Bladder Augment with Bladder Neck Closure and Continence Stoma. This case involves a 54-year-old female who presented with recurrent urinary tract infections, hematuria, lower abdominal pain, and recurrent stress urinary incontinence. The patient was a poor historian and was only able to report a prolapse and mesh incontinence procedure in 2006 with a possible mesh excision in 2011. We were unable to obtain past operative reports. Cystourethroscopy was performed revealing eroded mesh within the urethra as well as within the bladder. Two large stones were also noted to be attached to the mesh and were removed. After these findings were discussed with the patient, she was consented for the excision of the eroded mesh from her bladder and urethra as well as a rectus fascia sling for her recurrent stress urinary incontinence. During the surgery, the extensive erosion of the mesh and confusing course of the sling arms made it difficult to determine the placement and type of mesh that had initially been used. Additionally, by the time all the mesh had been removed, it was noted that the urethra was nearly completely disconnected from the bladder neck. The urethra was reattached to the bladder neck at the time of surgery in a two-layered fashion and was confirmed to be watertight. At her three-month follow-up, the patient demonstrated easy stress leakage with Valsalva. Cystourethroscopy revealed no residual mesh but scars in her bladder dome. The urethra was also noted to be foreshortened with a length of 1.5 centimeters, likely due to extensive removal of eroded mesh. Video urodynamics confirmed a low bladder capacity with intrinsic sphincter deficiency. Fluoroscopy showed an open bladder neck. The patient desired surgical management of her constant urinary leakage. Several options were discussed with her, including doing a bladder neck closure with a suprapubic catheter, a repeat tight rectus fascia sling with intermittent cell catheterization, or a bladder neck closure, bladder augment, and continent diversion. The patient did not desire to have a permanent suprapubic catheter, and she was not capable of intermittent cell catheterization due to her retracted external urethra meatus and morbid obesity. She desired to proceed with a bladder neck closure, bladder augment, and continent diversion. After making a midline vertical incision, the bladder was identified, and an anterior cystotomy was made. Bilateral ureteral stents were placed. The bladder neck was clearly identified, and the urethra was transected. The bladder neck was then closed with a two-layered running threovicral suture. At the tissue inferior of the bladder, three sutures of threovicral were placed in anticipation for future use of an omental flap to cover the bladder neck closure. The terminal ileum and cecum were identified. Specifically, the portion of the ileum that was to become the continent channel and the portion of the cecum to be used in a bladder augment were carefully examined and mobilized. The future stoma site was marked approximately 10 centimeters from the ileocecal valve with 3-0 silk suture. The vascular anatomy was delineated, and an area in the mesentery was marked. This was subsequently ligated with a ligature device. The GIA stapler was then used to transect the segment of ileum. The cecum was further mobilized, and the vascular arcades and mesentery were seen, and an area was marked. The ligature was used to divide the mesentery. The GIA stapler was then used to ligate the cecum, as had been done with the ileum. The balanostomosis between the colon and the ileum was then performed. The cecum and ileum now isolated, the previous staple line on the ileal segment was removed. The cecum was opened, and the bowel was cleaned and irrigated. A 14 French catheter was inserted into the ileum and advanced to the cecum. The GIA stapler was used to taper the ileal segment down to the level of the ileocecal valve. Three placating sutures were placed at the ileocecal valve to allow for an additional continence mechanism. The other two continence mechanisms are peristalsis of the bowel and the tapering of the ileal segment. The cecum was then brought into place for the bladder augmentation. The posterior aspect was first closed with a running threovigral suture. The anterior aspect was closed in a similar fashion. A 24 French suprapubic catheter was advanced through the skin and into the bladder prior to complete closure of the bladder. The bladder was filled via the suprapubic catheter to test for watertight closure and stomal patency. The omental flap was then mobilized and secured over the bladder neck using previously placed threovigral sutures. At a predetermined location, a cochlear clamp was placed on the skin and a stoma was developed. Using a Babcock, the ileal segment was grasped and brought through the opening. Four threovigral sutures were used to secure the stoma to the fascia. Threochromic sutures were circumferentially placed around the distal portion of the stoma to secure it to the skin. The bladder was filled and no leakage of urine was noted. A red rubber catheter was then advanced smoothly into the stoma and the bladder was easily drained. The abdominal wall was closed in the standard fashion. A blake drain was inserted overlying the bladder augment. The suprapubic catheter was secured with 2-0 silk and stat locks were used to secure the stomal catheter to the abdominal wall. The patient did well after surgery and was discharged home on post-operative day 5. She will follow up in the office to have her suprapubic catheter removed as long as there are no complications with her stoma.

urinary tract infections

hematuria

abdominal pain

stress urinary incontinence

mesh erosion