Video Clips on DVD
Urethral Prolapse Repair
Skene’s Duct Abscess
Periurethral Cyst Excision (Skene’s Duct Abscess 2)
Periurethral Abscess after Bulking Agent Injection
Repair of Urethral Diverticulum
Surgical Management of Urethral Diverticulum
Repair of Complex Urethral Diverticulum
Synthetic Sling Lysis
Urethrovaginal Fistula—Intraoperative Exam
Repair of Urethrotomy
Urethrovaginal Fistula Repair
Urethral Erosion of a Synthetic Sling Resulting in a Urethrovaginal Fistula
Urethrovaginal Fistula Repair: Complex Repair with Fat Pad Transposition
Loss of Posterior Urethra with Erosion of Synthetic Sling
Complete Urethral Reconstruction with Pubovaginal Sling and Martius Fat Pad Transposition
The female urethra is a small but complex organ that is responsible for maintaining urinary continence. It is roughly 3 to 5 cm in length and 5 to 7 mm in diameter, and is closely integrated with the anterior vaginal wall. It extends from the bladder neck in the retropubic space and penetrates the urogenital diaphragm, ultimately opening into the vaginal vestibule at the external urethral orifice.
The mucosa consists of a combination of epithelial types, depending on location. The distal urethral epithelium is essentially a continuation of the vulvar epithelium and is stratified squamous in nature, whereas the epithelium changes to transitional as the urethra approaches the bladder neck. The mucosa is supported by the lamina propria, a layer composed of elastic fibers and connective tissue, an abundance of glands, and a rich vascular supply. Glands become more numerous toward the distal aspect of the urethra, whereas the rich vascular supply is more prominent toward the proximal urethra and bladder neck and is thought to contribute to urethral resistance. Menopause, with associated estrogen deficiency, often leads to atrophic changes of the mucosa. These changes may contribute to decreased urethral resistance, in addition to hypersensitivity of the urethra, because atrophy may lead to irritation of the sensory fibers, resulting in urinary frequency and dysuria.
The urethra is composed of both smooth and striated muscle. The smooth muscle is contiguous with the bladder and is made up of inner longitudinal and outer annular layers. This complex smooth muscle group, under involuntary control, is primarily responsible for maintaining urinary continence at rest. During micturition, the inner longitudinal fibers contract, which shortens and opens the urethral lumen to facilitate urine flow. At rest, the outer circular smooth muscle is contracted, contributing to outflow resistance.
Striated muscles, under some voluntary control, originate from the deep transverse perineal muscles and form the urogenital sphincter. This complex group of muscles is historically divided into the rhabdosphincter and the urethrovaginal sphincter. The rhabdosphincter surrounds the upper two thirds of the urethra, whereas the urethrovaginal sphincter supports the distal third. Coordination of the appropriate relaxation of the urethral resistance mechanism, in conjunction with detrusor contraction, facilitates normal voiding. Kegel exercises, in part, incorporate the ability to contract the striated muscle groups, which provide tone and resistance during periods of increased intra-abdominal pressure.
Innervation to the urethra, both motor and sensory, is from the pudendal nerve as well as the vesical plexus. Lymphatic drainage from the upper urethra travels primarily to the internal iliac nodes, whereas the distal urethra drains to the superficial and deep inguinal nodes. Lastly, the blood supply to the urethra originates from several sources, including the internal pudendal, inferior vesical, and vaginal vasculature.
Surgical procedures involving the urethra usually center on creation of urethral support (procedures for stress urinary incontinence) or address iatrogenic (obstruction, fistula) or pathologic (abscess, diverticula, malignancy) processes. Like the bladder, the urethra is generally a forgiving organ when operated upon. However, adherence to basic surgical principles—efficient and accurate dissection with maintenance of blood supply, adequate tissue mobilization, hemostasis, tension-free tissue approximation, and prolonged drainage—is paramount to avoid unnecessary morbidity.
As with most areas of medicine, the workup begins with the patient history. How acute or chronic are her symptoms? Are there urinary tract symptoms? What has she had done surgically? What prior evaluations have been performed? All these questions guide further questions and subsequent evaluation.
