12 Female Urethral Reconstruction
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Knowledge of urethral anatomy is essential to fully understand the options for urethral reconstruction. The female urethra is relatively short compared with its male counterpart and is generally between 2 and 4 cm long. It has an inner layer of mucosal epithelium with numerous infoldings, which creates an effective seal against the passive loss of urine. Beneath the mucosa lies a rich network of elastic vascular tissue much like the corpus spongiosum. Finally, surrounding the spongy vascular tube is a collagen-rich fibromuscular envelope comprising the periurethral fascia. These three components of a normal urethra are crucial in maintaining continence and enabling dynamic function during increases in abdominal pressure as well as during normal micturition.
Two primary fascial attachments provide support to the urethra: the pubourethral ligaments and the periurethral fascia that makes up the suburethral hammock, which attaches to the arcus tendineus fasciae pelvis on each side. The pubourethral ligaments are a band of fascia that supports the urethra dorsally between the vagina and pubic symphysis. These ligaments often serve as a point of anatomical demarcation of the midurethra. The suburethral hammock is comprised of two layers of fascial condensation, the endopelvic fascia and the pubocervical fascia, which provide lateral attachment to the arcus tendineus. The midurethra is thought to be the center of continence where the striated sphincter complex maintains both active and passive tone.
Urethral reconstruction is most commonly performed to treat urethral stricture disease, urethral prolapse, urethral ablation, and urethrovaginal fistula. Female urethral stricture disease is relatively rare and can be caused by radiation exposure, inflammatory processes, difficult catheterization with subsequent fibrosis, prior dilation, urethral surgery, or trauma. Rarely strictures may be a consequence of estrogen deficiency. Urethral ablation usually results from urethral trauma, from long-term use of an indwelling urethral catheter (usually in a patient with decreased or absent sensation), or as a complication of urethral surgery.
The treatment algorithm for female urethral stricture is not as well defined as that for stricture in the male. Perhaps this discrepancy is attributable to the relative rarity of stricture disease in women, especially in cases of blunt pelvic trauma. Because of the short length of the female urethra, its anatomical position behind the pubic arch, and its relative mobility, the incidence of stricture following trauma in females is low (0% to 6%). More commonly, stricture disease in women is seen after endoscopic or open urethral surgery, urethral dilation, or pelvic radiation therapy for gynecological malignancies. Generally, repair of stricture disease is divided into endoscopic and open repairs, with the use of local tissue flaps or graft interposition. Because of the relatively short length of the female urethra (approximately 4 cm), stricture excision and end-to-end urethroplasty is not a feasible option. Distal and midurethral strictures may be treated with dilation or enlarged endoscopically with a cold knife or holmium laser. Treatment with dilation is usually a long-term commitment, and dilation can be done by the urologist or by the patient using intermittent self-catheterization. Endoscopic treatment, generally used for midurethral strictures, can be attempted for short strictures (<1 cm), although the failure rate is quite high. In most cases we prefer urethral reconstruction as the primary treatment.
This chapter describes urethral reconstructive options based on the anatomical location of the urethral lesion: distal, middle, or proximal urethra or bladder neck. Distal lesions are usually caused by strictures (including meatal stenosis) and urethral prolapse. Midurethral lesions generally result from strictures or distal urethral ablation. Proximal urethral or bladder neck lesions are due to complete bladder neck incompetence (usually as a result of trauma or prior surgery), extensive urethral ablation, or rarely stricture disease.
Distal Urethral Reconstruction
Stenosis or stricture of the distal urethra in women often presents with lower urinary tract voiding and storage symptoms (decreased force of stream, prolonged or incomplete emptying, and frequency and/or urgency). Distal stricture can be seen following traumatic urethral instrumentation and endoscopic procedures or radiation therapy to the pelvis or vulva for gynecological malignancy; it also occurs in postmenopausal women with significant vaginal atrophy from estrogen deficiency or with vulvar dystrophy. The diagnosis of a functional urethral stricture can be made using a combination of patient history (symptoms), physical examination findings (obvious scarring and/or the inability to pass a urethral catheter), endoscopy, radiography (voiding cystourethrography), and urine flow evaluation (decreased or abnormal flow). In cases of uncertainty videourodynamic testing can be helpful (Fig. 12-1). The two most common types of urethral reconstruction that we perform are distal urethrectomy with advancement meatoplasty, used for very distal strictures (generally involving the distal 1 cm of the urethra), and Blandy urethroplasty, used for lesions up to 1.5 to 2.0 cm proximal to the urethral meatus.
Figure 12-1 Videourodynamic study for a woman with frequency, urgency, and incomplete bladder emptying with poor flow. A, Pressure-flow study shows a stable, compliant bladder with high-pressure, low-flow voiding consistent with obstruction. Note that the patient was tested multiple times for stress urinary incontinence (SUI), which she did not have. B, Fluoroscopic image taken during a stress maneuver shows the level of continence at the bladder neck. This is important for determining the type of reconstruction. Fluoroscopic image taken during voiding shows an extremely dilated proximal and mid-urethra narrowing in the more distal urethra (arrow). Endoscopy confirmed the stricture to involve the distal 1.5 cm of the urethra.
