Bladder neck closure is rarely done. It is reserved for the patient with an end-stage urethra usually due to damage from a Foley catheter or multiple failed operations for urinary incontinence. Several approaches have been described: abdominal, vaginal and abdominal-vaginal.

The patient is a 40 year old woman who has severe stomal and urethral incontinence after multiple operations for interstitial cystitis resulting in with a refractory end-stage bladder and urethra. She had previously undergone several attempts at augmentation cystoplasty and a continent abdominal stoma, but remained incontinent through both sites. She ultimately wants a continent stoma, but was so tired and frustrated with intermittent catheterization and incontinence that she wanted a “rest.” This surgery, to create an ileal chimney and close the bladder neck is the first stage towards that goal. During this surgery, we also did yet another augmentation cystoplasty and creation of an incontinent ileo-vesicostomy (not depicted in this video). Ordinarily we would do the entire operation from above, but in this case, because of her multiple prior surgeries we elected the vaginal approach for the bladder neck closure buttressed with an omental flap.

A cystogram two weeks post-op shows an intact bladder neck and contrast filling the entire ileal chimney. Concomitant cystometerogram shows a low pressure bladder with slight discomfort at 360 mL at a pressure of 5 cm of water. She's doing well, but followup length has only been six month thus far.

We believe that transvaginal closure of the bladder neck is the procedure of choice for patients that will be managed with a suprapubic catheter. Compared to an abdominal approach, it is much easier to perform, much faster and is associated with much less morbidity.