- Email: [email protected]
Stress incontinence
Stress incontinence Retropubic bladder
wedge
resection
neck for failed
THOMAS
L.
BALL,
ROBERT
C.
KNAPP,
BERNARD LEO
D.
New York,
and plication
operations
New
York,
for stress urinary
M.D. M.D. M.D.
and Los Angeles,
California
T H E Marshall-Marchetti operation1 and the many variations of the fascial sling procedures, frequently used as a last resort operation for recurrent urinary stress incontinence, also have a disturbing number of failures. Multiple operations frequently leave the patient not only incontinent on stress but also with a secondarily contracted bladder due to scarring, fixation, and limitation of motion in the space of Retzius. This “frozen bladder syndrome” has become increasingly more common since gynecologists have resorted to more complex procedures and the abdominal approach in operations for stress incontinence. Pathogenesis of the frozen bladder syndrome Almost without exception, in the patients seen in a urologic or gynecologic practice, this condition is the result of a MarshallMarchetti periosteal suspension. It can occur, however, after one of the many sling operations (Aldridge, Studdiford, Millin) or any operative procedure within the space of Retzius. The bilateral, fragile plexuses of San-
From the Departments of Obstetrics and Gynecology, The New York HospitalCornell Medical Center; UCLA Center for the Health Sciences; and Queen of Angels Hospital, Los Angeles. Presented Chapter Surgeons,
incontinence
M.D.
NATHANSON, LAGASSE,
of the
before the Southern California of the American College of Palm Springs, Jan. 23, 1965.
torini are fractured in all of these procedures thus setting the stage for drainage if the operative field cannot be made completely dry. The placing of drains between bone and a hollow viscus, or, without drainage, the development of a retropubic hematoma or abscess will most certainly create a mass of solid scar tissue encompassing the supralevator portion of the anterior and anterolateral walls of the urethra, the bladder neck, and the anterior anterolateral aspects as well as the dome of the bladder. Trauma to the periosteum and interpubic fibrocartilage causes infection that may go on to an osteitis pubis.2 Since the bladder and urethra are found adherent to the pubic bones and symphyseal fibrocartilage, it is probable that some degree of osteitis pubis existed. We do not think a true osteitis pubis with x-rays showing an irregular and indistinct symphyseal margin and demineralization is always a predecessor of the frozen bladder. A periosteitis extending to involve the obturator fascia and structures overlying the levator sling may result in sufficient scarring to significantly limit the mobility of the bladder. A history of adductor spasm manifested by a waddling gait and pain over the symphysis for months after operation suggest that an obturator neuritis was created by the extension of the inflammatory process to these nerves. The obturatory nerve, a branch of the lumbar plexus, arises from the second,
998
Ball et al.
third, and fourth lumbar nerves: it leaves the pelvis through the upper part of the obturator foramen in company with the obturator vessels. It then divides into an anterior and a posterior branch. Its course in the pelvis is directly in the path of any inflammatory process in the region of the posterior symphyseal fibrocartilage and adjacent rami of the pubic bones. The severity of the trauma to bone, severity of the infection, and the number of drains and length of time they are in place seem to determine the extent of an osteitis pubis and an obturator neuritis with symptoms corresponding to the distribution of this nerve. The obturator-y nerve can first be identified on the medial side of the psoas muscle near the pelvic brim. It lies in a groove between the psoas muscle and the vertebral column. It then courses along the lateral pelvic wall, lateral to the hypogastric vessels, before entering the obturator foramen. It is easy to identify, since it lies above the obturator artery and vein and stands out as soon as the area is dissected out. The nerve is thick and firm so that in a radical dissection of the pelvis the obturator node and adjacent lymphatic and areolar tissue may literally be scooped out without disturbing the function of this nerve. Nevertheless, when exposed to a creeping inflammatory process, it gives rise to serious and crippling symptoms. The accessory obturator nerve (found in 30 per cent of patients) further complicates the range of symptoms a patient with osteitis pubis may have. Instead of descending into the pelvis, it follows the medial border of the psoas muscle to leave the abdomen between the pubic bone and pectineus muscle. It passes over the horizontal ramus of the pubis beneath the pectineus muscle where it divides into the following branches: an articular branch to the hip joint; a muscular branch to the pectineus, and a communicating branch to the anterior branch of the obturator nerve. Through the medium of the obturator and accessory obturator nerves, the patient’s gait may be affected as well as causing re-
ferred pain not only to the hip joint but also to the knee. This is usually bilateral. ‘T‘he adductor muscles that may be affected include the pectineus, gracilis, adductor longus, adductor brevis, and adductor magnus. An articular branch to the knee joint pierces the adductor magnus muscle and descends on the popliteal artery to pierce the posterior ligament of the joint. Thus, the referral of pain from an obturator neuritis within the pelvis can produce crippling pain in one or both extremities. A method of revision of these operative failures has been found successful with some limitations depending on the degree of secondary contraction of the bladder and adjacent vaginal wall. The operation involves a complete vaginal urethrolysis followed by a revision of the previous surgery from the space of Retzius. A wedge resection of the scarred nonfunctional anterior bIadder wall and proximal urethra is performed to permit approximation of functional bladder musculature. An anterior plication of the bladder neck is then done. Technique
