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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
Segmental or Total Female Urethrectomy
KirolosN.Meilika andJaspreetS.Sandhu
10
Urethrectomy forUrethral
Malignancies
Female urethrectomy could be performed for
various benign and malignant diseases; the decision to perform segmental or total urethrectomy
is based on the pathology and extent of the urethral lesion. Female primary urethral cancers
(PUCs) are rare, and most of the published studies mainly focus on oncological and survival outcomes [13, 19, 27, 39]. The female urethra is
about 4cm long and is divided based on the cellular lining or its relation to the surrounding anatomical structures, mainly the urethral sphincters.
Histologically, the proximal third is lined by urothelial cells, and the distal two-thirds are lined by
the squamous epithelium. The Skene (paraurethral) glands surround the urethra, and their ducts
open near the external meatus. Anatomically, the
female urethra is divided into the distal one-third
(anterior segment) and the proximal two-thirds
(posterior segment). The former can be resected
without affecting the urinary sphincter. In all,
28%–45% of female primary urethral cancers
K. N. Meilika
Department of Urology, University of Rochester
Medical Center, Rochester, NY, USA
e-mail: kirolos_meilika@urmc.rochester.edu
J. S. Sandhu (*)
Department of Surgery, Memorial Sloan Kettering
Cancer Center, New York, NY, USA
e-mail: sandhuj@mskcc.org
(PUCs) are urothelial carcinomas and arise from
the proximal urethra. Squamous cell carcinoma
arises from the distal urethra and accounts for
19%–29% of female PUCs. Adenocarcinoma
arises from the Skene glands, which are located
alongside the entire urethra, and represents 28%–
38% of female PUCs [9, 39] (Fig.10.1).
Distal urethral cancers occur in about onethird of patients; the remainder have proximal or
panurethral tumors—30%–50% of females with
PUC present with locally advanced disease [20].
A multimodal approach is usually utilized for
female PUC treatment and includes surgery, radiation therapy, and chemotherapy alone or in combination [39].
Urethra-sparing surgery or segmental urethrectomy is a valid therapeutic approach in
women with localized anterior carcinomas [16].
Segmental urethrectomy aims to achieve cancer
control without compromising the voiding function. Compared to minimally invasive approaches
such as transurethral resection (TUR) or laser
ablation, distal urethrectomy achieved higher
local cancer control and better cancer-specic
survival rates [10]. Distal urethrectomy is usually
performed via a transvaginal approach, which is
feasible for tumors in the urethral meatus or the
distal third of the urethra. Transvaginal distal urethrectomy (Fig.10.2) should also include removing part of the anterior vaginal wall and achieving
a negative proximal urethral margin on intraoperative frozen section pathology [27]. Dimarco
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_10
103
104
Female urethra
HistologyPathology
P
Division
a
Ur
a
b
e
c
d
Fig. 10.1 Female
urethra
K. N. Meilika and J. S. Sandhu
Clitoris
ethra
Vagina
osterior
Anterior
Distal
Proximal
Meatus
Transitional
Transitional cell
carcinoma
Squamous
Squamous cell
carcinoma
adenocarcinom
Fig. 10.2 Surgical steps for transvaginal distal urethrectomy: (a) The external genital anatomy of the female is
observed to be within normal limits. (b) A circumferential
incision is made around the external urethral meatus, followed by careful dissection and mobilization of the distal
urethra. (c) Alternatively, an inverted U-shaped incision
can be made on the anterior vaginal wall to facilitate the
etal. studied the outcome of partial urethrectomy
in 26 patients and found that the main complication was stress urinary incontinence (SUI) in 11
of them (42%). Additionally, two (8%) patients
developed urinary retention. One patient (4%)
developed urge incontinence [10].
