EUROPEAN UROLOGY 56 (2009)

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1 EUROPEAN UROLOGY 56 (2009) available at journal homepage: Female Urology Incontinence Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated with Urethrovaginal Fistulas Secondary to Pelvic Fracture Yue-Min Xu *, Ying-Long Sa, Qiang Fu, Jiong Zhang, Hong Xie, San-Bao Jin Department of Urology, Sixth People s Hospital, Jiaotong University of Shanghai, Shanghai , People s Republic of China Article info Article history: Accepted April 22, 2008 Published online ahead of print on April 30, 2008 Keywords: Buccal mucosa Female,urethral strictures Pedicle labial flaps Urethral injuries Urethrovaginal fistula Urethroplasty Abstract Background: Female urethral injury is rare, and there is no accepted standard approach for the repair of urethral strictures. Objective: To evaluate the efficacy of transpubic access using pedicle tubularized labial urethroplasty for urethral reconstruction in female patients with urethral obliterative strictures and urethrovaginal fistulas. Design, setting, and participants: Between January 1996 and December 2006, eight cases of female urethral strictures associated with urethrovaginal fistulas were treated using pedicle labial skin flaps. Interventions: A flap of approximately cm of the labia minora or majora with its vascular pedicle was tubularized over an Fr fenestrated silicone stent to create a neourethra. This technique was used in five women. Two flaps, approximately cm, were taken from bilateral labia minora or majora and were pieced together to create a neourethra. This technique was used in three patients. Measurements: We performed voiding cystourethrography and uroflowmetry to assess postoperative results. Results and limitations: The patients were followed up for mo (mean mo) after the procedure. There were no postoperative complications. Two patients complained of dysuria, which resolved spontaneously after 2 wk. One patient experienced stress incontinence that resolved after 4 wk. At 3-mo follow-up, one patient complained of difficulty voiding; the urinary peak flow was 13 ml/s, and the patient was treated successfully with urethral dilation. All other patients had normal micturition following catheter removal. Conclusions: Pedicle labial urethroplasty is a reliable technique for the repair of extensive urethral damage, and a transpubic surgical approach provides wide and excellent exposure for the management of complex obliterative urethral strictures and urethrovaginal fistulas secondary to pelvic fracture. # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, Sixth People s Hospital, Jiao Tong University of Shanghai, 600 Yi Shan Road, Shanghai , China. Tel x 8372,8382; Fax: address: xuyuemin@263.net (Y.-M. Xu) /$ see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 194 EUROPEAN UROLOGY 56 (2009) Fig. 1 (a) A severe pelvic fracture (arrow). (b,c) Cystourethrography demonstrated an urethrovaginal fistula in median urethra. (d) 5 mo postoperation, a patency of the urethra, retrograde urethrogram. (e) Voiding urethrogram.

3 EUROPEAN UROLOGY 56 (2009) Table 1 Preoperative patient characteristics Patient Features of trauma Suprapubic cystostomy No Age Bladder repair Incontinence colostomy 1 24 Multiple ischia fractures; urethral, vaginal injury Yes No No No 2 27 Multiple ischia, pubis fractures; urethral, vaginal injury Yes No SI No 3 46 Multiple ischia fractures; urethral, vaginal injury Yes No MI No 4 30 Multiple ischia, pubis fractures; urethral, vaginal, bladder injuries Yes Yes MI No 5 25 Multiple pelvic fractures; urethral, vaginal, bladder injuries Yes Yes SI No 6 19 Multiple ischia, pubis fractures; urethral, vaginal injury Yes No No No 7 17 Multiple ischia, pubis fractures; urethral, vaginal injury Yes No SI No 8 32 Multiple pelvic fractures (Fig. 1c); urethral, rectal, vaginal, bladder injuries Yes Yes No Yes SI = Stress incontinence; MI = Moderate incontinence. 1. Introduction Female urethral anomalies, whether congenital or acquired, are rare. The repair of recurrent female urethral stricture is an uncommon and complex procedure with no accepted standard approach. Various tissues have been used for constructing a neourethra in female patients [1 8], including tubularized bladder flaps, tubularized vaginal mucosa covered with a flap of adjacent vaginal wall, tubularized pedicle flaps of labial or buccal mucosa, and a modified neurovascular pudendal thigh flap (Singapore flap). These procedures are meant to create a neourethra to replace an absent or unrepairable urethra. We present our initial experience using pedicle tubularized labial urethroplasty for urethral reconstruction in eight patients with