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

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Presentation on theme: "Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor."— 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 Granulation tissue Fistula

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9 Complication of Colporraphy

10 Ureteral orifices

11 Stones on sutures Foley catheter 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 –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 –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 –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 –Lateral vaginal pedicle flap –Advancement flap –Labial minora peninsula pedicle flap –Labial minora island pedicle flap Buccal mucosal graft

64 Labia majora Bladder neck

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66 Vaginal Repair Primary closure Flaps –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 –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

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83 Results of Surgery Author#Cure FistulaContinent Amundsen, %56% Flisser, %87% Clemens, %43% Elkins, %50% Hamlin, %80% Kobashi, %20% Leng, %

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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