- Email: [email protected]
A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results
Journal Pre-proof
A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results Rishi Nayyar MCh Associate Professor , Siddarth Jain MCh Assistant Professsor , Kulbhushan Sharma MS Senior Resident , Sahil Pethe MS Senior Resident , Prashant Kumar MCh Fellow Reconstructive Urology PII: DOI: Reference:
S0090-4295(20)30161-8 https://doi.org/10.1016/j.urology.2019.12.037 URL 21978
To appear in:
Urology
Received date: Revised date: Accepted date:
25 October 2019 3 December 2019 5 December 2019
Please cite this article as: Rishi Nayyar MCh Associate Professor , Siddarth Jain MCh Assistant Professsor , Kulbhushan Sharma MS Senior Resident , Sahil Pethe MS Senior Resident , Prashant Kumar MCh Fellow Reconstructive Urology , A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results, Urology (2020), doi: https://doi.org/10.1016/j.urology.2019.12.037
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Article type Surgical techniques
Title A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results
Authors: Rishi Nayyar, Siddarth Jain, Kulbhushan Sharma, Sahil Pethe, Prashant Kumar
Author information and affiliations 1. Rishi Nayyar, MCh Associate Professor, Department of Urology, AIIMS, New Delhi. 110029 2. Siddarth Jain, MCh Assistant Professsor, Department of Urology, AIIMS, New Delhi. 110029 3. Kulbhushan Sharma, MS Senior Resident, Department of Urology, AIIMS, New Delhi. 110029 4. Sahil Pethe, MS Senior Resident, Department of Urology, AIIMS, New Delhi. 110029 5. Prashant Kumar, MCh 1
Fellow Reconstructive Urology, Department of Urology, AIIMS, New Delhi. 110029
Corresponding Author and contact details Rishi Nayyar Associate Professor, Address: Department of Urology, NMR Block, AIIMS, Ansari Nagar, New Delhi. 110029. India Email: [email protected] Phone: 9811414607, 011-26594884, 011-26593921
Address for reprints Same as above for corresponding author
Sources of support None
Acknowledgements None
2
Abstract word count: 219 Manuscript word count: 2289 Number of figures: 3
Keywords: Bladder neck contracture; Tanagho’s bladder flap; Pelvic fracture; Female urethral stricture A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results
Abstract Objective: To describe a novel tabularized bladder flap technique for repair of post-traumatic obliterate bladder neck and urethral stricture in women. Traumatic genitourinary injury in females is rare, and generally associated with pelvic fracture. Obliterate bladder neck is frequent in such cases. The options for obliterate strictures are limited with Tanagho‘s repair as one option. Limitations of Tanagho’s repair include bladder neck being shifted antero-superiorly posing voiding issues, posteriorly directed suture-line risking fistula formation with vagina and rotational tug of bladder putting tension at suture line. Here we present our initial results with our novel technique. Methods: 3
3 young females with bladder neck obliteration with or without associated uro-genital fistula were operated. A novel U-shaped anterior bladder wall flap was used to fashion a urethral tube and bladder neck. Native bladder neck fibres remained at bladder neck itself after reconstruction without limitation of length of urethral tube and continence outcome. Urogenital fistula was also repaired with omental interposition. Results: 3.5, 3 and 3.5 cm tubes were fashioned in the three cases respectively. No peri-operative complications were reported. Catheter was removed at 3 weeks. All cases had normal voiding and continence at follow up of 15, 7 and 3 months respectively. Conclusions: Our novel flap technique has provided good early results and aims to overcome the limitations of Tanagho’s repair.
Keywords: Bladder neck contracture; Tanagho’s bladder flap; Pelvic fracture; Female urethral stricture
Acknowledgements: None
4
Introduction Pelvic fracture associated urethral injury is less common in females than males (0-6% vs 10% in males).1 This may be explained due to shorter length, greater mobility, and relatively protected location of the urethra in females. Inability to void, urinary incontinence through vagina, hematuria or blood at the introitus in the setting of pelvic trauma should make one suspicious of an associated urethral or bladder injury.1 Unlike direct laceration or less severe blunt injuries, avulsion or distraction injuries of urethra are more commonly associated with major trauma. Immediate repair may not be possible because of non-availability of expertise or condition of patient necessitating management of other injuries on priority. Therefore, many patients are initially managed with suprapubic cystostomy (SPC) and present later with obliterate bladder neck and urethral stricture. Options for such obliterative distraction defects are very limited in females. Traditionally Tanagho’s tube repair from anterior bladder wall is used. However, Tanagho’s repair results in rotational tug of bladder putting tension at suture line, and a further higher placed bladder neck which may jeopardize subsequent voiding. Many such cases require self intermittent catheterization. To overcome these limitations we describe a novel bladder flap technique for bladder neck and urethral loss in females. The anatomical principle of continence described behind Tanagho’s reconstruction is also better preserved with our novel technique.
