nature affords the surgeon an opportunity to avoid them in his preoperative planning and during the execution of the procedure. The usual pitfalls of the Marshall-MarchettiKrantz’ urethropexy are well known, and care is taken to avoid trauma to the symphysis pubis, to avoid dilated vessels lying along and about the urethra, and to place sutures where the urethra itself will not be infringed on. An unusual, infrequently seen, and unexpected complication has recently been encountered in 2 patients which highlights the ever present need for constant surveillance even during the course of what at times appears to be the most mundane exercise. Case Reports
A fifty-five-year-old woman was admitted to Women’s Clinic of University Hospitals of Cleveland, Ohio, in August, 1973, with the complaint of stress incontinence, of increasing severity, of six months’ duration. Preoperative history, physical examination, and laboratory studies were all normal. At surgery an uneventful Marshall-Marchetti-Krantz operation was done seemingly without incident. Postoperatively the patient was left on constant drainage.
UKOLOGY
/ NOVEMBER
1976 / VOLUME
VIII,
FIGURE
dilatation
NUMBER 5
Case 1. Excretory urogram showing and poor visualization of upper tract.
1.
469
closed and a Marshall procedure done to correct the incontinence. In the postoperative period no urine flow was found. Cystoscopic study was undertaken. A preliminary urogram had suggested obstruction of the ureters at the level of the bladder with poor visualization. A cystogram indicated possible distortion of the base of the bladder at the ureterovesical junction, At endoscopy the usual cystoscopic landmarks were distorted and unrecognized. The incision was opened and the bladder entered. Again the offending agents leading to the ureteral blockage were the superior stitches of the urethropexy, which had also been placed through the anterior and posterior walls of the bladder catching and obstructing the ureters at that point. Relief of obstruction promptly attended removal of these stitches. Comment
FIGURE 2. Case 2. Cystographic phase of study showing filling defects due to dilatation of lower ureter.
It was noted after six hours that there was little or no urine flow. Excretory urograms were done on an emergency basis and showed poor excretion with minimal visualization (Fig. 1). The patient was returned to the surgical suite; the incision was reopened, a cystotomy was done, and the superior sutures which were placed seemingly at the bladder neck were found to be traversing the bladder and to have been placed Here they caught the through the trigone. ureters at their junction with the bladder and caused obstruction by a constricting mechanism. Both stitches were removed, and there was an instant copious flow of urine. The bladder was closed and the incision repaired. The patient’s hospitalization was subsequently uneventful. Case 2 A forty-five-year-old woman was admitted to Lake County Memorial Hospital West in March, 1974, for stress incontinence and a pelvic mass. Her preoperative studies revealed normal findings on physical examination; history and laboratory determinations were also in order. At the time of operation, a total hysterectomy was done for a fibroid uterus. After this had been carried out, the peritoneum was
470
The Marshall-Marchetti-Krantz procedure has afforded urologist and gynecologist a most effective approach to the relief of incontinence of the female. It can be utilized after previous repairs from above and below,’ has had modifications proposed by a variety of authors, but has in general varied little from the original description. It can be redone if initial efforts with it have failed and over-all is largely trouble free. Occasionally these patients will have bleeding from the torn varix; rarely will osteitis pubis develop, and infrequently a patient will continue to lose urine.3 The 2 patients described in this report present an unusual complication. Ordinarily there is no need for blood transfusions so that acute tubular necrosis would not be suspected when anuria is noted postoperatively. The operation is usually brief, poses no undue lengthy anesthetic time, and should not lead to hypotension or shock. Occasionally the placing of the sutures in the symphysis requires great force, or the actual use of drills, but this is not generally true. Anuria when it develops, therefore, must be due to a technical lapse and misadventure. In one of our patients cystoscopy was not done. In the second woman a hysterectomy had been part of the procedure and therefore the possibility of bilateral direct ureteral injury had to be entertained and investigated. In the main, we believe urography is worthwhile, takes little time, and is of relatively small risk. It was of great help in both cases, and in Case 2 there
UROLOGY
/ NOVEMBER1976
/ VOLUMEVIII.
NUMBER5
was even a suggestion of lower ureteral dilatation or filling defects at the ureterovesical junction (Fig. 2).
A period of delay to attempt a fluid push or the use of mannitol or other diuretics appears to be warranted in most instances of postoperative oliguria. However, when anuria is seen as a postoperative event after the Marshall-Marchetti repair, excretory urography we believe should be done first, followed by immediate surgical exploration and deligation. The need for ureteral catheters or stents post relief of obstruction has not been apparent in these 2 cases. Care in the placement of the most cranial sutures near the bladder neck must be exercised to avoid the complication discussed here (Fig. 3). Use of a large balloon catheter during surgery will facilitate recognition of the bladder neck, as well as the preliminary placement of a Babcock clamp at the urethrovesical junction. Awareness of the possibility of obstruction will make the complications seen in these 2 patients less likely. 2065 Adelbert Road Cleveland, Ohio 44106 (DR. PERSKY) References
MARSHALL, V. D., MARCHETTI, A. A., and KRANTZ,
FIGURE
offending
UROLOGY
Mechanism sutures.
3.
of ureteral
/ NOVEMBER1976
obstruction
/ VOLUMEVIII.
by
NUMBER5
K. E. : The correction of stress incontinence by simple vesicourethral suspension, Surg. Gynecol. Obstet. 88: 509 (1949). MARSHALL, V. F., et al. : Experience with suprapubic vesicourethral suspension after previous failures to correct stress incontinence in women, J. Urol. 100:647 (1968). EDRICH, M., et al. : The Marshall-Marchetti operation, Acta Urol. Belg. 42: 321 (1974).
471