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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Reconstruction of the Urethra 

Reconstruction of the urethra is indicated if a part of the urethra has been surgically removed or if there is a failure of fetal urogenital sinus development. Loss of a portion of the urethra may not be associated with total incontinence of urine. In cases of epispadias, however, there is total incontinence. In those patients who have lost the distal portion of the urethra and remain continent, considerable disability remains because the voided stream may by uncontrollable and, therefore, result in a significant esthetic problem.

When reconstruction of the urethra is required because of total epispadias, the patient may get a satisfactory anatomic result but remain incontinent unless the procedure is combined with a Goebell-Stoeckel fascia lata strap operation (see Vagina and Urethra).

Physiologic Changes. An epithelial channel is constructed from the base of the bladder to the urethral meatus. Although this neourethra has no muscle, it acts as a conduit for the proximal urethra or bladder.

Points of Caution. The vaginal flap must be designed to ensure that the vascular supply to the base of the flap is sufficient to support the length of the flap needed.

If the tube flap technique (Figs. 7-11) is employed, adequate flaps of epithelium must be mobilized to meet in the midline without tension.

In both techniques, mobilization of the lateral labial epithelium is essential to cover and support the neourethra without tension.


A sagittal section of the pelvis without a urethra is shown. The patient is placed in the dorsal lithotomy position. The perineum is surgically prepared. Careful measurements should be made to design an adequate flap with 2 cm of width at the base for every 1 cm of length to ensure an adequate blood supply to the flap.

The proposed flap should be marked off on the anterior vaginal wall. The mucosa is incised down to the pubovesical cervical fascia with a scalpel. A Foley catheter is inserted as indicated.

The flap has been mobilized. Two parallel incisions are made approximately 2 cm apart to prepare the receptor bed for the edges of the flap. Plication sutures are placed in the pubovesical fascia from the apex of the vaginal incision to the neourethral vesical angle.

The flap is sutured into position along the lateral grooves incised in the vestibule. This is performed with interrupted 4-0 synthetic absorbable suture. Lateral to the grooves, the labial tissue is mobilized by undermining it for a sufficient distance, usually 4 cm, to allow it to be brought to the midline without tension.

The vaginal wall defect should be closed with interrupted 2-0 synthetic absorbable sutures.

The previously mobilized labial epithelium is sutured in the midline with 2-0 synthetic absorbable sutures to cover the flap and provide nutrition and support.

The completed operation is shown.

A second technique for reconstruction of the urethra involves rolling a tube flap, then covering it with a second layer of periurethral tissue. The flap is marked with brilliant green solution along the proposed new urethra. Care should be taken to ensure that sufficient tissue is mobilized to allow it to meet in the midline without tension. The margins of the flap are incised with a scalpel, and the tissue is mobilized medially.

Tissue is then rolled toward the midline and sutured into place with interrupted 4-0 synthetic absorbable suture. The tissue lateral to the mobilized flap is undermined for a distance of about 4 cm.

The lateral tissue is closed over the flap in two layers with interrupted 3-0 synthetic absorbable suture. A Foley catheter remains in the bladder.

The epithelium is closed with interrupted 3-0 absorbable sutures.

The completed operation is shown with neourethra.


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