5
Methods 3 cases who presented with traumatic bladder neck contracture after suffering a pelvic fracture associated injury were considered for reconstruction of bladder neck and urethra without any sling surgery. A retrospective review of these three cases is presented. Institute review board approval was taken for the purpose. All cases had a voiding custourethrogram (VCUG) showing complete block at bladder neck. A detailed examination under anesthesia including urethroscopy, SPC-scopy and vaginoscopy was done in all before the surgical plan was made. Ureteric orifices were ensured to be away from bladder neck scar during the scopy. All cases received pre-operative phenazopyridine to stain the urine and easy identification of ureteric orifices during surgery. After discussing the options and possible outcomes, an informed consent was obtained in all three cases for surgical reconstruction. Individual details and presentation of the cases is provided. Case 1: A 26 Yr old female athlete fell from a moving train and suffered polytrauma 6 years back, sustaining bilateral superior and inferior pubic rami fracture along with compound fracture of femur, tibia and fibula. There was blood at introitus. After initial resuscitation, a failed attempt at urethral catheterization was made. Computed tomography revealed distended high urinary bladder with pelvic hematoma. Open SPC and fixation of leg fractures was done. Since then she was managing on SPC changes and presented to our tertiary care center. External genitalia including external meatus were normal on clinical examination. The bilateral pelvic floor muscle strength was adequate (Oxford scale 5). The vagina in relation to 6
proximal urethra was directly adherent underneath the pubic bone with no intervening urethral tissue. Renal function tests and urine analysis were normal. VCUG showed complete obliteration at bladder neck, normal capacity and right grade 3 vesico-ureteric reflux (Figure 1A). Endoscopic examination under anesthesia showed 2 cm healthy distal urethra, proximally opening into vagina and tethered underneath the bone (Figure 1B). The bladder neck was fibrosed and obliterated. No fistulous opening was seen on cystoscopy. Case 2 A 10 year old girl presented 18 months back after a road traffic accident requiring emergent jejunal resection anastomosis, SPC placement and bilateral internal iliac ligation for expanding pelvic hematoma with fracture pelvis and perineo-urethral injury. After recovering from bowel and orthopedic injuries, she was referred for urethral reconstruction. She had a bladder capacity of 100 cc with blind fibrosed bladder neck and proximal urethral loss similar to first case. Distal 2 cm of urethra was normal ending blindly. Pelvic floor strength was normal. Case 3 A 14 year old girl suffered a road traffic accident 14 months back leading to genital and rectal injury with pelvic fracture. She was resuscitated and SPC was placed in emergency. Subsequently she developed ano-vaginal fistula with intermittent fecal soiling of vagina. Examination under anesthesia with SPC-scopy confirmed bladder neck obliteration and total urethral loss, bladder capacity of 300 cc with high riding bladder, vaginal cicatrization with shelf formation and ano-vaginal fistula.
7
Surgical technique All the cases underwent a novel surgical reconstruction of bladder neck and urethra (Figure 2). An abdominal transperitoneal approach was used in dorsal lithotomy position. Anterior bladder wall was mobilized keeping the suprapubic catheter tract intact. Mobilization of anterior surface was continued in the space of Retzius, and turned posteriorly at the level of bladder neck. Fibrosis is encountered at the bladder neck region, which makes its identification and dissection difficult. Therefore, for a more controlled dissection of bladder neck, it is approached from posterior side as well. For this, a transverse incision was made on the peritoneum behind the bladder in the uterovesical pouch to expose lower segment uterus and cervix. This plane was continued inferiorly between bladder and vagina in the midline, till the level of bladder neck. Both the anterior and posterior planes of dissection were then fused together to lift up the entire bladder neck intact. The posterior plane of dissection between bladder and vagina is generally always preserved and easily developed. This posterior-vesical space was also subsequently utilized for transporting the omentum down for wrapping the repair. The scar tissue was then excised in bits, taking care to spare the anterior vaginal wall and delineate the proximal end of the urethra. Use of a Hegar dilator’s tip to pull the urethra away from underneath the bone aided in both the identification and the dissection of the remnant urethra. The urethra may need sub-symphyseal dissection underneath the periosteal plane because it may be tethered to the bone due to previous trauma. Normal muscular vascularized 8
