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274 Challenging Concepts in Urological Surgery
https://t.me/med1917
Learning point Symptoms
of POP
Non- specific
Bulge, pelvic pressure, lump
protruding from the vagina,
discomfort, dragging sensation
in the vagina, laxity, dyspareunia,
bleeding or infection, low back
ache, rarely renal failure if with
ureteric kinking in very large
prolapse.
Specific
● Cystourethrocele: urinary
frequency and urgency,
incomplete bladder emptying
leading to recurrent urinary tract
infection, slow stream, stress
urinary incontinence (SUI).
● Rectocele: incomplete bowel
emptying, digitation, splinting,
rectal urgency, passive anal
incontinence.
Clinical tip Clinical
examination
Perform examinations for
investigation of a prolapse in the
left lateral position using a Sims
speculum and a sponge holder or
tongue depressor.
On examination with a Sims speculum, there was descent of the cervix up to 2 cm
beyond the hymenal margin with a POP- Q score as demonstrated in Table 28.1 and
with stage III POP.
5
On discussion of options of management which included conservative management, use of vaginal pessary, or surgical management, this lady preferred to have
surgery to correct the prolapse.
Learning point Options for management of prolapse
1. Conservative management: pelvic floor muscle training (PFMT) or pessary.
2. Surgical management.
Conservative management
PFMT
Generally, preventative measures should be the most widely applied techniques. Pelvic floor exercises,
weight loss, treatment of chronic diseases including effective treatment of persistent cough, constipation,
and cessation of smoking should be advised. Oestrogen therapy not only helps to prevent osteoporosis
but also has positive effects on the various oestrogen- sensitive tissues of the pelvis.
Vaginal pessaries
Vaginal pessaries could be used, offering an excellent non- surgical option for women with prolapse
with virtually no contraindications.
Table 28.1 POP- Q score
+ 2
(Aa)
2
(gh)
+ 1
(Ap)
+ 2
(Ba)
2
(pb)
0
(Bp)
+ 3
(C)
8
(tvl)
– 2
(D)
Clinical tip Treatment
options
Options for treatment for the
various compartments of prolapse
are discussed in detail in the 2019
National Institute for Health and
Care Excellence (NICE) guidelines
(NG 123).8 Following diagnosis
of the type of prolapse, patients
should be given patient decision
aids to allow them to decide which
option they wish to pursue.
Learning point Vaginal pessaries
Pessaries are devices which are inserted into the vagina. They are offered to alleviate the symptoms
of prolapse and delay or eliminate the need for surgery. Pessaries may help with bowel and bladder
symptoms of prolapse. Kinking of the urethra due to the prolapse may cause voiding dysfunction leading
to bladder neck obstruction. By correcting this, obstructive and urgency symptoms may be relieved.
However, pessaries may also cause de novo/ occult SUI due to the ‘unkinking’ of the urethro- vesical angle.
Two categories of pessaries, support and space filling, exist for prolapse. The ring and other support
pessaries are typically recommended for stage I and II prolapse, whereas the space- filling pessaries
are usually used for stage III and IV prolapse. After initial fitting, follow- up checks to look for vaginal
9
excoriation and replacement of pessaries may be scheduled every 3– 6 months. Minor, transient
complications may be seen commonly including pessary expulsion, urinary incontinence, rectal
pressure, vaginal discharge or bleeding, and mechanical pressure ulcers. Serious complications of
pessary use can typically be avoided with regular follow- up examinations and are rare.
Learning point Surgical management of anterior compartment prolapse
Anterior colporrhaphy
The objective of this surgery is to plicate the layers of the pubocervical fascia in such a way as to
reduce the central protrusion of the bladder and vagina.
275Case 28 Genitourinary prolapse
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Paravaginal defect/ site- specific repair
Paravaginal defect is characterized by presence of rugae on the anterior vagina and absence of sulci
on the lateral vagina due to the detachment of the endopelvic fascia from the lateral pelvic side wall.
