Bladder Neck Closure
Bladder-neck closure is an operation intended to permanently exclude the urethral outlet in selected patients with refractory incontinence or a devastated, nonreconstructible outlet. It requires a dependable alternative drainage route: a continent catheterizable channel, an incontinent diversion, or a permanent suprapubic catheter. Here “closure” is distinct from bladder-neck contracture, which is also commonly abbreviated BNC.[1]
The AUA/SUFU NLUTD guideline permits bladder-neck closure with concomitant drainage for selected refractory SUI, based on expert opinion. Selection considers the bladder, urethra, hand and cognitive function, caregiver support, prior surgery and the patient's goals. It is not necessary to attempt every lesser operation when anatomy or function makes those options unsuitable.[1]
Indications and alternatives
Clinical settings include severe neurogenic urethral erosion after chronic catheterization, exstrophy with failed outlet reconstruction, extensive female urethral destruction, and selected devastated post-prostatectomy or radiated outlets. A bladder that is painful, infected, poorly compliant or otherwise unsalvageable may need a different diversion strategy rather than closure alone.[2][3][4][1]
For women with a severely compromised outlet, AUA/SUFU describes options including an autologous pubovaginal sling, an intentionally obstructing autologous sling, closure with a catheterizable stoma, selected AUS placement, and urinary diversion. These are alternatives chosen by anatomy and goals, not a sequence in which an AUS follows a formally closed bladder neck. An obstructing configuration should not use a synthetic sling because the required tension can make it unsafe; this does not mean autologous tissue tolerates unlimited tension.[5]
Chancellor's 14-woman series reported dryness at mean 24 months after an obstructing pubovaginal sling, but drainage and concomitant reconstruction varied: 2 had sling plus CIC alone, 5 enterocystoplasty, 5 a bladder chimney, and 2 suprapubic drainage. This small uncontrolled experience does not establish superiority over formal closure.[6]
In selected men with an end-stage urethra after AUS failure, permanent perineal urethral ligation with chronic suprapubic drainage is another salvage option. It is not a mandatory step before closure.[7][8]
Reservoir and drainage planning
| Drainage plan | Requirements and consequences |
|---|---|
| Continent catheterizable channel | Safe storage pressures, adequate reservoir, reliable intermittent catheterization by patient or caregiver, and durable access |
| Permanent suprapubic catheter | Dependable continuous drainage, catheter-change support and a plan for blockage or dislodgement; the tube remains the bladder's outlet |
| Ileovesicostomy or another incontinent route | Individual assessment of drainage, obstruction, appliance needs and possible reoperation |
| Augmentation with reconstruction | Selected when storage capacity/compliance cannot safely support the intended regimen; it adds bowel, metabolic, stone and perforation risks |
Assess bladder storage before increasing outlet resistance, particularly when the planned regimen requires intermittent emptying. Continuous suprapubic drainage is a different physiological plan from a continent storage reservoir. Augmentation is not automatically required for every closure.[1]
Grimsby's 109-child study concerned mixed bladder-neck reconstruction/closure/sling procedures without augmentation, not closure alone. Estimated ten-year rates of subsequent augmentation (30%), additional continence procedures (70%) and upper-tract changes (over 50%) support careful selection and long-term surveillance; they do not prove that every closure should include augmentation.[9]
Operative principles
Abdominal approach
- Obtain exposure appropriate to prior surgery and any planned augmentation or channel. Identify and protect the ureteral orifices and surrounding structures.
- Separate the bladder neck from the urethral outlet as required by the chosen technique, preserving viable tissue for a tension-free closure.
- Close the bladder side securely in layers and address the urethral stump. Separate suture lines when feasible; verify watertightness and unobstructed alternative drainage.[4][10]
- Consider vascularized interposition, particularly in scarred or previously operated tissue. Omentum or a suitable muscle flap can separate the closure from the distal stump. Tissue choice depends on availability and the defect; no comparative trial establishes a universally mandatory flap.[10][11]
A retrospective 147-patient exstrophy cohort associated human acellular dermis or native-tissue interposition with fewer fistulas (5.8% versus 20.8% without interposition). It does not establish that all interposition materials are equivalent, that dermis is superior to native tissue, or that the association is causal. Acellular dermis is not itself a vascularized flap.[12]
Transvaginal approach
In selected women, vaginal access avoids abdominal exposure. Separate the vaginal wall from the outlet, protect adjacent structures, close the bladder outlet with viable tissue and close the vagina separately. Described variants include Rovner's posterior urethral flap, which relocates the closure away from the vaginal incision; use the original operative description for its specific orientation.[13][14][15]
In Willis's retrospective comparison of 64 women with suprapubic drainage, initial continence was 85.7% after transvaginal and 81.5% after retropubic closure. The vaginal group had shorter mean operative time and stay and fewer short-term complications, but selection differences and the nonrandomized design preclude causal superiority or formal equivalence.[16]
Outcomes: keep closure and continence distinct
| Series | Patients and follow-up | Result |
|---|---|---|
| Spahn 2010 | 17 adults: 10 post-prostatectomy, 1 post-vulvectomy, 6 neurogenic; follow-up 68 months | Primary closure in all 17; initial continence 82%. Three needed further continence reconstruction and four had stomal stenosis. These are not the 28-patient exstrophy/neurogenic results below.[2] |
| Kavanagh 2012 | 28 patients: 15 exstrophy, 13 neurogenic; augmentation plus Mitrofanoff; median follow-up 69 months | Initial closure 27/28; one fistula repaired. Eleven patients (39.3%) required further surgery, including three augment-rupture repairs.[3] |
| Shpall 2004 | 39 adults with neurogenic dysfunction and varied reconstruction; mean follow-up 36.9 months | Overall complications 31%; six fistulas (15%), four requiring repair. High pressures, previous bladder-neck surgery and inadequate drainage contributed to difficulty.[4] |
| O'Connor 2005 | 35 patients; mean follow-up 79 months | 29 initial successful closures; 33 after one additional closure procedure.[17] |
Cross-series percentages do not provide a single universal fistula, stone, stomal stenosis or rupture rate. Those outcomes depend on population, reservoir, drainage route, follow-up and whether additional operations count as success.
