Shlomo Raz1
(1)
Division of Pelvic Medicine and Reconstructive Surgery, UCLA School of Medicine, Los Angeles, CA, USA
Electronic supplementary material
The online version of this chapter (doi:10.1007/978-1-4939-2941-2_6) contains supplementary material, which is available to authorized users.
Keywords
Anal sphincter incompetencePudendal nerve damageAnal manometryTransrectal ultrasoundClosure of the bladder neckNeourethraLabioplasty
6.1 Anal Sphincter Reconstruction
The etiology of anal sphincter incompetence can be multifactorial. Traumatic delivery can cause tearing of the internal and external anal sphincter musculature, particularly in the anterior segment. Repair immediately after delivery usually is highly effective, but some patients will develop significant stool incontinence. Pudendal nerve damage after traumatic delivery or other injury can cause sphincter neuropathy and poor sphincteric function. Posterior or lateral episiotomy can be another factor in anal sphincter damage. Surgery, inflammation, traumatic injury, or radiation can directly damage the anal sphincter, and neurogenic disease (e.g., paraplegia with sacral arc lesion) is often associated with anal incompetence.
6.1.1 Indications
Anal sphincter reconstruction is indicated in very selected symptomatic patients for whom medical therapy has failed. Patients with severe neurogenic paralysis of the anal sphincter will not improve after surgery. Factors controlling surgical success include the integrity of the anal skin tissues, the innervation, the anal sphincter musculature, the location of the damage (segmental or circular, external or internal sphincter, or both), and prior surgeries (Figs. 6.1, 6.2, and 6.3).
Fig. 6.1
Anatomical diagram of the distal rectum and anal sphincter. The internal sphincter is a continuation of the circular and longitudinal fibers of the rectum. The most medial segment of the levators is the puborectalis muscle, which forms a posterior sling or notch at the posterior rectal wall
Fig. 6.2
The external anal sphincter (ES) is divided into deep, superficial (Sup), and subcutaneous (Subc) sections and surrounds the internal anal sphincter (Int AS)
Fig. 6.3
Sagittal MRI cut of the midpelvis showing the elevation and angulation created by the levator plate on the distal posterior rectum, above the anal canal
6.1.2 Diagnosis
Most patients present with differing degrees of intermittent or daily episodes of stool incontinence or inability to control flatus. In some patients, the loss of stool occurs only with liquid stool, with good control of solid matter. The incontinence can be continuous or it can be intermittent, occurring with stress maneuvers such as cough, strain, or exercise. Physical examination should include perianal sensations, rectal tone, voluntary activity of the sphincter, sensations of the genitalia, and observation of any perianal scars or lesions. Anal manometry and transrectal ultrasound will confirm the diagnosis and better define the lesions (Figs. 6.4 and 6.5).
Fig. 6.4
Endorectal ultrasound showing the layers of the anal canal: submucosa and internal and external sphincter
Fig. 6.5
Endorectal ultrasound of a patient with extensive anterior external and internal sphincter damage after traumatic delivery and perineal tear
6.1.3 Surgical Technique
Prior to surgery a bowel preparation should be done. After anesthesia but before beginning surgery, the rectum is irrigated with copious amount of diluted antibiotic solution to clean any residual stool matter from the rectum.
6.1.3.1 Anterior anal Sphincter Repair
Figures 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14, and 6.15 illustrate the surgical technique for anterior anal sphincter repair.
