Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell...

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

Transcript of Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell...

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

Urethral Reconstruction

Jerry G. Blaivas, MDClinical Professor of Urology

New York Hospital Cornell Medical Center

Adjunct Professor of UrologySUNY-Downstate Medical Center

Page 2: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Indications for Reconstruction

• Urethro-vaginal fistula

• Urethral stricture

• Congenital abnormalities

Page 3: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Etiology

Page 4: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Complication of Urethral Diverticular Surgery

Page 5: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Fistula

diverticulum

Page 6: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 7: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Complication of Synthetic Sling

Page 8: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Granulationtissue

Fistula

Page 9: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Complication of Colporraphy

Page 10: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Ureteralorifices

Page 11: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Stoneson sutures

Foley catheter

Fistula

Page 12: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Sterile Abscess from Periurethral Injection

Page 13: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

meatus

Sterile abscess

Page 14: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Complication of Pelvic Fracture

Page 15: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 16: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Complication of Foley Catheter

Page 17: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 18: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Squamous Cell Carcinoma

Page 19: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 20: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Idiopathic Urethral Stricture

Page 21: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 22: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Diagnosis

• Usually evident on vaginal exam as– urethro-vaginal fistula– partial or complete loss of urethra

• Sometimes not so obvious, butdiagnosed by occluding meatus andobserving urine loss proximally

Page 23: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Diagnosis

• So, be aware of possibility of urethal damage when there is incontinenceafter:• vaginal / urethral surgery• difficult childbirth• pelvic fracture

• Diagnosis confirmed by cystsoscopy

Page 24: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Urethral Reconstruction

• Retropubic– Posterior bladder flap

(Young-Dees-Leadbetter)

– Anterior bladder flap(Tanagho)

• Transvaginal

Page 25: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 26: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 27: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 28: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 29: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 30: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 31: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 32: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 33: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 34: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 35: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 36: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 37: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 38: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 39: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 40: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 41: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 42: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 43: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 44: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Labiamajora

Labiamajora

Bladder neck

Page 45: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 46: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 47: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 48: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 49: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 50: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Vaginal Repair• Primary closure

• Flaps

– Lateral vaginal pedicle flap

– Advancement flap

– Labial minora peninsula pedicle flap

– Labial minora island pedicle flap

• Buccal mucosal graft

Page 51: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 52: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 53: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 54: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 55: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Dorsal urethral incision

Page 56: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Buccal graft

Page 57: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Buccal graft

Page 58: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Buccal graft

Page 59: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 60: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Judicious Use of VascularizedPedical Flaps

• Martius labial fat pad

• Omentum

• Rectus abdominis

• Gracilis

• Singapore

Page 61: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 62: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 63: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 64: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 65: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 66: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 67: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.
Page 68: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Results of SurgeryAuthor # Cure Fistula Continent

Amundsen, 2003 9 100% 56%

Flisser, 2003 74 93% 87%

Clemens, 2000 14 100% 43%

Elkins, 1990 20 90% 50%

Hamlin, 1969 50 98% 80%

Kobashi, 1999 34 100% 20%

Leng, 1998 18 89% 89%

Page 69: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Potential Complications

• Urethral obstruction

• Hemorrhage

• Ureteral obstruction

• Vesciovaginal fistula

• Sphincteric incontinence

Page 70: Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate.

Conclusions

• Vaginal repair is possible in almost all

patients

• Most patients with pre-op SUI shouldhave synchronous anti-incontinenceop +/- Martius flap

• Successful outcome is achievablein over 85% of patients


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