Postoperative drainage and lifelong follow-up
After formal closure, a urethral Foley does not traverse the closed bladder neck. Temporary healing catheters through a channel or suprapubic tract are managed according to the reconstruction and confirmation of healing. Do not remove a permanent suprapubic catheter because a 2–3-week cystogram is satisfactory: it remains the drainage route unless a working alternative has deliberately been established. Catheter blockage or dislodgement requires prompt assessment because the urethral escape route has been closed.[1][15]
Cystography at approximately 2–3 weeks is described in some operative protocols; it is a healing assessment, not permission to abandon permanent drainage. Maintain dependable decompression, assess leakage and infection, and distinguish fistula from catheter bypass or stomal incontinence.[4][15]
Follow renal function, upper tracts and bladder storage according to the underlying condition and reconstruction. Teach catheterization or catheter care and provide an emergency drainage plan. Augmented patients need the additional long-term surveillance and counseling described in augmentation cystoplasty.[1]
Related procedures
- Bladder-neck reconstruction principles
- Autologous pubovaginal sling
- Continent catheterizable channels
- Urinary diversion
Videos
References
1. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction: treatment and follow-up. J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239.
2. Spahn M, Kocot A, Loeser A, Kneitz B, Riedmiller H. Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy — long-term results and comparison of different techniques. Urology. 2010;75(5):1185-92. doi:10.1016/j.urology.2009.11.070.
3. Kavanagh A, Afshar K, Scott H, MacNeily AE. Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion for complex incontinence: closing the door for good. J Urol. 2012;188(4 Suppl):1561-5. doi:10.1016/j.juro.2012.02.027.
4. Shpall AI, Ginsberg DA. Bladder neck closure with lower urinary tract reconstruction: technique and long-term followup. J Urol. 2004;172(6 Pt 1):2296-9. doi:10.1097/01.ju.0000144072.15735.32.
5. Kobashi KC, Vasavada S, Bloschichak A, et al. Updates to surgical treatment of female stress urinary incontinence (SUI): AUA/SUFU guideline (2023). J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435.
6. Chancellor MB, Erhard MJ, Kiilholma PJ, Karasick S, Rivas DA. Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization. Urology. 1994;43(4):499-505. doi:10.1016/0090-4295(94)90241-0.
7. Van Dyke M, Ortiz N, Baumgarten A, et al. Permanent urethral ligation after AUS cuff erosion: is it ready for prime time? Neurourol Urodyn. 2021;40(1):211-218. doi:10.1002/nau.24535.
8. Arnold PJ, Soyster ME, Burns RT, Mellon MJ. The role of urethral ligation after AUS failure and end stage urethra. Int Urol Nephrol. 2022;54(11):2827-2831. doi:10.1007/s11255-022-03315-0.
9. Grimsby GM, Menon V, Schlomer BJ, et al. Long-term outcomes of bladder neck reconstruction without augmentation cystoplasty in children. J Urol. 2016;195(1):155-61. doi:10.1016/j.juro.2015.06.103.
10. Hensle TW, Kirsch AJ, Kennedy WA, Reiley EA. Bladder neck closure in association with continent urinary diversion. J Urol. 1995;154(2 Pt 2):883-5. doi:10.1097/00005392-199508000-00153.
11. Smith EA, Kaye JD, Lee JY, Kirsch AJ, Williams JK. Use of rectus abdominis muscle flap as adjunct to bladder neck closure in patients with neurogenic incontinence: preliminary experience. J Urol. 2010;183(4):1556-60. doi:10.1016/j.juro.2009.12.044.
12. Benz KS, Jayman J, Maruf M, et al. The role of human acellular dermis in preventing fistulas after bladder neck transection in the exstrophy-epispadias complex. Urology. 2018;117:137-141. doi:10.1016/j.urology.2018.04.011.
13. Petrikovets A, Sun H, Sheyn D, Slopnick E, Hijaz A. Transvaginal bladder-neck closure: a step-by-step video for female pelvic surgeons. Int Urogynecol J. 2019;30(1):159-161. doi:10.1007/s00192-018-3766-4.
14. Zimmern PE, Hadley HR, Leach GE, Raz S. Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization. J Urol. 1985;134(3):554-7. doi:10.1016/s0022-5347(17)47290-9.
15. Rovner ES, Goudelocke CM, Gilchrist A, Lebed B. Transvaginal bladder neck closure with posterior urethral flap for devastated urethra. Urology. 2011;78(1):208-12. doi:10.1016/j.urology.2010.11.054.
16. Willis H, Safiano NA, Lloyd LK. Comparison of transvaginal and retropubic bladder neck closure with suprapubic catheter in women. J Urol. 2015;193(1):196-202. doi:10.1016/j.juro.2014.07.091.
17. O'Connor RC, Stapp EC, Donnellan SM, et al. Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet. Urology. 2005;66(2):311-315. doi:10.1016/j.urology.2005.03.009.