In these cases, repair is done by fixing (reattaching) the endopelvic fascia to the arcus tendineus fascia
(white line) of the pelvis. This may be done laparoscopically, retropubically through the space of Retzius,
or vaginally. Vaginal paravaginal repair did not appear to offer any advantage over midline colporrhaphy
alone in terms of either maintenance of anatomical support or symptomatic improvement.
15
Learning point Surgical management of uterine prolapse
Historically, the treatment for symptomatic uterine prolapse has been a hysterectomy, which
is usually performed vaginally in combination with an apical suspension procedure, and
Evidence base PFMT
A large multicentre randomized
controlled trial (the Pelvic Organ
Prolapse PhysiotherapY (POPPY)
trial).10 showed that one- to- one
PFMT for prolapse is effective
for the improvement of prolapse
symptoms. Both the NICE and the
American College of Obstetricians
and Gynecologists list PFMT as a
treatment option in women with
all types of vaginal prolapse
and especially for POP- Q stage I– II
vaginal prolapse.
13,14
11,12
repair of coexisting defects.
Vaginal hysterectomy and repair
Several methods of vault suspension are used at the time of this surgery and include the following:
● Uterosacral suspension: the vault is suspended to the uterosacral ligaments with a delayed
absorbable stitch.
● McCall culdoplasty: a delayed absorbable suture is inserted through the full thickness of the posterior
vagina laterally. The suture is then passed through each uterosacral ligament and back out the posterior
vaginal wall. The stitch on either side is tied, suspending the apex to the uterosacral ligaments.
● Abdominal sacrohysteropexy: suspension of the vagina or uterus to the sacral promontory with an
intervening mesh depending if the woman wants to preserve the uterus or not.
● Manchester repair: this combines anterior vaginal wall repair with amputation of the cervix and
uterosacral ligament suspension.
● Sacrospinous hysteropexy: involves fixation of the uterus to the sacrospinous ligament. Variations of
this technique have been described:
- If an abdominal hysterectomy is performed because a woman has an enlarged uterus which
cannot be removed vaginally, additional intraperitoneal vault support procedures will be required
including Moschowitz, Halban, and uterosacral plication.
Evidence base Surgical management
Women with uterine prolapse who have no preference about preserving their uterus8 should be offered
a choice of:
● Vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures
● Vaginal sacrospinous hysteropexy with sutures
● Manchester repair
● Abdominal sacrohysteropexy using mesh.
Women with uterine prolapse who wish to preserve their uterus may be offered any of the above- listed
procedures except a hysterectomy.
When a mesh procedure is performed:
● Explain the type of mesh that will be used and whether or not it is permanent.
● Ensure that the details of the procedure and its subsequent short- and long- term outcomes are
recorded in a national registry.
● Give written information about the implant (including its name, manufacturer, date of insertion, and
the implanting surgeon’s name and contact details).
Learning point Surgical management of the vaginal vault
● Abdominal sacrocolpopexy: suspension of the vagina vault to the sacral promontory with an
intervening mesh.
Learning point Surgical
management of posterior
compartment prolapse
● Transvaginal approach: consists
of either midline posterior
colporrhaphy in a manner
similar to that in the anterior
compartment or a site- specific
defect repair.
● Transanal approach: considered
less effective than transvaginal
repairs.
● Perineorrhaphy:
reapproximation of torn dense
perineal connective tissue
including the bulbocavernosus
and perineal muscles in an
effort to restore the perineal
body when deficient.
276 Challenging Concepts in Urological Surgery
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Future directions Vaginal
mesh
The use of mesh in anterior
and posterior compartment
surgery is associated with an
increased risk of complications
and lower effectiveness than
native tissue repair.
time of writing this chapter, the
use of vaginal mesh is paused in
the UK awaiting implementation
of recommendations made by
the Independent Medicines and
Medical Devices Safety Review.20
The use of abdominal mesh is
under high- vigilance scrutiny
and should be used after careful
discussion with the patient and at a
multidisciplinary team meeting.
