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Simplified urethrovesical suspension and urethroplasty
Simplified urethrovesical suspension and urethropIasty* Major
W.
results
from
BENSON
ROKALD Norton
a minor
HARER,
procedure
JR.,
M.D.**
E. GUNTHER, Air
Force
Base,
M.D.***
California
T H E U R E T H R 0 V E s I C A L suspension operation by Marshall, Marchetti and Krantz? marked a milestone in the long journey toward control of urinary stress incontinence in the female. A greatly simplified operation is herein presented combining suprapubic \:esical neck suspension with vaginal urethroplasty. A single operator can readily perform it in less than 15 minutes. The anatomic and functional results appear identical to those of the more extensive procedures currently in vogue. Consistently excellent results can only follow from careful evaluation leading to the discovery of specific anatomic or functional defects followed in turn by specific oper&ive or medical therapy. Proper study
From the Department Gynecology,, 2,796th Force Hospital.
of Obstetrics United
States
includes history, physical examination, and laboratory tests as for any operation. Cystometrogram is useful to rule out suspected neurogenic problems. In addition, cystoscopy and cystourethrogram are essential. We feel the key factor in selecting patients who will be benefited by this operation is cystourethrographic demonstration of loss of support of the vesical neck, resulting in an angle of the urethra to the long axis of the body greater than 45 degrees. This follows the criteria established by Green.l The operation presented specifically elevates the vesical neck and corrects funneling of the posterior urethra, thereby correcting urethral inclination and restoring the posterior urethrovesical angle to the normal range. It may be that the procedure also gains efficacy through lengthening t h e urethra and elevating the vesical neck out of the most dependent position. All these changes are noted in comparing pre- and postoperative cystourethrograms (Figs. 1 and 2). The basic principle is to place strong sutures through the tissue on each side of the vesical neck and suspend them across a firm bridge of rectus fascia. This elevates the urethra and fixes it in a normal position. Plication of the posterior urethra and/or paraurethral fascia further narrows the posterior urethrovesical angle and corrects fun-
and Air
‘The contents of this article are the personal views of the authors and do not constitute a statement of oficial Air Force policy or Air Force indorsement of any commercial product. **Current Obstetric7 Colorado Colorado. ***Current Obstetrics Llniversity California.
address: Department of and Gynecology, University of Medical Center, Denver 20,
address: Department of and Gynecology, Stanford Medical
School,
Palo
Alto,
1017
1018
Harer
and
Fig. 1. (A). grams
Preoperative and demonstrating elevation
Fig. 2. (A). cystourethrograms
:11~1il I.
Gunther
Preoperative and demonstrating
\m.
(B), postoperative of vesical neck.
standing
lateral
stress
J, Olrc
1965 B (:mrc.
rystourethro-
(B), postoperative anteroposterior elevation of vesical neck.
neling. The ingenious ligature instrument+ reported by Pereyra.” in 1959, is used. Pereyra reported a technique in which wire, slings were placed through the vaginal mucosa on each side of the vesical neck and anchored across the rectus muscle. Blind paraurethral cautery was then used to induce fibrosis to maintain the urethra in
this position as the wire ,eraduallv cut through. We have modified his technique by va+nal dissection to mobilize the urethra and \mical neck. The suspensor\; sutures arc placed in a similar fashion and cornpletely buried. The paraurethral space is further obliterated or Kelly urethral plication done. Thus. the reaction induced by sutures and dissection is substituted for blind cautcrktion to induct> fibrosis, and nlore precise anatomic position.
