Urethro-vaginoplasty

Synopsis: Urethro-vaginoplasty is mending the torn wall of the internal urethral sphincter and closing the rupture that weakens the sphincter causing urinary incontinence SUI, DO and mixed type. Treating the anterior vaginal wall descent, and adding extra support and strength to the sphincter, is done by overlapping and fixing the two longitudinal anterior vaginal wall flaps on the mended sphincter wall.

Key Words: Urethro-vaginoplasty, internal urethral sphincter, Urinary continence, anterior vaginal wall descent.

Abstract: Urethro-vaginoplasty, an innovated operation for the treatment of Stress Urinary Incontinence (SUI), Detrusor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent.

Introduction: Urethro-vaginoplasty, a novel vaginal operation for the surgical management of Stress Urinary Incontinence (SUI), Detrusor Over activity (DO), Mixed-type of urinary incontinence and Anterior Vaginal wall descent is innovated, depending on a new concept. SUI is a sequel of a weak, defective internal urethral sphincter; the defect is mostly due to traumatic rupture of its wall. The internal sphincter is a collageno-muscular tissue cylinder that extends from the bladder neck down to the perineal membrane. Anterior vaginal wall descent is, mainly due to laxity, overstretching and rupture of the collagenous tissue sheet of the vagina. Urethro-vaginoplasty, is an original vaginal operation with 2 main steps; first, we identify The defect, (rupture), in the wall of the sphincter causing its weakness, and we mend the torn wall by simple interrupted sutures, “urethro-raphy”. Second step, we add additional protection, support and strength to the internal urethral sphincter, and repair the prolapsed lax overstretched anterior vaginal wall; by overlapping and fixing the 2 longitudinal anterior vaginal wall flaps of the cut, and bisected anterior vaginal wall over the mended sphincter. This narrows and strengthen the vagina, repairs the lax overstretched descending anterior vaginal wall, without cutting and dispensing parts of it. In addition, it is an autolgus source of collagen, and it separates the mended internal urethral sphincter wall from the overlying double layered repaired anterior vaginal wall. Thus the internal urethral sphincter, mended and well supported, restores its integrity, and strength to resist sudden increases of pressure, and a narrow, tough unprolapsed vagina ensues.

Aim of the Study: Microscopic histopathological examination is done of samples of the anterior vaginal wall from patients with anterior vaginal wall descent, to compare it with samples from normal tough vagina, after histopatholgical preparation, to assess the difference in the collagen tissue sheet.
Also evaluating the results of this new operation, is done by assessing the patients soon after surgery and for up to 12months following surgery.

Study Design: Samples of the anterior vaginal wall are taken from patients with vaginal wall prolapse, and from tough normal vagina for comparison, and are prepared, stained and microscopically examined.

Urethro-vaginoplasty operation is done to cases with SUI, DO, Mixed-type of urinary incontinence with anterior vaginal wall descent. The cases are followed up for urinary continence and vaginal wall descent up to 12months after the operation.

Results: Urethro-vaginoplasty operation had been done for 92 patients. Anterior vaginal wall descent was successfully repaired in all cases, and a tough unprolapsed vagina was the result. Success rate of gaining urinary continence was 92.4%; 85 patients gained continence. There was improvement in 5 patients; a rate of (5.4%).Failure was recorded in 2 women; a rate of 2. 2%. No post-operative troubles were recorded.

Conclusion: Doing “urethro-vaginoplasty” operation we get a strong internal urethral sphincter and a narrow, tough unprolapsed vagina that can support the mended and fortified internal urethral sphincter and the urinary bladder.

Introduction: A tough, intact and strong anterior vaginal wall is an essential support for the intimately overlying internal urethral sphincter and the lower portion of the posterior wall of the urinary bladder. The strength and the toughness of the vaginal walls depend on its rich compact collageno- -elastic tissue cylinder. The compact tough collagen bundles, which give strength to the vaginal canal, are essential elements of keeping the vagina in its normal upright position without descent.

Prolonged labor, difficult labor, and operative deliveries cause stretching, attenuation, split and actual lacerations of the collagen bundles sheet of the vagina causing weakness, overstretching and laxity of the vaginal walls.