wall of the urethra should be identified for anastomosis. Vaginal palpation was frequently done to aid during dissection of distal urethra from the vagina. Any existing genital fistula should also be mobilized and repaired at this stage. It may be done trans-vaginally or trans-abdominally as deemed appropriate by the surgeon. Thereafter, an inverted ‘U’ shaped incision was made on the anterior bladder wall incorporating the original bladder neck at the base of flap. The length of the flap was guided by the length of the defect to be bridged, measured from the closed bladder neck to the urethral end. The width of the flap was 3 cm. The flap was then rotated inferiorly and tubularized, anastomosing the apex of the tube to the remnant native urethra using full thickness sutures to circumferentially restore the vesico-urethral continuity. After completing the anastomosis, the neo-urethral tube and bladder neck were reconstructed in two layers. First layer included only the mucosal sutures, while second layer included only the detrusor muscle. This suture line was continued on the anterior bladder wall to close the bladder. 3’O polyglactin sutures on taper point neddle were used for entire reconstruction. The entire suture line remains directed anteriorly. A 16 F silicon coated latex catheter was placed in the end. For the third case with total urethral loss, bladder flap tube was first fashioned over a 16 F catheter. It was then pulled into the introitus through an incision at the site of urethral dimple in the introitus, where it was anastomosed to the introital incision from vaginal side. Lastly, omentum was mobilized and brought posterior to the bladder through the previously created tunnel to wrap around the neourethra and vesico-urethral anastomosis. We tailored the omentum in a manner to provide just enough sheet and bulk to cover the anastomosis and fill dead space. A pelvic drain was placed and the abdomen was closed. Vagina was loosely packed with betadine gauze for 24 hours in all cases. 9
Results 3.5, 3 and 3.5 cm tubes were fashioned in the three cases respectively. Third case also required ano-vaginal fistula closure and sigmoid colostomy, which was subsequently closed at 3 months. Peri-operative period was uneventful in all the cases. Blood loss was 200 – 300 ml, and hospital stay was 3, 5 and 6 days respectively. Peri-operative antibiotics were used for 48 hours, after which low dose prophylactic antibiotics were continued till catheter removal in all. The SPC was clamped and catheter removed at 3 weeks. SPC was removed after another one week once normal voiding was ensured. All the patients are fully continent and voiding well with low postvoid residue at follow up of 15, 7 and 3 months respectively. A follow up uroflowmetry, postvoid urine measurement, and cystoscopy was done in all cases. VCUG and cystoscopy image of the case 1 is shown in Figure 3.
Discussion Bladder neck contracture with or without associated urethral stricture or genital fistulae is a rare but challenging clinical scenario with not many surgical options to correct it. Tanagho has earlier described a ‘U’ shaped flap from the anterior bladder wall to reconstruct the bladder neck and urethra in such cases.2,3 However its limitations include relative obstruction to urine flow and formation of a dependent recess at trigone and base of bladder (Figure 3), because of 10
the movement of bladder neck antero-superiorly and the formation of two dog-ears its either side . Patient may not be able to void to completion or occasionally not at all, requiring intermittent self-catheterization. Radwan et al used Tanagho’s approach for reconstruction in six cases with full continence in two-third of their cases.4 It has been suggested in literature that a postoperative continence rate of approximately 50 % is to be expected when the vesical neck and proximal urethra are involved, unless a concomitant anti-incontinence procedure is performed.5 Although only three cases and early to say, our technique has so far provided 100% results for both voiding and continence. A probable principle behind good results obtained so far with our technique, is the incorporation of native bladder neck fibres in the bladder neck itself, unlike Tanagho’s approach which uses anterior wall fibres to reconstruct bladder neck. With our technique, the internal urethral meatus remains at its original place. Not only this, the Tanagho’s principle of achieving continence by using circularly arranged fibres at the bladder neck3, inherently limits the length of the flap that can be made. A longer length of the flap would mandate the use of detrusor fibres that are away from original bladder neck and not arranged in a synchronous circular fashion to be able to function adequately as a sphincter. Therefore poorer continence results are to be expected with increasing length of flap. Contrary to this, our technique is not limited by the length of the tube required, because the original bladder neck fibres would remain at new bladder neck also. Whether it can help in continence is not sure, but the new neck remainining at anatomically dependent position is likely to help for voiding to completion.
