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Urethral closure in management of urinary incontinence
URETHRAL URINARY M. J. STOWER, J. A. MASSEY,
CLOSURE IN MANAGEMENT
OF
INCONTINENCE D.M.,
F.R.C.S.
F.R.C.S.
R. C. L. FENELEY,
F.R.C.S.
From the Department of Urology, Bristol, United Kingdom
Southmead
and Ham Green
Hospitals,
ABSTRACTUrethral closure with suprapuhic catheterization has been used in 50 patients with urethral de,~truction due to an indwelling catheter. Thirty-seven of the patients were drg after the initial operation. Long-term complications were Seen in 33 patients. Those that did occur zcere not life threatening. This relatively minor procedure ojfers a good alternative to formal diversion in this group of severely disabled patients.
Urethral destruction is one of the consequences of a long-term indwelling catheter in patients with a neurogenic bladder resulting in continual leakage and expulsion of the catheter. Apart from being a distressing problem, it also exposes the patient to the risk of pressure sores developing. Urethral closure with suprapubic drainage has been used as a method of managing this problem. Material
and Methods
Since 1977, 50 patients have undergone urethral closure with suprapubic catheterization: 47 patients were female, with a mean age of 52.0 (f 3.7) years: males were aged thirtynine, fifty-three, and sixty-one years. All patients had had an indwelling catheter for at least six months. The underlying disease is shown in Table I. All the operations have been performed or supervised by one surgeon (RCLF). Four to six weeks prior to urethral closure the patients vvere cystoscoped to exclude any local cause for their incontinence, and a suprapubic catheter was inserted. Initially, the catheter vvas inserted by, a percutaneous stab. Latterly a Hey Groves dilator, through vvhich a hole had
been drilled at the tip, was inserted into the bladder, and then by cutting down on the tip a suprapubic tract is developed. A stitch is used to tie an 1%20F Silastic Foley catheter to the dilator which was then withdrawn thereby pulling the catheter into the bladder. When the patient was readmitted for urethral closure, no special preoperative preparation was needed, though a single injection of a suitable antibiotic was given with induction of anesthesia. With the patient in the lithotomy position an incision is made encircling the urethral meatus (a stitch in the distal urethra makes a useful retractor). The incision is extended, freeing the urethra from the vagina, to the base of the bladder. In particular, the pubourethral ligament which can be easily palpated on the anterior surface of the urethra must be divided (Fig. 1).
Disease Multiple sclerosis Other neurologic Senile dementia Others
Female diseases
(%)
Male
31 (66) 9 (19) :3 1
2 1
37
0
charged from hospital care, the patient’s sonal physician was contacted.
per-
Results There ha\,e been no perioperative deaths and onl\. 1 patient has had a postoperative bacteremia which responded to antibiotics. There was also one episode when the bou.el m.as perforated, but this was treated successfull!,. Despite the presence of chronicall!. infected urine, local infection has not been a problem, Fcmalcs
(II
=
47)
Follow~~p has ranged from six to one hundred eight months, mean 38.3. Eight patients have been lost to followup at least two !.ears after their initial operation. Thirty-four (70 % ) patients were clqr after the initial operation. Of the 13 \vho w’ere not, 12 had subsequent operations (one refused further surgery). and 7 were dr!, after the second operation. The remaining 5 all of m-horn had large \aesicovaginal fistulas had \,arious local procedures. one still remains npvt. had 110 longThirt!r-three (66 ‘X1) patients term complications. The problems seen in the other patients are shown in Table, 11. Some patients have had problems with catheter dislodgement, but we were unable to accuratel) record this. There were three late failures, for no apparent reason, which were all successfull) reclosed. No case of renal failure has been identified. Once the urethra has been fully mobilized, it is first ligated and then pushed into the bladder (like buqring an appendix stump). The in\.aginated urethra is held in position by inserting t\vo or three 3-O polyglycolic purse string sutures into the base of the bladder. After hemostasis is obtained, the anterior vaginal wall is ad\.anccd to close the resulting defect which is srltured with 3-O polvglycolic sutures. A \.aginal pack is left in overnight. In males the suprapubic catheter has to be inserted at a formal cystotomy, but the urethral closure is nluch simpler: the urethra is simpl!. ligated in the perineum. Via a skin incision the urethra is mobilized and ligated in continuit!. \\~ith t\vo suitable ligatures. The patients are discharged on the fifth to tenth postoperative day and arrangements made to change the catheter in six lveeks. Long-term results were obtained by either reviewing tht: notes or, if the patient had been dis-
Seven patients have subsequently died at a mean of 8.3 (+ 6.7) months after urethral closure of nonurologic causes. Follo\vup ranged from eight to thirtl -twv months. All 3 patients Lvere dr!- after their inthough all have hacl long-term tial operation, problems of either s!rmptomatic urinary tract infection (UTI) or bladder stone formation.