Surgical Technique for Distal Urethrectomy With Advancement Meatoplasty
Meatotomy can be performed to treat distal stenosis by simple ventral incision of the meatus and suturing of the cut end of the meatus to the vaginal wall. However, in our experience, circumferential distal urethrectomy and advancement meatoplasty works best for distal strictures and urethral prolapse. The technique can be applied to meatal stenosis and strictures within approximately 7.5 mm of the meatus (Video 12-1).
1. The extent of the stricture is identified. If desired, interrupted absorbable sutures can be placed in the more proximal, healthy urethral mucosa (at least 2 mm proximal to the strictured segment) at the 6 and 12 o’clock positions so that the mucosa does not retract inward. A nasal speculum can assist in identifying healthy mucosa. When the urethral meatus is severely narrowed, an initial ventral incision may be necessary to determine the extent of the stricture.
2. A circumferential incision is made around the urethra at the mucosal-epithelial junction, and the urethra is dissected off the periurethral fascia for the extent of the stricture.
3. The distal urethra and meatus are excised.
4. Healthy urethral mucosa is then advanced and circumferentially sutured to the vaginal epithelium in an interrupted fashion with 4-0 polyglycolic acid (PGA)* or poliglecaprone 25 (Monocryl) sutures. This creates a neomeatus with well-vascularized, nondiseased mucosa.
5. Depending on the degree of reconstruction, a urethral catheter may be left in place for 1 to 3 days postoperatively. This is particularly useful because postoperative swelling may cause urinary retention.
In adult women urethral prolapse can occur as a result of habitual straining to defecate or void but sometimes may have no clear cause. Urethral prolapse is characterized by a circumferential protrusion of the urethral mucosa (Fig. 12-2); in contrast, an inflammatory urethral caruncle usually occupies one or two quadrants of the urethra (Fig. 12-3). Urethral prolapse often is asymptomatic and requires no treatment. However, sometimes it can bleed or cause obstructive voiding symptoms requiring intervention. Surgery for urethral prolapse is similar to the procedure described earlier for distal urethrectomy with advancement meatatoplasty, except that the prolapsed urethra needs to be mobilized only to the mucosal-epithelial junction. After the prolapsed urethra is excised, a circumferential reapproximation as described previously is performed at the site of the original urethral meatus. In the case of a urethral caruncle, simple excision of the inflammatory mass with reapproximation of the cut mucosal edge to the epithelium is usually all that is necessary.
Figure 12-3 Urethral caruncle. The inflammatory tissue occupies the left side of the urethral meatus.
Case #1
View Video 12-1
A 59-year-old women presents with decreased force of stream and incomplete bladder emptying. She has had these symptoms for about 5 years and was previously diagnosed with urethral meatal stenosis (etiology unclear). She has been managed with periodic urethral dilations and topical estrogen. Initially, dilations relieved symptoms for about 6 months, but now they only last about 3 weeks. She is not interested in doing self-catheterization to keep the stricture open. Cystourethroscopy shows a scarred distal urethra (about 0.5 cm), and the rest appears normal. She elected to have definitive treatment with excision of the scarred distal urethra and an advancement meatoplasty, which is feasible due to the distal location of the stricture (see Video 12-1).
Surgical Technique for Blandy Urethroplasty
For strictures longer than 1 cm and those that originate in the mid-distal urethra, we prefer to perform Blandy urethroplasty. This procedure, which uses a proximally based vaginal pedicle flap, was originally described by Blandy but not reported in the literature. A description was subsequently published by Bath Schwender et al. The procedure (Video 12-2) is applicable to strictures that extend up to 2 cm from the urethral meatus. Blandy urethroplasty re-creates the ventral portion of the urethral meatus and replaces the distal ventral urethra with a flap of vaginal wall. The surgical steps are as follows:
1. The urethra is catheterized with a 14F catheter if possible, but a smaller catheter may be used if necessary.
2. An inverted-U incision is made in the anterior vaginal wall with the apex of the U at the urethral meatus (Fig. 12-4, A).
3. With sharp dissection, a proximally based vaginal flap is raised that is the approximate length of the stricture (2 to 3 cm) (see Fig. 12-4, B).
4. The proximal limit of the stricture is identified, which can be done by inserting a nasal speculum into the urethral meatus. The stricture is incised ventrally at the 6 o’clock position (see Fig. 12-4, C). Cystoscopy can also be used to aid in determining the limit of the stricture.
5. The apex of the vaginal flap is advanced to the apex of the incised urethra and is sutured in place with 4-0 PGA sutures (see Fig. 12-4, D). The edges of the vaginal flap are approximated to the urethral mucosal edges using interrupted 4-0 PGA or poliglecaprone 25 sutures (see Fig. 12-4, E).
6. A 14F to 16F Foley catheter is left indwelling for several days.
Figure 12-4 Blandy urethroplasty. A, The vaginal flap is outlined with a marker. B, The proximally raised flap is created (arrow shows distal end of the flap). C, The entire stricture is cut ventrally at the 6 o’clock position. D, The apex of the flap is sutured to the proximal cut edge of the stricture. E, Completed urethroplasty.
Related posts:
Pelvic Organ Prolapse: Introduction, Nonsurgical Management, and Planning of Surgical Repair
Vaginal Incisions and Dissection
Treatment of Obstruction Following Stress Incontinence Surgery
Indications and Techniques for Vaginal Hysterectomy for Uterine Prolapse
Avoiding and Managing Vaginal Surgery Complications—A Series of Case Discussions
Vaginal Repair of Enterocele and Apical Prolapse
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