Last updated date: 14-May-2023
Originally Written in English
Reconstructive urology is surgery to repair, redirect, or rebuild parts of the upper and lower urinary tract as well as some reproductive organs. Reconstructive urology may be required by patients due to diseases, birth deformities, trauma, complications from surgery, or other problems.
Reconstructive Urologic Surgery
The following are the most commonly performed procedures in reconstructive urology:
- Bladder reconstruction. Necessary for treating pelvic injuries or tumors, and frequently paired with significant pelvic cancer surgeries.
- Genital reconstruction. To treat genital injury, genital malignancies, congenital malformations, and Peyronie's disease, surgical restoration of the penis and scrotum is frequently required.
- Robotic-assisted bladder augmentation may be a possibility for some patients whose bladder dysfunction is brought on by nerve injury.
- Penile prosthesis. Implants and other operations help men with erectile dysfunction or urinary incontinence regain appearance and function.
- Ureter reconstruction. To treat ureter blockages, particularly those brought on by injury or ureteral stricture, experts offer minimally invasive techniques and complex bladder reconstruction.
- Ureteropelvic junction (UPJ) obstruction repair. When possible, doctors advise robotic pyeloplasty, a minimally invasive procedure, to remove a blockage in the region where the ureter and kidney connect.
- Urethral reconstruction. It is an option for people who have urethral stricture disease, urethral injuries or trauma, urine incontinence, urethral blockage, or rectourethral fistulas brought on by radiation, surgery, or trauma.
- Urogynecologic reconstruction. For pelvic floor relaxation, urethral diverticula, female patients' urethral injuries, urine incontinence, and vesicovaginal fistulas brought on by past trauma, surgery, or radiation.
Patients who have their bladder resected to treat bladder cancer or another illness should undergo bladder reconstruction. Urinary diversion surgery is required when a patient has a radical cystectomy or the removal of the bladder. There are different kinds of operations, all of which include surgically transforming a portion of the intestine. These treatments can either be performed to build a new reservoir for the body to store urine or a passageway for it to leave the body.
Bladder Reconstruction Procedures
Surgery for bladder repair comes in three types:
- Incontinent urinary diversion. In this operation, the surgeon makes a route linking the ureters, which deliver urine from the kidneys to an incision made in the belly known as a stoma, using a portion of the patient's small intestine. Then, urine drains into an external pouch.
- Continent cutaneous urinary diversion. To establish an internal urine reservoir that the patient can periodically empty by introducing a tube into a stoma formed during surgery, the surgeon uses a part of the patient's stomach or intestine.
- Bladder replacement (neobladder). If the patient's urethra is not lost during surgery, this option, which requires actual bladder reconstruction, might be achievable. A urine-holding sac made from a tiny segment of the patient's intestine is directly connected to the ureters and urethra. This enables the patient to urinate in the same manner as before surgery.
The pelvic area contains the genitalia, which are sexual organs. Internal and external genitalia are separated. Men's internal genitals consist of the testes, seminal vesicles, prostate gland, ejaculatory ducts, and urethra, whereas their external genitals are the penis and scrotum. The vulva, clitoris, labia, opening of the vagina, and urinary bladder are all elements of a woman's external genitals. A surgical treatment called genital reconstruction is used to remove damaged genital tissues and restore the area's natural function and appearance.
Genital reconstruction surgery includes the following:
- Clitoridectomy is known as any procedure to trim or remove tissue from the clitoris.
- Foreskin restoration involves stretching out the penile skin to resemble the foreskin.
- Hypospadias repair is changing the position of the urine outlet on a phallus through surgery.
- Intersex surgical procedures that alter unusual or ambiguous genitalia
- Labiaplasty is a type of plastic surgery used to change the skin folds around the vulva
- Phalloplasty is referred to as penile construction or reconstruction
- In female-to-male sex reassignment surgery, metoidioplasty creates a penis from an enlarged clitoris as a result of hormonal changes.
- Sex reassignment surgery is an operation to change a person's sexual features so they more closely resemble those of their assigned gender.
- Vaginoplasty is referred to any surgical procedure on the vagina, vulva, or connected structures.
Cystoplasty (bladder augmentation) is an operation used to enlarge your bladder so it can hold more water. It can take two to six hours to complete the treatment. Urinary tract infections and bladder stretching or tearing are risks if your catheters aren't cleaned regularly. Although it usually takes six weeks, recovery might sometimes take three months.
Your bladder may be affected by spinal cord injury, inherited spinal or neurological abnormalities, or acquired diseases like multiple sclerosis. These diseases could consist of:
- Urinary leaking.