Prior diagnostic studies and surgical reports should be reviewed. Direct visualization of the urethral area, including cystourethroscopy, is critical. If voiding symptoms are present, voiding cystourethroscopy is valuable in evaluating fistula and diverticula. Magnetic resonance imaging (MRI) is probably the best imaging modality overall for evaluating this region, especially when a mass is present. Analysis of the urine to rule out infection is indicated. The more complete the evaluation ahead of time, the less likely that surprises will be encountered intraoperatively.
Urethral Prolapse Repair
View DVD: Video 4-1
An 82-year-old woman presented for surgical correction of pelvic organ prolapse of all segments, which extended well beyond the hymen. In addition, she had circumferential mucosal prolapse from the external urethral meatus ( Figs. 4-1 and 4-2 ), which often bled when she wiped after voiding.
Prolapse of edematous urethral mucosa may be of sufficient degree to require surgical excision. It is important to differentiate urethral prolapse from a urethral caruncle. The former is circumferential in nature, less common, and treated surgically, whereas the latter is much more common, usually requires only topical estrogen therapy, and is usually isolated to the posterior urethral meatus.
The procedure begins by identifying the urethral lumen ( Fig. 4-3 ). Placement of a transurethral catheter is an option; however, it can be difficult to work around. The excision begins at the 12-o’clock position. A stay suture is placed to hold the tissue and provide traction. Working in a counterclockwise fashion, the redundant mucosa is either trimmed with a scissors or excised using needle-tip cautery ( Fig. 4-4 ). During excision, each anchoring suture (usually 3-0 chromic or 4-0 Vicryl) is placed as the mucosa is freed ( Fig. 4-5 ). This tissue is usually very edematous and friable. Failure to secure the mucosa with stay sutures as the mucosal prolapse is excised can result in the mucosa retracting superiorly, making it much more difficult to reapproximate. A transurethral catheter may be left in place for a day if there is significant swelling.
Skene’s Duct Cyst
View DVD: Videos 4-2 and 4-3
4-2: A 46-year-old patient presented with a vaginal bulge. She was largely asymptomatic, except having some discomfort during intercourse. During physical examination, a large cystic mass was seen beneath and to the right of the urethra ( Fig. 4-6 ).
4-3: A 21-year-old patient presented with periurethral pain and deviation of her urinary stream. During physical examination, a cystic mass was seen on the left side of the urethra near the external meatus ( Fig. 4-7 ).
Skene’s duct (periurethral) cysts usually are identified inferiorly or laterally to the distal urethra ( Fig. 4-7 ). They are generally slow growing and thus usually asymptomatic for a period of time; however, they may often cause urinary symptoms, such as spraying of the stream or frequency. Fast-growing cysts can be quite painful. Their constant site of origin usually differentiates them from urethral diverticula or Gartner’s duct cysts; however, these possibilities are considered in the differential diagnosis.
The procedure begins with placement of a transurethral catheter and palpation of the cystic area. Often the cyst extends beyond what was observed initially. The incision is made in the vaginal epithelium overlying the cyst ( Fig. 4-8 ). The epithelium is mobilized off the cyst and the cyst is excised. The supporting tissues are approximated with 2-0 Vicryl suture and the vaginal epithelium closed with 3-0 Vicryl suture ( Fig. 4-9 ). It is important to be aware of the proximity of the urethral lumen, because these cysts are commonly very close to the lumen. Use of a transurethral catheter to more easily identify defects in the lumen is encouraged. Likewise, one should be mindful of suture placement once the cyst has been removed to avoid entering the urethral lumen. It is best to define the dimensions of the cyst ( Fig. 4-10 ) and to remove the cyst entirely ( Fig. 4-11 ). However, if there is a large defect that cannot be reapproximated without tension, if acute infection is present, or if the complete cyst wall cannot be excised, marsupialization of the edges to the surrounding vaginal wall remains an option ( Fig. 4-12 ).