urethral strictures associated with urethrovaginal fistulas secondary to pelvic fractures. microscopy, culture, and sensitivity. Voiding cystourethrogram was performed to evaluate the bladder neck, and determine the location and length of the stricture (Fig. 1b and 1c). A broad-spectrum antibiotic was administered intravenously for 3 d before the procedure Surgical technique All patients were initially placed in the standard lithotomy position. Urethral urethroplasty was performed by transpubic approach in all eight patients. A lower midline incision was made above the pubic symphysis. The entire external surface of the symphysis was exposed. A segment of pubic bone was removed with a Gigli saw (Fig. 2). The urethra, adjacent fibrous tissue, callus, and fracture fragments were exposed. The anterior and posterior urethras were dissected and the fibrous tissue of the stricture was completely excised and detached from the vagina, exposing the healthy urethra and urethrovaginal fistula (Fig. 3a). The 2. Patients and methods 2.1. Clinical data collections Between January 1996 and December 2006, eight cases, mean age 27.5 yr (range yr), of urethral strictures were treated using pedicle labial skin flaps for urethral reconstructions. All cases were associated with urethrovaginal fistulas. A transpubic approach was used for urethral reconstruction. In our series, trauma was due to pedestrian motor vehicle accidents in five cases and bicycle motor vehicle accidents in three patients. Multiple associated injuries were common in all patients, including vaginal lacerations in eight, ruptured bladder in three patients, rectal injury in one patient, and severe lower extremity soft tissue injury in three patients. Three patients had more severe multiple pelvic disruption fracture (Fig. 1a). One of these three cases was treated primarily with external pelvic fixation. All eight patients had simultaneous vaginal injury and urethrovaginal fistula formation. One patient had simultaneous rectal injury, and a rectovaginal fistula developed in this case. Two patients presented with moderate urinary incontinence, and three presented stress incontinence before operation. However, distal vaginal stenosis did not occur in any cases. Three cases were treated initially with repair of the ruptured bladder. One patient with rectal injury underwent colostomy, and all patients underwent suprapubic cystostomy (Table 1). The preoperative evaluation included a history and physical examination and routine laboratory investigations, such as a full blood count, serum urea, electrolytes and creatinine, urinalysis, urine Fig. 2 A segment of pubic bone was removed with the Gigli saw.

4 196 EUROPEAN UROLOGY 56 (2009) Fig. 3 (a) The urethral defect measured 3 cm in length; arrows indicate the urethrovaginal fistula. (b) The urethrovaginal fistula was sutured. vaginal distraction defect was closed by approximating the free vaginal margins with 3-zero polyglactin continual sutures (Fig. 3b). An unstretched cm flap was marked on the skin of the labia minora or majora and mobilized on its vascular pedicle (Fig. 4a). The flap was tubularized over an Fr fenestrated silicone stent with running 5-zero polyglactin sutures to create a neourethra (Fig. 4b). If the labia minora was small, two flaps, approximately cm, were marked on the skin. The two flaps were sutured together with 5-zero polyglactin sutures and tubularized to create a neourethra (Fig. 5a 5d). The single face technique was used in five women. The double face technique was used in three patients (Table 2). The neourethra was brought down into the space previously occupied by the excised pubis. A tension-free end-to-end anastomosis was performed between the normal urethra and the neourethra with interrupted 6 8 sutures of 5-zero polyglactin. A pedicled rectus muscle flap was dissected off and wrapped around the anastomosis to obliterate the periurethral cavity. It also provided adequate blood supply, prevented fistula formation, and helped to preserve continence (Fig. 6). Bladder drainage was achieved through a suprapubic catheter, and the urethral silicone stent was left indwelling for d Postoperative management Patients received broad-spectrum intravenous antibiotics for 7 d, followed by oral prophylaxis thereafter until the suprapubic tube was removed. The retropubic drains were removed after 4 5 d. Postoperative evaluation included voiding cystourethrography and uroflowmetry after the catheter had been removed. Micturition patterns Fig. 4 (a) A flap of appropriate size and shape was mobilized on its vascular pedicle. (b) The flap was tubularized over a fenestrated silicone stent with continual 5-zero polyglactin sutures.