Future directions Recurrent
prolapses
NHS England are commissioning
units to undertake specialist work
and management of recurrent
prolapse will be undertaken in
these specialist units.
18,19
At the
● Vaginal sacrospinous fixation: fixation of the vaginal vault to the sacrospinous ligament with the
variations discussed previously.
● Other: transvaginal repairs include iliococcygeal suspensions, and high paravaginal suspensions
of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the
endopelvic fascia.
● Colpocleisis: operation which obliterates the lumen of the vagina. This is only an option for women
who do not wish to maintain sexual activity.
Evidence base Abdominal sacrocolpopexy versus vaginal sacrospinous fixation
A Cochrane review16 included three randomized controlled trials that compared abdominal
sacrocolpopexy versus vaginal sacrospinous fixation. Its meta- analysis showed that abdominal
sacrocolpopexy was associated with significantly lower rates of recurrent vault prolapse, and less
postoperative SUI and dyspareunia. There were no statistically significant differences in patient
satisfaction, the number of women reporting prolapse symptoms, objective failure at any site,
reoperation rates for SUI, and reoperation rates for prolapse. Sacrospinous fixation resulted in a
reduction in operative time, it was less expensive to perform, and women had an earlier return to their
daily activities.
17
Vaginal hysterectomy and anterior repair were performed uneventfully. The pa-
tient was well after surgery. Five years later, she went on to develop significant posterior compartment prolapse for which she underwent a posterior colporrhaphy and
perineorrhaphy.
A final word from the expert
POP is very common and one in ten women will require surgery over their lifetime for this
condition. It usually affects women after the menopause but can occur in younger women of
childbearing age too. It almost always occurs in women who have had vaginal deliveries, but
a caesarean is only protective if all deliveries are exclusively by caesarean section. Combined
vaginal and caesarean births do not offer protection.
When it affects a woman before she has completed her family, women should be encouraged to
avoid surgery and consider it after their family is complete. This avoids the need for unnecessary
caesarean sections and risk of the prolapse returning due to further childbearing.
Symptoms can sometimes be minimal, and surgery should be undertaken when there are
bothersome symptoms rather than purely because an asymptomatic POP has been diagnosed.
Women should be advised to perform their pelvic floor exercises as this will treat minor grades
of prolapse and will also prevent recurrence if they proceed with surgery.
In women opting for pessary control, regular follow- up is required and they should be kept
under surveillance to detect any complications that can arise from long- term pessary use.
Women opting for surgery should be given the range of options in accordance with the 2019
NICE guidelines (NG123).
Women opting for surgery should be forewarned of the risk of recurrence and the one in three
lifetime risk of needing further prolapse and/ or incontinence surgery and the one in ten risk of
the same compartment prolapsing again.
Baseline assessment of pelvic floor symptoms including urinary, bowel, and sexual dysfunction
should be undertaken prior to and after treatment particularly surgery. Women should be
informed that treatment of the prolapse is not guaranteed to cure the other symptoms of
https://t.me/med1917
pelvic floor dysfunction and some women may develop SUI following treatment of prolapse
(occult incontinence) whereas others may develop dyspareunia due to the formation of scar
tissue after surgery.
All complex cases should be discussed at a multidisciplinary team meeting and where facilities
exist, all primary cases of prolapse scheduled for surgery should also be discussed. Recurrent
prolapse surgery should be undertaken by adequately trained surgeons in units which are
commissioned to undertake this work.
277Case 28 Genitourinary prolapse
References
1. Haylen BT, Maher CF, Barber MD, et al. An International Urogynecological Association
(IUGA)/ International Continence Society (ICS) joint report on the terminology for female
pelvic organ prolapse (POP). Neurourol Urodyn. 2016;35(2):137– 168.
2. Samuelsson EC, Arne Victor FT, Tibblin G, et al. Signs of genital prolapse in a Swedish
population of women 20 to 59 years of age and possible related factors. Am J Obstet
Gynecol. 1999;180(2 Pt 1):299– 305.