of the operation
The vaginal phase of the operation consists of an anterior colporrhaphy and plication of the bladder neck. This is familiar to all who do vaginal surgery. However, the surgeon will encounter more than the usual amount of scar tissue and must extend his vaginal urethrolysis beyond that done in a simple repair. The urethra and bladder neck should be freed of all distorting scar tissue before the bladder neck is plicated. Seldom should the vaginal wall be trimmed, since it is already in short supply from the previous surgery and sufficient tissue is necessary to arch underneath the inferior border of the symphysis. If insufficient tissue is available, it would tend to again straighten the posterior urethrovesical angle and create the anatomical relationship between the urethra, bladder neck, and trigone that is unfavorable to bladder control. Sutures at the bladder neck should be placed to create an acute posterior urethrovesical angle. Seldom is this overdone among these patients with a
Volume Number
94 7
great deal of scar tissue in the area and loss of pliability of the bladder wall. The abdominal phase of the operation will be a revelation to any gynecologist or urologist who has not tried to revise a failed Marshall-Marchetti operation. When this operation fails, the bladder does not become detached from its per&teal suspension to the symphysis. Rather, the anterior bladder wall remains firmly and tenaceously attached to all the surrounding structures; while it thins out and becomes attenuated and functionless. Taking this apart is quite a feat. Fig. 1, A shows the approach to the space of Retzius with the dissection completed down to the rectus muscles. The dome of the bladder will be adherent. Starting just under the rectus muscle on the right, the operator should attempt to establish a normal line of cleavage that does not have extensive scar tissue. Then, the anterolateral walls of the bladder are freed by sharp and blunt dissection until the distorted anterolateral walls are mobilized. In Fig. 1, B is shown the dissection of the anterior bladder wall, bladder neck, and proximal urethra from the suture sites to the posterior interpubic fibrocartilage and adjacent posterior aspect of the symphysis. This is difficult and should it be so adherent that it would be macerated in the dissection, a cystotomy should be done at this time so this area can be palpated from within the bladder to help in the dissection. A cystotomy will be done later in any event. After some semblance of the normal anatomical landmarks are established, a cystotomy is done by incising the bladder near its dome in order to be above the scar tissue created by the previous surgery. The bladder has remarkable ability to recover from almost any insult so this is an excellent way to survey the amount of nonfunctional ‘: bladder wall that must be removed (Fig. 2, A). In Fig. 2, B the internal urethral meatus is noted and the extent of the scar tissue about the bladder neck and proximal urethra ascertained. A wedge resection of the bladder, bladder neck, and proximal urethra is then done as illustrated SO that
Stress incontinence
999
all nonfunctional scar tissue is removed. This will permit approximation of normal functional contractile bladder and urethral musculature during the closure. The proximal urethra is frequently found to be scarred throughout its intra-abdominal length. It must be dissected free to the inferior border of the symphysis where it passes through the triangular ligament to become extra-abdominal. The scarred anterior urethral wall is widely resected and approximated with interrupted sutures of No. 2-O chromic catgut. Excessive narrowing is not a problem since, apparently, healthy urethral musculature adjusts itself rather promptly to perform its function and prolonged urinary retention as a result of this resection has not been seen. The ureters are then catheterized with a No. 6 French ureteral catheter to a point above the pelvic brim to ensure their patency and to be certain they were not injured during the dissection. Should bloody urine be obtained, the ureter should be explored to determine the nature of the damage. If the bleeding seems to be caused by external trauma and not felt to be serious, the surgeon may simply elect to leave a splinting catheter in place anchored to a Foley catheter seated in the bladder neck. I have never encountered ureteral injury during this operation but one should always be alert to this possibility (Fig. 3, A) . Fig. 3, B shows the biadder being closed by interrupted No. 2-O chromic catgut sutures. Additional plication sutures are placed in the bladder neck as shown in Fig. 4, A. One suture is placed directly at the bladder neck, one about 2 cm. distal to this in the proximal urethra and one 2 cm. above the bladder neck in the anterior wall. The sutures should go fairly deep in the musculature. When tied, they create an anterior urethrovesical angle as well as contracting the bladder neck and increasing the effective length of the urethra. Two or more suspension sutures to the rectus tendons are then placed on the anterolateral walls of the bladder as shown in Fig. 4, B. These sutures further accentuate
1000
Ball
et al.