11
We believe that continence in our patients is also a function of good bilateral pelvic floor strength, besides achievement of an adequate urethral length. There was no pelvic floor muscle injury in any of our cases. Ours are therefore a selected group of patients and the continence results in girls with crush injury or lacerations extending beyond the external sphincter zone to pelvic floor muscles remains to be defined. Besides continence and voiding issues, our technique also provides some minor surgical advantages over a Tanagho repair. The Tanagho tube would tend to produce a rotational tug on the anastomosis with the urethra, proportionate to the length of the tube, unless sufficient wide mobilization of the bladder is done. Furthermore, the entire suture line of Tanagho repair is directed posteriorly and therefore chances of genitourinary fistula formation are theoretically higher in such patients, given that such injuries commonly pre-exist or may be iatrogenically created during mobilization of tissues for repair.Our technique also provides the advantage that bladder is closed after doing urethro-vesical anastomosis. This lends more working space during this most important step of surgery. This is unlike classical Tanagho’s repair where the bladder has to be closed before doing urethro-vesical anastomosis. With our technique care must be taken not to over-reach with the incisions of the flap on the posterior wall to avoid injuring the ureteric orifices. Once opened anteriorly, the incisions can be extended on the posterior wall keeping ureteric orifices under vision. Also the suture line runs across the anastomosis, but its impact on outcomes is unclear. We used an additional omental tissue interface around the anastomosis. This was used with the intent of preventing the repair from getting tethered to bone. We believe that such a tethering
12
may prevent anatomical coaptation of urethral walls or angulation of urethra during voiding hindering both voiding and continence mechanisms. The use of omentum may additionally help fill the dead spaces formed from removal of scar tissue and also provide a second tissue layer of defense against genito-urinary fistula formation. Because traumatic female urethral stricture is a rare disease, experience of managing these cases is also very limited across the world, and no guidelines for surgical reconstruction techniques for these cases exist as yet. Only short case series may be found as evidence in literature and therefore it would be futile to compare the approaches in terms of evidence based outcomes. Despite the rarity, urologists do come across such cases once in a while. Our approach provides an additional option in this scenario. Because incontinence is a major concern, any reconstruction attempt that does not incorporate the bladder neck fibres would necessitate use of an additional pubo-vaginal sling procedure. In conclusion, our early results with this novel technique are encouraging. This technique provides a anatomically sound option for reconstruction of urethra and bladder neck in cases of bladder neck obliteration and urethral loss.
References 1. Anast J, Brandes SB and Klutke C. Female urethral reconstruction. Urethral Reconstructive Surgery. Brandes, Steven B. (Ed.). Springer, 2008, 303-313.
13
2. Tanagho EA, Smith DR, Meyers FH, Fisher R. Mechanism of urinary continence. II. Technique for surgical correction of incontinence. J Urol. 1969;101(3):305-13. 3. Tanagho EA. Bladder neck reconstruction for total urinary incontinence: 10 years experience. J Urol. 1981;125(3):321-6. 4. Radwan MH, Abou Farha MO, Soliman MG, et al. Outcome of female urethral reconstruction: a 12-year experience. World J Urol. 2013;31:991–5. 5. Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol. 1989;141:542–5
Figure legends
Figure 1. (A) Voiding cysto-urethrography showing complete obliteration at bladder neck, normal capacity urinary bladder and right grade 3 vesico-ureteric reflux. (B) Graphical description of urogenital injury of the case after complete clinical, radiological investigations and examination under anesthesia. Mid-urethra was firmly adherent to pubis and bone-like scar tissue, with loss of whole circumference of proximal urethra and anterior vaginal wall. Midurethra opened into vagina forming a urethro-vaginal fistula. Case 2 was similar except for urethro-vaginal fistula, where urethra was also completely obliterated. Case 3 had total urethral loss.
14
Figure 2. (A) The entire bladder neck is dissected away from pubis and scar. (B) A tunnel is created in the midline behind the bladder in the utero-vesical plane from above downwards till the posterior aspect of bladder neck. Merging the anterior and posterior bladder planes of dissection helps to lift up the bladder neck intact. A right angle forceps passed through this plane shows the entire bladder lifted up in the midline. A suprapubic catheter can be seen in situ in the bladder. (C) Excision of all the scar and sub-symphyseal dissection of the proximal urethra to de-tether the urethra (arrow) from the pubis. Urethra is also separated from the anterior vaginal wall for about 1 cm. (D) An inverted ‘U’ shaped incision (arrows) is given on the anterior bladder wall incorporating the original bladder neck in its base. (E) The vaginal fistulous opening, if any is closed (arrow), the flap is rotated downwards and anastomosed to urethra or introitus. The anterior bladder opening is also closed. (F) Graphical description of all the surgical steps. The omentum is brought through the previously developed space and wrapped around the reconstruction to fill empty space, provide vascularity, reduce urethral adhesions/fixation and prevent fistula formation.
15
Figure 3. (A) Voiding cystourethrogram showing widely opening bladder neck and patent urethra. The post-void residue was nil. (B,C) Cystoscopy showed near normal contour of bladder neck flat with the trigone unlike after standard Tanagho’s repair. Image at the anastomotic side showing patent urethra. (D) Graphical description of standard Tanagho’s repair is shown for comparison. It results in a new bladder neck which lies much higher and anteriorly, and may also form a recess in the bladder posteriorly. It also creates a rotational tug on the anastomosis unless the bladder is mobilized anteriorly and bilaterally.
