Reconstructive Surgery

Dr. Neeraj Goyal, a renowned surgeon and urologist has performed several hundreds of reconstructive procedures. Dr. Neeraj has helped countless patients overcome issues related to strictures of the urethra and ureter, pelvic injuries, urinary fistulas, incontinence, and many uncommon urogenital disorders. Our highly skilled team specialize in all areas of male and female urinary tract and genital surgical reconstruction, including major reconstruction of the urethra, bladder, ureter, penis, and external genitalia, as well as other less common urogenital disorders.

Major Reconstructive Surgery Performed

• Laparoscopic Pyeloplasty for Uretero-pelvic junction obstruction (UPJ Obstruction)
• Urethral stricture surgery and Urethroplasty
• Urethral injuries from pelvic fracture
• Vesicovaginal or ureterovaginal fistulas after pelvic surgery
• Major ureter reconstruction
• Adult hypospadias
• Congenital penile curvature and Peyronie’s disease
• Urinary Leakage and Incontinence Surgery
• Post prostate surgery urinary leakage

Urethral Stricture

What is typically the best option for treating a urethral stricture?

The goal of stricture management is cure and not just temporary management. Open surgical urethroplasty (scar excision surgery) has a long-term success rate of roughly 80 to 95 percent, and should be considered the gold standard on which all other methods are judged.

What is the Success Rate of Urethral Dilation?

• Urethrotomy is potentially curative only for very short strictures (less than 1 cm) that have minimal to no surrounding urethral scar tissue.
• For strictures in the bulbar urethra that are less than 2 cm long, at one year , success rates after the first urethrotomy are 60 percent, and by five years, success falls in the range of 20-25 percent .
• Repeat urethrotomy typically has a zero % long term success.
• Laser urethrotomy sounds attractive and would improve the mediocre results of cold knife urethrotomy. However, results are no better than standard techniques.
• Side effects of urethrotomy potentially are: lumen (cavity) obliteration, as well as hemorrhage (heavy bleeding), sepsis (a serious, body-wide reaction to infection), incontinence (urine leakage), and a very rare and transient erectile dysfunction and glans numbness, after urethrotomy.

What is an Internal Urethrotomy?

“Urethro” (urethra) + “plasty” (to fix) = to fix the urethra.
Urethroplasty is open surgical reconstruction or replacement of the narrow and scarred urethra. Urethroplasty is considered the gold standard for urethral reconstruction with the best and most durable results.

What is the Success Rate of a Urethrotomy?

Before any urethroplasty, the scar should be stable and no longer contracting. Thus, it is preferred that the urethra not be dilated or cut for three months before planned definitive surgery. If the stricture patient goes into urinary retention prior to his surgery date, a suprapubic tube is typically placed. A suprapubic tube, also known as a SP tube, is a small tube that is placed through the skin and straight into the bladder. The tube is typically 2 to 3 cm above the pubic bone.

What is a Urethroplasty?

• For short strictures that involve the bulbar urethra (the part of the urethra under the scrotum and up to the prostate), a segment of the scarred urethra can be completely excised and then the two cut ends of the urethra are then sewn together.
• Excising a short segment of urethra and sewing the ends together typically has the best long term surgical results – which approach 95%
• Stricture excision cannot be performed in the penile urethra or for long strictures of the bulbar urethra because there will be two much tension, in trying to bring the two cut ends together. Tension on the suture line leads to surgical failure, and potentially to penile shortening and curvature.

When Should a Urethroplasty be Performed?

• A graft is a piece of tissue that is transferred from one part of the body to another. A graft does not have its own blood supply, so it relies on the blood supply of the host (where it was transferred to) to survive.
• Typical grafts that are used to reconstruct the urethra are harvested from the extra-genital skin or from the inner lining of the mouth. The mouth graft is known as a “buccal graft”.
• Grafts are used to reconstruct the narrow urethra by increasing the size of the urethra by patching it, rather than a total replacement

What is an Excision and Primary Anastomosis (EPA) Urethroplasty?

