Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence.

OBJECTIVE: To assess the presenting features and medium-term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition. PATIENTS AND METHODS: We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as postoperative outcomes. RESULTS: In all, 70 women with a mean (range) age of 46.5 (24-77) years underwent excision of urethral diverticulum with MLFP interposition. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%), and dysuria (57%). Pre-existing stress urinary incontinence (SUI) was present in 41% (29) of the women. After surgery, at a mean (SD) of 18.9 (16.4) months follow-up (median 14 months), complete excision of urethral diverticulum was achieved in all the women, with resolution of urethral mass, dysuria and dyspareunia in all, and urethral pain in 81%. Immediately after surgery, 10 (24%) patients reported de novo SUI, which resolved with time and pelvic floor muscle training such that at 12 months only five (12%) reported continued SUI. There was one symptomatic diverticulum recurrence (1.4%). CONCLUSIONS: The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with MLFP interposition results in complete resolution of symptoms in most women. The incidence of persistent de novo SUI in an expert high-volume centre is 12%.

Ventral inlay labia minora graft urethroplasty for the management of female urethral strictures.

OBJECTIVE: To evaluate the functional outcomes of ventral inlay labia minora graft urethroplasty (VILGU) for the management of female urethral strictures. METHODS: Data of 7 consecutive women treated with VILGU between 2011 and 2013 were reviewed. Two patients had cystostomy tubes at repair, and 5 had undergone previous urethral dilations and urethrotomies. Clinical evaluation included assessment of the effect of voiding symptoms with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography, and intraoperative urethrocystoscopy using a 6.5F pediatric ureterorenoscope. Preoperative AUA symptom score and peak urinary flow rate were compared with postoperative values. Cure was defined as the absence of any restenosis requiring additional intervention with subjective patient satisfaction at the last follow-up. RESULTS: Mean stricture length was 1.5 cm (range, 1-2.5), and mean operative time was 95 minutes (range, 70-110). With a mean follow-up of 18.2 months (range, 3-30), cure was achieved in 6 (86%) women. At the last follow-up, mean maximum urine flow (mL/s) increased from 3.9 ± 3.1 preoperatively to 22.7 ± 8.3 postoperatively (P <.001), and mean AUA symptom score decreased from 25.3 ± 5.2 preoperatively to 6.9 ± 3.7 postoperatively (P = .001). No fistulae developed after surgery. "De-novo" stress urinary incontinence was not evident in any case. CONCLUSION: VILGU effectively provides better urinary flow and significantly improves patient satisfaction in patients with female urethral stricture disease.

Vaginoplasty technique using vulvoperineal flaps.

UNLABELLED: The incidence of vaginal agenesis is 1 in 5,000 live newborn baby girls. The most frequent cause is Mayer-Rokitansky-Küster-Hauser syndrome. This report presents three reconstruction cases managed with vulvoperineal fasciocutaneous flaps in patients experiencing this syndrome. It depicts the stages of the procedure and the anatomic bases for it. This technique allows the creation of a sensitive neovagina with high-quality coverage that provides a physiologic and a natural inclination angle together with a correct anatomic axis to make a sexual relationship possible. The procedure is performed in one surgical stage with minimum morbidity for the patient. Its major inconvenience is hair growth inside the vagina. Nevertheless, this decreases as time passes due to follicle atrophy and cutaneous metaplasia. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Volar onlay urethroplasty for reconstruction of female urethra in recurrent stricture disease.

OBJECTIVE: • To report our experience with a new and simple method of urethral repair with a volar onlay of free labium minus graft. Strictures of the female urethra are rare, and it is well accepted that the therapeutic options of dilation and urethrotomy are not lasting solutions as a result of their high recurrence rates. However, there is no consensus regarding the best way to reconstruct the female urethra in the case of stricture disease. PATIENTS AND METHODS: • Four consecutive female patients with a long lasting history of recurrent urethral strictures underwent open urethroplasty with a volar situated free split thickness epidermal graft from the labium minus. • The surgical technique is described and a short-term follow-up is presented. RESULTS: • Operating time was 40-140 min (mean 105 min), and the graft measured between 2 × 1.5 cm and 3 × 2.5 cm. Follow-up time was 11-19 months. Maximum urinary flow rate could be improved from a baseline of 9.4-11.2 mL/s (preoperatively, after intermittent use of dilation) to 19-23 mL/s. • Postvoid residual urine volume was 0-50 mL preoperatively and no postvoid residual urine volume postoperatively. • Urinary catheters were removed after 21 days. Urinary stress incontinence did not occur postoperatively. No complications related to the graft donor site were found. CONCLUSIONS: • The reported data concerning a new therapeutic approach for the treatment of recurrent female urethral stricture show that a volar onlay urethroplasty represents a feasible, safe and simple surgical method. • Larger series with long-term follow-up are needed for further evaluation.

Dorsal urethroplasty with labia minora skin graft for female urethral strictures.

OBJECTIVE: to report a new dorsal labia minora skin-graft urethroplasty as a simple, safe and effective therapeutic alternative for female urethral strictures, as although distal urethral strictures can be treated by meatoplasty, proximal and mid-urethral strictures need appropriate urethroplasty. PATIENTS AND METHODS: eight women with a confirmed proximal or mid-urethral stricture had indications for urethroplasty with the use of a thin free labia minora skin graft using a dorsal (6 o'clock position) urethroplasty technique. Full informed consent was obtained. From the inner aspect of one labium minora a thin free skin flap was prepared. The strictured urethra and the anterior vaginal wall were transected and the graft sutured into the defect. All scar tissue was removed and the anterior vaginal wall closed in two layers over the area of the urethroplasty. Continence was evaluated by a stress test with a full bladder. RESULTS: all patients were operated on with no complications during or after surgery. After 1 and 2 years of follow-up seven and six of the eight patients had no recurrence of stricture disease. All patients remained continent. CONCLUSION: the urethroplasty using an inlay of free thin genital skin graft was safe, uncomplicated and effective.