Comment Urinary incontinence in female patients with advanced neurologic disease presents a challenge to all concerned. Once conservative methods, such as drugs, incontinence pads/ pants, and urethral catheterization have failed, urinary diversion has to be considered. Desmond and Shuttleworth,’ and recently Malone, Stanton, and Riddle2 have shown that an ileal conduit is acceptable in some patients, but they acknowledge that careful selection is needed. It has to be emphasized that the patients in this series either had severe neurologic disease, pressure sores, or refused an ileal conduit. Since greater care has been taken to divide the pubourethral ligament, a greater proportion of patients have been dry after their initial operation and only 10 percent remained wet after two operations. Surprisingly, there have been veq. few septic complications, despite the chronicall!. infected urine. The procedure has been well tolerated by this group of high-risk patients with no postoperative mortality. Postoperative leakage around the suprapubic catheter has not presented as severe a problem as Lvas the previous urethral leakage. Bladder stone formation has become an increasing problem with time (it was not reported in the first 24 patients3) though these stones can be easily remoored b>. dilating the suprapubic tract and removing the calculi Lvith stone forceps. Some patients have suffered from catheter displacement (usually due to balloon failure), but we have been unable to accurately document this since many Lvere replaced 1~~.the nursing or medical staff at the residential nursing homes lvhere so many of the patients li\re. Once a catheter falls out it must be replaced Lvithin a few hours or the tract closes do\\-n.
Though none of the patients has had an annual review of their renal function, we are not aware of any with renal failure. Long-term followup of ileal conduits has shown that upper tract problems often develop,4 thus converting what was simply a lower tract problem into an upper tract disease with its associated mortality. Zimmern et ~1.~ have reported their experience with a similar operation. They excised the ischemic and scarred remnants of the urethra while also completely mobilizing the base of the bladder from the pubic symphysis with closure of the bladder in two layers. In their 6 cases (similar to those in this series) all were dry after the procedure, and none has had deterioration of the upper tracts. Thus, in severely disabled patients with a neurogenic bladder whose urethra has been severely damaged by recurrent extrusion of a catheter balloon, urethral closure with suprapubic drainage has proved to be a suitable and safe alternative to formal urinary diversion. Southmead Hospital Westbury-on-Trym Bristol, BSlO SNB England (DR. STOWER) References I. IYk\r~~c~nd AI). anti Shuttlcwwrth KED: The resrdts of urinary di\wsiorr in multiple sclerosis, Br J Ural 49: 19.5 (1977). 2. klalone PR. Stanton St,. and Riddle PR: Urinary di\wsion for incontinence-a bmeficial prowd~w? Ann R Coil Surg Engl 67: 349 (lW5). .3. Fc~wlry HCI.: The managenwnt of felllalt, incontinurcv h! supraprlbic cathetuiution. \\ ith or \rithout urethral clo\cn-v, Br J Ural 55: 203 (1983). 1. Neal DE: Cornplicatiow of ilcal conduit dir r,r\ion in adults \vith cancer follow e&up for at Ivast five !wrs. Br 114 J 290: 169.5 (1985). 5. Zinlmcwl PF:, Iladk\~ IIR. lzach GE. and Raz S: ‘Ikarl\\.aginal clo\rlrv of thv bladder neck and placcmcmt of a supraphit cathtatvr for datroyed urethra after long-ttwrl indu clling cathctcrization. J L’rol 134: 5.54 (198.5).