• Grafts are highly successful in the bulbar urethra as an onlay or patch technique. The lining of the cheek is typically used as a patch graft because it is easy and quick to harvest, has a hidden suture line, does not contract much, and can result in durable success rates that approach 80-85%.
• Skin grafts used in urethral reconstruction can shrink as much as 50 percent, and thus result in lower success rates then buccal (oral) graft. Penile skin should be avoided as a graft when the penile skin is not very redundant or elastic, or when the penis is affected by Lichen Sclerosus (a skin disease).

What is a Graft Urethroplasty?

A flap is a transfer of tissue from one part of the body to another, where the donor blood supply is left intact. In other words, a flap of penile skin that is used to reconstruct a urethral stricture, does not rely on the scarred urethra for its survival. Penile skin flap are good for reconstructing long strictures of the penile urethra. Penile skin flaps are versatile and are used as a patch to the narrow urethral segments. Success rates in the short term approach 80-85%. Flaps that are rolled into a tube have nearly a 50 percent failure rate – so flaps are reserved for patching and not replacement.
Skin flaps from the scrotum should be avoided in urethroplasty, as their complication rate is high and their success rates poor.

What is a Staged Urethroplasty?

For patients who have failed prior urethroplasties or where the urethra and local skin are severely scarred, a staged urethroplasty is usually indicated. Here, the scarred urethra is typically surgically excised, and in its place, a buccal or skin graft is placed. This replaced urethra is left open to the air to heal over the next few months. As the meatus (pee hole) is often placed in front or under the scrotum – such patients need to sit to urinate for a few months. Once the graft is soft and well healed, the patient undergoes a second (‘staged”) surgery to roll the graft up into a tube to reconstruct the urethra. A staged urethroplasty can often be more than two steps and require more than one phase of grafting. Staged urethroplasty is typically reserved for the worst urethral strictures.

Urethral Injuries From Pelvic Fracture

Urethral injuries occur in up to 10 percent of pelvic fractures and are mainly due to high-speed motor vehicle accidents and industrial accidents.

How are urethral strictures that result from a pelvic fracture different?

Urethral injuries that occur from a pelvic fracture are not really strictures, but rather distraction injuries – where the urethra is torn off at the junction of the prostate and the membranous urethra or at the junction of the bulbar urethra and the membranous urethra. Typically, the gap between the torn ends of the urethra is roughly 2 cm.
Typically, the urethra is not repaired at the time of the pelvis fracture – as more life threatening injuries exist. To divert the urine, a tube is typically placed through the lower abdominal skin and straight into the bladder (known as a suprapubic tube). Once the patient has healed from his pelvic fracture, the urethra is reconstructed. This usually occurs at 3 or more months after the accident.

How are posterior urethral strictures evaluated?

Although newer imaging methods including ultrasound and magnetic resonance imaging (MRI) are sometimes used for evaluation, the simultaneous cystogram ( bladder X-ray) and retrograde urethrogram (dye injected into the penile urethra) remain the gold standard for evaluating posterior urethral strictures.
Aside from radiographic study, visualization of the stricture from above and below is important. This is performed with an in-office Cystoscopy (telescope) through the penile urethra and through the bladder.

How are posterior urethral strictures repaired?

One-stage open urethroplasty, where the scarred segment is excised and the two ends of the urethra are sewn together is the gold standard for posterior urethral stricture repair. Long-term success rates approach 90 to 95 percent.
Grafts are very rarely used due to the poor blood supply. Minimally invasive surgical techniques (via a telescope) results are generally very poor, and should be considered only a temporary measure and never a cure.

How are the two ends of the urethra brought together?

Once the scarred tissue is removed, the two ends of the urethra can be brought together based on the natural elasticity of the urethra. By freeing up the urethra from its underlying attachments, the urethra is very elastic and can stretch up to 70% in length.
Occasionally, the distance between the ends of the urethra is very far apart – and the elastic urethra will not make up the gap. In these cases, a small piece of the pubic bone is removed. Removing some of the pubic bone gives the urethra a straight shot to the prostate and thus shortens the distance.

How are the two ends of the urethra brought together?

Laparoscopic repair of Vesicovaginal or Ureterovaginal Fistulas

What is a vesicovaginal fistula (VVF)?