16
17
18
19
A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results Rishi Nayyar MCh Associate Professor , Siddarth Jain MCh Assistant Professsor , Kulbhushan Sharma MS Senior Resident , Sahil Pethe MS Senior Resident , Prashant Kumar MCh Fellow Reconstructive Urology PII: DOI: Reference:
S0090-4295(20)30161-8 https://doi.org/10.1016/j.urology.2019.12.037 URL 21978
To appear in:
Urology
Received date: Revised date: Accepted date:
25 October 2019 3 December 2019 5 December 2019
Please cite this article as: Rishi Nayyar MCh Associate Professor , Siddarth Jain MCh Assistant Professsor , Kulbhushan Sharma MS Senior Resident , Sahil Pethe MS Senior Resident , Prashant Kumar MCh Fellow Reconstructive Urology , A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results, Urology (2020), doi: https://doi.org/10.1016/j.urology.2019.12.037
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Article type Surgical techniques
Title A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results
Authors: Rishi Nayyar, Siddarth Jain, Kulbhushan Sharma, Sahil Pethe, Prashant Kumar
Author information and affiliations 1. Rishi Nayyar, MCh Associate Professor, Department of Urology, AIIMS, New Delhi. 110029 2. Siddarth Jain, MCh Assistant Professsor, Department of Urology, AIIMS, New Delhi. 110029 3. Kulbhushan Sharma, MS Senior Resident, Department of Urology, AIIMS, New Delhi. 110029 4. Sahil Pethe, MS Senior Resident, Department of Urology, AIIMS, New Delhi. 110029 5. Prashant Kumar, MCh 1
Fellow Reconstructive Urology, Department of Urology, AIIMS, New Delhi. 110029
Corresponding Author and contact details Rishi Nayyar Associate Professor, Address: Department of Urology, NMR Block, AIIMS, Ansari Nagar, New Delhi. 110029. India Email: [email protected] Phone: 9811414607, 011-26594884, 011-26593921
Address for reprints Same as above for corresponding author
Sources of support None
Acknowledgements None
2
Abstract word count: 219 Manuscript word count: 2289 Number of figures: 3
Keywords: Bladder neck contracture; Tanagho’s bladder flap; Pelvic fracture; Female urethral stricture A novel anterior bladder tube for traumatic bladder neck contracture in females: initial results
Abstract Objective: To describe a novel tabularized bladder flap technique for repair of post-traumatic obliterate bladder neck and urethral stricture in women. Traumatic genitourinary injury in females is rare, and generally associated with pelvic fracture. Obliterate bladder neck is frequent in such cases. The options for obliterate strictures are limited with Tanagho‘s repair as one option. Limitations of Tanagho’s repair include bladder neck being shifted antero-superiorly posing voiding issues, posteriorly directed suture-line risking fistula formation with vagina and rotational tug of bladder putting tension at suture line. Here we present our initial results with our novel technique. Methods: 3
3 young females with bladder neck obliteration with or without associated uro-genital fistula were operated. A novel U-shaped anterior bladder wall flap was used to fashion a urethral tube and bladder neck. Native bladder neck fibres remained at bladder neck itself after reconstruction without limitation of length of urethral tube and continence outcome. Urogenital fistula was also repaired with omental interposition. Results: 3.5, 3 and 3.5 cm tubes were fashioned in the three cases respectively. No peri-operative complications were reported. Catheter was removed at 3 weeks. All cases had normal voiding and continence at follow up of 15, 7 and 3 months respectively. Conclusions: Our novel flap technique has provided good early results and aims to overcome the limitations of Tanagho’s repair.
Keywords: Bladder neck contracture; Tanagho’s bladder flap; Pelvic fracture; Female urethral stricture
Acknowledgements: None
4
Introduction Pelvic fracture associated urethral injury is less common in females than males (0-6% vs 10% in males).1 This may be explained due to shorter length, greater mobility, and relatively protected location of the urethra in females. Inability to void, urinary incontinence through vagina, hematuria or blood at the introitus in the setting of pelvic trauma should make one suspicious of an associated urethral or bladder injury.1 Unlike direct laceration or less severe blunt injuries, avulsion or distraction injuries of urethra are more commonly associated with major trauma. Immediate repair may not be possible because of non-availability of expertise or condition of patient necessitating management of other injuries on priority. Therefore, many patients are initially managed with suprapubic cystostomy (SPC) and present later with obliterate bladder neck and urethral stricture. Options for such obliterative distraction defects are very limited in females. Traditionally Tanagho’s tube repair from anterior bladder wall is used. However, Tanagho’s repair results in rotational tug of bladder putting tension at suture line, and a further higher placed bladder neck which may jeopardize subsequent voiding. Many such cases require self intermittent catheterization. To overcome these limitations we describe a novel bladder flap technique for bladder neck and urethral loss in females. The anatomical principle of continence described behind Tanagho’s reconstruction is also better preserved with our novel technique.
