Complete urethral defect reconstruction

Urinary fistula is one of the problems in vaginal surgery. If you don't have the ability to make a full estimate of the success or failure of the surgery and skilled repair techniques, don't take it lightly. Because the pupils seem small, the relationship is often complicated, and the organizations that can be used to fill around are very limited. If the estimation is insufficient, the pupils will become loose after the incision, or they will not be able to clean up in all directions, or the surrounding tissues will be less, and the seams will be barely sewed. If the tension is too large, the surgery will often fail. Moreover, it has damaged a lot of valuable filling organizations, which made it difficult to repair it again. Some patients have changed their urinary tracts due to repeated patch failures, so they must not rush. Most of the urinary fistula is caused by birth injury, so the patient is often a young adult woman, and it still occurs in rural and mountainous areas of China. Disease-causing people have cancer erosion, radiation damage, tuberculosis ulceration, stone embedding, etc., can occur at all ages. Followed by surgical accidental injuries: such as radical cancer surgery, difficult hysterectomy, vaginoplasty, etc. Others have congenital malformations: such as the ureter or urethra opening in the vagina or vestibule. In addition, there are trauma, uterine tube compression and necrosis, drug corrosion and so on. The cause is different, the location and size of the pupil, the extent of the involvement, and the degree of scar formation are different. Therefore, the diagnosis must be carefully diagnosed before surgery to avoid passive operation. It is difficult to repair urinary fistula, and it is necessary to carefully analyze and estimate before surgery. Special examinations such as methylene blue test, cystoscopy, and urography should be used when necessary. The most difficult to repair are the following factors: pupil > 3cm, scar thick and hard, vaginal stenosis, high pupil position and less active cervix, urethral split, fracture, obstruction, defect, pupil from the ureteral orifice <0.5cm, The pupil is close to the back of the pubis, multiple repair failures, radiation damage, tuberculous fistula, combined with fecal fistula, stones, multiple hernias. There are many types of urinary fistula, and only those who can be repaired from the vagina are described here. In addition to careful selection of indications and conditions from vaginal repair of urinary fistula, surgical operations must pay attention to: 1. Cherish the normal tissue, the operation is gentle, accurate and fine. 2. Strictly sew the corners of both ends of the pupil to ensure no bleeding or leakage. 3. The suture can not be pulled by force. The assistant should push the two cutting edges together and gently knot them to avoid cutting the cutting edge tissue during the pulling, which makes the suturing difficult. 4. The blood stain of the wound surface is gently sucked up with a small suction head. It can not be pressed with gauze or cotton ball, rubbing it, so as not to damage the tissue and remove the knot. 5. After the first layer of the pupil is sewn, the rubber catheter must be inserted into the urethral opening, and the methylene blue solution or sterile milk should be injected to test whether the suture is leaked. If there is a leak, it must be filled until it is leak-free. Treatment of diseases: urethral injury Indication In the case of trauma, surgical trauma causes partial or complete rupture of the urethra; or due to radiation damage, drug corrosion, most patients can not be repaired at the time of injury. Therefore, the oldness is more common. Due to trauma or corrosion at the time, local tissues were destroyed and contaminated, repairing was not easy, and the prognosis was poor. It is necessary to wait for the local tissue inflammation to disappear, the formation of leaky holes, and the possibility of tissue newborn repair, which can be repaired. Contraindications Systemic or local acute and chronic inflammation, diabetic patients must be treated after or after treatment. Except pregnancy. Preoperative preparation In addition to the repair of the urinary fistula at the time, the old urinary genital majority of the vulva and the inner thigh, diaper dermatitis in front of the breech, cystitis and vaginitis, etc., must be cured before surgery, the method is as follows: 1. Urine dermatitis with 1:1000 benzalkonium or potassium permanganate bath 2 times a day, external anti-inflammatory ointment. Change the shade pad until the inflammation disappears. 2. Cystitis and vaginitis should be supplemented with sensitive antibiotics. Partially washed once a day with nitrofurazone or boric acid solution until the inflammation and redness completely disappeared, and the urine culture was negative. 3. Each enema is given 1 time before and on the morning of the operation. Shave the pubic hair and wash the vulva with soapy water. 