The next patient is a 35-year-old female who initially presented with an ectopic ureter that was implanting into the urethra and a very congenitally short urethra. She underwent a reimplantation of that ectopic ureter and a cadaveric fasciolata suburethral sling. It was also noted at that time that she had a blind remnant of a ureter that was present and connected to the urethra but was left alone at the first operation. She then represented, as I said, approximately two years later with a complete loss of her posterior urethra. They theorized that this remnant became infected and created a breakdown of the posterior urethra. There's a complete disappearance of the cadaveric fasciolata. One can see here the anterior vaginal wall is very foreshortened and there's a large defect in the posterior urethra extending all the way into the distal portion of the trigone, also seen here as the uterine cervix. The goal is to reconstruct the urethra and most likely place a fat pad between the reconstructed urethra and the anterior vaginal wall and then finally place a suburethral sling as the patient's urethra will definitely be incompetent if this isn't done. One can see with some gentle traction of the Foley ball the defect does extend into the trigone of the bladder. The vagina is now dissected away from the wall of the urethra and the hope is to mobilize enough tissue to allow for a tension-free initial closure of the urethral defect. Dissection is extended laterally to the level of the inferior pubic ramus on each side and will eventually also extend into the retropubic space. Further mobilization at the level of the bladder is now being performed again to hopefully allow enough tissue to close the defect under minimal tension. Sufficient tissue has now been mobilized to allow the closure of the defect in a transverse fashion and this will be performed with interrupted chromic sutures. One can see when closed in this fashion that the tissue approximates nicely. With minimal to no tension. Further mobilization on the left side allows the remainder of the defect to be closed. Again, interrupted threochromic sutures are used for the primary closure of the defect. The urethra has been completely closed now and we will proceed with an attempt to mobilize a second layer to cover the initial closure. A second layer of tissue has been mobilized off the anterior vagina on the right side and this is laid down over the initial closure to add strength and support to the repair. A Martius fat pad will then be transposed. This will come in from the patient's left labia. Fat pad is mobilized and then tunneled into the vagina to cover the repaired area. This will bring in a fresh vascular pedicle and hopefully prevent any recurrence or breakdown of the repair. Also in place is the cadaveric fasciolata sling. Fat pad will be laid down over the defect and this will be followed by placement of the sling over the fat pad. Sling is placed loosely so one can easily pass a right angle clamp between the sling and the underlying tissue. The final aspect of the repair involves closing the anterior vaginal wall. As this patient had a very foreshortened anterior vaginal wall, there is not enough vagina to mobilize to close the repaired area so a labia minora skin flap will be mobilized from the left side to cover up this portion of the anterior vagina. One can see now that the labial skin graft has been used to close the defect of the anterior vaginal wall and this thus completes the repair.

urethra reconstruction

complications

tissue mobilization

closure techniques

suburethral sling