Figs. 1-4. V. Mosby
From Ball, Company.
T.
L.:
Gynerologic
Surgery
and
Urology.
ed. 2, St. Louis,
1963,
The
C
Fig. 1. A, The difficulty in re-entering the space of Retzius through dense scar tissue must be done by sharp dissection. The dome of the bladder will be difficult to identify. B, The scarred anterolateral walls of the bladder and proximal urethra must be literally chipped from the posterior border of the symphysis by knife dissection,
Volume Number
94 7
Stress incontinence
Fig. 2. A, The scarred nonfunctional areas of the proximal urethra and bladder are now free. A cystotomy is performed to further ascertain the extent of the scar tissue. B, A wedge resection of all the nonfunctional scar tissue of the bladder and proximal urethra is done.
1001
1002
Ball
et al.
Fig. 3. A, While point above the or at the previous catgut.
the bladder is open a small ureteral catheter is passed up each ureter to a pelvic brim to ensure that there has been no damage during the dissection surgery. B, The bladder is closed with interrupted sutures of No. 2-O chromic
Volume Number
94 7
Stress incontinence
1003
A
B
Fig. 4. A, Additional sutures are placed at the bladder neck and proximal urethra to plicate and further narrow the vesicourethra! junction. II, Suspension sutures are placed laterally above the plication sutures and passed through the tendons of the rectus muscles. When tied these sutures create an anterior urethrovesical angle.
1004
Ball
et al.
the anterior urethrovesical angle but 1 doubt that they add much to the function of the bladder neck. Drainage of the bladder may be by cystostomy as illustrated or by urethral catheter. Done both ways about an equal number of times, there seemed to be little preference. The catheter is left 8 days. When a cystostomy tube is removed, a urethral catheter should be inserted for a few days while the tract closes. Urinary antiseptics are routinely administered. Results
and
comments
These patients represent the ultimate in operative failures in the surgery of urinary stress incontinence. All have had a MarshallMarchetti operation preceded by a variety of vaginal plastic procedures. Table I shows the total previous operations among the fourteen patients reported in this study. In addition to the invasion of the space of RetGus, they had a total of 14 anterior and posterior repairs. Two had vaginal hysterectomies and two had Manchester type repairs. One had incontinence after reconstruction of an artificial vagina and was worse after a periosteal suspension of the urethra. Only one had a transurethral resection of the bladder neck after which the usual female patient with retention becomes incontinent. In summary, 14 patients had a total of thirtyfour operative procedures prior to a wedge resection of the bladder. Some patients may have had two procedures and some have had four. These previous operations are charted only to emphasize that all or most of the standard procedures used to correct this condition were tried.
