urethral reconstruction jerry g. blaivas, md clinical professor of urology new york hospital cornell...
TRANSCRIPT
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