Volume Number
91 7
Urethrovesical
suspension
and urethroplasty
1019
Technique With the patient in dorsolithotomy position, the vagina, perineum, and suprapubic area are prepared and draped. If vaginal hysterectomy is planned, it should be done first. A Foley catheter is inserted into the bladder. The vaginal mucosa is then incised longitudinally from urethral meatus to beyond the vesical neck. The dissection should be somewhat wider than usual for a urethroplasty, and a space is developed on each side of the urethra which readily admits the operator’s finger tip. A vs inch midline stab incision is then made in the skin, 1 inch above the symphysis pubis. The cannula of the Pereyra instrument is inserted through this incision and through the right side of the rectus fascia, directed toward the midportion of the posterior surface of the symphysis. The operator now places his left hand in the vagina with the index and middle fingers placed on each side of the urethra in the spaces previously developed. Simultaneously, the thumb and palm make traction on the Foley catheter to maintain the bag at the urethrovesical junction. The fingers of the left hand can readily palpate the posterior surface of the symphysis and feel the tip of the instrument. The cannula is slowly advanced down the posterior surface of the symphysis without picking up any periosteum, thereby reducing risk of osteitis pubis. Under direct palpation, the cannula is brought out lateral to the urethra near its mid point on the right and can then be seen free in the vagina. With the left hand as previously described, the index finger can feel the point of angulation of the cannula, through which the stylet will be introduced. The instrument position is adjusted so that this point of angulation is at the urethrovesical junction on the same (right) side. The stylet is gently pushed through until its end is also free in the vagina. The ends of a half length of No. 1 chromic catgut are then threaded into the limbs of the ligature carrier. The instrument carrying the suture is withdrawn through the abdominal incision. Thus, a
Fig. 3. Schematic drawing showing placement of main suture through tissue on each side of vesical neck and bridging rectus sheath. P, pubic bone; R, rectus sheath; B, bladder; S, ends of suture. Note that suture does not cross under urethra.
sling is formed along the right side of the vesical neck out through the right rectus sheath. The end of suture is removed from the stylet portion only. The cannula with one end of suture still in it is then reinserted through the same skin incision, pushed through the left rectus fascia, continued down the posterior surface of the symphysis, and out lateral to the midportion of the urethra on the left side. The stylet portion is similarly pushed through to the left of the vesical neck. The end of suture is removed from the cannula and inserted into the stylet. The instrument is then withdrawn through the abdominal incision. A sling is now formed on each side of the vesical neck (Fig. 3). Elevating the suture markedly lifts the vesical neck behind the symphysis. The suture is tied across the rectus tendon. In tying down, the vesical neck must not be lifted to its maximum position as this may over-correct the problem, and cause considerable postoperative discomfort. The suture is cut above the knot and permitted to fall through the stab incision. An Allis clamp across the abdominal incision provides hemostasis and a Band-Aid is later applied.
1020
Harer
and
Table I. Duration Months
2 to 3 4 to 6 7 to 9 10 to 12 13 to 15 16 to 18 19to21 22 to 24 27 29 36
Gunther
of follow-up Cases
5 3 4 4 2 1 2 6 1 1 1
Fairly persistent bleeding may be seen from the vaginal dissection. Because the entire operation usually takes only 10 to 15 minutes, it is not necessary to ligate these vessels as the next sutures readily control bleeding. About three interrupted sutures of No. 0 chromic catgut approximate the paraurethral tissue across the midline. Plicating the urethra, as in the Kelly urethroplasty, may not be feasible. These sutures primarily close dead space and promote hemostasis. Usually it is more convenient to place these sutures prior to tying down the suprapubic suture which suspends the vesical neck. The vaginal mucosa is then closed with interrupted or continuous sutures of No. 2-O chromic catgut. Redundant vaginal mucosa may be excised, but since it contributes nothing to the ultimate support, such excision is done primarily for its esthetic value. No vaginal packing was used in this series. It is probably best to leave the catheter for 4 or 5 days as many patients experienced difficulty voiding due to swelling in the early postoperative days. Most patients establish adequate bladder function with residual urine under 60 ml. within 1 to 3 days after removal of the catheter. All patients receive sulfisoxazole prophylactically. Suprapubic swelling and tenderness respond well to local heat and mild anodynes. Because the marked change in anatomic relationships causes resistance to urinary leakage in response to simple stress, many patients have had to learn to void by bearing
down while perineum.
