Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology...
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Transcript of Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology...
Urethrovaginal Fistula & Urethral Reconstruction
Jerry G. Blaivas, MDClinical Professor of Urology
New York Hospital Cornell Medical Center
Adjunct Professor of UrologySUNY-Downstate Medical Center
Etiology of Damaged Urethra
Urethral Tic29%
BNS22%
Childbirth4%
Trauma4%
Stricture4%
Synthetic sling27%
COLPORRAPHY10%
Complication of Urethral Diverticular Surgery
Eroded sling
Fistula
diverticulum
Complication of Synthetic Sling
Granulationtissue
Fistula
Complication of Colporraphy
Ureteralorifices
Stoneson sutures
Foley catheter
Fistula
Sterile Abscess from Periurethral Injection
Complication of Pelvic Fracture
Complication of Foley Catheter
Squamous Cell Carcinoma
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
Urethral Reconstruction
• Posterior bladder flap(Young-Dees-Leadbetter)
• Anterior bladder flap(Tanagho)
• Vaginal wall / labial flap
Vaginal Repair• Primary closure
• Lateral flap
–Unilateral vaginal wall pedicle flap
–Bilateral vaginal wall pedicle
• Advancement flap
• Labial minora island pedicle flap
• Buccal graft
Judicious Use of VascularizedPedical Flaps
• Martius labial fat pad
• Omentum
• Rectus abdominis
• Gracilis
• Singapore
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Labiamajora
Labiamajora
Bladder neck
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Vaginal Repair• Primary closure
• Flaps
– Lateral vaginal pedicle flap
– Advancement flap
– Labial minora peninsula pedicle flap
– Labial minora island pedicle flap
• Buccal mucosal graft
Dorsal urethral incision
Buccal graft
Buccal graft
Buccal graft
Buccal graft
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%
Potential Complications
• Urethral obstruction
• Hemorrhage
• Ureteral obstruction
• Vesciovaginal fistula
• Sphincteric incontinence
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