3. Beck RP. Pelvic relaxational prolapse. In: Kase NG, Weingold AB, eds. Principles and
Practice of Clinical Gynecology. New York: John Wiley & Sons; 1983:677– 685.
4. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet
Gynecol. 1992;166(6 Pt 1):1717– 1724.
5. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P. The standardization
of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet
Gynecol. 1996;175(1):10– 17.
6. Lowenstein L, FitzGerald MP, Kenton K, Dooley Y, Templehof M, Mueller ER. Patientselected goals: the fourth dimension in assessment of pelvic floor disorders. Int Urogynecol J
Pelvic Floor Dysfunct. 2008;19(1):81– 84.
7. Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urol Nurs.
1994;14(3):136– 40.
8. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ
prolapse in women: management. NICE guideline [NG123]. National Institute for Health
and Care Excellence. 2019. https:// www.nice.org.uk/ guidance/ ng123
9. National Institute for Health and Care Excellence (NICE) guideline. Urinary incontinence
and pelvic organ prolapse in women: management: tools and resources. NICE guideline
[NG123]. National Institute for Health and Care Excellence. 2019. https:// www.nice.org.uk/
guidance/ ng123/ resources
10. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women
with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet.
2014;383(9919):796– 806.
11. Committee on Practice Bulletins- Gynecology, American College of Obstetricians and
Gynecologists. ACOG Practice Bulletin No. 79: pelvic organ prolapse. Obstet Gynecol.
2007;109(2 Pt 1):461– 473.
12. National Institute for Health and Care Excellence. Sacrocolpopexy using mesh for vaginal
vault prolapse repair. Interventional procedures guidance [IPG583]. National Institute for
Health and Care Excellence. 2009. https:// www.nice.org.uk/ guidance/ ipg583
13. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in
women. Cochrane Database Syst Rev. 2011;12:CD003882.
14. Hagen S, Stark D, Glazener C, Sinclair L, Ramsay I. A randomized controlled trial of pelvic
floor muscle training for stages I and II pelvic organ prolapse. Int Urogynecol J Pelvic Floor
Dysfunct. 2009;20(1):45– 51.
278 Challenging Concepts in Urological Surgery
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15. Morse AN, O’Dell KK, Howard AE, Baker SP, Aronson MP, Young SB. Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and
quality of life outcomes. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):245– 9.
16. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in
women. Cochrane Database Syst Rev. 2013;4(4):CD004014.
17. Royal College of Obstetricians and Gyanecologists, British Society of Urogynaecology.
Post- Hysterectomy Vaginal Vault Prolapse. London: Royal College of Obstetricians and
Gyanecologists; 2015.
18. Morling JR, McAllister DA, Agur W, Fischbacher CM, Glazener CM, Guerrero K. Adverse
events after first, single, mesh and non- mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997– 2016: a population- based cohort study.
Lancet. 2017;389(10069):629– 640.
19. Campbell P, Jha S, Cutner A. Vaginal mesh in prolapse surgery. Obstet Gynecol.
2018;20(1):49– 56.
20. Independent Medicines and Medical Devices Safety Review. First Do No Harm— The report
of the Independent Medicines and Medical Devices Safety Review 2020.
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SECTION 10
Reconstruction
Case 29 Urethral stricture disease
Case 30 Urethral diverticulum
Case 31 Management of ketamine- induced bilateral upper urinary
tract injury
Case 32 Vesicovaginal fistula
https://t.me/med1917
29
https://t.me/med1917
CASE
Urethral stricture disease
Jamie V. Krishnan and Nadir I. Osman
Expert commentary Christopher R. Chapple
Case history 1
A 19- year- old man was referred by his general practitioner (GP) with gradually
worsening voiding lower urinary tract symptoms for 2 years. He was otherwise fit and
well with no history of perineal trauma, urethral instrumentation, or sexually transmitted infection. No abnormalities were found on examination. Urinalysis showed a
trace of blood. Urethral stricture, bladder neck dysfunction, and bladder underactivity
were considered in the differential diagnoses.
