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Urethrovaginal Fistula & Urethral Reconstruction

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Presentation on theme: "Urethrovaginal Fistula & Urethral Reconstruction"— Presentation transcript:

1 Urethrovaginal Fistula & Urethral Reconstruction
Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate Medical Center

2 Etiology of Damaged Urethra

3 Complication of Urethral Diverticular Surgery

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5 Eroded sling Fistula diverticulum

6 Complication of Synthetic Sling

7 Fistula Granulation tissue

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9 Complication of Colporraphy

10 Ureteral orifices

11 Foley catheter Stones on sutures Fistula

12 Sterile Abscess from Periurethral Injection

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14 Complication of Pelvic Fracture

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16 Complication of Foley Catheter

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18 Squamous Cell Carcinoma

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20 Diagnosis High index of suspicion: post-vaginal / urethral surgery
synthetic sling difficult childbirth pelvic fracture Vaginal examination: witness urine loss from urethra Occlude meatus with finger during cough Look for urine loss proximal to meatus Cystoscopy

21 Preoperative Considerations
Accurate diagnosis – SUI vs fistula Recognize associated abnormalities Sphincteric incontinence Urethral diverticulum Periurethral abscess Vesicovaginal fistula Accessibility of local tissue for flap Timing of surgery

22 Intra-operative Considerations
Choice of procedure (usually decided intraop) Assess adequacy of local tissue Adequate operative exposure

23 Urethral Reconstruction
Posterior bladder flap (Young-Dees-Leadbetter) Anterior bladder flap (Tanagho) Vaginal wall / labial flap

24 Vaginal Repair Primary closure Lateral flap
Unilateral vaginal wall pedicle flap Bilateral vaginal wall pedicle Advancement flap Labial minora island pedicle flap Buccal graft

25 Judicious Use of Vascularized Pedical Flaps
Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

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30 Judicious Use of Vascularized Pedical Grafts
Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

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33 Judicious Use of Vascularized Pedical Grafts
Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

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36 Judicious Use of Vascularized Pedical Grafts
Martius labial fat pad Omentum Rectus abdominis Gracilis Singapore

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39 sling Martius flap

40 sling Martius flap

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43 Operative Technique Dorsal lithotomy position Adequate exposure
Outline flaps (burn no bridges)! Tension free, multiple layered closure)

44 Operative Technique Repair of sphincter (usually pubovaginal sling)
Martius or labial flap Vaginal flap to cover wound Suprapubic & Foley catheter

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46 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

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53 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

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58 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

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63 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

64 Bladder neck Labia majora Labia majora

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66 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

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70 Vaginal Repair Primary closure Flaps Buccal mucosal graft
Lateral vaginal pedicle flap Advancement flap Labial minora peninsula pedicle flap Labial minora island pedicle flap Buccal mucosal graft

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76 Dorsal urethral incision

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78 Buccal graft

79 Buccal graft

80 Buccal graft

81 Buccal graft

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83 Results of Surgery Author # Cure Fistula Continent Amundsen, 2003 9
100% 56% Flisser, 2003 74 93% 87% Clemens, 2000 14 43% Elkins, 1990 20 90% 50% Hamlin, 1969 50 98% 80% Kobashi, 1999 34 20% Leng, 1998 18 89%

84 Potential Complications
Urethral obstruction Hemorrhage Ureteral obstruction Vesciovaginal fistula Sphincteric incontinence

85 Conclusions Vaginal repair is possible in almost all patients
Most patients with pre-op SUI should have synchronous anti-incontinence op +/- Martius flap Successful outcome is achievable in over 85% of patients


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