3-26. BLADDER NECK OPERATION (Y-V-PLASTY)
a. General. This operation involves the plastic repair of the bladder neck. It is
done to overcome contracture of the bladder neck due to primary or secondary stricture.
b. Operative Procedure.
(1) The bladder is approached as for cystostomy. The prevesical fat is
removed, using long forceps and dissecting scissors. The vessels over the bladder
neck are occluded with right-angled clamp, ligated with number 2-0 plain gut, and
divided. The self-retaining bladder retractor is placed.
(2) Traction sutures of fine silk on small, fine, cutting-edge needles (cleft
palate-type) are placed at the base and on either side of the urethra to start the pattern
for the plastic dissection.
(3) With the aid of the traction sutures and an Allis forceps, the Y is incised
through all layers as evenly as possible, using sharp-pointed scissors. Bleeding vessels
in the wall of the bladder and bladder neck are ligated with plain number 2-0 gut on
small Ferguson needles. The V flap is folded free, and the length of the Y arm is
determined with a caliper and ruler.
(4) The apex of the V is brought to the neck of the bladder to overcome the
stricture and broaden the outlet. A catheter is placed in the urethra to guide the needle
and prevent the suture from penetrating the urethral mucosa. A stitch of chromic
number 2-0 suture is taken through the apex of the V under the urethra to the base of
the Y and tied. The closure of the plastic repair is completed with mattress suture of
number 2-0 chromic on Atraumatic needles.
(5) A cystostomy tube is placed in the bladder, and the bladder and
abdominal wall are closed in the usual manner for cystostomy.
3-27. VISICAL-URETHRAL SUSPENSION (MARSHALL-MARCHETTI OPERATION)
a. General. This operation involves the suspension of the bladder neck to the
posterior surface of the pubis in the female patient for treatment of stress incontinence.
b. Patient Preparation. The patient is usually placed in a supine position with
Trendelenburg modification, but the surgeon may prefer a frogleg modification and
vaginal preparation with the insertion of a Foley catheter.
c. Operative Procedure.
(1) A suprapubic incision is made to expose the prevesical space of
Retzius. The bladder and urethra are separated from the posterior surface of the rectus
muscles and pubis by gentle, blunt dissection.