The overstretching, attenuation, degeneration, split and lacerations which affect the anterior vaginal wall will, without doubt, affect the intimately overlying internal urethral sphincter causing rupture of its closely related posterior wall. This will lead to a defective weak internal urethral sphincter with lowered urethral closing pressure, which can not resist provocations and subsequent urinary leakage, stress urinary incontinence, SUI, detrusor overactivity, DO, or mixed type of urinary incontinence depending on the level and extent of the lacerations along the length of the collageno-muscular tissue cylinder of the internal urethral sphincter. (1&2)

A new vaginal operation “urethro-vaginplasty” is innovated to treat urinary incontinence SUI, DO, and Mixed types of urinary incontinence accompanied by anterior vaginal wall laxity and descent.

It depends on identifying the rupture in the wall of the internal urethral sphincter and mending the torn wall with simple interrupted sutures, “Urethro-raphy” (1&2). Furthermore, in order to fortify the internal urethral sphincter, and to repair the lax, overstretched, prolapsed anterior vaginal wall; we do overlapping longitudinally of the two vaginal wall flaps of the cut and bisected anterior vaginal wall. This will provide an additional mechanical support to the internal urethral sphincter; it, also, acts as an autologus source of collagen for the torn internal urethral sphincter, and the weakened anterior vaginal wall. In addition, it separates the mended internal urethral sphincter from the overlapping double-flap repaired anterior vaginal wall i.e. it separates the two suture lines.

The objectives of urethro-vaginoplasty are to reconstruct a strong internal urethral sphincter that is well supported and protected by double-flapped anterior vaginal wall. Also it narrows and strengthens the lax prolapsed vagina without cutting and dispensing any vaginal tissue, and saving its own collagen.

Objectives: This work compares the collagen bundles lay out in the normal tough vagina, to its arrangement in the over stretched, prolapsed anterior vaginal wall. Also, this paper reports and evaluates the results of the new, “urethro-vaginoplasty” operation in the surgical treatment of anterior vaginal wall descent with urinary incontinence, SUI, DO and mixed type of urinary incontinence soon after surgery and for up to twelve months of follow up.

Study design: Patients with anterior vaginal wall descent, and urinary incontinence, stress urinary incontinence, SUI, detrusor overactivity, DO, and mixed type of urinary incontinence are chosen for the study. Comprehensive history is taken, physical examination is done, laboratory investigations are done, and imaging with 3-dimension ultra sound, and magnetic resonance are done.

Urethro-vaginoplasty is done, and a sample of the anterior lax, prolapsed anterior vaginal wall is taken for histopathological examination, to compare it with pieces of normal tough vagina.

Follow up assessments of patients are done after one month, 3, 6, and 12 months.

Sections of the vaginal samples were prepared and stained with hematoxylin and eosin and Masson’s trichrome which stains collagen fibers green, for histopathological examination, and comparison.

Patients and Methods: All patients in this study gave an informed consent to the operation, and the study was approved by the local ethics committee.

Ninety two patients suffering from anterior vaginal wall descent, Aa ranged from +1 to +2cm.; Ba ranged from +2 to+4 cm.; C ranged from -4 to -6cm. While Gh, (Genital hiatus),_ranged from 3.5 to 5 cm. Pb , (perineal body), ranged from 1 to 2 cm. and TVl, (total vaginal length), ranged from -7 to -9 cm. according to Pelvic Organ Prolapse (POP) quantitative scoring system (3). The patients were also suffering from Urinary incontinence, SUI, DO, and mixed-type of urinary incontinence.
Patients suffering, as well, from posterior vaginal wall prolapse, Ap is +2 cm., and Bp ranged from +1 to +3 cm. and short perineum, Pb is 2cm or less were included in the study.

Preoperative assessment: All the 92 patients had been evaluated at the urogynaecology clinic. Evaluation include special questionnaire that inquire about lower urinary tract function and its social impact. The questionnaire ends in identifying either stress urinary incontinence, detrusor overactivity or mixed type of incontinence. Frequency and nocturia were defined as voiding more than seven times during the day and more than once during night respectively.

Following recruitment, each patient was asked to keep a voiding diary to assess the severity of the leakage, and to monitor the results in the pre-operative and the post-operative follow up period.

Then, physical examination, measurement of any residual urine, urinalysis and tests for bacteriological culture and sensitivity were done, and accordingly treated from any infection.

Urodynamic studies, namely cystometry, urethral pressure profile, stress cysto-urethral pressure profilometry and leak-point pressure were done before surgery and after surgery at the follow up periods.