A vesicovaginal fistula is a hole between the bladder and vagina. Depending on the size of the hole, the urine will drain continuously out the vagina, requiring multiple pullups or pads.

How does a VVF occur?

In the US, the most common cause for a VVF is bladder injury that occurs during a hysterectomy (uterus removal). Bladder injuries most commonly occur during open abdominal hysterectomies, followed by laparoscopic assisted vaginal hysterectomies. Bladder injury during a vaginal hysterectomy is very uncommon.

When does a VVF present?

Most VVF present within days of the hysterectomy. Initially, leakage from the vagina may be confused from peritoneal fluid that leaks from the vaginal cuff.

How is a VVF diagnosed?

VVF diagnosis is typically made in the office by performing what is called a “pad test”. Here a gauze pad is packed in the vagina. The bladder is then filled via a catheter with blue-dyed water. A blue stained vaginal gauze confirms a VVF. Aside from the pad test, the urologist will look in the bladder and vagina with a telescope (cystoscope), and perform a pelvic exam. About 10% of the time, aside from the VVF, there is also ureterovaginal fistula – a hole between the ureter and the bladder.

How is a ureterovaginal fistula (UVF) diagnosed?

UVF is usually diagnosed by a CT urogram of the pelvis. If the ureter is not well visualized on the CT, then dye can be injected into the ureter through a telescope placed in the bladder. A UVF can also be suggested by the vaginal “pad test” used to diagnose a VVF – here the patient is given an oral medicine that stains the urine orange-red. If the vaginal gauze stains orange-red, then a UVF is typically also present.
Evaluation of the ureter is always part of the VVF evaluation.

What is the best timing for VVF surgical repair?

Once the inflammation has gone down after hysterectomy surgery, a VVF surgical repair is safe to perform. If the fistula is still inflamed and friable, the success rate of repair goes down. For this reason, is important to wait a few weeks before undergoing repair. Waiting months for surgery is unnecessary and does not improve success.

How is a VVF surgically repaired?

There are two main methods of repairing VVF through surgery – one through the vagina and the other through an incision in the abdomen. Most VVF can be repaired through a vaginal incision. If the hole is large, a pad of fat from the side of the vagina can be harvested and sewn as a patch to the fistula. This fat pad is called a “Martius flap” and harvesting it requires a separate incision on the side of the vagina. If the fistula is also the result of pelvic radiation, a muscle from the leg can be rotated off the leg and into the vagina to act as a patch.
Fistulas that are very high in the vagina and/or close to the ureter in the bladder often require an abdominal approach because the hole may be difficult to reach through the vagina. If the ureter is involved, it may need to be resewn to the bladder – which is much easier to perform via the abdomen. The best way to repair is by Laparoscopic repair.

How is a ureterovaginal fistula (UVF) repaired?

A UVF is usually repaired by cutting the ureter and re-attaching it to the bladder. In select cases, a stent (plastic tube) can be placed via the bladder up the cut end of the ureter and into the kidney. If this stent can be placed, the UVF will often heal without the need for a major surgery.

Major Ureter Reconstruction

What is a ureter?

A ureter is a thin tube that allows urine to travel from the kidney to the bladder. Each ureter is a muscular tube about 8 to 10 inches long. The muscles tighten and relax to force urine down into the bladder, away from the kidneys.

During what types of surgeries can the ureter be injured?

The ureter can be injured during any type of pelvic surgery. It is most commonly injured during gynecological surgery. Colorectal surgery also can lead to ureter injury.
In patients who have a large uterus due to benign fibroids or cancer, a large sized rectal or sigmoid colon cancer, or have received prior pelvic radiation, the normal ureter anatomy may be very distorted. This distorted anatomy can place the ureter in an abnormal place or very close to a tumor. Sometimes, the tumor involves the ureter and thus a segment of the ureter has to be removed in order to remove all the cancer.
The ureter can also be injured during endoscopic surgery for kidney stones. Here, a telescope is placed up into the ureter and the stones are fragmented with a laser. The ureter can be injured particularly if the stone is large or stuck to the wall. The injured ureter can become badly scarred and prevent urine draining from the kidney. Such scar tissue of the ureter requires surgical reconstruction.