5 EUROPEAN UROLOGY 56 (2009) Fig. 5 (a) The flaps were marked on the skin of the labia minora. (b) The flap was mobilized on its vascular pedicle. (c) Two flaps were pieced together with 5-zero polyglactin continual sutures. (d) The flap was tubularized with 5-zero polyglactin continual sutures. were assessed with regard to initiation, stream, and continence. When cystourethrography confirmed no evidence of strictures or fistula, the suprapubic cystostomy was removed. The cases were followed up every 1 2 mo for the first 6 mo, then every 3 mo for the next year, and annually thereafter. 3. Results Follow-up was obtained for a total of mo (mean mo) postoperatively. The catheters were removed 3 4 wk after the operation. No severe early or late postoperative complications developed in any patients. Two patients complained of dysuria, which resolved spontaneously after 2 wk. Another patient reported mild self-limiting stress incontinence, which resolved after 4 wk. At 3-mo follow-up, one patient complained of difficulty voiding; urinary peak flow was 13 ml/s, and the patient underwent two urethral dilations, after which the symptoms resolved. All other patients had normal micturition with a mean urinary peak flow of ml/s (range

6 198 EUROPEAN UROLOGY 56 (2009) Table 2 Postoperative patient characteristics Patient Procedure Maximum flow (ml/s) Further therapy needed Follow-up (mo) No Age* 1 24 DFU 19 No DFU 20 No SFU 18 No SFU 21 No SFU 21 No SFU 31 No SFU 42 No DFU 19 UD 10 * At time of injury. DFU = double face flaps urethroplasty. SFU = single face flap urethroplasty. UD = urethral dilation 2 times ml/s) (Table 2). Urethrograms were used to demonstrate the patency of the urethra (Fig. 1d and 1e). 4. Discussion Blunt injury to the urethra in female patients is uncommon, although a few reports have studied the urethral injuries secondary to pelvic fracture in children [9 11]. Orkin et al reported a 6% incidence of this kind of trauma in a review of 2000 patients [12]. Traumatic fracture of the pelvis may result in simple urethral contusion, partial or complete transection of the female urethra, or longitudinal urethral injury [13,14]. Urethral reconstruction requires: (1) adequate exposure of the urethral bed, (2) mobilization of a large flap to prevent suture stretching and (3) careful preparation of the island flap to provide a good vascular pedicle. Fig. 6 An end-to-end anastomosis was performed between the normal urethra and neourethra, and the rectus muscle flap (arrow) was wrapped around the anastomosis. Several approaches to female urethral reconstruction have been described in the literature [1 8]. Montorsi et al report a series of 17 patients treated with a pedicled flap isolated from the vaginal vestibulum, which was anastomosed with two longitudinal running sutures along the two edges of an opened urethra [1]. In their series, 15 of 17 patients (88%) reported that their symptoms resolved following this procedure. Blaivas and Heritz [2] presented a retrospective study of one-stage urethral reconstruction using a vaginal flap in 47 female patients with anatomical damage to the urethra or the bladder neck. They used a fascial pubovaginal sling in 41 patients, a modified Pereyra procedure in 5 patients, and a Kelly plication in 1 case; continence was obtained globally in 42 subjects. Migliari et al describe the technique for dorsal buccal mucosa graft urethroplasty in three female patients with urethral stenosis. In all cases, following catheter removal, both voiding urethrogram and uroflowmetry were normal [3]. Hemal et al [4] describe the technique of a bladder flap tube neourethra in three patients with complete urethral loss. Following this procedure, all three patients were continent, although one required intermittent catherization for a short period. Mundy [5] used five different surgical techniques, including pedicle labial skin tube urethroplasty. In all techniques, the neourethra was wrapped with either labial fat or omentum. Tanello et al [6] performed urethral reconstruction using a pedicle labial flap in two patients. They used a flap obtained from the labia minor as a patch and obtained normal micturition in both patients after 24 mo. Falandry et al [7] reported their experience using a single pedicle flap and double-face pedicle flaps obtained from the labia minora and majora for urethral reconstruction in patients with a history of obstetrical injury. They treated 56 female patients (mean age 18 yr) using a patch in 27 cases, a tabularized flap for complete reconstruction of the urethra in 18 patients, and a double-faced urethroplasty in the other 11 cases. The average follow-up period was 23 (range 5 47) mo. The global success rate was 82%. Recovery of normal micturition without incontinence was obtained in 36 cases (69%). These authors concluded that the pedicle labial flap is a highly suitable treatment for the management of urethral injury in this patient population.

