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

2. Indications for Reconstruction Urethro-vaginal fistula Urethral stricture Congenital abnormalities

3. Etiology

4. Complication of Urethral Diverticular Surgery

5. Fistula diverticulum

7. Complication of Synthetic Sling

8. Granulation tissue Fistula

9. Complication of Colporraphy

10. Ureteral orifices

11. Stones on sutures Foley catheter Fistula

12. Sterile Abscess from Periurethral Injection

13. meatus Sterile abscess

14. Complication of Pelvic Fracture

16. Complication of Foley Catheter

18. Squamous Cell Carcinoma

20. Idiopathic Urethral Stricture

22. 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

23. 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

24. 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

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

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

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

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

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

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

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

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

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

48. Labia majora Bladder neck

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

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

59. Dorsal urethral incision

60. Buccal graft

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

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

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

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

78. sling Martius flap

79. sling Martius flap

83. Results of Surgery Author#Cure FistulaContinent Amundsen, 2003 9100%56% Flisser, 20037493%87% Clemens, 200014100%43% Elkins, 19902090%50% Hamlin, 19695098%80% Kobashi, 199934100%20% Leng, 19981889%

84. Potential Complications Urethral obstruction Hemorrhage Ureteral obstruction Vesciovaginal fistula Sphincteric incontinence

85. 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