In cases of higher-stage urethral cancers
where it is impossible to achieve negative margins with partial urethrectomy, primary radical
urethrectomy (Fig. 10.3) is the recommended
dissection and mobilization of the distal urethra. (d)
Consider removing a section of the anterior vaginal wall to
achieve a negative proximal urethral margin on intraoperative frozen section pathology. (e) The healthy urethra is
then sutured to the anterior vaginal wall using simple interrupted absorbable sutures to establish a new urethral meatus
approach to achieve a local cure. This surgical
procedure entails removing the periurethral tissue completely, including both bulbospongiosus muscles. Moreover, the excision should
extend superiorly up to the pubic symphysis
and posteriorly to the anterior vaginal wall,
ensuring thorough tumor removal while preserving the bladder neck. Following the procedure, bladder neck closure is performed and
urinary diversion is accomplished by creating a
Bulbospongiosus
10 Segmental or Total Female Urethrectomy
a
muscle (perineal
fascia removed)
b
105
tion therapy, and surgery is recommended to
manage such cases effectively [7]. Surgical intervention for locally advanced female urethral cancer often involves anterior pelvic exenteration,
accompanied by lymphadenectomy in both the
inguinal and pelvic regions. When the tumor
extends into the external genitalia, additional
excision of the vaginal and labial tissues may be
necessary to ensure negative surgical margins.
The potential complications associated with pelvic exenteration and urinary diversion will be
addressed in a separate chapter of this book.
Segmental and total female urethrectomy can
also be performed during the excision of vulvar
and vaginal cancers. The complications of surgical excision of vulvar and vaginal cancers will be
discussed in the corresponding chapters.
Urethrectomy forNoncancerous
Diseases
Fig. 10.3 Radical (total) urethrectomy excision margins.
(a) The bulbocavernosus (bulbospongiosus) muscles on
both sides delineate the lateral margins for a radical
urethrectomy. (b) The dotted line represents the
anteroposterior and cephalocaudal margins for a radical
urethrectomy
catheterizable continent stoma [10]. The complications following radical urethrectomy and
stoma creation include supercial wound infections, urine leakage (stula formation between
the bladder neck and the perineum), pelvic
abscesses, and sepsis.
Locally advanced female urethral carcinomas,
particularly those situated proximally, tend to be
of a high stage and may exhibit inltration into
the bladder and vagina. A comprehensive treatment approach combining chemotherapy, radia-
Female urethrectomy can also be performed for
the treatment of benign conditions, commonly
urethral diverticula, urethral caruncle [6, 38], or a
Skene gland cyst [15, 36]. Other less common
benign diseases are Bartholin duct cysts and
abscesses [41], Gartner’s duct cysts [29], and leiomyomas [40]. The complications of urethral diverticulectomy are addressed in a separate chapter of
this book. This chapter will present the complications commonly seen after partial or total urethrectomy, including distal (meatal) urethral stricture
and stress or total urinary incontinence.
Meatal Stenosis andDistal Urethral
Stricture After Partial Urethrectomy
Meatal stenosis (Fig. 10.4) and distal urethral
stricture in females are generally rare, and only
1% of women who present with voiding complaints are found to have urethral stenosis [1].
Symptoms of meatal stenosis include varying
degrees of obstructive and irritative lower urinary
tract symptoms (LUTSs), such as urinary fre-
106
K. N. Meilika and J. S. Sandhu
quency, urgency, weak urinary stream, urinary
incontinence, and recurrent urinary tract infections. Occasionally, meatal stenosis may present
with urinary retention [25], renal failure, hydronephrosis, or pyelonephritis [34]. Diagnostic
workup for meatal stenosis entails urinary ow
studies, post-void residual urine, exible urethroscopy, and video urodynamics [1].
Meatal stenosis can be avoided by performing
wide ventral spatulation before suturing the urethral edge to the vagina. The role of meatal dilation using urethral sounds (Fig.10.5) is feasible
in mild meatal stenosis [1]. The success rate of
urethral dilation is 47% at a mean follow-up of
43months [30]. Other authors do not recommend
meatal dilation, especially for recurrent cases
[11] [18].
Fig. 10.4 Meatal stenosis
Meatotomy
Urethral meatotomy in females is performed for
short segment distal and supercial strictures by
making an endoscopic dorsal incision [35].
Alternatively, a 1-cm open incision on the ventral
aspect of the distal urethra can be made followed
by suturing the urethral mucosa to the vagina
using a 4–0 Vicryl in a “V”-shaped manner [11].