UROLOGY
/
NOVEMBER
1989
i
VOLUME
XXXIV. NUMBER
5
CLOSURE IN MANAGEMENT
OF
INCONTINENCE D.M.,
F.R.C.S.
F.R.C.S.
R. C. L. FENELEY,
F.R.C.S.
From the Department of Urology, Bristol, United Kingdom
Southmead
and Ham Green
Hospitals,
ABSTRACTUrethral closure with suprapuhic catheterization has been used in 50 patients with urethral de,~truction due to an indwelling catheter. Thirty-seven of the patients were drg after the initial operation. Long-term complications were Seen in 33 patients. Those that did occur zcere not life threatening. This relatively minor procedure ojfers a good alternative to formal diversion in this group of severely disabled patients.
Urethral destruction is one of the consequences of a long-term indwelling catheter in patients with a neurogenic bladder resulting in continual leakage and expulsion of the catheter. Apart from being a distressing problem, it also exposes the patient to the risk of pressure sores developing. Urethral closure with suprapubic drainage has been used as a method of managing this problem. Material
and Methods
Since 1977, 50 patients have undergone urethral closure with suprapubic catheterization: 47 patients were female, with a mean age of 52.0 (f 3.7) years: males were aged thirtynine, fifty-three, and sixty-one years. All patients had had an indwelling catheter for at least six months. The underlying disease is shown in Table I. All the operations have been performed or supervised by one surgeon (RCLF). Four to six weeks prior to urethral closure the patients vvere cystoscoped to exclude any local cause for their incontinence, and a suprapubic catheter was inserted. Initially, the catheter vvas inserted by, a percutaneous stab. Latterly a Hey Groves dilator, through vvhich a hole had
been drilled at the tip, was inserted into the bladder, and then by cutting down on the tip a suprapubic tract is developed. A stitch is used to tie an 1%20F Silastic Foley catheter to the dilator which was then withdrawn thereby pulling the catheter into the bladder. When the patient was readmitted for urethral closure, no special preoperative preparation was needed, though a single injection of a suitable antibiotic was given with induction of anesthesia. With the patient in the lithotomy position an incision is made encircling the urethral meatus (a stitch in the distal urethra makes a useful retractor). The incision is extended, freeing the urethra from the vagina, to the base of the bladder. In particular, the pubourethral ligament which can be easily palpated on the anterior surface of the urethra must be divided (Fig. 1).
Disease Multiple sclerosis Other neurologic Senile dementia Others
Female diseases
(%)
Male
31 (66) 9 (19) :3 1
2 1
37
0
charged from hospital care, the patient’s sonal physician was contacted.
per-
Results There ha\,e been no perioperative deaths and onl\. 1 patient has had a postoperative bacteremia which responded to antibiotics. There was also one episode when the bou.el m.as perforated, but this was treated successfull!,. Despite the presence of chronicall!. infected urine, local infection has not been a problem, Fcmalcs
(II
=
47)
Follow~~p has ranged from six to one hundred eight months, mean 38.3. Eight patients have been lost to followup at least two !.ears after their initial operation. Thirty-four (70 % ) patients were clqr after the initial operation. Of the 13 \vho w’ere not, 12 had subsequent operations (one refused further surgery). and 7 were dr!, after the second operation. The remaining 5 all of m-horn had large \aesicovaginal fistulas had \,arious local procedures. one still remains npvt. had 110 longThirt!r-three (66 ‘X1) patients term complications. The problems seen in the other patients are shown in Table, 11. Some patients have had problems with catheter dislodgement, but we were unable to accuratel) record this. There were three late failures, for no apparent reason, which were all successfull) reclosed. No case of renal failure has been identified. Once the urethra has been fully mobilized, it is first ligated and then pushed into the bladder (like buqring an appendix stump). The in\.aginated urethra is held in position by inserting t\vo or three 3-O polyglycolic purse string sutures into the base of the bladder. After hemostasis is obtained, the anterior vaginal wall is ad\.anccd to close the resulting defect which is srltured with 3-O polvglycolic sutures. A \.aginal pack is left in overnight. In males the suprapubic catheter has to be inserted at a formal cystotomy, but the urethral closure is nluch simpler: the urethra is simpl!. ligated in the perineum. Via a skin incision the urethra is mobilized and ligated in continuit!. \\~ith t\vo suitable ligatures. The patients are discharged on the fifth to tenth postoperative day and arrangements made to change the catheter in six lveeks. Long-term results were obtained by either reviewing tht: notes or, if the patient had been dis-
Seven patients have subsequently died at a mean of 8.3 (+ 6.7) months after urethral closure of nonurologic causes. Follo\vup ranged from eight to thirtl -twv months. All 3 patients Lvere dr!- after their inthough all have hacl long-term tial operation, problems of either s!rmptomatic urinary tract infection (UTI) or bladder stone formation.