Abscess after Transurethral Bulking
View DVD: Video 4-4
An 84-year-old patient had a previous vaginal hysterectomy and bilateral salpingo-oophorectomy with anterior and posterior repairs and placement of a midurethral sling. Persistence of urinary incontinence led to a transurethral bulking procedure more than 2 years previously. She presented with acute urinary retention that required catheterization. A large right periurethral mass was identified, which displaced the urethra to the left ( Figs. 4-13 and 4-14 ).
The procedure begins by identifying the urethral meatus and placing a transurethral catheter. It is reasonable to consider cystourethroscopy at this point if patient discomfort and deviation of the urethra did not allow that to be performed at the initial evaluation.
If palpation of the mass reveals fluctuancy, a stab incision is made in the mass to decompress it and allow further evaluation of the mass and urethra. A thick, nonodorous, purulent material is usually liberated, representing a sterile abscess. If odorous, active infection is encountered, cultures should be taken. The stab incision can be extended to thoroughly examine the cavity and liberate all debris. The redundant tissue is then excised. If there is any suggestion of infection, marsupialization of the cavity wall to the surrounding vaginal epithelium is indicated to avoid closing an infected area and risking recurrent abscess formation. If there is no evidence of acute infection, the wound may be closed primarily. Depending on the extent of dissection near the urethra, as well as the degree of urinary retention preoperatively, leaving a transurethral catheter in place may be indicated.
View DVD: Videos 4-5 to 4-7
4-5: A 36-year-old presented with pelvic pressure and vaginal pain. She was found to have a midurethral diverticulum.
4-6: A 48-year-old had chronic urinary tract infection, dysuria, and dyspareunia. She was referred for further evaluation and was found to have a urethral diverticulum on preoperative evaluation. Palpation of the suburethral area revealed a firm, palpable mass.
4-7: A 47-year-old presented with urinary incontinence. Previously she had a midurethral sling performed without benefit. Evaluation revealed a complex midurethral diverticulum with multiple openings.
Repair of urethral diverticulum may be much more challenging than the size of the lesion predicts. The potential for complications depends on the size and number of diverticula, the degree of inflammation, the viability of the tissues, and the position of the ostium in relation to the floor of the urethra and bladder neck. Resection of multiple, large, multiloculated, or saddle-shaped diverticula can require extensive dissection about the floor of the urethra, including at the bladder neck and trigone. This inflammatory process, and the dissection required to address it, can result in urethrovaginal fistula and/or stress urinary incontinence. Accurate reconstruction, with adherence to sound surgical principles, does not eliminate these risks, but does reduce their frequency.
The typical straightforward urethral diverticulum presents as an isolated suburethral mass with a single ostium to the posterior urethra ( Fig. 4-15 ). The surgeon should attempt to evaluate the nature of the diverticula as accurately as possible preoperatively, because there may be more than one, they may have multiple ostia, and they can extend well around the urethra and bladder neck. A transurethral catheter is inserted in the urethra. A vertical incision is made in the anterior vaginal wall beneath the mass ( Fig. 4-16 ). The vaginal epithelium is mobilized laterally, exposing the underlying pubocervical fascia, which is then incised and mobilized laterally for future layered closure ( Fig. 4-17 ). It is preferable to enter the diverticulum at this point, which may contain pus, stone debris, or loculations. Placing an index finger within the diverticular sac may guide further dissection of the diverticulum from the surrounding tissue ( Fig. 4-18 ). Before complete excision of the diverticulum, a probe is placed through the ostia to help identify the tract ( Figs. 4-19 and 4-20 ). The urethral defect is then closed in a linear direction (occasionally the closure is performed transversely) with 4-0 chromic suture in an extramucosal fashion ( Fig. 4-21 ). Once the urethral closure is performed, the previously mobilized pubocervical fascia is closed in layers (vest-over-pants) with 2-0 Vicryl suture over the urethral repair ( Fig. 4-22 ). A layered closure in this manner provides reconstruction, and it avoids overlying suture lines, which may increase the chance of fistula formation. The vaginal epithelium is reapproximated and a catheter is left in place for 10 to 14 days ( Fig. 4-23 ).