simultaneously
relaxing
the
Results This procedure has been used with only slight variations in 30 patients with severe longstanding stress incontinence. They have been followed postoperatively from 2 to 36 months (Table I). Associated hysterectomy and/or vaginal plastic procedures were done in 17 instances for indications other than stress incontinence. Five of those treated solely by this technique had one or more prior operations which failed. Excellent results, both anatomically and functionally, were obtained in 25 patients. Anatomic correction was confirmed by cystourethrogram in most cases. Two patients showed definite functional improvement, but cystourethrograms demonstrated that vesicourethral relationships had not been fully corrected into the normal range. Both had associated vaginal hysterectomy with Kennedy type anterior culporrhaphy. The 2 early failures were treated only by the simple urethrovesical suspension a n d urethroplasty. Postoperative cystourethrogram in the first showed failure to achieve vesical neck suspension, probably because the sutures were placed too low along the urethra. The other failure was in the only patient in the series who had a wound infection, and this necessitated removal of the suprapubic sutures. Subsequent reoperation with this procedure was successful. A third patient has had recurrence of symptoms 2 years postoperatively associated with chronic bronchitis. Urgency incontinence was experienced by about one third of the patients for 1 to 3 weeks postoperatively. This responded well to therapy with methantheline bromide or Donnatal and gradually subsided. Only one patient has had recurrent difficulty with urgency. Several patients described an illdefined feeling of diminished bladder sensation for 1 to 3 weeks postoperatively which gradually faded. Only one patient has subsequently conceived. Twenty-one months postoperatively, she was delivered of a 7
Volume Number
91 I
Urethrovesical
pound, 14 ounce baby vaginally without any adverse effect on bladder control during or after her pregnancy. It has now been 36 months since her operation. In conclusion, we feel this is a simple, rapid technique for treating cases of severe stress incontinence, which would otherwise require the more extensive Marshall-Marchetti procedure or sling type operation. Summary
1. A technique is presented for combined urethrovesical suspension and urethroplasty which is so simple a single operator can carry it out in less than 15 minutes. 2. This procedure produces anatomic
REFERENCES
1.
Green, T. H., 83: 632, 1962.
AM.
J.
OBST.
& GYNEC:.
and urethroplasty
1021
changes equivalent to the Marshall-Mar‘chetti-Krantz operation, and is, therefore, applicable in cases of stress incontinence due to loss of support of the vesical neck. 3. Excellent results functionally and anatomically were obtained in 26 of 30 cases (including one failure later reoperated successfully) . Two patients showed functional improvement with only partial anatomic correction. One patient was an immediate failure both anatomically and functionally and one has had recurrence of symptoms beginning 24 months postoperatively. The authors wish to acknowledge and encouragement of Dr. Armand in this work.
2. Jr.:
suspension
the advice J. Pereyra
Marshall, V. F., Marchetti, A. A., and Krantz, K. E.: Surg. Gynec. & Obst. 88: 509, 1949. 3. Pereyra, A. J.: West. J. Surg. 67: 223, 1959.
W.
results
from
BENSON
ROKALD Norton
a minor
HARER,
procedure
JR.,
M.D.**
E. GUNTHER, Air
Force
Base,
M.D.***
California
T H E U R E T H R 0 V E s I C A L suspension operation by Marshall, Marchetti and Krantz? marked a milestone in the long journey toward control of urinary stress incontinence in the female. A greatly simplified operation is herein presented combining suprapubic \:esical neck suspension with vaginal urethroplasty. A single operator can readily perform it in less than 15 minutes. The anatomic and functional results appear identical to those of the more extensive procedures currently in vogue. Consistently excellent results can only follow from careful evaluation leading to the discovery of specific anatomic or functional defects followed in turn by specific oper&ive or medical therapy. Proper study
From the Department Gynecology,, 2,796th Force Hospital.
of Obstetrics United
States
includes history, physical examination, and laboratory tests as for any operation. Cystometrogram is useful to rule out suspected neurogenic problems. In addition, cystoscopy and cystourethrogram are essential. We feel the key factor in selecting patients who will be benefited by this operation is cystourethrographic demonstration of loss of support of the vesical neck, resulting in an angle of the urethra to the long axis of the body greater than 45 degrees. This follows the criteria established by Green.l The operation presented specifically elevates the vesical neck and corrects funneling of the posterior urethra, thereby correcting urethral inclination and restoring the posterior urethrovesical angle to the normal range. It may be that the procedure also gains efficacy through lengthening t h e urethra and elevating the vesical neck out of the most dependent position. All these changes are noted in comparing pre- and postoperative cystourethrograms (Figs. 1 and 2). The basic principle is to place strong sutures through the tissue on each side of the vesical neck and suspend them across a firm bridge of rectus fascia. This elevates the urethra and fixes it in a normal position. Plication of the posterior urethra and/or paraurethral fascia further narrows the posterior urethrovesical angle and corrects fun-
and Air
‘The contents of this article are the personal views of the authors and do not constitute a statement of oficial Air Force policy or Air Force indorsement of any commercial product. **Current Obstetric7 Colorado Colorado. ***Current Obstetrics Llniversity California.
address: Department of and Gynecology, University of Medical Center, Denver 20,
address: Department of and Gynecology, Stanford Medical
School,
Palo
Alto,
1017
1018
Harer
and
Fig. 1. (A). grams
Preoperative and demonstrating elevation
Fig. 2. (A). cystourethrograms
:11~1il I.