Uroflowmetry, ultrasound scanning for post- void residual urine, retrograde
urethrography, and a flexible cystourethroscopy were requested. Uroflowmetry showed
reduced maximal flow rate (Qmax) of 5.5 mL/ s and a prolonged plateau pattern
(Figure 29.1a). There was no residual urine on the ultrasound scan. The urethrogram
suggested a narrowing in the mid and proximal bulbar urethra and flexible cystoscopy
demonstrated the distal end of the impassable stricture (Figure 29.1b,c).
Figure 29.1 (a) Flow rate of patient with urethral stricture. (b) Retrograde urethrogram highlighting a
bulbar stricture. (c) View of a bulbar stricture during attempted flexible cystoscopy.
282 Challenging Concepts in Urological Surgery
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The patient underwent a direct visual internal urethrotomy (DVIU) of a 1.5 cm stricture involving the mid and proximal bulbar urethra. An indwelling silicone catheter
was left in place and removed after 2 days. A repeat flow rate showed an improved
flow with a Qmax of 20 mL/ s and parabolic flow curve.
The patient was subsequently followed up with uroflowmetry and post- void residual estimation every 4 months for a period of 1 year with no change in flow parameters and post- void residual before being discharged back to his GP.
Case history 2
The 19- year- old man in case history 1, who had undergone a DVIU, was re- referred by
his GP several months following discharge with a resumption in voiding difficulties.
He underwent repeat uroflowmetry which showed a further deterioration in Qmax
and flexible urethroscopy confirmed an impassable urethral stricture. A urethrogram
showed bulbar urethral narrowing.
He was counselled for the possible treatment options of (1) repeat DVIU followed
by long- term intermittent self- dilatation (ISD) or (2) urethroplasty. He chose to have
a urethroplasty.
Case history 3
A 72- year- old man had a transurethral resection of the prostate procedure 2 years before. His flow improved significantly after the operation but started deteriorating after
a few months. He presented with a poor flow with a Qmax of 3 mL/ s. Urethroscopy
revealed an impassable submeatal narrowing. Urethrography confirmed a lengthy
stricture of his penile urethra. He underwent urethral dilatation and was instructed
to perform ISD postoperatively but found this difficult. He wanted to discuss other
options. The options discussed with him included a permanent suprapubic catheter,
substitution urethroplasty, or a perineal urethrostomy. He chose to have a perineal
urethrostomy.
Clinical tip Flowchart illustrating the management of a urethral stricture
D
urethroplasty
Concurrent on-lay
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See Figure 29.2.
283Case 29 Urethral stricture disease
1st presentation with
Penile stricture
Excision &
circumferential
reconstruction
Two-stage
stricture
Single-stage
urethroplasty
DVIU or UD
Recurrence
Assess & discuss options
and intent with patient
CURE PALLIATION
1) Further DVIU or UD +/– IS
2) ISD alone
3) SPC insertion
Bulbar stricture
4) Perineal urethrostomy
Very short Short Long
Non-
transecting
Anastamotic
Urethroplasty
Excision & End
to End
Anastamotic
Urethroplasty
+/– BMG
Stricturotomy &
BMG Patch
Dorsal on-lay
Ventral on-lay
Lateral on-lay
Figure 29.2 Algorithm demonstrating management options. BMG, buccal mucosal graft; DVIU,
direct visual internal urethrotomy; ISD, intermittent self- dilatation; SPC, suprapubic catheter; UD,
urethral dilation.
Introduction
Learning point Definition and pathology
A urethral stricture is defined as a constriction of the urethral lumen caused by concentric scarring,
involving the epithelium, and extending to a variable depth into the corpus spongiosum. The
underlying pathology is that of an ischaemic spongiofibrosis. This definition applies to the part of the
urethra surrounded by spongiosal tissue, the anterior urethra. It is important to recognize that the
configuration of the urethra does vary, being thickest ventrally in the bulbar urethra and uniformly
narrowing in the penile urethra. Narrowings of the posterior urethra are conventionally termed
stenoses and not considered as stricture.
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