5
Methods 3 cases who presented with traumatic bladder neck contracture after suffering a pelvic fracture associated injury were considered for reconstruction of bladder neck and urethra without any sling surgery. A retrospective review of these three cases is presented. Institute review board approval was taken for the purpose. All cases had a voiding custourethrogram (VCUG) showing complete block at bladder neck. A detailed examination under anesthesia including urethroscopy, SPC-scopy and vaginoscopy was done in all before the surgical plan was made. Ureteric orifices were ensured to be away from bladder neck scar during the scopy. All cases received pre-operative phenazopyridine to stain the urine and easy identification of ureteric orifices during surgery. After discussing the options and possible outcomes, an informed consent was obtained in all three cases for surgical reconstruction. Individual details and presentation of the cases is provided. Case 1: A 26 Yr old female athlete fell from a moving train and suffered polytrauma 6 years back, sustaining bilateral superior and inferior pubic rami fracture along with compound fracture of femur, tibia and fibula. There was blood at introitus. After initial resuscitation, a failed attempt at urethral catheterization was made. Computed tomography revealed distended high urinary bladder with pelvic hematoma. Open SPC and fixation of leg fractures was done. Since then she was managing on SPC changes and presented to our tertiary care center. External genitalia including external meatus were normal on clinical examination. The bilateral pelvic floor muscle strength was adequate (Oxford scale 5). The vagina in relation to 6
proximal urethra was directly adherent underneath the pubic bone with no intervening urethral tissue. Renal function tests and urine analysis were normal. VCUG showed complete obliteration at bladder neck, normal capacity and right grade 3 vesico-ureteric reflux (Figure 1A). Endoscopic examination under anesthesia showed 2 cm healthy distal urethra, proximally opening into vagina and tethered underneath the bone (Figure 1B). The bladder neck was fibrosed and obliterated. No fistulous opening was seen on cystoscopy. Case 2 A 10 year old girl presented 18 months back after a road traffic accident requiring emergent jejunal resection anastomosis, SPC placement and bilateral internal iliac ligation for expanding pelvic hematoma with fracture pelvis and perineo-urethral injury. After recovering from bowel and orthopedic injuries, she was referred for urethral reconstruction. She had a bladder capacity of 100 cc with blind fibrosed bladder neck and proximal urethral loss similar to first case. Distal 2 cm of urethra was normal ending blindly. Pelvic floor strength was normal. Case 3 A 14 year old girl suffered a road traffic accident 14 months back leading to genital and rectal injury with pelvic fracture. She was resuscitated and SPC was placed in emergency. Subsequently she developed ano-vaginal fistula with intermittent fecal soiling of vagina. Examination under anesthesia with SPC-scopy confirmed bladder neck obliteration and total urethral loss, bladder capacity of 300 cc with high riding bladder, vaginal cicatrization with shelf formation and ano-vaginal fistula.
7
Surgical technique All the cases underwent a novel surgical reconstruction of bladder neck and urethra (Figure 2). An abdominal transperitoneal approach was used in dorsal lithotomy position. Anterior bladder wall was mobilized keeping the suprapubic catheter tract intact. Mobilization of anterior surface was continued in the space of Retzius, and turned posteriorly at the level of bladder neck. Fibrosis is encountered at the bladder neck region, which makes its identification and dissection difficult. Therefore, for a more controlled dissection of bladder neck, it is approached from posterior side as well. For this, a transverse incision was made on the peritoneum behind the bladder in the uterovesical pouch to expose lower segment uterus and cervix. This plane was continued inferiorly between bladder and vagina in the midline, till the level of bladder neck. Both the anterior and posterior planes of dissection were then fused together to lift up the entire bladder neck intact. The posterior plane of dissection between bladder and vagina is generally always preserved and easily developed. This posterior-vesical space was also subsequently utilized for transporting the omentum down for wrapping the repair. The scar tissue was then excised in bits, taking care to spare the anterior vaginal wall and delineate the proximal end of the urethra. Use of a Hegar dilator’s tip to pull the urethra away from underneath the bone aided in both the identification and the dissection of the remnant urethra. The urethra may need sub-symphyseal dissection underneath the periosteal plane because it may be tethered to the bone due to previous trauma. Normal muscular vascularized 8
