Experiences With Female Urethral Reconstruction

Vol. 102, Aug. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright @ 1969 by The Williams & Wilkins Co.

EXPERIENCES WITH FEJ\IALE URETHRAL RECONSTRUCTION LELAND R. ELLIS

AND

CLARENCE V. HODGES

From the University of Oregon Medical School Hospitals and Clinics, Portland, Oregon

suggested the use of ileal segrn.ents for replacement of involved or absent portions of the urethra1 Leadbetter has reported an excellent review of the literature pertinent to operative correction of incontinence. 2

Even though circumstances requiring total reconstruction of the female urethra are uncommon, the degree of patient discomfort from associated incontinence demands intensive effort to provide relief. Various reconstructive procedures have been used for congenital urethral aplasia, urethral and vesicovaginal fistulas and traumatic urethral injuries from pelvic fracture or obstetric manipulation. Occasionally, indications have

REVIEW OF LITERATURE

Vaginal flap techniques. A vaginal flap technique was reported by several early authors (fig.

B

D Fm. 1. Vaginal flap technique (Harris). A, vaginal flap outlined. B, surrounding tissue freed to permit formation of tube from vaginal flap. C, urethral tube constructed over catheter. D, closure of lateral tissue over reconstructed tube. included instances of urethral carcinoma, bladder exstrophy and epispadias. Normally, techniques have involved the use of vaginal or bladder flaps constructed into tubes or urethral tubularization procedures. Experimental work has also Accepted for publication July 1, 1968 Read at annual meeting of Western Section, American Urological Association, Reno, Nevada, April 21-25, 1968.

1).3 A flap is elevated and fashioned as a tube of proper diameter, extending from the proximal 1 Kimura, C., Harada, N. and Tatsumi, W.: Antepubic vesicoileal-neourethrostomy. J. Urol., 77: 227, 1957. 2 Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J. Urol., 91: 261, 1964. 3 Harris, S. H.: Reconstruction of the female urethra. Burg., Gynec. & Obst., 61: 366, 1935.

214

215 Tube flop urethral segment \

Fw. 2. Modified vaginal flap technique (Woodard and Marshall). A, thick asymmetric vaginal flap outlined and mobilized. B, formation of tube with distal orifice in normal anatomic position. C, sagittal view displays elongated urethral segment and anterior vesicourethral suspension depicted by arrow.

orifice to a distal site normally situated anatomically. A variant of the vaginal flap method is that described more recently by Woodard and Marshall (fig. 2) .4 They used an eccentric vaginal flap as well as a Marshall-Marchetti anterior vesicourethral suspension." All vaginal flap techniques represent attempts to gain continence creating a long urethral segment to accentuate peripheral resistance. The addition of a vesicourethral suspension attempts to improve results providing fixation, elevation and tightening of the vesical neck. Unfortunately, and fistulas complicate vaginal flap and reduce their effectiveness. Bladder 1Ar:11,n1,rn11•is An anterior ,rnll blad4 vVoodard. J. R and ::Vfarshall. V. F.: Rec on struction of· the female urethra to reduce posttraumatic incontinence. Surg., Gynec. & Obst., 113: 687, 1961. 5 l\1arsha1L V. F., Marchetti, A. A. and Krantz, K. E.: The correction of stress incontinence by simple vesicourethral suspension. Surg,, Gynec. & Obst., 88: 509, 1949.

der flap was first used by Barnes 6 and later Y oung.7 A flap tube is constructed and brought under the symphysis pubis to approximate B normal urethral location (fig. A modification of the bladder flap technique was described by Tsuji and associates (fig. 4) Two operations are done. A flap is elevated at the first operation. After 5 to 6 weeks the flap has assumed a tubular configuration in continuity with the bladder and the upper end is detached and brought to the vaginal vestibule under the symphysis pubis. Bladder fiap tubes represent attempts tc create an artificial urethra in continuity with the 6 Barnes, R. vV, and vVilson, 11/. W : Reconstruction of the.urethra with a tube from bladder flap. Urol & Cutan. Rev., 53: 604, 1949. 7 Young, B. W. and Mills, R. L: Artificial urethra constructed from a bladder flap: preliminary report. Plast. & Reconstr. Surg., 12: 279, 1953, 8 Tsuji, I., Kuroda, K, and Ishida., H.: A new method for the reconstruction of the urinary tract: bla.dder flap tube. J. Ural., 81: 282, 1959.

