TABLE 37.1 CAUSES OF URETHRAL DAMAGE IN A CASE SERIES OF 74 WOMEN | ||||||||||||||||||||||||
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or symptoms suggestive of bladder neck injury. VUD helps to diagnose problems with bladder function such as the presence detrusor overactivity, abnormal bladder compliance, bladder capacity, bladder outlet obstruction, ureteral reflux, and urethral stricture and can identify concurrent vesical fistulas or diverticula.
TABLE 37.2 GENERAL PRINCIPLES OF URETHRAL RECONSTRUCTION | |||||||
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Small urethral defects: A tension-free primary closure (Fig. 37.1) is often adequate for small urethral defects. A 14Fr or 16Fr urethral catheter is placed, and the balloon is inflated. The vaginal wall around the fistula is marked and then hydrodissected using sterile saline. The vaginal wall around the fistula is dissected to mobilize a vaginal flap to help with closure (alternatively an inverted U-shaped incision is used). Then the periurethral fascia is dissected and mobilized to expose the urethra. The urethra is closed primarily with interrupted 4-0 or 5-0 absorbable sutures. It is often not necessary to excise the epithelium of the fistulous wall because such tissue can often be mobilized and used as a first layer of closure. This avoids increasing the size of the fistula. The periurethral fascia is then closed over the repair in a perpendicular direction to minimize overlapping of the suture lines. The vaginal wall is then advanced beyond the fistula repair and secured with absorbable sutures ensuring a lack of overlapping suture lines.
Obliterated distal urethral tissue: A U-shaped advancement anterior vaginal flap (Fig. 37.2) is used if the distal urethral is obliterated and no sufficient urethral tissue exists for primary closure. Bilateral parallel incisions are made on the vaginal wall distal to the proximal urethra to the site of the urethral meatus. A flap is dissected of the anterior vaginal wall, advanced, and rotated 180 degrees and is sutured to the incisions on the distal vaginal wall to form the posterior and lateral walls of the neourethra. The urethra is closed over a 14Fr urethral catheter using 4-0 or 5-0 absorbable sutures. The vaginal wall is then advanced and closed primarily.
Extensive loss of urethral tissue: A vaginal wall flap can be employed, as a tube flap (Fig. 37.3), as another available option in the setting of extensive loss of urethral tissue. A wide rectangular area (about 2.5 cm × 3.5 cm) is marked on the vaginal wall at the location of the distal urethra. Incisions are made and then the rectangular vaginal wall flap is mobilized and fashioned into a tube over a 14Fr urethral catheter using 4-0 or 5-0 absorbable sutures. The tube is then connected to the proximal urethra and to the site of urethral meatus using 3-0 absorbable sutures. In this situation, a pubovaginal sling is often used to achieve continence. A rotational flap of the vaginal wall is then mobilized to close the gap of the vaginal wall.
Extensive urethral damage and insufficient vaginal wall: A labia minora pedicle flap (Fig. 37.4) is best suited for patients with this problem. A rectangular flap 3 cm × 3.5 cm is marked on the labium and then it is incised close to the site of the urethral reconstruction and mobilized. A tunnel is created under the vaginal wall and the labium flap is then mobilized with its vascular pedicle and underlying fat and is passed beneath the vaginal wall to the site of the urethra. The flap is then fashioned around a 14Fr catheter in a tension-free manner so that the mucosal surface is facing inward to form the lumen of the future urethra. The vaginal wall is then closed. A Penrose drain is placed in the labial harvest site for 24 hours and the labial skin is closed with 3-0 absorbable sutures. The Foley catheter is left to gravity for 10 to 14 days.
Extensive urethral damage and extensive vaginal wall scarring: An anterior bladder flap can be used as an alternative to a vaginal wall flap in case of extensive vaginal scarring and vaginal wall loss secondary to a large urethrovaginal fistula that precludes using vaginal flaps. However, in this case, a concomitant anti-incontinence procedure should be strongly considered (6) (Fig. 37.5).
![]() FIGURE 37.6 Pubovaginal sling. A: A lower abdominal Pfannenstiel incision is made at the skin crease, and dissection is carried out to the level of the rectus fascia. A 2 to 3 cm wide and 8 cm to 10 cm in length graft is outlined with the incision kept parallel to the direction of the fascial fibers. B: A 2-0 nonabsorbable running horizontal mattress suture is placed across the most lateral portion of the graft, and the ends are left long. C: Each end of the fascial graft is transected approximately 1 cm lateral to the mattress suture. D: Transvaginally, dissection is begun with Metzenbaum scissors in the avascular plane just beneath the vaginal skin. E: The endopelvic fascia is perforated with Mayo scissors with the tips of the scissors directed toward the patient’s ipsilateral shoulder and ensure the tip of the scissors are marching on the posterior aspect of the pubic bone until the retropubic space is entered. F: A Pereyra-Raz ligature carrier or a long tonsil clamp is passed from the abdominal to the vaginal wound lateral to the urethra while protecting the urethra with a finger to bring one end of the graft to the abdominal incision. G: The fascial graft is passed around the urethra and brought to the abdominal wound. H: The long ends of the sling are tied together in the midline under no tension. The labial fat pad, if used, is positioned between the sling and the vesical neck. (A-G from Blavais JG. Pubovaginal sling procedure. In: Whitehead ED, ed. Current Operative Urology. Philadelphia: JB Lippincott Co, 1990:93-101, with permission.)
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