The long-term functional outcomes of meatotomy are generally unsatisfactory, and additional
procedures such as circumferential, distal urethrectomy and advancement meatoplasty are
required in the future.
Distal Urethrectomy
andAdvancement Meatoplasty
Surgical reconstruction has the highest success rate
if compared to less invasive procedures such as
dilations and meatotomy. The minimally invasive
procedure should be reserved for short urethral stenosis in women with high comorbidity [12]. The
initial step of distal urethrectomy with advancement meatoplasty is identifying a healthy proximal
tissue, followed by placement of circumferential
stay sutures to prevent retraction, sparing as much
of the healthy mucosa as possible. The brotic tissue is then completely excised, and the healthy urethral mucosa is sewn to the healthy vaginal mucosa
with interrupted absorbable sutures [35] (Fig.10.6).
Vulvar cancers are typically not estrogen-dependent [37], so local estrogen can be safely applied
postoperatively to promote healing and prevent
stricture recurrence [14].
Fig. 10.5 Urethral sounds. (a) Van Buren urethral sounds are characterized by their distinctive J-shaped or curved
design. (b) The sound diameter (in French size) usually found on the handle. (c) The urethral sound tip
bc
10 Segmental or Total Female Urethrectomy
a
de
107
Fig. 10.6 Surgical steps for distal urethrectomy and
advancement meatoplasty. (a) A circumferential incision
is performed around the external urethral meatus. (b)
Healthy urethral tissue proximal to the brotic segment is
identied. (c) Circumferential stay sutures are placed to
Stress Urinary Incontinence (SUI) After Partial Urethrectomy
The female urethral sphincteric mechanism is
complex with multiple contributing factors; the
external sphincter is composed of circular and
longitudinal striated muscles (Figs. 10.7 and
10.8).
Additionally, a healthy urethral mucosa tends
to stay coapted, and the spongy, vascular nature
of the submucosal layer adds more support to the
urethral wall (Fig.10.9).
The middle third of the urethra is supported
posteriorly by the anterior vaginal wall and the
endopelvic fascia, which is rmly connected to
the arcus tendon fascia pelvis and the levator ani
muscle (Fig. 10.10). These pubourethral ligaments prevent the transmission of intra- abdominal
pressure to the distal urethra during straining
(Fig.10.11).
prevent tissue retraction, preserving as much healthy
mucosa as possible. (d) The brotic urethra is completely
excised. (e) Interrupted absorbable sutures are used to
attach the healthy urethral mucosa to the healthy vaginal
mucosa, establishing a new urethral meatus
The incidence of stress urinary incontinence
(SUI) after partial urethrectomy is variable. de
Mooij etal. compared the SUI outcome between
2 groups of patients with vulvar cancer: 18
patients with vulvar cancer affecting the urethra,
treated with radical vulvectomy and partial urethrectomy, and 17 patients treated with vulvectomy alone without partial urethrectomy. After
6 months of follow-up, they found that partial
resection of 1–1.5cm of the distal urethra during
radical local excision for vulvar cancer does not
lead to a signicant increase in the frequency of
urinary incontinence when compared to vulvar
cancer patients who did not undergo partial urethrectomy [8]. The incidence of new or worsening SUI after partial urethrectomy is about
24–40% [10, 33]. The incidence of urge incontinence after partial urethrectomy is about 4%,
and it usually responds to medical treatment
[10, 33].
108
Ur
ethrae muscle
urethrovaginal compartment
ethral
P
Fig. 10.7 Anatomy of
the urethral sphincter
muscle. Bladder,
urethral sphincter,
vaginal wall, urethra,
vagina, compressor
urethrae muscle,
transverse vaginal
muscle, ischial ramus,
urethrovaginal sphincter,
smooth muscle of the
urethrovaginal
compartment
Urethral sphincter
Vaginal wall
Urethra
Vagina
K. N. Meilika and J. S. Sandhu
Bladder
Vaginal wall
Compressor ur
Transverse vaginal muscle
Pubic ramus
ubococcygeus m.