Fig. 6.6
The perineum, the vaginal area, and the rectum are exposed. An inverted U incision will be performed around the anal sphincter, extending superiorly to the posterior fourchette and laterally to the medial aspect of the ischial tuberosities
Fig. 6.7
The incision is made, and the margins are retracted using a ring retractor and hooks
Fig. 6.8
A flap of the perineal skin will be created. The skin is dissected toward the anal canal to expose the superficial anal sphincter fibers, the ischial fossa, and the transverse perineal musculature
Fig. 6.9
The skin flap is retracted inferiorly, exposing the posterior perineum, the external anal sphincter, and the ischial fossa
Fig. 6.10
Dissection is carried out just lateral to the anal sphincter toward the ischial fossa, exposing the external anal sphincter fibers. An anterior defect is present due to traumatic delivery and perineal tear
Fig. 6.11
Exposure of the ischial fossa and perirectal area is obtained. With a finger in the rectum to prevent passage of sutures through it, figure-of-eight sutures of #0 delayed absorbable sutures are applied
Fig. 6.12
The sutures include the 3 o’clock, 12 o’clock, and 9 o’clock portions of the anal sphincter. Care should be taken not to perforate the rectal wall and to include only rectal musculature without the fatty tissue
Fig. 6.13
After application of the sutures, traction is applied to ensure approximation and tightening of the open rectal canal
Fig. 6.14
A series of three or four sutures are applied sequentially, with the most superior sutures incorporating the transverse perineal musculature. Care should be taken not to incorporate the skin flap. Again it is important that all the sutures are applied with a finger in the vagina to ensure that no sutures are in the rectum and that elevation of the sutures tightens the anal sphincter. The sutures will be tied
Fig. 6.15
Throughout the surgery and prior to closure, the area is irrigated with copious amounts of antibiotic solution. The inverted U flap is advanced to cover the area of the reconstruction. A two-layer closure is done with delayed absorbable sutures. A local anesthetic agent is injected to improve postoperative pain control
6.1.3.2 Combined Anterior and Posterior Anal Sphincter Repair
In selected cases of circular defect of the anal sphincter, both anterior and posterior plications of the anal sphincter may be indicated (Figs. 6.16, 6.17, 6.18, 6.19, 6.20, and 6.21).
Fig. 6.16
Wide-open anal sphincter with mild rectal mucosal prolapse in a patient with severe stool incontinence and a wide circular open anal sphincter
Fig. 6.17
A semicircular inverted U incision is made in the perineum
Fig. 6.18
Similar to the previously described procedure, the anterior anal sphincter musculature is exposed and will be repaired with a sequence of delayed absorbable sutures. Tying these sutures does not produce adequate anal sphincter approximation
Fig. 6.19
A transverse semicircular incision is made posterior to the anal sphincter. Dissection is carried out laterally to expose the puborectalis and pubococcygeus muscles and the posterior structures of the anal sphincter
Fig. 6.20
Under finger control in the rectum, figure-of-eight sutures approximate the posterior fibers of the anal sphincter. Care is taken not to penetrate the rectal wall. Traction of the sutures produces tightening and further closure of the anal sphincter
Fig. 6.21
The posterior anal sphincter area is irrigated with copious amounts of antibiotic solution and closed in layers with delayed absorbable sutures
6.1.4 Postoperative Care
The surgery is done as an outpatient procedure. Postoperative antibiotics, stool softeners and laxatives, and pain medications are given. The patient starts in sitz baths soon after surgery. Injection of long-acting local anesthetic at the end of surgery will help with pain control. No particular restrictions of activities are required.
6.1.5 Intraoperative Complications
The most important intraoperative complication is rectal wall injury, which can lead to fistula formation, wound infection, and dehiscence. Bleeding can occur from injury to the internal pudendal branches in the ischial fossa. Dissection close to the pubococcygeus and external anal sphincter fibers will avoid this complication. If the tissues have damage from prior trauma, surgery, or radiation, proper approximation of the anal sphincter structures may not be possible. In cases with difficult reconstruction, bleeding, or rectal injury, bilateral JP drains can be inserted in each ischial fossa and the end transferred superiorly, lateral to the labia.
6.1.6 Postoperative Complications
The most important postoperative complication is wound infection, which is reported in 5–25% of patients. Some surgeons prefer to leave the skin open after surgery. Opening the wound in one or more areas can be required for drainage.
In spite of good surgical technique and anatomical reconstruction, some patients continue to suffer from sphincter incompetence, which probably is due to neuropathic damage (anatomy does not correlate with function). It is also possible that the sutures may have become dislodged, broken, or detached owing to sudden strain or cough episodes. The patient may feel a pop in the perineum at the time of the sudden event.