216

ELLIS AND HODGES

"

;<

l' ¥.

',

-·.

~

,t(,.,~

---">+,-'_~,.'..~(; _.- - /

~ t\: / ~ /)~, FIG. 3. Bladder flap technique (Young). A, formation of bladder flap. B, construction of bladder flap urethral tube. C, completion of bladder flap urethra, using fine chromic gut sutures and placed under symphysis pubis with fixation at vaginal introitus.

C

FIG. 4. Modified bladder flap technique (Tsuji). A and B, first operation: bladder strip outlined (A) and elevation of bladder strip with closure of bladder incision beneath strip (B). Small open defect remains above and below. C and D, second operation done 5 to 6 weeks after first: tube formed from previous bladder strip (C) and bladder tube detached at superior aspect and turned down under symphysis pubis to vaginal introitus (D).

bladder, in the hope that a muscular tube will provide sufficiently increased resistance to overcome incontinence. Other factors such as surrounding tissue pressure, flap angulation and bladder neck fixation are also considered important. However, such tubes do not act as an effective sphincter in the dependent infrapubic position. The obligatory creation of a bas-fond bladder configuration is an undesirable facet of the procedure. More associated elastic tissue is required for consistent results than is provided by the typical bladder flap. Urethral retubularization. A representative urethral retubularization technique was used by Leadbetter (fig. 5) .2 • 9 Parallel incisions are made in the floor of the bladder after proximal ureteral reimplantations have been done. A long proximal tube is constructed and trigonal muscle is incorporated. This incorporation of trigonal muscle in conjunction with the elongation is felt to provide continence. Satisfactory results are reported with the use of such a technique, but there is limitation to its application for all circumstances. The technique originally used by Lapides in 1 9 Leadbetter, G. W., Jr. and Fraley, E. E.: Surgical correction for total urinary incontinence: 5 years after. J. Ural., 97: 869, 1967.

FEM.ALE URETHRAL RJ,JCONSTRUCTION

Frn. 5. Urethral retubularization (Leadbetter). A, bladder opened and right ureter reimplanted proximally. Dotted line shows intended incision which when combined with similar incision on left side creates urethral flap. B, imbrication of urethral layers to form elongated urethral segment. Figure shows both ureters reimplanted proximally. Dog-eared flaps not excised but incorporated in closure of a.nterior bladder wall. C, closure of bla.dder with completed urethral retubularization and suprapubic tube in place. D, cross-section view of reconstructed urethra shows imbrication of layers.

FIG. 6. Female urethral reconstruction (Lapides) A, dotted line displays intended transverse suprapubic incision. B, bladder neck and urethral remnant exposed. Dotted line indicates margins of combined anterim· vaginal wall, urethral flap in continuity with bladder. Distal end of flap is transected.

onrselves with modifications in case10 and used a. group of 6 patients, is an outgrowth of studies on the structure and function of the internal vesical sphincter.11 The internal sphincter is a 1 c. Lapides, J,: Reconstruction of damaged urinary sphincter in a female child. J. U rol., 91: 58, 1964. 11 Lapides, J.: Structure and function of the internal vesical sphincter. J. Urol., 80: 341, 1958.

tubular structure composed of extensions of bladder smooth muscle and associated elastic tissue synonyrn.ous with the female urethra. According to Laplace's law the NJu.111c,,e1 marntains continence via resistance presented to urinary outflow- which varies directly with length of urethra and adherent tension of the urethral walls and inversely with luminal diameter of the

218

ELLIS AND HODGES

urethra. To achieve sustained continence a combination of proper urethral resistance, optimal urethral length and appropriate luminal diameter is required. Integrity of cortico-regulatory tracts supplying inhibitory influences to the lower motor neurons of the bladder is also necessary. METHODS AND MATERIALS