Can the ureter be injured during uterus removal (hysterectomy)?

The ureter can be injured during a hysterectomy. The drawing below shows that the part of the ureter that lies in the pelvis, close to the uterus and vagina, is the most common site of surgical misadventure and injury of the ureter.

Does risk of ureter injury differ depending on the type of hysterectomy performed?

Yes, ureter injuries occur most often during open surgical removal of the uterus. Radical hysterectomy for removal of a cancerous uterus is by far the most risky for ureter injury. Here, the injury risk is more likely because the tumor can distort the anatomy and push the ureter into an abnormal position. Ureter injury can also occur during laparoscopic assisted vaginal hysterectomy. With pure vaginal hysterectomy, ureter injuries are extremely uncommon.

 

What surgical methods are used to reconstruct the injured ureter?

• Ureter reimplant • Psoas hitch surgery • Boari flap surgery • Ureter patch or interposition with the appendix • Ileal ureter • End-to-end repair

What is psoas hitch surgery?

When the ureter is injured relatively high above the bladder (close to the junction where the pelvis meets the abdomen), the amount of ureter loss can be great. In order to bridge the gap of the injured segment of ureter, two surgical methods are used:

• Freeing up the ureter and stretching it, and pulling it down to reach the bladder • Freeing up the bladder and stretching it toward the kidney.

A ‘psoas hitch’ entails stretching the bladder toward the kidney and tacking it in position, by sewing it (“hitching”) to the psoas muscle. See illustrations below: “B” shows the bladder being stretched toward the kidney with two fingers. “C” shows the bladder sewn to the psoas muscle, “D” shows the opening in the bladder sewn closed.

What are the potential side effects or complications from psoas hitch surgery??

By freeing up and stretching the bladder, it sometimes becomes a little unstable, causing frequent urination. This is a temporary side effect, but It will often take months for the bladder to stretch up till normal. If the frequent urination is annoying, there is medicine to calm the bladder down (Ditropan). Another possible side effect of psoas hitch surgery is injury of the genito-femoral nerve. This occurs very rarely and usually only when the ureter is stuck to the nerve. The consequence of this nerve injury is numbness of the anterior thigh skin. Numbness typically resolves or gets much better with time.

What is the follow-up after psoas hitch surgery?

After psoas hitch surgery, patients require a Foley catheter in the bladder for 10-14 days. They will get an X-ray of the bladder (cystogram) to confirm the bladder has healed before the catheter is removed.
A stent in the ureter that was placed at the time of the surgery will need to be removed 3 to 6 weeks after surgery. Stent removal is a quick in office procedure, done under local anesthesia.

Are there are any activity restrictions after psoas hitch surgery?

• No driving for 2 weeks or until the Foley catheter is removed • No heavy lifting or strenuous activity for 4 to 6 weeks

What is Boari (bladder) flap surgery?

Boari flaps are used when the ureter injury is high in the abdomen and too far up for the psoas bladder hitch to reach. Boari flap surgery involves a tongue of bladder wall that is cut from bladder top side and then rolled in and sewn into a tube. The tube is pulled toward the kidney in order to bridge the missing segment of injured ureter.

What are the potential side effects or complications from Boari flap surgery?

By freeing up and stretching the bladder and rolling a segment of it into a tube, the bladder sometimes becomes a little unstable, causing frequent urination. It will often take months for the bladder to stretch up till normal. If the urinary side effects are annoying, there is good medicine to calm the bladder down (Ditropan).

What is the follow-up after Boari flap surgery?

After Boari flap surgery, patients require a Foley catheter in the bladder for 10-14 days. They will get an X-ray of the bladder (cystogram) to confirm the bladder has healed before the catheter is removed.A stent in the ureter that was placed at the time of the surgery will need to be removed 3 to 6 weeks after surgery. Stent removal is a quick in office procedure, done under local anesthesia.

Are there are any activity restrictions after Borai flap surgery?

