Reconstruction of the Severely Damaged Female Urethra

The severely damaged female urethra is a rare occurrence that has two main causes—obstetric injury and surgical trauma. Obstetric injuries are exceedingly uncommon in industrial countries but not so in the Third World. Damage to the trigone, vesical neck, and urethra during delivery is thought to be the result of prolonged and neglected labor, most often associated with maternal–fetal disproportion wherein the fetal head compresses these structures against the pubis, causing pressure necrosis. Surgical damage may occur during any of the Peyrera-type bladder neck suspension procedures, anterior colporrhaphy, urethral diverticulectomy, and, much less commonly, vaginal hysterectomy. In our experience, urethral diverticulectomy is the most common cause of extensive urethral damage. This most likely results from failure to obtain a tension-free closure of the urethral defect that results from excision of the diverticulum. During bladder neck suspension, inadvertent injury to the bladder or urethra may occur, or an errant suture may result in fistula formation or tissue necrosis. We have also seen several patients who sustained extensive tissue loss after a seemingly simple Kelly plication. It is postulated that the plication sutures were tied too tightly around a urethral catheter, resulting in pressure necrosis.

Closure of Bladder Neck in the Male and Female

Bladder neck closure (BNC) is an uncommon procedure that has traditionally been reserved as a final alternative for the management of the female patient with neurogenically induced intractable incontinence arising from long-term Foley catheter drainage. It has also been used in the treatment of nonneuropathic conditions such as traumatic urethral destruction or recalcitrant fistula. BNC in the male is usually reserved for patients with neurogenic bladder or a history of incontinence secondary to trauma or urethrocutaneous fistula failing multiple prior attempts at surgical correction or artificial sphincter placement.

Vaginal Repair of Vesicovaginal Fistula

There are numerous causes for the formation of a fistula tract between the bladder and the vagina. In developing countries the primary etiology is prolonged and obstructed labor, but in more developed countries the cause of approximately 90% of vesicovaginal fistula (VVF) is surgical trauma following gynecologic procedures. Total abdominal hysterectomy for benign disease accounts for the majority offistulae secondary to gynecologic surgery. Common nonsurgical causes include advanced local carcinoma (cervical, vaginal, endometrial) and radiation therapy. Risk factors for VVF formation include prior uterine surgery (Cesarean section), endometriosis, infection, diabetes, arteriosclerosis, pelvic inflammatory disease, and prior radiation therapy.

Female Urethral Diverticula

More female urethral diverticula are now being diagnosed than ever before because of a higher index of clinical suspicion and improved diagnostic techniques such as voiding cystourethrogram (VCUG) and transvaginal ultrasound. Because of the complexity and variability of diverticula, thorough evaluation is required to completely assess important pretreatment facors and plan appropriate management. With proper pretreatment evaluation, surgical treatment is generally associated with an excellent outcome.

Vaginal Hysterectomy

In the United States hysterectomy is the second most commonly performed operation on women following cesarean section. It may be indicated for a variety of gynecologic conditions including symptomatic uterine leiomyomas, endometriosis, carcinoma of the female genital tract, endometrial hyperplasia, and uterine prolapse. Many of these conditions have confounding diagnostic and therapeutic implications outside the realm of urology; thus, in this chapter the discussion is limited to vaginal hysterectomy only as it pertains to the surgical treatment of uterine prolapse. Uterine prolapse is particularly well suited to vaginal hysterectomy as the laxity of the ligamentous support of the uterus resulting in the prolapse allows excellent operative exposure transvaginally.