- Your bladder can become spastic (stiff), which can cause urgency, urge-related leaks, frequent urination, or pain in the genital region or bladder.
- Bladder capacity loss (i.e., you cannot hold the amount of urine as before).
- Your bladder muscles aren't functioning correctly. For instance, if your bladder doesn't stretch enough, the pressure inside of it will rise. Infections and damage to the kidneys could be caused by bladder pressure.
After you've had to self-catheterize for a considerable amount of time, your doctor may frequently advise bladder augmentation. To drain your urine, you can self-catheterize by inserting a tiny, hollow tube (a catheter) through your urethra.
Penile implants are used to treat Peyronie's disease and erectile dysfunction. Implants have a natural appearance and feel, and they have no impact on your ability to climax. Due to the advantages that implants provide over traditional medical procedures, many men opt for them:
- Firm and fulfilling erection for sexual activities.
- Having the ability for spontaneity in their sexual lives.
- The capacity to plan and exert control over the erection's duration and frequency.
- Paraphernalia is absent. In other terms, the erection should be spontaneous and unrelated to any devices or other impediments.
Penile Implant Types
Implants come in many different varieties. Your healthcare professional will help you in selecting the implant that is ideal for you.
- One-piece implants. Flexible or semirigid cylinders are used in single-piece implants. Some people compare flexibility to a goose-neck light. This implant is soft enough to hide in with your clothing but stiff enough for intercourse. Good for men who need a prosthesis to hold on to a condom-style catheter but have impaired hand function or men who have buried penis.
- Two-piece implants. Two-piece cylinders are constructed from a pump and a cylinder. Your scrotum is where the pump is located. You get an erection by pumping fluid into the cylinders. Your penis might become flaccid by bending since this causes the fluid to escape the cylinders. Good for males with exceedingly severe pelvic conditions that make the implantation of a three-piece implant less acceptable. Examples include men who have experienced specific pelvic crush injuries or those who have complex vascular reconstruction.
- Three-piece implants. The most widely utilized implants are three-piece ones. They are made up of a saline reservoir, a pump put in your scrotum close to your testicles, and two cylinders in the penis. Your scrotum's pump contracts, forcing saline into the cylinders and causing a hard, comfortable erection. Even after the climax, implants continue to be inflated for as long as you like. When you're ready, you'll press the pump's deflate button to restore the penis to its flaccid, soft state. Good for the majority of men who experience erectile dysfunction, including those with prostate cancer, diabetes, vascular problems, spinal cord injury, pelvic trauma, transplant recipients, and other conditions.
Surgery can be used to treat and repair ureters in a variety of ways. These can range from straightforward outpatient procedures that only require camera approaches and a short recovery period to extensive abdominal surgeries that demand long hospital stays and recovery periods of several months. Each repair is based on a variety of factors, such as the injury's location, duration, mechanism, complicating issues, and other medical disorders that may influence the situation. Recurrence of urinary tract obstruction or blockage, bleeding, infections, kidney stones, kidney damage, blood clots, or urine leak (urinoma) is all possible side effects after surgery.
Cystoscopy accompanied by ureteral dilation and stenting
Typically, individuals who are not considered to be strong surgical candidates for definitive repair use this endoscopic method. These methods necessitate stent exchanges because of encrustation and occlusion.
The lower distal ureter's built-in redundancy is utilized in this surgical strategy. Reimplantation procedures do not require extensive bladder and bowel reconstruction since the ureter is relocated into the bladder at a different site and redirected above the level of obstruction. This typical repair method is only effective for lower ureter issues; it is ineffective for upper obstructions.
Boari Flap Repair
The length of the ureter injury can be greater and necessitate a more difficult repair when it occurs above the bladder but higher in the pelvis. In these cases, the bladder is used to bridge the gap. The upper ureter is mobilized, stretched downward, and the bladder is freed and moved in the direction of the damaged side to reduce length. To mobilize the bladder, the bladder must first be hitched or tacked into place along the psoas muscle in the pelvis. Combining this with a bladder flap in which a portion of the bladder is tubularized to bridge the space is an option. Due to the involvement of the bladder in the repair, bladder frequency and urgency are potential side effects of these treatments. This is typically transient and is treatable with medications.
An end-to-end repair of the ureter tube is known as a uretero-ureterostomy (UU). In this procedure, the diseased piece of the tube is removed, the cut ends are opened up and made mobile, and the tube is then sewn back together. Longer strictures and blockages cannot be corrected with this method since only tiny parts of the tube can be removed. Avoiding more complicated treatments, retaining normal anatomy, and achieving good long-term success and patency are all benefits of this method.