wall of the urethra should be identified for anastomosis. Vaginal palpation was frequently done to aid during dissection of distal urethra from the vagina. Any existing genital fistula should also be mobilized and repaired at this stage. It may be done trans-vaginally or trans-abdominally as deemed appropriate by the surgeon. Thereafter, an inverted ‘U’ shaped incision was made on the anterior bladder wall incorporating the original bladder neck at the base of flap. The length of the flap was guided by the length of the defect to be bridged, measured from the closed bladder neck to the urethral end. The width of the flap was 3 cm. The flap was then rotated inferiorly and tubularized, anastomosing the apex of the tube to the remnant native urethra using full thickness sutures to circumferentially restore the vesico-urethral continuity. After completing the anastomosis, the neo-urethral tube and bladder neck were reconstructed in two layers. First layer included only the mucosal sutures, while second layer included only the detrusor muscle. This suture line was continued on the anterior bladder wall to close the bladder. 3’O polyglactin sutures on taper point neddle were used for entire reconstruction. The entire suture line remains directed anteriorly. A 16 F silicon coated latex catheter was placed in the end. For the third case with total urethral loss, bladder flap tube was first fashioned over a 16 F catheter. It was then pulled into the introitus through an incision at the site of urethral dimple in the introitus, where it was anastomosed to the introital incision from vaginal side. Lastly, omentum was mobilized and brought posterior to the bladder through the previously created tunnel to wrap around the neourethra and vesico-urethral anastomosis. We tailored the omentum in a manner to provide just enough sheet and bulk to cover the anastomosis and fill dead space. A pelvic drain was placed and the abdomen was closed. Vagina was loosely packed with betadine gauze for 24 hours in all cases. 9
Results 3.5, 3 and 3.5 cm tubes were fashioned in the three cases respectively. Third case also required ano-vaginal fistula closure and sigmoid colostomy, which was subsequently closed at 3 months. Peri-operative period was uneventful in all the cases. Blood loss was 200 – 300 ml, and hospital stay was 3, 5 and 6 days respectively. Peri-operative antibiotics were used for 48 hours, after which low dose prophylactic antibiotics were continued till catheter removal in all. The SPC was clamped and catheter removed at 3 weeks. SPC was removed after another one week once normal voiding was ensured. All the patients are fully continent and voiding well with low postvoid residue at follow up of 15, 7 and 3 months respectively. A follow up uroflowmetry, postvoid urine measurement, and cystoscopy was done in all cases. VCUG and cystoscopy image of the case 1 is shown in Figure 3.
Discussion Bladder neck contracture with or without associated urethral stricture or genital fistulae is a rare but challenging clinical scenario with not many surgical options to correct it. Tanagho has earlier described a ‘U’ shaped flap from the anterior bladder wall to reconstruct the bladder neck and urethra in such cases.2,3 However its limitations include relative obstruction to urine flow and formation of a dependent recess at trigone and base of bladder (Figure 3), because of 10
the movement of bladder neck antero-superiorly and the formation of two dog-ears its either side . Patient may not be able to void to completion or occasionally not at all, requiring intermittent self-catheterization. Radwan et al used Tanagho’s approach for reconstruction in six cases with full continence in two-third of their cases.4 It has been suggested in literature that a postoperative continence rate of approximately 50 % is to be expected when the vesical neck and proximal urethra are involved, unless a concomitant anti-incontinence procedure is performed.5 Although only three cases and early to say, our technique has so far provided 100% results for both voiding and continence. A probable principle behind good results obtained so far with our technique, is the incorporation of native bladder neck fibres in the bladder neck itself, unlike Tanagho’s approach which uses anterior wall fibres to reconstruct bladder neck. With our technique, the internal urethral meatus remains at its original place. Not only this, the Tanagho’s principle of achieving continence by using circularly arranged fibres at the bladder neck3, inherently limits the length of the flap that can be made. A longer length of the flap would mandate the use of detrusor fibres that are away from original bladder neck and not arranged in a synchronous circular fashion to be able to function adequately as a sphincter. Therefore poorer continence results are to be expected with increasing length of flap. Contrary to this, our technique is not limited by the length of the tube required, because the original bladder neck fibres would remain at new bladder neck also. Whether it can help in continence is not sure, but the new neck remainining at anatomically dependent position is likely to help for voiding to completion.
