female urethral reconstruction

Urinary incontinence treatment caused by female urethral defect is very difficult. It has long been used for urinary diversion surgery, but there are many complications, which brings inconvenience to patients' lives. According to recent studies on the mechanism of urination, it is believed that the urethra is composed of myotubes that continue from the bladder. The urethral pressure during storage is higher than the bladder pressure. When the detrusor contractes and the bladder pressure is higher than the urethral pressure, urination occurs. Therefore, it is envisaged to use the bladder wall to make a smooth muscle tube that is continuous with the bladder. Its length and circumference are similar to those of the normal urethra, and it is transplanted into the perineum. It is expected that the artificial urethra can function as a normal urethra. There are two ways to reconstruct the urethral valve: one is to reconstruct the urethra with the anterior wall of the bladder, and the other is to reconstruct the urethra after the posterior wall of the bladder (the triangle of the bladder). The effect is similar, but the posterior wall requires a ureteral anastomosis. Surgery, surgery is more complicated than using the front wall. In general, the anterior wall of the bladder is used. If there is a defect in the anterior wall, such as bladder valgus and urethral rupture, the posterior wall is used. In addition, if the anterior wall of the bladder is operated many times and the anterior wall is excessively scarred, the posterior wall can also be used. Curing disease: Indication 1. Patients with early urethral cancer or other urethral diseases undergoing total urethral resection. 2. Female urethral trauma or surgical injury, or dystocia, so that the bladder neck or urethral defect can not be repaired by other methods. 3. Congenital bladder neck defects and urethral muscle dysplasia, such as bladder valgus, female urethral fissure. Contraindications 1. Neurogenic urinary incontinence. 2. Contracture bladder. 3. The bladder muscles are thin and atrophy. 4. Great bladder urethra vaginal fistula, severe defect in the posterior wall of the bladder and urethra. It is estimated that the bladder volume will be too small after the operation, or the large defect of the vaginal wall can not be repaired. Preoperative preparation 1. Carefully perform bladder, urethra and vaginal examinations to ensure that there are no contraindications to the above surgery. If the patient with urinary tract cancer must belong to the early stage of lower urinary tract cancer and can be completely removed, to avoid recurrence of urethral cancer after surgery. 2. Long-term urinary incontinence, there are many eczema, dermatitis, etc. in the perineum. You should take a bath with 1:5000 potassium permanganate solution several times before surgery. After taking the bath, use infrared radiation to change the diaper and keep it dry. After the eczema and dermatitis are cured, surgery is performed. 3. Apply antibacterial drugs to prevent infection. 4. Prepare a ruler for easy measurement of the length and width of the bladder flap during surgery. Other preoperative preparations are the same as general bladder and vaginal surgery. Surgical procedure Take the anterior urethral reconstruction of the bladder as an example. 1. Free urethra and bladder neck surgery were performed in two groups. Abdominal group underwent lower abdominal pubic transverse incision or abdominal midline incision. The anterior wall of the bladder was routinely exposed. The vaginal group made a small transverse incision in the vestibule below the clitoris, close to the pubis. The lower edge of the joint separates the anterior wall of the vagina from the posterior pubic symphysis. If necessary, the anterior wall of the vagina is cut longitudinally. The two groups guide each other and cooperate with each other to separate the bladder neck and urethra. 2. The bladder neck is made into a free edge, and the triangle at the bottom of the bladder should also be free to partially loosen the bladder neck. The free bladder neck is lifted with tissue forceps and pulled through the abdominal incision. 3. Cut the bladder flap in the middle of the anterior wall of the bladder and cut a full-thickness bladder flap. From the leading edge of the bladder neck, vertically upward, 5.0cm long and 3.0cm wide, the base of the bladder flap is connected to the bladder to ensure blood supply. 4. The urethral bladder flap was made with a 16F catheter, and the 3-0 absorbable intestinal line was sutured, and the muscle layer was sutured intermittently with a No. 0 silk thread. In this way, the bladder flap can be made into a smooth muscle tube that grows 5.0 cm and has a circumference of 3.0 cm. 5. Suture the bladder neck and suture the free bladder neck with a 3-0 absorbable line. The muscle layer is then sutured with thin wire sutures to make the whole bladder and the newly formed urethra pot-like. 6. Urethral perineal transplantation The smooth muscle tube formed by the bladder wall is pulled out from the vagina through the pubic symphysis and placed in the position of the urethral bed. The soft tissue around the myotube and its adjacent soft tissue are sutured with a wire for fixation to prevent retraction. The anterior wall of the vagina was sutured intermittently with a 2-0 absorbable line to cover the newly formed urethra. The reconstructed urethral opening was sutured with a 3-0 absorbable line and a vestibular mucosa, and fixed at the position of the normal urethral opening. The reconstructed urethra was replaced with a 12-gauge silicone rubber catheter and properly fixed. Place a sterile dry gauze in the vagina. The pubic osseous bladder stoma, the posterior pubis rubber strip was drained, and the abdominal incision was closed. complication The following complications can occur in this operation, and the prevention measures are as follows. 1. Urinary incontinence This is the most common complication. The severity of urinary incontinence varies from stress urinary incontinence to severe urinary incontinence. The establishment of the new urethra often has no sphincter function at the beginning. Therefore, those with urinary incontinence should first strengthen the exercise of urinary control and perform physical therapy. Generally, urinary incontinence can be gradually reduced or disappeared. Reconstructed urethral length is insufficient and the circumference is too large, which is an important cause of urinary incontinence. Therefore, attention should be paid to the width and width of the bladder flap. If there is still urinary incontinence 3 months after surgery, the length of the urethra and urethral pressure should be measured again. If necessary, follow the pressure urinary incontinence and then undergo surgery. 2. Urinary dysfunction in the early postoperative dysuria, mostly for bladder function has not recovered and reconstruction of urethral edema, physical therapy can be used. Urination can occur early in the postoperative period, and gradually dysuria occurs later, mostly due to urethral stricture, and urethral dilatation should be performed regularly. Reconstruction of the posterior wall of the junction of the urethra and the bladder is inadvertently formed into a sickle-like bulge, and dysuria may also occur. Light urethral dilatation is effective, severe cases should be cut or surgically removed. 3. Urethral stenosis and urethral retraction due to scar contraction, often can cause urethral stricture or retraction into the vagina, feasible urethral dilation treatment. As long as it does not affect urination, the urethral retraction may not be treated.