Modification of the Four-Quadrant Excisional Technique for Urethral Prolapse Repair
Kurt Strom, Joshua Holyoak, Scott Matz*, Columbia, MO
INTRODUCTION AND OBJECTIVES: Various treatments have been described for the treatment of urethral prolapse and include excision and suture reapproximation of the mucosal edges, ligation of the prolapsed urethra over a catheter with eventual tissue sloughing, cauterization, cryosurgery, bladder neck suspension, and, urethral fixation with a retropubic sling. We demonstrate a modification of the four-quadrant excision technique.
METHODS: The patient is positioned in dorsal lithotomy. Next, a weighted vaginal speculum and stay sutures for labial retraction are placed. An 18 French metal sound is then inserted into the urethra allowing for easy placement of four holding sutures into the four quadrants of the urethra. After placement of the holding sutures, the modification we present consists of passage of two mucosal trapping sutures. These are placed before excision of each quadrant to prevent the retraction of the inner urethral mucosal edge into the bladder. The metal sound is removed and then the first trapping suture is placed in the vertical plane by entering on the dorsum of the outer base of the prolapsed uretha, passing through the tissue, and entering the inner base of the dorsal urethral mucosa. Once inside the urethra, the needle is passed into the ventrum of the inner base of the prolapsed urethra, through the tissue and out through the outer base of the ventral aspect. The same maneuver is performed in the horizontal plane in a similar fashion. Each quadrant is then excised.
RESULTS: With the incised inner mucosal edge held in position by the trapping sutures, the approximation of the mucosal edges with twelve simple interrupted sutures consisting of 4-O chromic is precise. The patient had a catheter placed which was removed on post-operative day three and to date is without symptoms.
CONCLUSIONS: The use of trapping sutures allow for a more careful excision of the prolapsed urethra with a precise reapproximation of the mucosal edges.
