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

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Page 1: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Urethrovaginal Fistula & Urethral Reconstruction

Jerry G. Blaivas, MDClinical Professor of Urology

New York Hospital Cornell Medical Center

Adjunct Professor of UrologySUNY-Downstate Medical Center

Page 2: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Etiology of Damaged Urethra

Urethral Tic29%

BNS22%

Childbirth4%

Trauma4%

Stricture4%

Synthetic sling27%

COLPORRAPHY10%

Page 3: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Complication of Urethral Diverticular Surgery

Page 4: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 5: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Eroded sling

Fistula

diverticulum

Page 6: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Complication of Synthetic Sling

Page 7: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Granulationtissue

Fistula

Page 8: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 9: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Complication of Colporraphy

Page 10: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Ureteralorifices

Page 11: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Stoneson sutures

Foley catheter

Fistula

Page 12: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Sterile Abscess from Periurethral Injection

Page 13: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 14: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Complication of Pelvic Fracture

Page 15: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 16: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Complication of Foley Catheter

Page 17: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 18: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Squamous Cell Carcinoma

Page 19: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 20: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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

Page 21: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Urethral Reconstruction

• Posterior bladder flap(Young-Dees-Leadbetter)

• Anterior bladder flap(Tanagho)

• Vaginal wall / labial flap

Page 22: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Vaginal Repair• Primary closure

• Lateral flap

–Unilateral vaginal wall pedicle flap

–Bilateral vaginal wall pedicle

• Advancement flap

• Labial minora island pedicle flap

• Buccal graft

Page 23: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Judicious Use of VascularizedPedical Flaps

• Martius labial fat pad

• Omentum

• Rectus abdominis

• Gracilis

• Singapore

Page 24: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 25: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 26: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 27: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 28: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 29: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 30: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 31: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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 32: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 33: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 34: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 35: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 36: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 37: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 38: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 40: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 41: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 42: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 43: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 45: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 46: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 47: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 48: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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 49: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Labiamajora

Labiamajora

Bladder neck

Page 50: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 51: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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 52: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 53: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 54: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 55: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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 56: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 57: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 58: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 59: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 60: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 61: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Dorsal urethral incision

Page 62: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 63: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Buccal graft

Page 64: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Buccal graft

Page 65: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Buccal graft

Page 66: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Buccal graft

Page 67: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor
Page 68: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

Potential Complications

• Urethral obstruction

• Hemorrhage

• Ureteral obstruction

• Vesciovaginal fistula

• Sphincteric incontinence

Page 70: Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

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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