Introduction: The loss of the urethra with subsequent urinary incontinence is a challenge. Urinary diversion is one option. We investigated the possibility of urethral reconstruction by distal bladder wrapping, followed by artificial urinary sphincter (AUS) placement.
Methods: In this pilot study five patients (4 female, 1 male) were included that lost their urethral function either through severe pelvic trauma or previous cuff erosion in patients with AUS and paraplegia/ myelomeningocele. As the urethra was either absent or severely scarred, an AUS cuff could not be placed in the standard fashion. The urethra was lengthened by wrapping the trigonal area into a tube. The cuff was then placed around healthy tissue as part of the AUS placement. Ureteroneostomies were performed as necessary. Post operatively after 6-8 weeks the AUS was activated.
Results: All patients were continent after AUS activation. The average age was 33 years at the time of surgery, and the mean follow-up was 6,9 years. Cuff sizes used: 4.5, 6.5, 8, 8 and 10 cm (?). Three patients with myelomeningocele needed intermittent self – catheterization to void. One patient needed an ureteroneostomy for a single ureter of a single duplex kidney. The two patients after severe pelvic trauma could void spontaneously. One female patient needed a urethral neomeatus dilatation for meatal stenosis. During follow-up two patients became pregnant and delivered healthy babies (one spontaneous transvaginal birth, one cesarean section in a patient with myelomenigocele). The only male patient (myelomeningocele and paraplegia) developed an infection and needed AUS explantation, cystoprostatectomy and an ileum conduit.
Conclusions: With a follow-up of close to seven years the circumtrigonal cuff placement seems to be a useful alternative in patients that lost urethral function. Wrapping of the bladder outlet, proximal to the bladder neck, to reconstruct the urethra seems promising in select complex cases of total urinary incontinence, especially in young females.
Figure1: AUS cuff placement around new urethra reconstructed from distal bladder outlet +/- ureteroneostomy. Source of
