DIAGNOSIS

Although urethral damage is rare, it should be suspected in certain clinical scenarios: 1) urinary incontinence after pelvic surgery, particularly urethral diverticular surgery, incontinence surgery, anterior colporrhaphy, and Kelly plication; 2) large urethral diverticula; 3) urinary incontinence or other lower urinary tract symptoms after pelvic fracture; 4) urinary incontinence that occurs around an indwelling urethral catheter; and 5) urinary incontinence or lower urinary tract symptoms in patients who have undergone pelvic irradiation. Most patients with significant damage to the urethra have urinary incontinence, but they occasionally present with overactive bladder or voiding symptoms. In patients who have undergone recent synthetic sling placement, urethral erosion should be suspected when the patient has intractable vaginal or urethral pain, recurrent urinary tract infections, vaginal discharge, or hematuria.

For patients with incontinence, the first step in diagnosis is physical examination with a comfortably full bladder; the physician should witness urethral leakage of urine with his or her own eyes before a definitive diagnosis of sphincteric incontinence is made. On more than one occasion, we have diagnosed a urethra-vagina fistula in a woman already scheduled for anti-incontinence surgery because the fistula was misdiagnosed as sphincteric incontinence. When incontinence is observed from the urethral meatus and there is reason to suspect a fistula, the examination should be repeated with a finger obstructing the meatus to observe for leakage more proximally from the fistula itself. Conversely, some women with urethrovaginal fistula have no symptoms, particularly when the fistula is in the distal half of the urethra and the vesical neck remains intact. These fistulas usually are discovered incidentally on physical examination and need no treatment. For examination, we find it best to use the posterior blade of a vaginal retractor to depress the posterior vaginal wall downward. In many instances, the anatomic deformity is obvious, or urinary leakage may be seen proximal to the urethral meatus.

The next step in diagnosis is cystourethroscopy to evaluate the extent of the fistula and to assess the remainder of the urethra, particularly the length, viability, and sphincteric function of the proximal urethra. Visualization of the urethra is best accomplished with a 0- or 30-degree lens and a cystoscope with a 90-degree beak or flexible cystoscope. Cystourethroscopy is the modality of choice for diagnosing urethral erosions after sling placement.

When a urethral injury is diagnosed, an equally high index of suspicion should be maintained for concomitant abnormalities such as vesicovaginal or ureterovaginal fistula, ureteral obstruction, vesicoureteral reflux, and sphincteric deficiency. A careful evaluation to exclude each of these conditions should be undertaken before surgery. Detrusor function may be compromised in the form of low bladder compliance, impaired detrusor contractility, or detrusor overactivity. However, it is difficult to diagnose these conditions preoperatively, and even when present, they should not be surgically treated when the damaged urethra is repaired because most subside spontaneously after successful repair of the urethra.

Urethral stricture is a rare complication of pelvic fracture or other trauma, multiple urethral dilations, prior surgery, and pelvic irradiation. This condition is usually diagnosed by cystoscopy, but it is occasionally found by urodynamic study.

MANAGEMENT

Indications for Surgery

The mere presence of extensive urethral damage is not an indication for surgery. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction, but neither is an absolute indication. Urethral erosions after urethral synthetic sling surgery are a definite indication for surgery because of the presence of foreign material in contact with the urinary tract. If there is an associated condition such as a vesicovaginal fistula, it should be repaired at the same time.

Urethral reconstruction is technically demanding and requires a considerable degree of experience and skill. In inexperienced hands, the risks may be prohibitive, and when there is insufficient local tissue for reconstruction, it may be more prudent to consider urinary diversion than urethral reconstruction, particularly when complications of radiation therapy are suspected.

