Surgical Technique for Urethral Reconstruction Using a Vaginal Flap. The patient is a 50-year-old woman who initially presents to our institution with complaint of severe stress urinary incontinence in the setting of previous anti-incontinence procedure with complication. She reports a prior synthetic sling procedure and states sling was subsequently removed for mesh extrusion. After sling removal, she describes return of her stress urinary incontinence, which is more severe than it has been. On physical examination, the urethra is noted to be short and there appears to be a distal dorsal plate of urethral mucosa about 2 centimeters in length. There is high-grade stress urinary incontinence with Valsalva. The patient demonstrates urodynamic stress incontinence with a very low abdominal leak point pressure. Cystoscopy confirms the short urethra with no residual mesh. Surgical options are discussed and the decision is made to proceed with autologous fascial pubovaginal sling and urethral reconstruction. Once under anesthesia, attention is turned to the abdomen for harvest of pubovaginal sling. An approximately 8 centimeter long by 1.5 centimeter wide strip of rectus fascia is excised transversely. Whip stitches of number 1 proline are placed in each end of the sling. Upon initial evaluation, a largely hypospadic urethra is identified. It is noted to be approximately 2 centimeters in length. The dorsal plate is noted to be intact for at least 1 half of the distal urethra. The intact portion of the urethra is about 1 centimeter in length. B-sided rectangular incision, right and left, lateral and distal, is made at the border of the vaginal wall and the dorsal plate of the urethra. The incision is extended distally to the top of the dorsal plate and proximally to the level of the ventral urethral meatus. The vaginal flaps are dissected laterally to separate the vagina from the urethra. The urethra is then mobilized medially on both sides so that it can be rolled into a tube. Next, an inverted U incision is made in the vaginal wall with the apex at the urethral meatus. The vaginal wall is then dissected off of the periurethral fascia below the bladder neck. The endopelvic fascia is identified on both sides. The area is then perforated. The area is then perforated and the retropubic space entered bilaterally. A finger is then placed into the retropubic space. On each side, a Ras-Pereira double-pronged ligature carrier is passed from the inferior border of the rectus fascia at the level of the pubic tubercle through the retropubic space under direct finger guidance. It is passed through the vaginal incision. The proline sutures on each end of the sling are placed into the ligature carrier and it is brought back up to the abdominal incision. This places the sling around the urethra. Cystourethroscopy is performed to verify there is no injury to the urethra or to the bladder. The sling is then left loose and out of the way so the urethroplasty can be performed. The lateral edges of each side of the dorsal plate of the urethra are further mobilized and then rolled over the midline. A midline closure is performed over a 14 French Foley catheter. This is done with an interrupted forovicral at the distal end and a forovicral suture at the proximal end and then a running forovicral suture is placed between the two. After the neourethra is created, the pubovaginal sling is secured into position at the bladder neck proximally and the midurethra distally into the periurethral fascia with a threovicral suture. The urethral sling is then inserted into the periurethral fascia proximally and the midurethra distally into the periurethral fascia with a threovicral suture. The wound is then irrigated. The inverted U vaginal flap is advanced up to the pneumiatus of the urethra. It is closed laterally to the vaginal wall with interrupted and running 3-0 PGA sutures on each side. The pneumiatus is created, securing the new urethra to the vaginal epithelium and vaginal flap with interrupted 4-0 PGA sutures. The pneumiatus is created, securing the new urethra to the vaginal epithelium and vaginal flap with interrupted 4-0 PGA sutures. © BF-WATCH TV 2021 © BF-WATCH TV 2021 After the miatoplasty is completed, the Foley catheter is removed and a new one is placed. Next, the pubovaginal sling is tied across the midline loosely. The bladder is filled and pressure is placed on the bladder to evaluate for evidence of stress incontinence. The sling is then secured into position. Three finger breaths are able to be placed between the pubovaginal sling knot and the fascia. Scarpa's fascia is closed with interrupted 2-0 Vicryl and the skin is closed with a running subcuticular 4-0 Monocryl. The Foley catheter is left in place for 10 to 14 days after the operation.

surgical technique

urethral reconstruction

vaginal flap

stress urinary incontinence

pubovaginal sling