6.2 Closure of the Bladder Neck
6.2.1 Indications
Closure of the bladder neck and urethra is indicated in patients with severe urinary incontinence due to serious damage to the urethra from trauma, radiation, surgery, or a chronic indwelling catheter. In patients with indwelling catheters, the presenting symptoms are generally severe incontinence with leakage around a Foley catheter and the need to progressively increase of the size of the catheter to maintain continence.
Closure of the bladder neck is also indicated in patients with paraplegia and urinary retention who are unable to perform self-catheterization, even if they have an intact urethra.
Closure of the bladder neck requires a concomitant procedure for urinary diversion. The simplest is the placement of a suprapubic catheter. Patients with severe frequency or bladder spasms due to an overactive detrusor may not be good candidates for this procedure because the spasms and pain can be exacerbated by the indwelling catheter.
Patients with paraplegia and neurogenic bladder suffering from incontinence in whom other treatments have failed are candidates for placement of a suprapubic catheter, continent or incontinent augmentation cystoplasty, and closure of the bladder neck.
In patients with pelvic radiation, the urethra and the bladder are usually affected, and augmentation procedures are required at the time of bladder neck closure.
6.2.2 Diagnosis
The findings on physical examination depend on the etiology of the condition. The urethra may be intact, as in paraplegic patients, or it may be a totally open channel with constant leakage of urine. Sometimes the whole urethral length has necrosed and only the bladder neck and trigone are seen on examination.
Before any surgery, it is important to assess the quality of the surrounding vaginal tissues and labial tissues because it is necessary to cover the area of the closed bladder neck with rotational or advancement flaps.
The ability of the patient or a family member to perform self-catheterization via an abdominal stoma will indicate the use of a continent or an incontinent bladder diversion.
Cystoscopy should be performed prior to surgery to rule out any intravesical pathology. Upper tract evaluation by ultrasound or CT urogram is indicated to rule out any upper tract condition such as stones or obstruction, which may change the surgical procedure.
6.2.3 Surgical Technique
Figures 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, 6.28, 6.29, 6.30, 6.31, 6.32, 6.33, 6.34, 6.35, 6.36, 6.37, 6.38, 6.39, 6.40, and 6.41 illustrate the technique for bladder neck closure, including the optional use of a Martius flap.
Fig. 6.22
Exposure of the anterior vaginal wall is obtained. A Foley catheter is inserted, and a ring retractor with hooks will help with the exposure
Fig. 6.23
An anterior inverted U vaginal flap is created and dissected free from the periurethral tissues down to the bladder neck area
Fig. 6.24
Dissection is carried out laterally around the periurethral fascia to enter the retropubic space, detaching the urethropelvic fascia from the arcus tendineus fascia pelvis. Sharp and blunt dissection is performed in the retropubic space to free any adhesions of the bladder or urethra from the lateral and posterior pubic bone
Fig. 6.25
Diagram of the incisions used for the bladder neck closure. An anterior vaginal flap and a circular incision around the urethra will be made. The incision is begun 5–10 mm lateral to the remnant of the urethral meatus and is extended superiorly to the mid-anterior rami of the pubic bone
Fig. 6.26
A circular incision is made around the urethra toward the anterior rami of the pubic bone
Fig. 6.27
Dissection is carried out toward the anterior pubic bone. The periosteum of the anterior pubic bone is exposed. The urethra is pushed inferiorly, and with sharp dissection the pubourethral fascia is detached, allowing entrance into the retropubic space
Fig. 6.28
All adhesions of the retropubic space are freed to expose the anterior bladder wall and the lateral attachments of the urethra. A finger is inserted in the retropubic space from the vaginal periurethral incision. Under finger control in the vagina, a right-angle retractor is inserted anterior and lateral to the bladder neck. This maneuver will isolate all the remaining tissue that supports the urethra to the lateral pelvic wall
Fig. 6.29
Diagram of the exposure of the anterior bladder wall after detaching the pubourethral fascia from the inferior rami of the pubic bone
Fig. 6.30
