Preoperative Diagnosis
urinary incontinence, NGB

Postoperative Diagnosis
same

Name of Operation
1. transvaginal bladder neck closure with Acell graft
2. cystoscopy with intravesical botox injection
3. SPT placement

Description of Operation Performed, Including Technique
The risks, benefits and alternatives were explained to the patient and informed consent obtained. She was brought to the OR and placed on the table in supine position. After undergoing adequate anesthesia, she was placed in the dorsal lithotomy position. She was prepped and draped in standard fashion. Prior to the beginning of the procedure, a timeout was performed to identify the patient. Perioperative antibiotics were given within 1 hour of incision.

A flexible cystoscopy was performed and the bladder was visualized. No stones, masses or diverticuli noted. The bladder was difficult to distend secondary to a patulous urethra. A botox sheath was placed through the scope and 100 units of botoz was injected into the bladder into 10 sites with a 27 g needle. The trigone was avoided. Hemostasis was evident. The scope was removed.

The bladder was filled with 150 ml of saline and a Lowsley tractor was placed through the urethra and advanced toward the abdominal wall. She was placed in steep trandelenburg position. A 1 cm incision was made just above the pubic symphysis and electrocautery was used to dissect down to the fascia. The Lowsley was palpated and the fascia was opened at the site of the Lowsley. The claws were opened once visualized and a 20F catheter was placed into the tractor and brought through the bladder out of the urethra. The tip of the catheter was grasped and placed into the bladder. 10 ml was placed in the balloon and the catheter was brought to the dome of the bladder. The subcutaneous tissue was closed with 2-0 vicryl suture. The SPT was secured with two 2-0 silk sutures to the skin.

A 16F foley was placed into the urethra with 30 ml placed into the balloon. The anterior vaginal wall was infiltrated with normal saline. A Lonestar retractor was placed for visualization. A circumferential incision was made around the urethra with a #15 blade. Metzenbaum scissors were used to dissect away the periurethral tissue circumferentially to perform a formal urethrolysis. Lateral vaginal wall flaps were developed for later closure. Once the entire urethra was mobilized the foley was removed. The urethra was closed with two 2-0 vicryl sutures in 2 layers. A piece of Acell graft was then soaked for 15 minutes in saline and placed over the urethra. It was secured to the periurethral tissue with interrupted 3-0 vicryl sutures. The urethra was then rotated anteriorly and secured to the tissue posterior to the pubic symphysis with multiple interrupted 3-0 vicryl sutures. The suture line was no longer visible. The wound was copiously irrigated with saline. The vaginal mucosa was closed with multiple running, locking 2-0 vicryl sutures. Hemostatis was evident. The vagina was irrigated and Kerlix packing with antibiotic ointment was placed in the vagina.

The sponge, needle and instrument counts were correct at the end of the procedure.

I was present and scrubbed for the entire case.

The patient tolerated the procedure well.

Description of Any Drains, Catheters, or Packing Left in Place
20F SPT, Kerlix vaginal packing

Findings
patulous urethra

I would appreciate any help on this – thank you in advance!

~Kara