Table I. Total previous fourteen patients Marshall-Marchetti
operations
among
operation
Anterior and posterior Vaginal hysterectomy Manchester repair Artificial vagina Transurethral resection Total
operations
14
repair
of bladder
on all patients
the
neck
14 2 2 1 1 34
Tablr 11 shows the results ol’ this olxration. When one is dealing with lq~elessl~ incontinent individuals. we feel the clinician is entitled to list his operative results as improved (vague indeed) when the patient is able to circulate among her friends and daily activities without the use of a protective device. It is difficult to gradate the de,gree of incontinence with any accuracy. Using this completely arbitrary criterion, there were ten patients completely dry under all conditions of stress. Two were improved and two were complete failures. Since many of these patients were confronted with urinary diversion as the solution to their problem, this operation can salvage a substantial number of patients who can retain the normal channels. Table III shows the length of follow-up of these 14 patients. The first patient was operated upon 7 years ago and is still incontinent. The last patient is continent 2 months after surgery. When operations for urinary incontinence fail, it is usually evident at the second postoperative visit and this is within 2 months. One might ask why it has taken more than 6 years to study 14 patients. The answer is simply that most Table
II. Results Cured Improved (no protective Complete failure Total
Table
10 device
needed)
2 2
cases
14
III
Case No. 1 L’ 3 4 5 6 7 li 10 11 12 13 14
)
Length 6 6 5 5 4 3 2
Years, Years, Years, Years, Years, Years, Years,
12 1 1 1 10 2
Year, Years, Year, Year, Year Months Months
of follow-up 11 5 9 6 1 4 9
months months months months month months months
69 months 5 months 1 month
Volume Number
94 7
patients with repeated operative failures give up as well as their physicians and resign themselves to a life of various devices to avoid offending their friends and family.
Stress
incontinence
1005
cedure, can be reconstructed with specific emphasis on the anatomical relationship of the bladder neck to the urethra to restore the anatomical figuration compatible with urinary continence.
Conclusions Repeated failures in the surgery of urinary stress incontinence should be further studied to determine whether surgery short of urinary diversion may restore continence. The human bladder, with its inestimable capacity to recover from any surgical pro-
REFERENCES
1. Marshall, V. F., Marchetti, A. A., and Krantz, K. E.: Surg. Gynec. & Obst. 88: 509, 1949. 2. O’Leary, J. A. : Obst. & Gynec. 24: 73, 1964. 947 West 8th Street Los Angeles 17, California
wedge
resection
neck for failed
THOMAS
L.
BALL,
ROBERT
C.
KNAPP,
BERNARD LEO
D.
New York,
and plication
operations
New
York,
for stress urinary
M.D. M.D. M.D.
and Los Angeles,
California
T H E Marshall-Marchetti operation1 and the many variations of the fascial sling procedures, frequently used as a last resort operation for recurrent urinary stress incontinence, also have a disturbing number of failures. Multiple operations frequently leave the patient not only incontinent on stress but also with a secondarily contracted bladder due to scarring, fixation, and limitation of motion in the space of Retzius. This “frozen bladder syndrome” has become increasingly more common since gynecologists have resorted to more complex procedures and the abdominal approach in operations for stress incontinence. Pathogenesis of the frozen bladder syndrome Almost without exception, in the patients seen in a urologic or gynecologic practice, this condition is the result of a MarshallMarchetti periosteal suspension. It can occur, however, after one of the many sling operations (Aldridge, Studdiford, Millin) or any operative procedure within the space of Retzius. The bilateral, fragile plexuses of San-
From the Departments of Obstetrics and Gynecology, The New York HospitalCornell Medical Center; UCLA Center for the Health Sciences; and Queen of Angels Hospital, Los Angeles. Presented Chapter Surgeons,
incontinence
M.D.
NATHANSON, LAGASSE,
of the
before the Southern California of the American College of Palm Springs, Jan. 23, 1965.
torini are fractured in all of these procedures thus setting the stage for drainage if the operative field cannot be made completely dry. The placing of drains between bone and a hollow viscus, or, without drainage, the development of a retropubic hematoma or abscess will most certainly create a mass of solid scar tissue encompassing the supralevator portion of the anterior and anterolateral walls of the urethra, the bladder neck, and the anterior anterolateral aspects as well as the dome of the bladder. Trauma to the periosteum and interpubic fibrocartilage causes infection that may go on to an osteitis pubis.2 Since the bladder and urethra are found adherent to the pubic bones and symphyseal fibrocartilage, it is probable that some degree of osteitis pubis existed. We do not think a true osteitis pubis with x-rays showing an irregular and indistinct symphyseal margin and demineralization is always a predecessor of the frozen bladder. A periosteitis extending to involve the obturator fascia and structures overlying the levator sling may result in sufficient scarring to significantly limit the mobility of the bladder. A history of adductor spasm manifested by a waddling gait and pain over the symphysis for months after operation suggest that an obturator neuritis was created by the extension of the inflammatory process to these nerves. The obturatory nerve, a branch of the lumbar plexus, arises from the second,
998
Ball et al.
