Reconstructive urology is performed when urological conditions, such as Peyronie's disease, cause a change in the structure and function of the urinary tract or sexual reproductive system. As a result of the condition, urination problems or sexual dysfunction may present. Reconstructive urology aims to reinforce the structures and cosmetically repair them. While a number of surgical approaches exist, this article will address the chief methods utilized.
Conditions Treated Via Reconstructive Urology
When the tube that carries urine out of the body from the bladder (urethra) is abnormally narrow (urethral stricture) due to inflammation or scar tissue from injury, disease, or surgery, it can make urinating difficult. If urine output is severely hampered because of the obstruction, the fluid can travel back up the urinary tract, which can cause a urinary tract infection or the organs the urine settles in to become dilated (such as is the case with hydronephrosis). Distended too long, tissue damage can occur.
There are two main reconstructive urology approaches that can be taken to correct urethral strictures:
- Urethrostomy: A long, thin tube with a light and video camera at its end (endoscope) is inserted directly into the urethra. Using the hollow center of the scope, a cutting instrument is guided through to slice the stricture lengthwise. This allows the flow of urine to open up. A urinary catheter is typically put in place to keep the channel open while the urethral incision made is allowed to heal. A stent can also be positioned in the urethra, allowing it to stretch and stay propped open.
- Urethroplasty: This approach involves making an incision at or near the area where the stricture has occurred. The scar tissue is removed and either the remaining portion of the urethra is reconnected, or a graft taken from inside the patient's cheek can be used to form a reconstructed urethra. A skin flap may also suffice. The amount and location of tissue removed depends upon the size of the urethral stricture. This surgery is associated with a 95 percent success rate, but requires wearing a urinary catheter for 10 to 14 days until the urethra has healed.
Urinary incontinence is a condition that affects the bladder muscle's abilities to control and hold urine. Depending on the type of incontinence and its severity, a variety of reconstructive procedures can be performed.
- Detrusor myectomy with an enterocystoplasty: This surgery is performed when the patient has urge incontinence, which is characterized by an involuntary loss of urine after experiencing a strong, sudden urge to urinate. The approach can potentially correct this often-embarrassing condition by removing a portion of the bladder muscle that does not work properly and replacing it with tissue from the patient's intestine.
- Pubovaginal sling: If a woman has stress incontinence, whereby urine leaks when performing activities that place extra stress on the bladder, such as sneezing, laughing or exercising, a surgeon can access the bladder through an abdominal or vaginal incision. The vaginal approach is used to insert a pubovaginal sling, which involves taking tissue from the abdomen or using man-made materials to create a sling underneath the urethra and a portion of the bladder. This sling keeps urine from leaking from the patient's bladder.
- Burch colposuspension: Since the uterus, rectum, and bladder are situated near and around the vaginal canal, it is possible for the organs to protrude into or out of the vagina if the supportive tissues in the pelvic are weakened due to childbirth, menopause, obesity, natural aging, heavy lifting, chronic constipation, or prolonged coughing. This is known as pelvic organ prolapse. Tissue may too hang from outside the vagina. Should this occur, it could be difficult to urinate, or urine may leak involuntarily (urinary incontinence). To fix this condition, the surgeon may recommend an abdominal surgical approach known as a Burch colposuspension. This procedure involves strategically placing stitches near the bladder's opening that are fixed to the back portion of the pubic bone to keep the bladder in place and create a more even pressure gradient across the urinary structures. This can reduce stress on the bladder during coughing, laughing or exercise that leads to urine leakage.
Peyronie's disease is a connective tissue disorder that causes fibrous plaque to form in the soft tissue of the penis. Surgery is typically recommended if the condition has lasted more than a year and interferes with sexual function. Options include:
Grafting: The penis can be straightened and its length can be restored by extracting the plaque and supplanting a skin graft that is taken from the abdominal wall. The graft helps lengthen the short (curved) side of the penis. Though a viable option, this difficult procedure can result in erectile dysfunction and numbness.
Nesbit procedure: This approach attempts to correct the penis arc or curve. An incision is made along the penis and the skin is pulled down to reveal the underlying tissue. The penis is put into a straight position, while the extra tissue on the outside of the arc is either removed or bound together with sutures. This method is less likely to result in erectile dysfunction or numbness, but may reduce penis size.
This is a congenital condition in which the opening of the urethra is positioned elsewhere besides the tip of the penis. Hypospadias treatment depends on the location of the opening, but repair aims to:
Straighten the shaft of the penis
Create a new urinary channel
Position the urethra at the head of the penis
Reconstruct the tip of the penis using foreskin or a graft
Penile Prosthesis Implantation
For men who suffer from erectile dysfunction, congenital anomalies, accidental penile trauma, an unusually small penis, or Peyronie's disease, reconstructive urology can come in the form of an penile prosthesis. A surgeon places an implant into the portion of the penis responsible for achieving and maintaining erection. A variety of penile prostheses are available, ranging from one- to three-piece implants. They can be an option for men with erectile dysfunction related to prostate cancer, diabetes, spinal cord injury, vascular trauma, and pelvic trauma.
If a patient has lost a significant amount of genital tissue due to injury, burns or necrotizing fasciitis (like Fournier's gangrene), genital reconstruction procedures can help restore the anatomy and minimize scarring. The genitals have traditionally been difficult to reconstruct since penile and scrotal tissue tend to be very different from other tissues within the body, making skin grafting an issue. However one approach reconstructive surgeons use is the application of tissue expanders (inflatable balloons), which are placed underneath the skin. When tissue is stretched beyond its typical limits, the body stimulates new cell production. This gives the surgeon additional skin from which to graft onto damaged genital areas to restore their cosmetic appearance.
Urinary Incontinence in Women. (2010). National Kidney and Urologic Diseases Information Clearinghouse. NIH Publication No. 08-4132