Repair of the distal closure mechanism
Next, the distal urethral closure mechanism, fig.1, is surgically restored, VIDEO2. https://youtu.be/QM0rEtQ7i8w. Taking the midline incision to within 0.5 cm of the external urethral meatus (EUM) allows access to the external urethral ligament (EUL) which is sited immediately lateral to the EUM. As per the VIDEO, a 00 vicryl suture is inserted into the left EUL, then into the smooth muscle layer of the vagina on the same side, then on the right side and finally, the right EUL. The suture is lightly tied.
If the patient is continent on coughing with 300 ml in the bladder at the end of the operation, it is highly likely she will remain cured. The immediate post-operative treatment is as per a standard MUS operation.
* Compression of 0.5 millimetre beyond the normal urethral diameter, fig2, requires a far higher detrusor pressure to evacuate the urine from the detrusor, as the pressure change is exponentially determined, being the inverse of the 4th power of the radius (Poiseuille’s Law).