Female urethral avulsion and bladder neck closure: What now? Trigonal tubularization with placement of an artificial urinary sphincter

Abstract

Bladder neck closure after severe polytrauma with an absent urethra poses a huge challenge for a young woman wanting to urinate normally. Considerations are reconstruction of a neourethra and operative means to gain continence. We describe a case of trigonal tubularization to function as a neourethra, together with the implantation of an artificial urinary sphincter. Eleven years after suffering from an open book pelvic rim fracture at 18 years, successful reconstruction of a trigonal neourethra enabled continence and residual-free spontaneous voiding at 29 years.

Keywords: Artificial urinary sphincter; Trigonal tubularization; Urethral avulsion and pelvic fracture; Urethral reconstruction.

Fig. 1

A) 2008: 3-D-CT-reconstruction of pelvis and big vessels on admission to emergency room. Asterisks indicate extreme dislocation of symphysis, thus pelvic floor rupture and urethral avulsion from bladder neck. B) 2008: Widening of symphysis indicated by asterisks after sacral stabilization. C) 2018: Overview of pelvis at clinical presentation during consultation to “get rid of suprapubic tube”. D) 2019: X-ray during videourodynamics showing bladder with 500ml capacity. The suprapubic catheter is in-situ and the bladder neck closed without remaining urethral or sphincter structures.

Fig. 2

Overview of surgery: a) arrow refers to elective opening of bladder at dome to allow inspection from inside, placement of double-J ureteric stents ± facilitate bilateral ureteroneostomies as needed; b) access to dissect around trigone well above bladder neck on top of anterior vaginal wall; c) dissection only at upper edge of introitus underneath symphysis to leave the anterior vaginal wall intact.

Fig. 3

Meatus of neourethra: A) Peanut swab on a straight clamp pushing bladder outlet from inside the bladder towards the anterior vaginal wall with excision of a small full-thickness round piece of vaginal wall (arrow). B) Bladder outlet opened and neourethral meatus sutured into position with interrupted dissolvable sutures (arrow).