What is Reconstructive Surgery?
Reconstructive urologic surgery is a sub-specialty of urology that focuses on restoring normal urine flow in both the upper and the lower urinary tract following injury or obstruction of the urethra. The urethra is the tube that extends from the bladder out of the body to expel urine. When an injury occurs, slow urine flow, urinary tract infection, urinary incontinence, and bladder infection can become real problems for patients.
The narrowing of the urethra, the urinary channel from the bladder to the outside of your body, can be caused by trauma to the bicycle seat area, infections, pelvic bone fractures or unknown causes.
- Weak urine stream
- Reduced urine output
- Painful urination
- Incomplete emptying of the bladder
- Inability to void
- Recurrent urinary tract infections
- Urine cultures
- Uroflow studies
- Pressure flow studies
- X-rays – fluoroscopic studies and ultrasound
For mild cases, observation is reasonable. For moderate to severe cases, it depends on the location and length of the urethral stricture. Endoscopic therapies include urethral dilation or cutting with urethrotomy. Surgical techniques include the removal of scar tissue with the reconstruction of the urethra without graft vs. with graft tissue.
When the bladder and bladder outlet are no longer functional due to bladder cancer, pelvic trauma, scar tissue, neurologic conditions, or radiation therapy, then a new channel must be constructed to allow the urine to exit the body.
Surgical Options Include:
- Ileal conduit (with an abdominal stoma)
- Continent catheterizable channel (small stoma with no bag)
- Neobladder (a reservoir created out of intestine with no stoma and no bag)
An abnormal opening of, or connection to, a urinary tract organ is called a fistula. There are many types of fistulas, but all types can lead to increased morbidity and diminished physical activity.
- The vesicouterine fistula occurs between the uterus and the bladder and is between the vagina and the urinary tract.
- The urethrovaginal fistula is between the ureter and the vagina
- The rectovaginal fistula occurs between the rectum and vagina.
Fistulas are almost always caused by injury, such as a car accident, or during surgery such as a cesarean section. In developed countries, urinary fistulas may occur after hysterectomies, but in underdeveloped countries, obstetric trauma is usually responsible for the problem. Fistulas are very rare and occur in less than 1% of patients who undergo a hysterectomy. They usually only develop in more complex hysterectomies or in instances of severe blood loss during the surgery.
Symptoms from fistulas vary dramatically. Some fistulas cause constant urine leakage from the vagina, frequent urinary tract infections, diarrhea, fever, vomiting, or nausea. A doctor will want to examine a patient believed to have a fistula and may find the fistula during a physical exam. In order to visualize the fistula after the initial doctor’s visit, the physician will likely order an MRI or a retrograde cystogram, both of which visualize the internal organs. Patients with a fistula will often complain of side and abdominal pain and occasionally of unusual discharge or liquid from the vagina. Examinations may be painful and patients may have to be placed under general anesthesia to be evaluated for further treatment.
While some small, early fistulas can be treated with a catheter, most fistulas will require surgery. Surgical repair can fix the undesired opening or connection between two organs. Trans-abdominal surgery is the most common surgery. While it is safer for the patient if the surgeon were to gain access to the fistula through the vagina, it can be very difficult to do so. The main goal of vesicovaginal fistula surgery is to separate the two organs and create a watertight closure to keep the vagina and bladder separate.