third, and fourth lumbar nerves: it leaves the pelvis through the upper part of the obturator foramen in company with the obturator vessels. It then divides into an anterior and a posterior branch. Its course in the pelvis is directly in the path of any inflammatory process in the region of the posterior symphyseal fibrocartilage and adjacent rami of the pubic bones. The severity of the trauma to bone, severity of the infection, and the number of drains and length of time they are in place seem to determine the extent of an osteitis pubis and an obturator neuritis with symptoms corresponding to the distribution of this nerve. The obturator-y nerve can first be identified on the medial side of the psoas muscle near the pelvic brim. It lies in a groove between the psoas muscle and the vertebral column. It then courses along the lateral pelvic wall, lateral to the hypogastric vessels, before entering the obturator foramen. It is easy to identify, since it lies above the obturator artery and vein and stands out as soon as the area is dissected out. The nerve is thick and firm so that in a radical dissection of the pelvis the obturator node and adjacent lymphatic and areolar tissue may literally be scooped out without disturbing the function of this nerve. Nevertheless, when exposed to a creeping inflammatory process, it gives rise to serious and crippling symptoms. The accessory obturator nerve (found in 30 per cent of patients) further complicates the range of symptoms a patient with osteitis pubis may have. Instead of descending into the pelvis, it follows the medial border of the psoas muscle to leave the abdomen between the pubic bone and pectineus muscle. It passes over the horizontal ramus of the pubis beneath the pectineus muscle where it divides into the following branches: an articular branch to the hip joint; a muscular branch to the pectineus, and a communicating branch to the anterior branch of the obturator nerve. Through the medium of the obturator and accessory obturator nerves, the patient’s gait may be affected as well as causing re-
ferred pain not only to the hip joint but also to the knee. This is usually bilateral. ‘T‘he adductor muscles that may be affected include the pectineus, gracilis, adductor longus, adductor brevis, and adductor magnus. An articular branch to the knee joint pierces the adductor magnus muscle and descends on the popliteal artery to pierce the posterior ligament of the joint. Thus, the referral of pain from an obturator neuritis within the pelvis can produce crippling pain in one or both extremities. A method of revision of these operative failures has been found successful with some limitations depending on the degree of secondary contraction of the bladder and adjacent vaginal wall. The operation involves a complete vaginal urethrolysis followed by a revision of the previous surgery from the space of Retzius. A wedge resection of the scarred nonfunctional anterior bIadder wall and proximal urethra is performed to permit approximation of functional bladder musculature. An anterior plication of the bladder neck is then done. Technique
of the operation
The vaginal phase of the operation consists of an anterior colporrhaphy and plication of the bladder neck. This is familiar to all who do vaginal surgery. However, the surgeon will encounter more than the usual amount of scar tissue and must extend his vaginal urethrolysis beyond that done in a simple repair. The urethra and bladder neck should be freed of all distorting scar tissue before the bladder neck is plicated. Seldom should the vaginal wall be trimmed, since it is already in short supply from the previous surgery and sufficient tissue is necessary to arch underneath the inferior border of the symphysis. If insufficient tissue is available, it would tend to again straighten the posterior urethrovesical angle and create the anatomical relationship between the urethra, bladder neck, and trigone that is unfavorable to bladder control. Sutures at the bladder neck should be placed to create an acute posterior urethrovesical angle. Seldom is this overdone among these patients with a
Volume Number
94 7