11
We believe that continence in our patients is also a function of good bilateral pelvic floor strength, besides achievement of an adequate urethral length. There was no pelvic floor muscle injury in any of our cases. Ours are therefore a selected group of patients and the continence results in girls with crush injury or lacerations extending beyond the external sphincter zone to pelvic floor muscles remains to be defined. Besides continence and voiding issues, our technique also provides some minor surgical advantages over a Tanagho repair. The Tanagho tube would tend to produce a rotational tug on the anastomosis with the urethra, proportionate to the length of the tube, unless sufficient wide mobilization of the bladder is done. Furthermore, the entire suture line of Tanagho repair is directed posteriorly and therefore chances of genitourinary fistula formation are theoretically higher in such patients, given that such injuries commonly pre-exist or may be iatrogenically created during mobilization of tissues for repair.Our technique also provides the advantage that bladder is closed after doing urethro-vesical anastomosis. This lends more working space during this most important step of surgery. This is unlike classical Tanagho’s repair where the bladder has to be closed before doing urethro-vesical anastomosis. With our technique care must be taken not to over-reach with the incisions of the flap on the posterior wall to avoid injuring the ureteric orifices. Once opened anteriorly, the incisions can be extended on the posterior wall keeping ureteric orifices under vision. Also the suture line runs across the anastomosis, but its impact on outcomes is unclear. We used an additional omental tissue interface around the anastomosis. This was used with the intent of preventing the repair from getting tethered to bone. We believe that such a tethering
12
may prevent anatomical coaptation of urethral walls or angulation of urethra during voiding hindering both voiding and continence mechanisms. The use of omentum may additionally help fill the dead spaces formed from removal of scar tissue and also provide a second tissue layer of defense against genito-urinary fistula formation. Because traumatic female urethral stricture is a rare disease, experience of managing these cases is also very limited across the world, and no guidelines for surgical reconstruction techniques for these cases exist as yet. Only short case series may be found as evidence in literature and therefore it would be futile to compare the approaches in terms of evidence based outcomes. Despite the rarity, urologists do come across such cases once in a while. Our approach provides an additional option in this scenario. Because incontinence is a major concern, any reconstruction attempt that does not incorporate the bladder neck fibres would necessitate use of an additional pubo-vaginal sling procedure. In conclusion, our early results with this novel technique are encouraging. This technique provides a anatomically sound option for reconstruction of urethra and bladder neck in cases of bladder neck obliteration and urethral loss.
References 1. Anast J, Brandes SB and Klutke C. Female urethral reconstruction. Urethral Reconstructive Surgery. Brandes, Steven B. (Ed.). Springer, 2008, 303-313.
13
2. Tanagho EA, Smith DR, Meyers FH, Fisher R. Mechanism of urinary continence. II. Technique for surgical correction of incontinence. J Urol. 1969;101(3):305-13. 3. Tanagho EA. Bladder neck reconstruction for total urinary incontinence: 10 years experience. J Urol. 1981;125(3):321-6. 4. Radwan MH, Abou Farha MO, Soliman MG, et al. Outcome of female urethral reconstruction: a 12-year experience. World J Urol. 2013;31:991–5. 5. Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol. 1989;141:542–5
Figure legends
Figure 1. (A) Voiding cysto-urethrography showing complete obliteration at bladder neck, normal capacity urinary bladder and right grade 3 vesico-ureteric reflux. (B) Graphical description of urogenital injury of the case after complete clinical, radiological investigations and examination under anesthesia. Mid-urethra was firmly adherent to pubis and bone-like scar tissue, with loss of whole circumference of proximal urethra and anterior vaginal wall. Midurethra opened into vagina forming a urethro-vaginal fistula. Case 2 was similar except for urethro-vaginal fistula, where urethra was also completely obliterated. Case 3 had total urethral loss.
14
Figure 2. (A) The entire bladder neck is dissected away from pubis and scar. (B) A tunnel is created in the midline behind the bladder in the utero-vesical plane from above downwards till the posterior aspect of bladder neck. Merging the anterior and posterior bladder planes of dissection helps to lift up the bladder neck intact. A right angle forceps passed through this plane shows the entire bladder lifted up in the midline. A suprapubic catheter can be seen in situ in the bladder. (C) Excision of all the scar and sub-symphyseal dissection of the proximal urethra to de-tether the urethra (arrow) from the pubis. Urethra is also separated from the anterior vaginal wall for about 1 cm. (D) An inverted ‘U’ shaped incision (arrows) is given on the anterior bladder wall incorporating the original bladder neck in its base. (E) The vaginal fistulous opening, if any is closed (arrow), the flap is rotated downwards and anastomosed to urethra or introitus. The anterior bladder opening is also closed. (F) Graphical description of all the surgical steps. The omentum is brought through the previously developed space and wrapped around the reconstruction to fill empty space, provide vascularity, reduce urethral adhesions/fixation and prevent fistula formation.
15
Figure 3. (A) Voiding cystourethrogram showing widely opening bladder neck and patent urethra. The post-void residue was nil. (B,C) Cystoscopy showed near normal contour of bladder neck flat with the trigone unlike after standard Tanagho’s repair. Image at the anastomotic side showing patent urethra. (D) Graphical description of standard Tanagho’s repair is shown for comparison. It results in a new bladder neck which lies much higher and anteriorly, and may also form a recess in the bladder posteriorly. It also creates a rotational tug on the anastomosis unless the bladder is mobilized anteriorly and bilaterally.
16
17
18
19