Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate Medical Center

Indications for Reconstruction Urethro-vaginal fistula Urethral stricture Congenital abnormalities

Etiology

Complication of Urethral Diverticular Surgery

Fistula diverticulum

Complication of Synthetic Sling

Granulation tissue Fistula

Complication of Colporraphy

Ureteral orifices

Stones on sutures Foley catheter Fistula

Sterile Abscess from Periurethral Injection

meatus Sterile abscess

Complication of Pelvic Fracture

Complication of Foley Catheter

Squamous Cell Carcinoma

Idiopathic Urethral Stricture

Diagnosis Usually evident on vaginal exam as –urethro-vaginal fistula –partial or complete loss of urethra Sometimes not so obvious, but diagnosed by occluding meatus and observing urine loss proximally

Diagnosis So, be aware of possibility of urethal damage when there is incontinence after: vaginal / urethral surgery difficult childbirth pelvic fracture Diagnosis confirmed by cystsoscopy

Preoperative Considerations Accurate diagnosis – SUI vs fistula Recognize associated abnormalities Sphincteric incontinence Urethral diverticulum Periurethral abscess Vesicovaginal fistula Accessibility of local tissue for flap Timing of surgery

Operative Technique Dorsal lithotomy position Adequate exposure Outline flaps (burn no bridges)! Tension free, multiple layered closure)

Operative Technique Repair of sphincter (usually pubovaginal sling) +/- Martius or labial flap (between sling & urethra Vaginal flap to cover wound Suprapubic & Foley catheter

Intra-operative Considerations Choice of procedure (usually decided intraop) Assess adequacy of local tissue Adequate operative exposure

Urethral Reconstruction Retropubic –Posterior bladder flap (Young-Dees-Leadbetter) –Anterior bladder flap (Tanagho) Transvaginal

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Labia majora Bladder neck

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Vaginal Repair Primary closure Flaps –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

Dorsal urethral incision

Buccal graft

Judicious Use of Vascularized Pedical Flaps Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

Judicious Use of Vascularized Pedical Grafts Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

Judicious Use of Vascularized Pedical Grafts Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

Judicious Use of Vascularized Pedical Grafts Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

sling Martius flap

sling Martius flap

Results of Surgery Author#Cure FistulaContinent Amundsen, %56% Flisser, %87% Clemens, %43% Elkins, %50% Hamlin, %80% Kobashi, %20% Leng, %

Potential Complications Urethral obstruction Hemorrhage Ureteral obstruction Vesciovaginal fistula Sphincteric incontinence

Conclusions Vaginal repair is possible in almost all patients Most patients with pre-op SUI should have synchronous anti-incontinence op +/- Martius flap Successful outcome is achievable in over 85% of patients