Using a coagulation knife, all the lateral supporting tissue of the urethra to the lateral pelvic wall is transected. The urethra, the bladder neck, and the bladder are totally free in the retropubic space. The same maneuver is performed on the contralateral side
Fig. 6.31
The urethra is transected at the level of the bladder neck (arrow) over the Foley catheter
Fig. 6.32
Diagram of the closure of the bladder neck. A two-layer closure is performed using delayed absorbable sutures
Fig. 6.33
The bladder neck has been closed with a first layer of running, locking delayed absorbable sutures and a second layer of imbricating sutures to cover the first layer of closure. Electively, a retropubic drain can be inserted under finger control in the retropubic space, using a small suprapubic puncture. If a suprapubic catheter is present, it should be irrigated with diluted indigo carmine solution to ensure the integrity of the closure. The arrow indicates the stump of the closed bladder neck
Fig. 6.34
Wide exposure of the anterior bladder wall is obtained. Several delayed absorbable sutures are applied to the anterior bladder wall and posterior to the line of sutures at the closed bladder neck, to advance it toward the retropubic space and away from the vagina. Arrow indicates bladder neck closure
Fig. 6.35
Diagram of the anterior bladder wall showing the advancement of the closed bladder neck toward the retropubic space. The closed bladder neck will be away from the vaginal area
Fig. 6.36
The sutures from the closed bladder neck to the anterior bladder have been tied, showing the repositioning of the closed bladder neck (arrow) into the retropubic space
Fig. 6.37
In cases of severe urethral necrosis, radiation, or difficult closure of the bladder neck due to poor tissue quality, the use of a Martius flap is an option. An incision is made over the labia majora and the fibro-fatty tissue is isolated over a drain
Fig. 6.38
The superior pedicle of the flap is transected and a tunnel is created under the skin of the labium to transfer the flap toward the anterior vaginal wall
Fig. 6.39
The Martius flap has been transferred to the retropubic space. Multiple sutures are used to cover the bladder neck closure
Fig. 6.40
Diagram showing the advancement of the vaginal wall distally to cover the area of the reconstruction
Fig. 6.41
The previously created anterior vaginal wall flap is advanced distally and anastomosed to the medial labial incisions. The closure should be tension-free. If required, distally interrupted sutures approximate the medial labial incisions, reducing the distance required for the flap advancement
At the end of the procedure, vaginal packing will be inserted and a bladder diversion procedure will be performed. In cases of placement of a suprapubic catheter, only the catheter should be inserted prior to the closure of the bladder neck.
6.2.4 Postoperative Care
Closure of the bladder neck only without bladder augmentation is usually done as outpatient surgery. Oral antibiotics are continued as indicated. In cases of additional continent or incontinent urinary diversion, patients are kept NPO until bowel activity resumes. In these patients, a suprapubic and stoma catheter will be inserted.
6.2.5 Intraoperative Complications
Bleeding in the form of profuse oozing is not uncommon, especially in patients with active infection. The lateral dissection of the bladder neck from the urethra and the detachment of the urethra from the inferior rami of the pubic bone can be the source of significant bleeding from the periurethral and perivesical vessels. Entering the retropubic space flush under the pubic bone to detach the pubourethral fascia will avoid the periurethral plexus. The lateral dissection to detach the urethropelvic fascia from the lateral levator should be performed with care, and the entrance to the retropubic space should be as far lateral as possible and parallel to the urethra, pointing the scissors superiorly. A vaginal packing and dedicated hemostasis with coagulation or interrupted sutures should control this oozing.
Difficulty in closing the bladder neck because of a large defect or radiation damage may require further mobilization of the bladder wall, with creation of an anterior flap. In this case, a Martius flap should be used to cover the defect.
Large proximal urethral diverticula may extend into the trigone and bladder, or ureteric injury may occur. Instillation of indigo carmine into the bladder will ensure bladder integrity. Cystoscopy after intravenous indigo carmine may be performed in selected cases to rule out ureteric injury.
