Urethral Reconstruction

Jerry G. Blaivas, MDClinical Professor of Urology

New York Hospital Cornell Medical Center

Adjunct Professor of UrologySUNY-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

Granulationtissue

Fistula

Complication of Colporraphy

Ureteralorifices

Stoneson 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, butdiagnosed by occluding meatus andobserving urine loss proximally

Diagnosis

• So, be aware of possibility of urethal damage when there is incontinenceafter:• vaginal / urethral surgery• difficult childbirth• pelvic fracture

• Diagnosis confirmed by cystsoscopy

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

Labiamajora

Labiamajora

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

Buccal graft

Buccal graft

Judicious Use of VascularizedPedical Flaps

• Martius labial fat pad

• Omentum

• Rectus abdominis

• Gracilis

• Singapore

Results of SurgeryAuthor # Cure Fistula Continent

Amundsen, 2003 9 100% 56%

Flisser, 2003 74 93% 87%

Clemens, 2000 14 100% 43%

Elkins, 1990 20 90% 50%

Hamlin, 1969 50 98% 80%

Kobashi, 1999 34 100% 20%

Leng, 1998 18 89% 89%

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 shouldhave synchronous anti-incontinenceop +/- Martius flap

• Successful outcome is achievablein over 85% of patients