4. Administration before anesthesia is carried out in accordance with the anesthetic regulations used. Several days before surgery, estrogen such as Premarin can be used as appropriate to promote the healing of vaginal mucosa. However, there are many people who do not advocate the addition of sex hormones. 5. In addition to the commonly used vulvovaginal surgical instruments, surgical instruments must be prepared for urinary fistula repair with long handle thin, straight, curved small scissors, small pointed blades, small scorpion-shaped pointed blades, sickle catheters, female metal catheters, Ureteral catheter, small suction tube (front curved tube), well-lit spotlights, etc. The needles and stitches are complete. Surgical procedure 1. Urethral splitting or defect repair (Urethroplasty) (1) Incision: Pull out the cervix to the outside of the vaginal opening, and fully expose the anterior wall of the vagina and the urethral orifice or the bladder pupil. A ventral vaginal mucosa was made by making a long U-shaped incision in the direction of the outer urethra about 1 cm from the periphery of the pupil. The vaginal submucosal tissue was separated outward by 1.5 cm. A metal catheter is placed in the urethral reconstruction (inserted into the pupil from the outer urethral opening) to assist in positioning the catheter. (2) suture: using 3-0 absorbable suture or 3-0 or 4-0 gut, the incision vaginal mucosa layer on both sides of the centrally wrapped metal catheter for intermittent varus suture, Rebuild the urethra. 1 to 2 needles should be reinforced at the neck of the bladder. The fresh sterilized placenta plate or the corpus cavernosum muscle fat flap is taken from the outside of the vagina to cover the junction of the new urethra and the bladder to strengthen it. The vaginal wall can then be sutured with a 2-0 absorbable suture or a 0 or 2-0 gut, either intermittently or intermittently. Place a 1 to 2 needle on the placenta or fat flap to fix it. (3) Urine drainage: should be done on the pubis on the pubis, and keep the circulation smooth. 7d began to clamp the pubic urethral catheter every day to rebuild the urethra for 2 to 3 times. After 1 week of training, the pubis urinary catheter can be removed and the abdominal wall wound can be sutured. 2. Bladder vaginal fistula with partial repair of the urethra (Repair of Vesico urethro vaginal Fistula) Take the frog-style prone position and expose it for easy operation. (1) Incision: The vagina is used to widen the vaginal exposed pupil and the rupture of the urethra. The metal urinary catheter is placed outside the urethra to test the length of the unruptured urethra and the presence or absence of occlusion. If there is a blockage, it should be cut open from here and the scar tissue should be trimmed. Then, the entire vaginal mucosa was cut from the sides of the urethral rupture and around the pupil of the bladder to reach the submucosal connective tissue. With a small knife, the blade separates the vaginal mucosa from the bladder and urethral muscle wall. The sides of the urethra are about 1 cm wide and about 1.5 to 2 cm wide around the bladder. Retract the vaginal mucosal margin and fully expose the surgical field. Trim the scar and the scar tissue around the urethral rupture to make it smooth, but do not hurt healthy tissue. A metal or rubber catheter is placed to aid in the formation of the urethra. (2) suture: with a needle 4-0 absorbable suture or 3-0 gut first to open the upper and lower sides of the bladder pupil to make the pupil transversely interrupted varus suture, the central bladder neck and the urethra mouth should be The urethra is moving at a right angle. A three-needle suture was sutured at the intersection to close the three-sided incision. The second layer of the bladder muscle layer is then sutured from the periphery of the suture. The needle should be offset from the first layer of the needle to cover the muscle layer on the first layer of suture. And a needle is placed at the neck of the bladder to form the urethral opening. Then use a needle 4-0 absorbable suture or a small round needle 4-0 gut longitudinal varus or suture the urethra through the urethral mucosa to the outer urethral wall of the rupture. Seal the top corner of the urethral rupture, test leaks, the same method as before. When not leaking, use 2-0 absorbable suture or round needle 2-0 gut for longitudinal or T-shaped valgus suture vaginal mucosa, close the corners and intersections of each incision. If the bladder muscle layer is thin and only the first layer is sewn, a fresh sterile placenta or bulbous muscle fat flap should be disposed in the bladder neck, and 3 to 4 needles can be fixed with 3-0 absorbable suture as a pad to ensure The success of the repair. (3) Urine drainage is the same as above. complication If strictly implemented in accordance with the principles of surgery, success is still the main outcome. In case of infection or bleeding, the treatment is the same as vaginal surgery. If the wound is split, the operation fails, and the infection is treated, and only after the inflammatory bleeding stops, consider the subsequent operation. In the near future, heavy sewing will not help.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.