6.2.6 Postoperative Complications
Perioperative antibiotic therapy is mandatory. The presence of chronic indwelling catheters or constant incontinence will increase the chances of wound infection and dehiscence. During surgery, copious irrigation with antibiotic solution is recommended.
The most important postoperative complication is a vesicovaginal fistula due to the disruption of the bladder neck closure. Obstructed or poor bladder drainage, infection, severe bladder spasms, or poor tissue quality contribute to this complication. Sometimes the fistula may close spontaneously, but many cases require re-exploration and reclosure of the bladder neck. Important factors in operative success and avoidance of fistula formation include a watertight closure, precise dissection, and anatomical closure of the urethral layers.
6.3 Construction of a Neourethra
6.3.1 Indications
Urethral reconstruction is required to rebuild a urethra lost by trauma, surgery, radiation, or anti-incontinence surgery. The surgery is aimed at constructing a full-length urethra that is fistula-free and continent. In patients with incontinence, sling procedures (fascial slings) can be used at the time of the reconstruction or in a second stage. Insertion of a concomitant fascial sling can lead to obstruction or fistula formation. Martius flaps are used all the time to cover the area of the reconstruction and prevent fistula formation.
To perform this type of reconstruction, a significant amount of anterior vaginal wall must be inverted and advanced; the anterior vaginal wall in the defective area should be mobile and well vascularized. Figures 6.42, 6.43, 6.44, 6.45, 6.46, 6.47, 6.48, 6.49, 6.50, 6.51, 6.52, 6.53, 6.54, 6.55, 6.56, 6.57, 6.58, 6.59, 6.60, 6.61, 6.62, and 6.63 show a few examples of the type of urethral reconstruction used in most cases.
Fig. 6.42
Diagram of the incision used for urethral reconstruction. The area of the defect will be the posterior plate, and the anterior plate will be a flap of the anterior vaginal wall proximal to the defect. A U flap is created inferior to the displaced urethral meatus. The flap is dissected free. An incision lateral to the urethra is made on each side. The lateral margins of the incision are undermined and mobilized
Fig. 6.43
The flap is advanced forward to cover the urethral defect. Interrupted sutures are used to anastomose the flap to the anterior vaginal wall incisions. The sutures should cover the catheter without tension. The undermined lateral incisions are sutured to cover the area of the reconstruction
Fig. 6.44
Diagram of the urethral reconstruction using in situ vaginal wall as the tube. A U incision is made around the Foley catheter lateral enough to be able to cover the catheter tension-free. The lateral margins of the incision are dissected free and mobilized
Fig. 6.45
Diagram of the next step of the reconstruction. The medial margins of the anterior plate are sutured around the catheter to form a tube. The lateral margins will be used to cover the defect
Fig. 6.46
Picture showing the urethral defect in a patient who lost half of the urethra through prior surgery. The Foley catheter is in place. The external meatus is located in a posterior location. The patient is continent and the main complaint is vaginal voiding and urethral discomfort
Fig. 6.47
Two incisions are made in the anterior vaginal wall, distal to the urethral meatus. The new location of the external meatus is selected
Fig. 6.48
The urethral margins are approximated and the distal half of the urethra is reconstructed with a two-layer closure using running and interrupted fine delayed absorbable sutures
Fig. 6.49
An in situ Martius flap is prepared by dissection under the right labium, exposing the fibro-fatty tissue. The upper segment of the flap is transected and the base of the flap is rotated toward the vaginal canal
Fig. 6.50
The flap is transferred toward the left side and multiple sutures are applied to widely cover the area of the reconstructed urethra
Fig. 6.51
Labial and distal vaginal tissue is used to cover the Martius flap and the area of the reconstruction
Fig. 6.52
View of the anterior vaginal wall in a patient with significant loss of the distal urethra after surgery. The urethra is hypospadiac and the patient complains of vaginal voiding
Fig. 6.53
Voiding cystogram showing the contrast filling the vaginal canal (arrow). No significant stress incontinence was present
Fig. 6.54