Three-Dimension Ultrasonic assessment of the internal urethral sphincter was done for each patient using trans-vaginal route and trans-perineal route by a vaginal probe multi-frequent 5-7.5 MHz, General Electric, integrated 3D-4D Unit (GE Kretz) 730 pro machine. (Figures: 1, 2, 3 & 4.)

Also magnetic resonance imaging, M.R.I. was done in some patients to confirm the rupture in the internal urethral sphincter wall and its extent, and to demonstrate the laxity, and descent of the anterior vaginal wall. (Figures: 5, 6, 7 & 8).

Urethro-vaginoplasty operation, the procedure

General or regional (spinal or epidural) anesthesia is used. (Figures: 9, 10, 11 & 12).

The urethro-vaginoplasty operation entails two main steps; first step is to expose clearly the rupture in the posterior wall of the internal urethral sphincter, and to mend it by consecutive, simple interrupted sutures, “Urethro-raphy” (1 &2). Second step is to correct the anterior vaginal wall laxity and descent, aiming at getting a tough narrow unprolapsed vagina and, also, providing additional strength and support to the internal urethral sphincter.

“Urethro-raphy” starts by dissecting the anterior vaginal wall separately from the posterior wall of the internal urethral sphincter, visualizing the rupture in the internal urethral sphincter and its extent. It is important to dissect the internal urethral sphincter wall clearly free from the vaginal wall and not to dissect through the internal urethral sphincter wall, keeping in mind that the vaginal wall is about half a centimeter thick. When clearly dissected the internal urethral sphincter wall would be obvious with the rupture nicely demonstrated either affecting the whole length of the sphincter or the main insult affects part of it, the upper part, or the lower part of the collageno-muscular tissue cylinder. The repair is done in the torn collagenous tissue cylinder which is thick and tough. Mending the rupture with fine, (number zero) slowly absorbed suture material, e.g. polyglycan. That is achieved by putting about ten interrupted simple stitches. Good "bite" of the torn edges of the collagenous tissue cylinder is taken and sutures are tied with enough strength to bring the torn edges together, “Urethro-raphy”. No harm is done to the muscle fibers of the internal urethral sphincter; and no narrowing of the urethral lumen, as we do not put plicatory stitches. And so no voiding troubles are noticed after surgery. (Figures: 9, 10 &11).

After carefully mending the torn posterior wall of the internal urethral sphincter, the lax, overstretched anterior vaginal wall is then repaired by overlapping the two longitudinally bisected anterior vaginal wall flaps, over the mended internal urethral sphincter.

This is done by bringing the right anterior vaginal wall flap underneath the left vaginal wall flap. This is accomplished by several consecutive longitudinal mattress sutures starting near the external urethral orifice and going up to the transverse cut in the vagina over the cervix, using number 1 slowly absorbed suture material, e.g. polyglycan.

The mattress suture starts far laterally in the left vaginal flap going to the edge of the right vaginal flap, then passing the needle 3-5 mm. up again near the edge of the right vaginal flap, and then passing it to the far lateral start on the left vaginal flap. When tying the two arms of the thread together, this will draw the right vaginal flap underneath the left vaginal flap. This is repeated about five, six times going up to the transverse cut in the anterior vaginal wall over the cervix uteri. The free edge of the left vaginal flap is then sutured far laterally to the right part of the intact anterior vaginal wall laterally. Thus the lax, overstretched, prolapsed vagina is narrowed by overlapping the left vaginal flap over the right vaginal flap, double flapping, without cutting and dispensing any vaginal tissue. The mended internal urethral sphincter is thus strengthened and well supported by a double-layer of vaginal wall. In addition, this procedure narrows, and strengthens the anterior vaginal wall and restores its tough unprolapsed position, “Urethro-vaginoplasty”. (Figures: 9, 10, 11 & 12).

The mended internal urethral sphincter is, thus, well supported by the double flap repaired tough anterior vaginal wall, saving all its collagen.

In addition to the protection it provides to the internal urethral sphincter, it is an autolgus source of collagen to both the internal urethral sphincter, and the anterior vaginal wall; and it separates the two suture lines. It also, restores a narrow tough unprolapsed vagina.

Posterior repair is done, if needed i.e. posterior vaginal wall prolapse, Ap is +2 cm., and Bp ranged from +1 to +3 cm., and TVl ranged from -6 to -8 cm.; and short perineum, Pb is 2cm or less, according to Pelvic Organ Prolapse (POP) quantitative scoring system.