The method under discussion is accomplished by a combined abdomino-vaginal approach. A transverse suprapubic incision is made with wide exposure of the bladder neck and anterior urethral region. A thick flap of anterior vaginal wall and urethra is outlined in continuity with the vesical neck and then extended inferiorly (fig. 6). This flap is wide-based to insure adequate vascularity. Width of the flap in millimeters equals the intended caliber of urethral lumen. A urethral tube is then constructed, usually over a 14 or 16Fr. catheter, using 2-zero interrupted chromic sutures (fig. 7). The anterior vaginal wall defect is closed with interrupted 2-zero chromic sutures. A small inferior defect remains for attachment of the urethral tube. The distal spatulated end of the tube is then sutured to the vaginal mucosa with

Fm. 7. Female urethral reconstruction (Lapides technique, continued). A, urethral flap turned back after transection and tube is reformed. Anterior vaginal wall defect closed except for new urethral meatus. B, rectus pedicle flap has been constructed and swung down over vaginal suture line and sutured to vaginal wall.

Fm. 8. Female urethral reconstruction (Lapides technique, continued). A, reconstructed urethra lies on top of rectus pedicle flap and is sutured in place to defect in vaginal wall. B, sagittal view of completed operation displays relationship of reconstructed urethra to rectus flap and anterior vaginal wall.

4-zero chromic sutures, after first interposing an inferiorly based rectus muscle pedicle flap between the posterior wall of the reconstructed urethra and the now closed anterior vaginal wall defect (fig. 8). A small Penrose drain is placed between the vagina and urethra and brought to the skin via the retropubic space. A vaginal pack is used for 24 hours to obliterate dead space. The urethral catheter utilized during reconstruction is then removed. Suprapubic cystostomy drainage is instituted for 3 to 4 weeks postoperatively after which time the tube is clamped for trial voiding. Urethral reconstruction by the previously described technique has been done on 6 female patients from 3 to 53 years old. All patients had total incontinence but no neurogenic component, and all but one had adequate bladder capacity. Operative indications included 4 cases of acquired urethrovaginal fistulas and single cases of congenital urethral agenesis and vesico-perineal fistulas with attenuated urethra. Five patients had previous unsuccessful reparative attempts. Initial urethral length varied from O to 3 cm. and urethral caliber ranged from non-existent to more than 30Fr. Ureterovesical reflux was not

2H)

FElVIALE 1JRETHRAL RECG~¾JS-TRUC'l'ION TABLE

II

Patient

Age (yrs.)

'I

Preop. Diagnosis

Previous Operation

S.M.

1--3-1' Urethral agenesis

No

P.R.

I

Yes

S.R.

8

I ii

I

M.N.

I

Type of ReConstruction

f

II

Complications

Initial Urethral Length

Initial Urethrnl Caliber

;_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,_<_c_m_.)_ _ _ _ _ _ _ _

____ I

.J.R.

1. Review of cases

10

29

40 53

Vesicoperineal fistulas ,vith short urethra Urethrovaginal fistula with patulous urethra Urethrovaginal and vesicovaginal fistulas

I I

Lapides

Prolonged suprapubic drainage Lapides Postop. wound infection, neoroeatal stenosis Modified Lapides'· None I

Yes

0

1.0

Absent urethra 20 Fr. 24 F:r,

I

Yes

I/ Post-partum urethral destruction Urethrovagina.1 fistula

Lapides (initial op.) Vaginal flap (sec-

Yes

ood~.) Modified Lapidest

Yes

Lapides

I

Vaginitis, total urethral slough

None

I Vaginitis, I slough

partial urethral

Absent urethra

1.0

30 Fr

1

28 Fr.

·;: Excision of longitudinal nrethral strip-rectus flap used" t No interposed rectus flap. TABLE

2. Postoperative evaluation: 6 cases of urethral reconstruction ;

I

Pa!tient

I I

Continence

I

I

I

• 1

I

I

:

I

i Slight im- I 1

P.R.

Night

Day

-- ; S_JL

Urethral Stress Length (cm.)

Unchanged

Bladder Capacity (cc)

I Urethral Caliber I (Fr.)

-1~1-I

I

Yes

2.5

I

I

25-50

14

0

I Unchanged

2. 0

No

I I

S.R,

I Good 1

I

KN. M.K.

Good

225

14

10-15

200

I !

