TRAUMATIC ABSENCE OF THE PROXIMAL URETHRA

M.L. Roenneburg

Mercy Medical Center, Baltimore, MD

OBJECTIVE:  Traumatic Absence of the Proximal Urethra or TAPU is a unique form of obstetrical vesicovaginal fistula in Niger, Africa.  Obstructed labors in this region result in necrosis of the proximal urethra with a blind distal urethra noted on examination and the open urethrovesical junction seen at the top of the vaginal vault. My objective was to assess the success rate of direct reanastomosis of the urethra to the urethrovesical junction as the primary technique for repair.

MATERIALS AND METHODS:  A prospective case series was undertaken which included 20 women with TAPU type obstetrical fistulas out of the 180 obstetrical fistulas evaluated.  This injury represented 11% of all fistulas.  Women who had Stage IV fistulas which included a TAPU as only a portion of their complex fistula were excluded from this study.  All 20 patients with TAPUs underwent direct reanastomosis of the urethra to the urethrovesical junction via a layered repair.  Preoperative antibiotics were given.  Foley catheter drainage was continued for two weeks post-operatively.

RESULTS:  45% (9) of patients are dry from direct reanastomosis of the urethra alone.  Two of these patients required a bulbocavernosa flap for adequate closure.  An additional 20% (4) of patients are dry after undergoing a subsequent suburethral sling procedure.  Although their fistulas had healed, they were left with continued urinary incontinence.  1 (5%) additional patient just underwent a suburethral sling and her follow up results are pending. 20% (4) of patients continue to be wet but have been lost to follow up.  They have not been reexamined, and it is unknown whether they have persistent fistulas or urinary incontinence from an intrinsic sphincter deficiency or mixed incontinence.  1 (5%) patient continues to be wet from a persistent fistula. Only 1 (9%) patient has been lost to follow up with the initial results of her surgery being unknown.

CONCLUSIONS:  Since 45% of patients were dry from direct reanastomosis of the distal urethra to the remaining urethrovesical junction, with or without a bulbocavernosa flap, this is an acceptable primary procedure for repair of TAPUs.  An additional 25% of patients will require a repeat surgery for placement of a suburethral sling for urinary incontinence.  Placement of a sling is not automatically indicated in the treatment of TAPU.  It is reasonable to view this repair as a possible two stage procedure with only some women requiring the second stage sling procedure.  Although 25% of patients were lost to follow up, this is in keeping with the nature of working in a third world nation.  Attempts are currently being made to locate these women with the help of the Peace Corp.

Key Words:  fistula, urethrovaginal fistula, TAPU, obstetrical trauma

Disclosure – Nothing to disclose.