When sphincteric incontinence is present preoperatively, we believe that it should be surgically corrected at the time of urethral reconstruction. We prefer to construct an autologous fascial pubovaginal sling ^9,¹⁰ with an interposed labial fat pad flap^7,^9,^11,¹² between the sling and the reconstructed vesical neck. Others have recommended transvaginal bladder neck suspension,¹³ but in our experience, this has a failure rate of about 50%.⁹ Although it is tempting to use a synthetic sling, we do not recommend it because of the possibility of infection or erosion. It may be prudent to use allograft or xenograft tissue for the sling, but because of lack of long-term follow-up and some early failures, we have chosen these kinds of tissue grafts very selectively.^4,⁸

There are three general approaches to urethral reconstruction: anterior bladder flaps,^13,¹⁴ posterior bladder flaps,¹⁵ and vaginal wall flaps.^1,^7,^12,¹⁶^–¹⁸ These techniques appear to be comparable with respect to creation of a neo-urethra. However, when the vesical neck and proximal urethra are involved, which is usually the case, postoperative incontinence rates of about 50% are to be expected unless a concomitant anti-incontinence procedure is performed.¹³^–¹⁵ We believe that vaginal reconstruction is considerably easier and faster, is much more amenable to concomitant anti-incontinence surgery, and is associated with much less morbidity than the bladder flap operations.

Timing of Surgery and Preoperative Management

In the past, much controversy surrounded the timing of surgical repair. For decades, it had been taught that surgery should be delayed for 3 to 6 months or even longer to allow adequate time for tissue inflammation and edema to subside. In our experience, surgery can be safely performed as soon as the vaginal wound is free of infection and inflammation and the tissues are reasonably pliable.

Principles of Surgical Technique

In women with damaged urethras, the vaginal tissue is often scarred, fibrotic, and ischemic. Before surgery, careful examination of the vagina is necessary to determine the actual extent of urethral tissue loss and to assess the availability of local tissue for use in the reconstruction. In most instances, there is sufficient tissue in the anterior or lateral vaginal wall that can be mobilized and used for the reconstruction.^1,^7,^9,^12,^13,¹⁶^–¹⁸ Occasionally, it may be necessary to use an adjacent labial^16,¹⁹ or thigh flap.^20,²¹ Alternatively, an anterior bladder flap can be used.¹³

In patients undergoing urethral reconstruction for urethral erosion after synthetic sling placement, attempts should be made to remove all synthetic material, including nonabsorbable mesh and sutures.² When infection is absent, bone anchors can be left in place because of the difficulty in retrieving them. However, if infection exists, it is advisable and usually straightforward to identify and remove bone anchors. The urethra usually can then be reconstructed primarily.

After reconstruction of the urethra, it is often advisable to interpose a well-vascularized pedicle flap over the site of the repair. Sources include labial,^9,^13,²² rectus abdominal,^17,²³ gracilis,⁷ and thigh tissue.^20,²¹ In most patients, nothing more than a labial fat pad graft is necessary (Fig. 80-1).

Figure 80-1 Labial fat pad graft—a Martius flap. A, A vertical incision is made over the labia majora, and the fat pad is mobilized. The initial dissection should begin beneath Scarpa’s fascia. If the plane is more superficial than that, troublesome bleeding may be encountered from thin, wide, flat veins that are difficult to visualize. The fat pad is mobilized anteriorly, suture ligated and divided, and the end of the suture is left long. B, A tunnel is made underneath the vaginal epithelium, and the fat pad is pulled into place with the long suture (arrow). C, It is sewn in place over the suture lines of the neo-urethra.

(Modified from Mattingly RF, Thompson JD: Ch. 27. In Mattingly RF, Thompson JD [eds]: TeLinde’s Operative Gynecology, 6th ed. Philadelphia, JB Lippincott, 1985, p 665.)

The most important principles of surgical repair include clear visualization and exposure of the operative site; creation of a tension-free, multilayered closure; an adequate blood supply; and adequate bladder drainage. Bladder drainage is best accomplished with a suprapubic catheter, which should be placed at the beginning of the procedure to avoid damaging the reconstructed urethra. We use a urethral catheter as a stent postoperatively. The catheter must be sewn to the anterior abdominal wall in a gentle curve to avoid putting tension of the suture line.