• No driving for 2 weeks or until the Foley catheter is removed • No heavy lifting or strenuous activity for 4 to 6 weeks

When is the method of “end to end” repair used to repair the injured ureter?

When the mid-portion of the ureter is surgically injured, the ureter can be repaired by sewing the two cut ends together as long as the gap between them is less than 3 cm. At the time the ureter is sewn together a stent (plastic tube) is also placed in the ureter. The stent helps the ureter to heal. The stent is typically removed 3 to 4 weeks after repair. See the drawing below illustrating this surgical method.

Adult Hypospadias

(A congenital urethral problem) What is hypospadias?

Hypospadias is a congenital (present at birth) condition in which the penile urethra does not close properly during its development. Children born with hypospadias have a urethra that does not extend up to the end of the head of the penis. Instead, the urethra ends short and on the penile shaft. Most hypospadias urethras have the hole on the underside of the penis and not at the tip. However, in some very severe cases the urethra ends in the scrotum.
The urethra is the tube that carries urine from the bladder to the outside of the body. It also serves as the channel though which semen is ejaculated. Most of the time, hypospadias is diagnosed right after birth. Your child will require surgery to correct the defect at 1 year of age. Depending on the location of the urethral opening, the closer to the scrotum it is, the more difficult it is to reconstruct. Learn more about hypospadias.

What kind of problems do adults who were born with hypospadias have?

Many former hypospadias patients reach adulthood and continue to have issues with urination or chronic urine infections. Common problems are urethral stricture, urethra- skin fistula (hole to the skin), hair in the urethra (from a prior reconstruction that used hair-bearing skin), urethral stones, or urinary tract infections.
Patients who reach adulthood with complications from childhood surgical repairs, usually present with complex problems that require further complex repairs. Such repairs typically require a combination of grafts from the lining of the inner cheek and skin flaps. Often times, more than one surgery is needed to reconstruct the complex adult hypospadias patients, in particular since local or reliable skin is absent after failed prior childhood surgeries.

Penile Curvature and Peyronie’s Disease

Congenital curvature of the penis with erection is typically called “chordee”. The penis typically bends down. Patients who have had a life-long bend of the penis have no pain with erection. However, erections that are bent more than 15 degrees can make it difficult to penetrate during intercourse, and some women complain of discomfort or pain from the abnormal bend. Chordee repair requires a surgical approach where permanent sutures are placed to straighten the erect penis. The out-patient surgery typically takes an hour. Risks to erection quality is remote to nil. Success of chordee repair approaches 95%. Chordee is not to be confused with Peyronie’s disease, which is an acquired bend of the penis, that typically presents late in life.

Male Urinary Incontinence

(Urine Control Issues)

Male urinary leakage is usually the consequence of prostate cancer and prostate removal. Post-prostate surgery urine leakage typically occurs during physical activity or straining. This type of urine leakage is called “stress” incontinence. It is caused by a faulty urinary valve – also known as a “sphincter”. If the sphincter (valve) has been injured during prostate surgery and does not close properly, a person can leak urine. Valve function typically comes back with time and by doing regular isometric exercises of the pelvic floor muscles. These muscle exercises are called “Kegels”. Six months after prostate surgery, the majority of valve function typically has returned. Patients who are still leaking 6 months after prostate surgery can consider a surgical repair.

What types of surgeries can cure male stress incontinence?Sling:

Patients who are leaking less than 250 ml of urine a day – which usually works out to 4 or fewer pads a day – are best served by a sling procedure. Sling surgery is performed through an incision in the area between the scrotum and the anus. This surgery takes about an hour and is out-patient (go home after the surgery). In the properly selected patient, success rates (marked improvement to near dry) approach 80%.

Artificial Urinary Sphincter (AUS):

Patients who have very poor urine control – needing more than 4 pads a day or pullups – usually require an artificial urinary sphincter (AUS) device.
An AUS is a mechanical device that is surgically implanted, which can open and close the urethra. It is totally concealed underneath the skin. The sphincter is the gold standard of devices to control post-prostate surgery urine leakage. It has been in existence for over 30 years and has a greater than 90% satisfaction rating.