Gunther
Preoperative and demonstrating
\m.
(B), postoperative of vesical neck.
standing
lateral
stress
J, Olrc
1965 B (:mrc.
rystourethro-
(B), postoperative anteroposterior elevation of vesical neck.
neling. The ingenious ligature instrument+ reported by Pereyra.” in 1959, is used. Pereyra reported a technique in which wire, slings were placed through the vaginal mucosa on each side of the vesical neck and anchored across the rectus muscle. Blind paraurethral cautery was then used to induce fibrosis to maintain the urethra in
this position as the wire ,eraduallv cut through. We have modified his technique by va+nal dissection to mobilize the urethra and \mical neck. The suspensor\; sutures arc placed in a similar fashion and cornpletely buried. The paraurethral space is further obliterated or Kelly urethral plication done. Thus. the reaction induced by sutures and dissection is substituted for blind cautcrktion to induct> fibrosis, and nlore precise anatomic position.
Volume Number
91 7
Urethrovesical
suspension
and urethroplasty
1019
Technique With the patient in dorsolithotomy position, the vagina, perineum, and suprapubic area are prepared and draped. If vaginal hysterectomy is planned, it should be done first. A Foley catheter is inserted into the bladder. The vaginal mucosa is then incised longitudinally from urethral meatus to beyond the vesical neck. The dissection should be somewhat wider than usual for a urethroplasty, and a space is developed on each side of the urethra which readily admits the operator’s finger tip. A vs inch midline stab incision is then made in the skin, 1 inch above the symphysis pubis. The cannula of the Pereyra instrument is inserted through this incision and through the right side of the rectus fascia, directed toward the midportion of the posterior surface of the symphysis. The operator now places his left hand in the vagina with the index and middle fingers placed on each side of the urethra in the spaces previously developed. Simultaneously, the thumb and palm make traction on the Foley catheter to maintain the bag at the urethrovesical junction. The fingers of the left hand can readily palpate the posterior surface of the symphysis and feel the tip of the instrument. The cannula is slowly advanced down the posterior surface of the symphysis without picking up any periosteum, thereby reducing risk of osteitis pubis. Under direct palpation, the cannula is brought out lateral to the urethra near its mid point on the right and can then be seen free in the vagina. With the left hand as previously described, the index finger can feel the point of angulation of the cannula, through which the stylet will be introduced. The instrument position is adjusted so that this point of angulation is at the urethrovesical junction on the same (right) side. The stylet is gently pushed through until its end is also free in the vagina. The ends of a half length of No. 1 chromic catgut are then threaded into the limbs of the ligature carrier. The instrument carrying the suture is withdrawn through the abdominal incision. Thus, a
Fig. 3. Schematic drawing showing placement of main suture through tissue on each side of vesical neck and bridging rectus sheath. P, pubic bone; R, rectus sheath; B, bladder; S, ends of suture. Note that suture does not cross under urethra.
sling is formed along the right side of the vesical neck out through the right rectus sheath. The end of suture is removed from the stylet portion only. The cannula with one end of suture still in it is then reinserted through the same skin incision, pushed through the left rectus fascia, continued down the posterior surface of the symphysis, and out lateral to the midportion of the urethra on the left side. The stylet portion is similarly pushed through to the left of the vesical neck. The end of suture is removed from the cannula and inserted into the stylet. The instrument is then withdrawn through the abdominal incision. A sling is now formed on each side of the vesical neck (Fig. 3). Elevating the suture markedly lifts the vesical neck behind the symphysis. The suture is tied across the rectus tendon. In tying down, the vesical neck must not be lifted to its maximum position as this may over-correct the problem, and cause considerable postoperative discomfort. The suture is cut above the knot and permitted to fall through the stab incision. An Allis clamp across the abdominal incision provides hemostasis and a Band-Aid is later applied.
