Stekkel Operation

STEKKEL OPERATION, direct muscle plasty («directe Muskelplastik») for treating urinary incontinence in women due to injuries in the area of the posterior urethral circumference and bladder base. Such injuries occur almost exclusively after childbirth (pressure from the fetal head on the bladder sphincter, extraction of the fetus with forceps, etc.). According to Stekkel, with such injuries, the bladder sphincter muscles separate, defects form between the muscle fibers, which are filled with connective tissue. Thus, the contractile ability of the muscular apparatus that closes the bladder is impaired. Additionally, scars developing between the urethra, bladder, and underlying tissues can lead to changes in the urethral lumen, displacement of the bladder, and impairment of the bladder's closing apparatus. The Stekkel operation consists of a sagittal incision, starting slightly away from the external urethral opening almost to the external cervical os. The urethrovesical and vesicovaginal septum is partially dissected bluntly and partially with scissors, widely freeing the bladder base and urethra. Scars between the vaginal wall, urethra, and bladder are exclusively dissected with a sharp instrument. Careful hemostasis. A series of catgut sutures are placed on the separated muscles of the posterior urethra and bladder neck. A widely encompassing suture may be used to correct urethrocele. A special suture at the internal urethral opening («Sphinkternaht»). Excess vaginal wall is excised, catgut sutures on the vaginal mucosa. For eight days, a Pezzer catheter, irrigation of the bladder with a boric acid solution (3%). In a number of cases, the Stekkel operation gives an excellent functional result. With significant damage to the urethra and sphincter muscles, Stekkel recommends the use of other operations (Goebel-Stoeckel operation, interpositio uteri by Wertheim-Schauta). When discussing the essence of the Stekkel operation, it must be borne in mind that the enormous role in the occurrence of urinary incontinence belongs less to the direct damage to the muscular apparatus than to the connective tissue formations thanks to which the bladder and urethra maintain their normal position. Indeed, with impairment of the stability of the connective tissue apparatus, the position of the bladder and urethra changes, which takes a more or less pronounced horizontal position, with its upper part expanding conically. Under such conditions, when the posterior wall of the urethra bulges (urethrocele), unfavorable conditions are created for the apparatus that closes the bladder, and both the smooth and striated sphincters must work with greater effort, subsequently revealing their inadequacy. Therefore, in the treatment of urinary incontinence, a good effect is obtained even without plastic surgery on the muscular apparatus (operations by Figurnov, Yartsev, Gudim-Levkovich, etc.). The success of the Stekkel operation is therefore explained mainly by the restoration of correct anatomical relationships and strengthening of connective tissue formations. As can be seen from the description of the Stekkel operation, sutures are placed not only on the bladder sphincter; a series of sutures also widely encompass adjacent tissues, which ultimately leads to strengthening of the connective tissue apparatus and restoration of the function of the closing muscular apparatus. It must also be emphasized that the data provided by Stekkel to justify the operation he proposed—divergence of the sphincter muscle fibers, filling of the defect between them with connective tissue in urinary incontinence—are completely not confirmed by other authors.