Urethral meatus
Introitus
Vaginal wall
Perineal body
Anus
ethrovaginal
sphincter
Ischial ramus
Smooth muscle of the
Bladder
External ur
sphincter
Urethral
compressor
Urethrovaginal
sphincter
Transverse
vaginal m.
External anal
sphincter
Levator ani m.
Fig. 10.8 Anatomy of the urethral sphincter muscle
Tr igonal
Superficial
Str
e
nous
a
10 Segmental or Total Female Urethrectomy
109
urothelium
Tr igonal ring
Pubovesical
muscle
Longitudinal
smooth muscle
Circular
smooth muscle
iated urogenital
sphincter muscle
Symphysis pubis
Distal venous
plexus
trigonal muscle
Deep trigone
Detrusor muscl
Crista urethralis
Tr igonal plate
Longitudinal
subepithelial
venous plexus
Proximal ve
plexus
Submucosal
vaginal muscle
Vaginal mucosa
Nonkeratinizing
squamous
epithelium
b
Fig. 10.9 The urethral mucosa and submucosal layers
Internal meatus
Proximal venous
plexus
Mucosa
Lamina
propria
Longitudinal
coat
Circular
coat
External
striated sphincter
Distal venous plexus
Collagen ring
External meatus
110
Ar
membrane
Hor
ligaments
vis
Fig. 10.10 Posterior
urethral support
cus tendon
fascia pelvis
Anterior
vaginal wall
Endopelvic
fascia
External
sphincter
K. N. Meilika and J. S. Sandhu
Levator
ani
Urethra
Perineal
izontal portion of
pubocervical fascia
supports bladder
and vagina
Vertical portion of
vagina
Urethra
Pubourethral
Fig. 10.11 Ligaments and fascial support to the urethra
Treatment ofPost-Urethrectomy
Stress Urinary Incontinence
inWomen
Mid-urethral slings are ineffective in treating SUI
after partial urethrectomy due to the short urethra, vaginal wall retraction, and brosis [22].
Uterosacral
ligament
Cardinal
ligament
Horizontal
portion of
vagina
Arcus
tendineus
fasciae pel
Both a transurethral Macroplastique injection
(Fig. 10.12) and a pubovaginal sling (PVS)
(Fig. 10.13) are effective in treating SUI after
partial urethrectomy [24].
A transurethral Macroplastique injection is a
minimally invasive approach. It has a success rate
of about 40%, but the drawback of this modality
10 Segmental or Total Female Urethrectomy
111
ba
Fig. 10.12 A transurethral Macroplastique injection
Fig. 10.13 Diagram showing the location of the pubo-
vaginal sling
c
is the need for subsequent injections and its
higher costs [24, 32]. Massive urethral prolapse
is reported after transurethral Coaptite injection
[21, 23, 31] (Fig.10.14).
112
K. N. Meilika and J. S. Sandhu
Fig. 10.14 Urethral prolapse after transurethral bulking agent injection
Pubovaginal Slings (PVSs)
Compared to mid-urethral slings, pubovaginal
slings yield superior continence results owing to
their strategic placement at the bladder neck, taking advantage of unique anatomical factors.
Among various sling materials, autologous fascia
pubovaginal slings are considered the benchmark, excelling in terms of performance. While
the autologous sling exhibits reduced urethral
perforation rates, it requires longer operative
time, and patients may experience heightened
postoperative pain and extended hospital stays
compared to procedures involving biological or
synthetic grafts [28].
The most commonly used tissues for autologous PVSs are the fascia lata (Fig.10.15) and the
rectus sheath (Fig.10.16).
The success rates of pubovaginal slings range
from 31% to 97%. Morgan etal. reported a cure
rate of 85% in 247 patients after a mean of
51 months of follow-up. In all, 92% of the
Fig. 10.15 The autologous fascia lata
patients in this study reported high satisfaction
and overall improvement in their quality of life
[26].
Iatrogenic bladder injury is a common complication after a PVS surgery, leading to urinary
urgency, bladder outlet obstruction, and urinary
retention. Urinary urge incontinence is reported
in 20% of patients who received a PVS.Complete
urinary obstruction and retention are reported in