Two longitudinal incisions will be made in the anterior vaginal wall in the area of the lost urethral wall
Fig. 6.55
Two incisions of the distal anterior vaginal wall are made that will be used to create the urethral tube. The incisions should be placed lateral enough to be able to rotate the margins and form a tension-free tube around the 12- or 14-Fr Foley catheter. The lateral margins of the incisions are undermined laterally and will be used to cover the urethral tube
Fig. 6.56
The medial margins of the incision are sutured in a circular fashion around the Foley catheter. The reconstruction is done in two layers of running and interrupted fine delayed absorbable sutures. The catheter is moved back and forth to ensure tension-free closure
Fig. 6.57
An in situ Martius flap will be created from the left labial fibro-fatty tissue. Scissors are used to dissect under the left labial skin
Fig. 6.58
The fatty tissue of the left labium is exposed and mobilized
Fig. 6.59
The Martius flap has been mobilized and rotated toward the right to cover the area of reconstruction
Fig. 6.60
Multiple sutures are used to fix and spread the Martius flap around the neourethra
Fig. 6.61
The anterior vaginal wall and labial margins are used to cover the Martius flap. The anterior vaginal wall is seen at the end of the procedure with the new external meatus located in the normal distal position
Fig. 6.62
Exposure of the anterior vaginal wall in a patient with an accidental surgical incision from the external meatus to the bladder neck resulting in total incontinence of urine and vaginal voiding
Fig. 6.63
Reconstruction of the urethra in this patient is described in detail in Chap. 5, on transvaginal repair of fistulas
6.4 Labioplasty for Excess Labia Majora
6.4.1 Indications
Though most of these surgeries are done for cosmetic reasons, some patients have clear medical indications. These include difficulties with spraying during urination, pain, discomfort, and dyspareunia.
On examination, other vaginal or urethral pathology should be ruled out. The excess labia are demonstrated by lateral traction of the upper margins of the labia.
6.4.2 Surgical Procedure
Figures 6.64, 6.65, 6.66, 6.67, 6.68, 6.69, 6.70, 6.71, 6.72, 6.73, 6.74, and 6.75 illustrate the technique for reduction labioplasty.
Fig. 6.64
The anterior vaginal wall is exposed after applying lateral traction to the labia
Fig. 6.65
The upper corner of the labium will be transferred to an inferior position after excision of the excess labial skin. The arrows indicate the extent of the line of incision of the inner labia majora
Fig. 6.66
A stay suture is applied to the upper margin of the labium. An oblique incision is made in the lateral aspect of the labium, extending to its base. The arrows indicate the lateral labial incision prior to excision
Fig. 6.67
Similarly to the lateral labial skin incision, an oblique incision is made in the medial aspect of the labial skin
Fig. 6.68
The labial skin between the two incisions is excised, taking care to be very superficial and prevent any excision of the labial fibro-fatty tissue
Fig. 6.69
The labium is retracted superiorly after the excision of the medial and lateral skin
Fig. 6.70
The upper margin of the reduced labial skin is brought down to the inferior margin of the introitus
Fig. 6.71
Fine delay absorbable sutures are used to anastomose the reduced labium to the medial and lateral aspects of the initial incision
Fig. 6.72
A similar dissection is performed on the contralateral side. Medial and lateral incisions of the labium are performed and a triangular segment of skin is excised
Fig. 6.73
The upper margin of the reduced labium is elevated superiorly
Fig. 6.74
The anastomosis of the reduced labium to the medial and lateral labial incisions is performed using fine delay absorbable sutures
Fig. 6.75
Final result of the reduction labioplasty
6.4.3 Postoperative Care
A small dressing is applied for a few hours. The patient can resume normal activities but is prevented from sexual intercourse for 3–4 weeks.
6.4.4 Complications
Skin infection should resolve with antibiotics and drainage, if required. Bleeding or hematoma of the labia can occur and should resolve with conservative measures. Rarely, drainage is required. Dissatisfaction with the cosmetic result may require further intervention. Labial pain and numbness should resolve with time. Deep excision of the labial skin may result in long-term lack of labial sensations.
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