1020
Harer
and
Table I. Duration Months
2 to 3 4 to 6 7 to 9 10 to 12 13 to 15 16 to 18 19to21 22 to 24 27 29 36
Gunther
of follow-up Cases
5 3 4 4 2 1 2 6 1 1 1
Fairly persistent bleeding may be seen from the vaginal dissection. Because the entire operation usually takes only 10 to 15 minutes, it is not necessary to ligate these vessels as the next sutures readily control bleeding. About three interrupted sutures of No. 0 chromic catgut approximate the paraurethral tissue across the midline. Plicating the urethra, as in the Kelly urethroplasty, may not be feasible. These sutures primarily close dead space and promote hemostasis. Usually it is more convenient to place these sutures prior to tying down the suprapubic suture which suspends the vesical neck. The vaginal mucosa is then closed with interrupted or continuous sutures of No. 2-O chromic catgut. Redundant vaginal mucosa may be excised, but since it contributes nothing to the ultimate support, such excision is done primarily for its esthetic value. No vaginal packing was used in this series. It is probably best to leave the catheter for 4 or 5 days as many patients experienced difficulty voiding due to swelling in the early postoperative days. Most patients establish adequate bladder function with residual urine under 60 ml. within 1 to 3 days after removal of the catheter. All patients receive sulfisoxazole prophylactically. Suprapubic swelling and tenderness respond well to local heat and mild anodynes. Because the marked change in anatomic relationships causes resistance to urinary leakage in response to simple stress, many patients have had to learn to void by bearing
down while perineum.
simultaneously
relaxing
the
Results This procedure has been used with only slight variations in 30 patients with severe longstanding stress incontinence. They have been followed postoperatively from 2 to 36 months (Table I). Associated hysterectomy and/or vaginal plastic procedures were done in 17 instances for indications other than stress incontinence. Five of those treated solely by this technique had one or more prior operations which failed. Excellent results, both anatomically and functionally, were obtained in 25 patients. Anatomic correction was confirmed by cystourethrogram in most cases. Two patients showed definite functional improvement, but cystourethrograms demonstrated that vesicourethral relationships had not been fully corrected into the normal range. Both had associated vaginal hysterectomy with Kennedy type anterior culporrhaphy. The 2 early failures were treated only by the simple urethrovesical suspension a n d urethroplasty. Postoperative cystourethrogram in the first showed failure to achieve vesical neck suspension, probably because the sutures were placed too low along the urethra. The other failure was in the only patient in the series who had a wound infection, and this necessitated removal of the suprapubic sutures. Subsequent reoperation with this procedure was successful. A third patient has had recurrence of symptoms 2 years postoperatively associated with chronic bronchitis. Urgency incontinence was experienced by about one third of the patients for 1 to 3 weeks postoperatively. This responded well to therapy with methantheline bromide or Donnatal and gradually subsided. Only one patient has had recurrent difficulty with urgency. Several patients described an illdefined feeling of diminished bladder sensation for 1 to 3 weeks postoperatively which gradually faded. Only one patient has subsequently conceived. Twenty-one months postoperatively, she was delivered of a 7
Volume Number
91 I
Urethrovesical
pound, 14 ounce baby vaginally without any adverse effect on bladder control during or after her pregnancy. It has now been 36 months since her operation. In conclusion, we feel this is a simple, rapid technique for treating cases of severe stress incontinence, which would otherwise require the more extensive Marshall-Marchetti procedure or sling type operation. Summary
1. A technique is presented for combined urethrovesical suspension and urethroplasty which is so simple a single operator can carry it out in less than 15 minutes. 2. This procedure produces anatomic
REFERENCES
1.
Green, T. H., 83: 632, 1962.
AM.
J.
OBST.
& GYNEC:.
and urethroplasty
1021
changes equivalent to the Marshall-Mar‘chetti-Krantz operation, and is, therefore, applicable in cases of stress incontinence due to loss of support of the vesical neck. 3. Excellent results functionally and anatomically were obtained in 26 of 30 cases (including one failure later reoperated successfully) . Two patients showed functional improvement with only partial anatomic correction. One patient was an immediate failure both anatomically and functionally and one has had recurrence of symptoms beginning 24 months postoperatively. The authors wish to acknowledge and encouragement of Dr. Armand in this work.
2. Jr.:
suspension
the advice J. Pereyra
Marshall, V. F., Marchetti, A. A., and Krantz, K. E.: Surg. Gynec. & Obst. 88: 509, 1949. 3. Pereyra, A. J.: West. J. Surg. 67: 223, 1959.