great deal of scar tissue in the area and loss of pliability of the bladder wall. The abdominal phase of the operation will be a revelation to any gynecologist or urologist who has not tried to revise a failed Marshall-Marchetti operation. When this operation fails, the bladder does not become detached from its per&teal suspension to the symphysis. Rather, the anterior bladder wall remains firmly and tenaceously attached to all the surrounding structures; while it thins out and becomes attenuated and functionless. Taking this apart is quite a feat. Fig. 1, A shows the approach to the space of Retzius with the dissection completed down to the rectus muscles. The dome of the bladder will be adherent. Starting just under the rectus muscle on the right, the operator should attempt to establish a normal line of cleavage that does not have extensive scar tissue. Then, the anterolateral walls of the bladder are freed by sharp and blunt dissection until the distorted anterolateral walls are mobilized. In Fig. 1, B is shown the dissection of the anterior bladder wall, bladder neck, and proximal urethra from the suture sites to the posterior interpubic fibrocartilage and adjacent posterior aspect of the symphysis. This is difficult and should it be so adherent that it would be macerated in the dissection, a cystotomy should be done at this time so this area can be palpated from within the bladder to help in the dissection. A cystotomy will be done later in any event. After some semblance of the normal anatomical landmarks are established, a cystotomy is done by incising the bladder near its dome in order to be above the scar tissue created by the previous surgery. The bladder has remarkable ability to recover from almost any insult so this is an excellent way to survey the amount of nonfunctional ‘: bladder wall that must be removed (Fig. 2, A). In Fig. 2, B the internal urethral meatus is noted and the extent of the scar tissue about the bladder neck and proximal urethra ascertained. A wedge resection of the bladder, bladder neck, and proximal urethra is then done as illustrated SO that
Stress incontinence
999
all nonfunctional scar tissue is removed. This will permit approximation of normal functional contractile bladder and urethral musculature during the closure. The proximal urethra is frequently found to be scarred throughout its intra-abdominal length. It must be dissected free to the inferior border of the symphysis where it passes through the triangular ligament to become extra-abdominal. The scarred anterior urethral wall is widely resected and approximated with interrupted sutures of No. 2-O chromic catgut. Excessive narrowing is not a problem since, apparently, healthy urethral musculature adjusts itself rather promptly to perform its function and prolonged urinary retention as a result of this resection has not been seen. The ureters are then catheterized with a No. 6 French ureteral catheter to a point above the pelvic brim to ensure their patency and to be certain they were not injured during the dissection. Should bloody urine be obtained, the ureter should be explored to determine the nature of the damage. If the bleeding seems to be caused by external trauma and not felt to be serious, the surgeon may simply elect to leave a splinting catheter in place anchored to a Foley catheter seated in the bladder neck. I have never encountered ureteral injury during this operation but one should always be alert to this possibility (Fig. 3, A) . Fig. 3, B shows the biadder being closed by interrupted No. 2-O chromic catgut sutures. Additional plication sutures are placed in the bladder neck as shown in Fig. 4, A. One suture is placed directly at the bladder neck, one about 2 cm. distal to this in the proximal urethra and one 2 cm. above the bladder neck in the anterior wall. The sutures should go fairly deep in the musculature. When tied, they create an anterior urethrovesical angle as well as contracting the bladder neck and increasing the effective length of the urethra. Two or more suspension sutures to the rectus tendons are then placed on the anterolateral walls of the bladder as shown in Fig. 4, B. These sutures further accentuate
1000
Ball
et al.
Figs. 1-4. V. Mosby
From Ball, Company.
T.
L.:
Gynerologic
Surgery
and
Urology.
ed. 2, St. Louis,
1963,
The
C
Fig. 1. A, The difficulty in re-entering the space of Retzius through dense scar tissue must be done by sharp dissection. The dome of the bladder will be difficult to identify. B, The scarred anterolateral walls of the bladder and proximal urethra must be literally chipped from the posterior border of the symphysis by knife dissection,
Volume Number
94 7
Stress incontinence
Fig. 2. A, The scarred nonfunctional areas of the proximal urethra and bladder are now free. A cystotomy is performed to further ascertain the extent of the scar tissue. B, A wedge resection of all the nonfunctional scar tissue of the bladder and proximal urethra is done.
1001
1002
Ball
et al.