Ureter Cross Over
The Trans UU reconstruction method crosses the diseased ureter over the body's midline and connects it to the healthy contralateral side to bypass the distal ureter. Patients who have undergone extensive pelvic surgery in the past, which would make other procedures challenging, benefit greatly from this operation.
Ileal Ureter (Bowel Interposition)
In this delicate reconstructive procedure, shorter parts of the diseased or damaged ureter are replaced with a small intestinal segment. This method is only used when more conventional methods have failed to resolve more serious ureteral issues. Urine after surgery may appear cloudy or contain mucus because the bowel is being used to replace a portion of the urinary system. This is expected and normal.
Urethroplasty is a surgical treatment used to treat scarring-related constriction or damage to the urethra. Excellent and long-lasting results are obtained via urethroplasty for urethral repair.
- Excision and primary anastomosis (EPA) urethroplasty. The bulbar urethra, which runs between the scrotum and the prostate, is cut short, and the severed ends are stitched back together.
- Graft urethroplasty. To improve the size of the urethra, a patch is often made from tissue taken from the extra-genital skin or the buccal lining (buccal graft).
- Staged urethroplasty. A buccal or skin graft is used to repair the damaged urethra after it has been surgically removed. In a later procedure, the graft is transformed into a tube to repair the urethra when the replaced urethra has healed over a few months.
- Penile flap urethroplasty. A urethral stricture is repaired by a flap of the penile skin.
An obstruction that prevents urine from reaching the bladder is removed during this procedure. Most of the time, pyeloplasty physically removes a blocked portion of the urinary tube (called the ureter). Due to an anomaly in how the tube developed, these obstructions frequently occur just where the urine exits the kidney to travel down the tube toward the bladder. The ureteropelvic junction, or UPJ, is where this is found.
Other times, the UPJ is being blocked or pushed against by another body part, making it difficult for urine to pass. For instance, a blood vessel may overlap the top of the urine tube, causing a space to become smaller. This may result in back or side pain, which frequently precedes kidney pain. Pyeloplasty in these situations entails cutting the urinary tube and withdrawing it from behind the blood vessel. So that the urine flow is no longer obstructed, the tube is then rejoined above the blood vessel.
There are three methods for doing the surgery:
- Open surgery. A few centimeter-wide incision is made on the problematic side. To view and operate on the child directly, the surgeon pulls back the skin. Young babies typically undergo this procedure.
- Laparoscopic surgery. Several very small cuts are made in the abdomen during laparoscopic surgery. The surgeon works from the outside of the belly while holding long, thin sticks that include instruments and a camera inside the small holes.
- Robotic surgery. The abdomen is cut with several extremely small incisions. The robotic arms are guided by the surgeon's computer as they move tiny instruments under the skin to do the procedure.
Urogynecologic Reconstructive Surgery
Many women experience prolapse, urinary incontinence, and other disorders that are common but treatable. Specialists provide expert examination and treatment in a safe, friendly setting. They can help in the treatment and cure of ladies who are affected by these illnesses thanks to urodynamic testing, cystoscopy, and a comprehensive list of non-surgical and surgical treatments. Reconstructive pelvic surgery involves corrective surgery on the pelvic organs to treat abnormalities caused by endometriosis, uterine prolapse, urine incontinence, or previous pelvic procedures. Without removing the organs, these techniques fix the defects.
Depending on the underlying cause of the patient's ailment, numerous surgical procedures can be used to treat the pelvic area. Among the most popular reconstruction methods are:
- Urethral sling procedures. This surgery is intended to assist weak pelvic floor and urethral sphincter muscles in women who experience urine incontinence. A pubovaginal sling, which resembles a synthetic hammock, is wrapped around the urethra to prevent urine leakage.
- Tension-free vaginal tape. For the treatment of female stress incontinence, a tension-free vaginal tape (TVT) sling is a more advanced version of the conventional pubovaginal sling.
- Vaginal repair of pelvic organ prolapse. Transvaginal or abdominal surgery can be used to correct pelvic organ prolapse. Through the vagina, pelvic organ prolapse can be repaired in the least invasive way possible. Surgery for prolapse can correct pelvic floor muscle abnormalities and restore the affected anatomical structures.
- Robotic sacrocolpopexy. Any prolapse or fall of a pelvic floor structure, such as the vagina, uterus, or bladder, is repaired with a sacrocolpopexy.
Reconstructive urology, also known as genitourinary reconstruction, can be utilized to manage specific bladder control issues such as incontinence and overactive bladder as well as to treat physical abnormalities, repair trauma from major surgery or accidents, and correct physical abnormalities.