Surgical management of vaginal mesh erosion: an alternative to excision.

UNLABELLED: HYPOTHESIS AND INTRODUCTION: Management of vaginal mesh erosion can be conservative, but in a large proportion of patients, excision/trimming of the mesh is needed. This paper describes a technique using an intervening vulval pad of fat graft between the vaginal epithelium and the mesh as an alternative to excision. MATERIALS AND METHODS: Three cases are presented where vaginal mesh erosion was treated using an intervening vulval pad of fat as a graft to cover polypropylene mesh erosion, and the technique is described. RESULTS: There were no intraoperative complications. All patients reported no further symptoms at follow-up, and examination revealed no further mesh erosions. CONCLUSION: The use of intervening graft of vulval fat can be an alternative to excision in the management of patients with vaginal mesh erosion.

[Labia minora skin flap vaginoplasty using tissue expansion].

OBJECTIVE: This is to introduce a method for vagina reconstruction using the expanded labia minora flap. METHODS: Two tissue expanders were implanted in the labia minora bilaterally and expanded slowly over 4 weeks. In the operation, the expanded labial tissue was advanced as a bipedicle flap to line the reconstructed vagina. Five patients were treated with this method. Postoperative stent placement and dilation resulted in a vaginal canal exceeding 8 cm in depth. RESULTS: During the follow-up of 6 months to 2 years, four of the five patients got married. The vulva exhibited almost indistinguishable appearance. The reconstructed vagina had sensory and secretary functions. Its morphology and depth well meet the physiological demand. CONCLUSIONS: The modified method of tissue expansion vaginoplasty using the labia minora bipedicle flap is a good option for vagina surgery. The reconstructed vagina possesses the anatomical and physiological resemblance.

Vaginoplasty using deepithelialized vulvar transposition flaps: the Grünberger method.

BACKGROUND: One of the most important criteria indicative of the longterm success of vaginal enlargement is the absence of postoperative contracture. Numerous procedures have been developed for reconstruction of an inadequate vagina. Some are technically complex techniques (myo- and fasciocutaneous flaps) with few postoperative complications of vaginal contracture, and others implement autografts with a greater tendency of tissue contraction. STUDY DESIGN: We report here a method of vaginoplasty using deepithelialized vulvar transposition flaps to enlarge the width of narrow vaginas found mainly in cases of congenital adrenogenital syndrome-associated vaginal atresia, but also in cases of acquired vaginal atresia (surgery and radiotherapy-induced). We used deepithelialized dermis from the labia majora to construct an enlarged vaginal entrance and cavity, a technique that is easy to learn and perform. RESULTS: The healing phase of this operation is free of tissue rejection, most likely because of the close embryologic relationship of the cornified, paravaginal squamous epithelium of the labia majora and the noncornified squamous epithelial lining of the lower third of the vagina. The epithelium of the graft loses its cornified layer and becomes nonhair-bearing; its cytology and histology mimic normal vaginal epithelium. Postoperative function and sexual contentment were reported to be satisfying. CONCLUSIONS: The followups of 17 patients who underwent this operation in the last 16 years show optimal cosmetic and functional results.

[Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin]. / Urétroplastie labiale pédiculée: un procédé original de traitement des lésions urétrales étendues d'origine obstétricale.

Destruction of the urethra is the most severe complication of pregnancy-related vesicovaginal fistula. Although uncommon in Europe, pregnancy-related urethral destruction is still observed in Africa. In this study we describe our experience with a new reconstruction technique using a pedunculated skin flap raised from the labia majora. Between January 1992 and June 1996 we treated 35 patients in the Urology Department of Niamey Hospital in Niger. All patients were black. Mean age was 18 years and mean follow-up was 19 months. Two plasty techniques were used, i.e. extension (16 cases) and tubulisation (19 cases). Urinary incontinence was treated using a suburethral loop system created using a fatty flap taken from the labia majora (Martius method). Urethrocervico-suspension of the vagina was necessary in 6 cases. Normal micturition with no leakage was obtained in 24 patients (68.6%) and functional improvement in 6 cases (17.1%) Treatment failed in 5 cases (4.2%). In comparison with previously reported techniques, urethral reconstruction using a pedunculated labial flap and suburethral looping system allows successful treatment of pregnancy-related urethral destruction in 70% of cases. This technique is particularly well suited for use in developing countries where occurrence of this complication is most frequent. However even with the greatest skill, creation of a physiologically perfect closure system is currently impossible.

Full-thickness cutaneous martius flaps: a useful technique in female reconstructive urology.

The labial fat pad is a versatile adjunct to many reconstructions. In some cases, not only is healthy tissue required for interposition, but epithelium is needed to close the vaginal defect. We report on full-thickness cutaneous Martius flaps from the medial labia majora used in complex vaginal repairs.

Breast reconstruction following radical mastectomy, using custom designed implants.

Procedures are described for total breast reconstruction in patients who have undergone radical and modified radical mastectomies. The reconstruction includes restoration of the contour of the breast, including the nipple-areola complex and filling the defect from loss of the pectoral muscles. The reconstructions have been done in 37 patients with good results, and several are illustrated.