Fig. 3. A, While point above the or at the previous catgut.
the bladder is open a small ureteral catheter is passed up each ureter to a pelvic brim to ensure that there has been no damage during the dissection surgery. B, The bladder is closed with interrupted sutures of No. 2-O chromic
Volume Number
94 7
Stress incontinence
1003
A
B
Fig. 4. A, Additional sutures are placed at the bladder neck and proximal urethra to plicate and further narrow the vesicourethra! junction. II, Suspension sutures are placed laterally above the plication sutures and passed through the tendons of the rectus muscles. When tied these sutures create an anterior urethrovesical angle.
1004
Ball
et al.
the anterior urethrovesical angle but 1 doubt that they add much to the function of the bladder neck. Drainage of the bladder may be by cystostomy as illustrated or by urethral catheter. Done both ways about an equal number of times, there seemed to be little preference. The catheter is left 8 days. When a cystostomy tube is removed, a urethral catheter should be inserted for a few days while the tract closes. Urinary antiseptics are routinely administered. Results
and
comments
These patients represent the ultimate in operative failures in the surgery of urinary stress incontinence. All have had a MarshallMarchetti operation preceded by a variety of vaginal plastic procedures. Table I shows the total previous operations among the fourteen patients reported in this study. In addition to the invasion of the space of RetGus, they had a total of 14 anterior and posterior repairs. Two had vaginal hysterectomies and two had Manchester type repairs. One had incontinence after reconstruction of an artificial vagina and was worse after a periosteal suspension of the urethra. Only one had a transurethral resection of the bladder neck after which the usual female patient with retention becomes incontinent. In summary, 14 patients had a total of thirtyfour operative procedures prior to a wedge resection of the bladder. Some patients may have had two procedures and some have had four. These previous operations are charted only to emphasize that all or most of the standard procedures used to correct this condition were tried.
Table I. Total previous fourteen patients Marshall-Marchetti
operations
among
operation
Anterior and posterior Vaginal hysterectomy Manchester repair Artificial vagina Transurethral resection Total
operations
14
repair
of bladder
on all patients
the
neck
14 2 2 1 1 34
Tablr 11 shows the results ol’ this olxration. When one is dealing with lq~elessl~ incontinent individuals. we feel the clinician is entitled to list his operative results as improved (vague indeed) when the patient is able to circulate among her friends and daily activities without the use of a protective device. It is difficult to gradate the de,gree of incontinence with any accuracy. Using this completely arbitrary criterion, there were ten patients completely dry under all conditions of stress. Two were improved and two were complete failures. Since many of these patients were confronted with urinary diversion as the solution to their problem, this operation can salvage a substantial number of patients who can retain the normal channels. Table III shows the length of follow-up of these 14 patients. The first patient was operated upon 7 years ago and is still incontinent. The last patient is continent 2 months after surgery. When operations for urinary incontinence fail, it is usually evident at the second postoperative visit and this is within 2 months. One might ask why it has taken more than 6 years to study 14 patients. The answer is simply that most Table
II. Results Cured Improved (no protective Complete failure Total
Table
10 device
needed)
2 2
cases
14
III
Case No. 1 L’ 3 4 5 6 7 li 10 11 12 13 14
)
Length 6 6 5 5 4 3 2
Years, Years, Years, Years, Years, Years, Years,
12 1 1 1 10 2
Year, Years, Year, Year, Year Months Months
of follow-up 11 5 9 6 1 4 9
months months months months month months months
69 months 5 months 1 month
Volume Number
94 7
patients with repeated operative failures give up as well as their physicians and resign themselves to a life of various devices to avoid offending their friends and family.
Stress
incontinence
1005
cedure, can be reconstructed with specific emphasis on the anatomical relationship of the bladder neck to the urethra to restore the anatomical figuration compatible with urinary continence.
Conclusions Repeated failures in the surgery of urinary stress incontinence should be further studied to determine whether surgery short of urinary diversion may restore continence. The human bladder, with its inestimable capacity to recover from any surgical pro-
REFERENCES
1. Marshall, V. F., Marchetti, A. A., and Krantz, K. E.: Surg. Gynec. & Obst. 88: 509, 1949. 2. O’Leary, J. A. : Obst. & Gynec. 24: 73, 1964. 947 West 8th Street Los Angeles 17, California