U-V Reflux

0

200

30

4. 0

Yes

20

Good Unchanged

No Yes

I I '

3. 0 2. 0

I

250 i 3 250 100

20 28

I

I

I

I

up

(mos.)

I, ____ ,:_______

Neg. Abnormal blad-1 der contour

No

I Partial I cure I

Neg. Normal bladder neck, narrov,,red urethra Neg. Normal

No

I No

Neg. Patulous proxi1nal urethra

No

I

12

cure

PartiaJ cure Partial cure

No Cure Neg I Normal Neg. Information not i Rt. distal Partial available ureter cure I

5

I

iI Partial

I

1-n-2

Follow-

I Over-all Result~' I

I

Lnchanged Slight i1nprovernent

hrs. Good Good 4-6 hrs.

14

3

No

gram

,

I J.R.

Cystourethro-

-- -- --

proven1entj 1-n2 I hrs. Good 4 hrs.

Residual UrinUrine alysis (cc)

rn I

I

5

i

I

18 42

I

"'Cure-no urine leakage even 1vith stress, no residual urine, no reflux and no urinary tract infection. Partial cure-some incon~ tinence (usually stress or nocturnal). Failure-constant urinary leakage which ,vill require urinary diversion.

present and upper tracts were normal in all cases 1). RES'CLTS

Results were considered cure, partial cure or failure (table One patient had a complete cure and 5 patients had partial cures. Of these 5 pal patient had an early postoperative slough of the original reconstruction but achieved urinary control following a partially successful vaginal flap procedure. Another patient had partial postoperative slough of the basic reconstruction but is presently considered sufficiently improved

to qualify as a partial cure. Both of the~e complications occurred in patients who manifested severe vaginitis postoperatively. It is that suboptimal flap vascularity was a factor. After some initial delay, diurnal continence was improved in all patients. However, only 2 have achieved optimal nocturnal control a.nd postoperative stress incontinence 1s present in 3 cases. Postoperative urethral length varies from 2 to 4 cm. Satisfactory urethral caliber for age was achieved in all but 2 cases. One patient now re-

220

ELLIS AND HODGES

quires urethral dilatation every 3 months. Bladder capacity is adequate except for one case displaying a reduced preoperative capacity. Postoperative urine cultures and urinalyses have been negative and significant ureterovesical reflux or upper tract deterioration has not occurred. Cystourethrographic findings have revealed structural and functional adequacy in most cases. DISCUSSION

The urethral reconstructive method used fulfills basic criteria essential for a satisfactory result. Anatomic continuity of the bladder neck and urethra is maintained. A well-vascularized and innervated musculo-elastic flap of normal length is constructed which mimics the structure and function of the normal female urethra. The method is adaptable to a variety of pathologic lesions. The use of a rectus pedicle flap reduces the likelihood of fistulas. The procedure has not been completely successful. However, since the only effective therapeutic alternative for these patients would involve various diversionary procedures, initial attempts to restore anatomic continuity and function are warranted. Despite the lack of perfect results, patients and parents are generally pleased with the improvements. Acceptable levels of social activity have been attained. This fact alone offered encouragement to continue efforts with this procedure. An analysis of failures suggests the need for careful attention to certain details of technique.

Wide-based, well-vascularized flaps must be created. Poor blood supply was probably contributory in 2 cases of early postoperative urethral slough. Vigorous attempts to combat postoperative infection are required. The width of the constructed flap must be carefully controlled to minimize any tendency for postoperative stricture. Also, 1 patient presently has a patulous vesical neck after reconstruction which contributes to a continuing state of partial incontinence, further indicating that a uniform luminal caliber should be obtained. Because some degree of unavoidable tissue retraction must be expected, no tension is permitted in fixing the reconstructed urethra to its location at the vaginal introitus. We attempt the reconstruction of a urethral segment longer than 3 cm., but have not always found correlation in the form of entirely satisfactory postoperative results. Patients with neurogenic vesical dysfunction or fibrotic bladders of decreased capacity are not candidates for this procedure. SUMMARY

Our experience with the Lapides female urethral reconstructive technique in 6 cases of total urinary incontinence is presented. Only 1 case represents a total cure but partial cures have been attained in the remainder. With continued experience certain technical factors will be overcome and improved results may be expected. The degree of success attained justifies continued use of this procedure.