7 EUROPEAN UROLOGY 56 (2009) In the present study, we consider eight patients with obliterative urethral strictures and urethrovaginal fistulas. These patients were successfully treated with single- and double-face pedicle labia flap urethroplasty, performed via a transpubic approach. The transpubic approach is indicated if: (1) the patient has complex urethral strictures and urethrovaginal fistulas; (2) there is extensive scar tissue; and (3) there are anatomical defects. This approach not only provides excellent exposure for urethral anastomosis, but also allows for synchronous repair of bladder neck incompetence and urethral fistulas. Furthermore, the transpubic route facilitates the use of a pedicled omental graft of the rectus muscle to obliterate the peri-anastomotic dead space, absorb inflammatory debris, and prevent fibrosis. This approach provided good exposure of the distorted anatomy in these patients. We chose the pedicle labial skin because the labial skin presents many suitable features for creating an island flap: It is hairless, naturally wet, elastic, and easily obtainable. After an average of 48 mo of follow-up, all patients achieved good micturition and were continent. Our experience demonstrated the feasibility of using a pedicle flap obtained from the labia for one-stage urethroplasty in the reconstruction of female urethral strictures. Several factors must be considered when reconstruction of posttraumatic urethral obliteration is performed: (1) anatomical damage to the lower urinary tract and associated organs in the affected area must be identified; (2) the fibrous tissue enclosing the urethral breach must be excised; and (3) the separated urethral ends must be delicately exposed and urethral continuity must be restored by a tension-free end-to-end anastomotic repair, provided that a healthy anterior urethra is present. Urinary incontinence is a common and distressing complication on traumatic pelvic fracture urethral injuries. Venn et al [13] described 12 patients with urethral injury as a consequence of a pelvic fracture. Two patients had less serious injuries and presented with stress incontinence. The other patients presented with total incontinence and were treated by multiple surgical techniques, including implantation of an artificial urinary sphincter (AUS), Mainz-type ureterosigmoidostomy, ileal conduit, bilateral cutaneous ureteromies, and a suprapubic catheter. Woodside [15] described two patients requiring a sling procedure for incontinence as a consequence of pelvic trauma. In our series, all patients had mid-to-distal urethral completely disrupted or destroyed and vaginal injury. Of these eight patients, two presented with moderate urinary incontinence, and three presented stress incontinence before operation (Table 1). We chose the rectus muscle flap to wrap around the normal urethra and the neourethra, which may not only obliterate the peri-anastomotic dead space, but also improve continence. In this study, all patients were completely continent during the follow-up. Female Sexual Dysfunction (FSD) is a comment problem following traumatic pelvic fracture urethral injuries. Sexuality was influenced not only traumatic pelvic fracture urethral injuries, but also by other factors, such as impaired body image, concomitant disease, hormonal influences such as menopause, and partnership [16]. In our series, all patients were sexually inactive before operation of the urethral reconstruction. Four patients became sexually active again postoperatively. Of the four sexually inactive patients, two had no partner, one had no sexual desire that directly related to the operation, and the last patient was related to a partner with erectile dysfunction. 5. Conclusions Complex recurrent female urethral strictures are uncommon and there is no standard approach to repair such injuries. We demonstrate that pedicle labial flap urethroplasty through a transpubic approach is feasible for treating obliterative urethral strictures and urethrovaginal fistulas. Further evaluation of this technique, with long-term followup of treated patients, is merited. Author contributions: Yue-Min Xu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Xu, Jin. Acquisition of data: Xie. Analysis and interpretation of data: Zhang. Drafting of the manuscript: Xu. Critical revision of the manuscript for important intellectual content: None. Statistical analysis: None. Obtaining funding: None. Administrative, technical, or material support: Xu, Jin, Fu. Supervision: Sa. Other (specify): None. Financial disclosures:i certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. References [1] Montorsi F, Salonia A, Centemero A, et al. Vestibular flap urethroplasty for strictures of the female urethra: impact on symptoms and flow patterns. Urol Int 2002;69:12 6. [2] Blaivas JG, Heritz DM. Vaginal flap reconstruction of the urethra and vesical neck in women: a report of 49 cases. J Urol 1996;155: [3] Migliari R, Leone P, Berdondini E, et al. Dorsal buccal mucosa graft urethroplasty for female urethral strictures. J Urol 2006;176: [4] Hemal AK, Dorairajan LN, Gupta NP. Posttraumatic complete and partial loss of the urethra with pelvic fracture in girls: an appraisal of management. J Urol 2000;163: [5] Mundy AR. Urethral substitution in women. Br J Urol 1989;63:80 3. [6] Tanello M, Frego E, Simeone C, et al. Use of pedicle flap from the labia minora for the repair of female urethral strictures. Urol Int 2002;69:95 8.