Comment Urinary incontinence in female patients with advanced neurologic disease presents a challenge to all concerned. Once conservative methods, such as drugs, incontinence pads/ pants, and urethral catheterization have failed, urinary diversion has to be considered. Desmond and Shuttleworth,’ and recently Malone, Stanton, and Riddle2 have shown that an ileal conduit is acceptable in some patients, but they acknowledge that careful selection is needed. It has to be emphasized that the patients in this series either had severe neurologic disease, pressure sores, or refused an ileal conduit. Since greater care has been taken to divide the pubourethral ligament, a greater proportion of patients have been dry after their initial operation and only 10 percent remained wet after two operations. Surprisingly, there have been veq. few septic complications, despite the chronicall!. infected urine. The procedure has been well tolerated by this group of high-risk patients with no postoperative mortality. Postoperative leakage around the suprapubic catheter has not presented as severe a problem as Lvas the previous urethral leakage. Bladder stone formation has become an increasing problem with time (it was not reported in the first 24 patients3) though these stones can be easily remoored b>. dilating the suprapubic tract and removing the calculi Lvith stone forceps. Some patients have suffered from catheter displacement (usually due to balloon failure), but we have been unable to accurately document this since many Lvere replaced 1~~.the nursing or medical staff at the residential nursing homes lvhere so many of the patients li\re. Once a catheter falls out it must be replaced Lvithin a few hours or the tract closes do\\-n.
Though none of the patients has had an annual review of their renal function, we are not aware of any with renal failure. Long-term followup of ileal conduits has shown that upper tract problems often develop,4 thus converting what was simply a lower tract problem into an upper tract disease with its associated mortality. Zimmern et ~1.~ have reported their experience with a similar operation. They excised the ischemic and scarred remnants of the urethra while also completely mobilizing the base of the bladder from the pubic symphysis with closure of the bladder in two layers. In their 6 cases (similar to those in this series) all were dry after the procedure, and none has had deterioration of the upper tracts. Thus, in severely disabled patients with a neurogenic bladder whose urethra has been severely damaged by recurrent extrusion of a catheter balloon, urethral closure with suprapubic drainage has proved to be a suitable and safe alternative to formal urinary diversion. Southmead Hospital Westbury-on-Trym Bristol, BSlO SNB England (DR. STOWER) References I. IYk\r~~c~nd AI). anti Shuttlcwwrth KED: The resrdts of urinary di\wsiorr in multiple sclerosis, Br J Ural 49: 19.5 (1977). 2. klalone PR. Stanton St,. and Riddle PR: Urinary di\wsion for incontinence-a bmeficial prowd~w? Ann R Coil Surg Engl 67: 349 (lW5). .3. Fc~wlry HCI.: The managenwnt of felllalt, incontinurcv h! supraprlbic cathetuiution. \\ ith or \rithout urethral clo\cn-v, Br J Ural 55: 203 (1983). 1. Neal DE: Cornplicatiow of ilcal conduit dir r,r\ion in adults \vith cancer follow e&up for at Ivast five !wrs. Br 114 J 290: 169.5 (1985). 5. Zinlmcwl PF:, Iladk\~ IIR. lzach GE. and Raz S: ‘Ikarl\\.aginal clo\rlrv of thv bladder neck and placcmcmt of a supraphit cathtatvr for datroyed urethra after long-ttwrl indu clling cathctcrization. J L’rol 134: 5.54 (198.5).
UROLOGY
/
NOVEMBER
1989
i
VOLUME
XXXIV. NUMBER
5