8 200 EUROPEAN UROLOGY 56 (2009) [7] Falandry L, Xie D, Liang Z, et al. Utilization of a pedicled labial flap, single or double face, for the management of post-obstetric urethral damage. J Gynecol Obstet 1999;28: [8] Zorn KC, Bzrezinski A, St-Denis B, et al. Female neo-urethral reconstruction with a modified neurovascular pudendal thigh flap (Singapore flap): initial experience. Can J Urol 2007;14: [9] Williams DI. Rupture of the female urethra in childhood. Eur Urol 1975;1: [10] Okur H, Kucikaydin M, Kazez A, et al. Genitourinary tract injuries in girls. Br J Urol 1996;78: [11] Ahmed S, Neel KF. Urethral injury in girls with fractured pelvis following blunt abdominal trauma. Br J Urol 1996;78: [12] Orkin LA. Trauma to the bladder, ureter, and kidney. In: Sciarra JJ, editor. Gynecology and Obstetrics. Philadelphia: JB Lippincott; 1991, chap 88. [13] Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int 1999;83: [14] Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol 1992;147: [15] Woodside JR. Pubovaginal sling procedure for the management of urinary incontinence after urethral trauma in women. J Urol 1987;138: [16] Dennerstein L, Hayes DR. Confronting the challenges: epidemiological study of female sexual dysfunction and the menopause. J Sex Med 2005;2(Suppl 3): Editorial Comment on: Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated with Urethrovaginal Fistulas Secondary to Pelvic Fracture Dmitry Pushkar Department of Urology of MSMSU, Moscow, Russia pushkardm@mail.ru Complex urethral traumas in female patients are among the most difficult cases to treat. Since blunt injury to the urethra in females with traumatic pelvic fracture is extremely uncommon, and often associated with other visceral lesions, this type of trauma may initially be overlooked. Yue-Min Xu and coworkers presented a unique series of cases involving eight patients with such injuries. All eight patients presented urethrovaginal fistulae associated with urethral strictures, and one patient showed rectovaginal fistula. The authors described in detail urethroplasty via transpubic approach. A part of the new urethra was created from labia minora or majora skin. The authors used a pedicled rectus muscle flap wrapped around the anastomosis in order to obliterate a periurethral cavity [1]. It is believed that the vast majority of urethrovaginal fistulas can be restored via simple vaginal route [2]. This is the case for a majority of patients, although the most severe cases require an individual approach, with major reconstruction. For such cases, a wide variety of procedures has been introduced [3]. Recently, buccal mucosa, with an element of tissue engineering, has come to be used more widely in female patients [4]. Labial skin is an attractive, local material with great flexibility. The creation of a neourethra is not enough for a majority of patients. Several procedures are sometimes required in order to complete urethral restoration. I do not believe that applying additional tissues such as muscle, omentum, or fat is helpful in restoring continence, although it does bring additional blood supply. Those who perform such procedures should understand that patient care may be a life-long commitment, as a majority of patients will develop voiding dysfunctions and incontinence. I feel that such patients should be evaluated and treated in centres specializing in major pelvic surgery. A properly trained pelvic surgeon can now provide his patients with a quality of life that was previously unattainable. References [1] Xu Y-M, Sa Y-L, Fu Q, Zhang J, Xie H, Jin S-B. Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture. Eur Urol 2009;56: [2] Pushkar DY, Dyakov VV, Kosko J, Kasyan GR. Management of urethrovaginal fistulas. Eur Urol 2006;50: [3] Wadie BS, El Hifnawy A. Reconstruction of the female urethra: versatility, complexity and aptness. J Urol 2007;177: [4] Bhargava S, Patterson JM, Inman RD, MacNeil S, Chapple CR. Tissue-engineered buccal mucosa urethroplasty clinical outcomes. Eur Urol 2008;53: DOI: /j.eururo DOI of original article: /j.eururo