A Folly’s catheter is fixed and a vaginal pack is applied for 24 hours, and then both are removed.

Postoperative care:

The catheter and the vaginal pack were removed on the second postoperative day. Patients were allowed to void freely for one day and discharged with an outpatient appointments after 4 weeks, 6 months, and 12 months.

Post-operative follow up, each patient is assessed clinically, by 3DUS examination and by urodynamic studies.

Postoperative evaluation includes:

Subjective assessment was done by recording symptoms, assessment of urinary incontinence, SUI, DO, or both, frequency, nocturia, , and any voiding troubles.
Subjective cure is defined as no urine loss on provocation. In addition, the patient should not have any voiding problems, e.g. urine retention, urge nor residual urine, more than 50 mL.

Objective cure depends on clinical, urodynamic, and 3DUS assessment.

On urodynamic parameters, there should no demonstrable urine leakage on coughing, significant increase in urethral closure pressure and bladder capacity, no significant detrusor contractions during filling the bladder, an increase of the level of first sensation to void, correction of the transmission ratio to more than one, elevation of abdominal leak-point pressure and reduction of postvoiding residual urine to less than 50mL.

On 3DUS there should be disappearance of defects with the appearance of compact thick wall, the restoration of the urethro-vesical angles and correction of the apparent urethral collapse with restoration of the normal urethral length. In addition there should be no laxity, overstretching and prolapsed anterior vaginal wall.
Improvement is defined as marked reduction in the number of leakage episodes, more than 50% the number before the operation, also not having voiding problems. There should significant improvement in the urodynamic and 3DUS parameters.

Failure is defined as post operative leakage episode more than 50% the number before the operation. Urodynamic and 3DUS parameters are not improved significantly.

Results:

- The mean age of the patients was 53.0 years, S.D. 5.8 a range from 38 to 64 years.
- The mean parity was 6.5, S.D. 1.7, a range from 3-10.
- The mean body mass index is 29.3, S.D. 2.24, a range from 24.7to 36.0
- All 92 patients have anterior vaginal wall descent, in addition to urinary incontinence, stress urinary incontinence, SUI, detrusor overactivity, DO, or mixed type.
- All 92 patients needed pads, mean 7 pads per day, S.D. 1.56, a range from 5 to 12 pads per day.

Histopathological examination of the vaginal wall samples showed:
- A tough compact collagen bundles, forming a compact sheet is seen in normal nulliprous vagina which did not suffer insults of vaginal labor.
- While, in patients with vaginal laxity, the collagen bundles are seen separated, torn and degenerated as proved by the appearance of new blood vessels; figures: 13, 14 &15.
- Assessment of the condition of each patient after surgery is done by the subjective, clinical examination, objective, urodynamic tests and the 3DUS assessment.
- The anterior vaginal wall regained its tough, strong, high unprolapsed position in all patients, with all points back to normal. Aa -3cm; Ba -3cm and C at -8 to -9.5 cm. and the hymen introitus, gh 2, and is not patulous anymore. Also Ap -3cm. Bp -3cm. TVl range from -10cm to -11cm. and Pb is 2.5cm.to 3cm.

In urinary incontinence, using the subjective criteria, in addition to objective clinical signs, 3DUS, and urodynamic parameters; 85 patients from the 92 patients, (92.4%), gained continence successfully.

There was improvement in 5 patients a rate of (5.4%).

Failure was recorded in 2 women, a rate of (2. 2%).

There has been high cure rate and improvement as proved by subjective and objective parameters.

The urodynamic parameters improved significantly. The first desire to void increased from 86.11 S.D.6.98 mL. water to 148.64 S.D. 4.30 and remained high for the whole follow up period. The urinary bladder capacity almost doubled, increased from 199.3 S.D.10.85 to 430.88 S.D.15.41 mL. The urethral pressure increased significantly from 40.36 S.D.8.32 cm. water to 75.90 S.D.3.88 and persisted at the high pressure all through. The functional length of the urethra increased from 20.29 S.D.1.28mm. to 35.60 S.D.1.62mm. the abdominal leak point pressure increased significantly from 52.6 S.D.9.45 to 154.48 S.D. 5.10 cm water. This significant improvement persisted along the follow up periods.

Discussion:

Urinary continence depends on two, (2) main factors, one inherent and one acquired: (1, 2, 4, 5, 6, 7, 8, 9, 10 & 11)

I -The inherent factor:
It is the presence of an intact and strong internal urethral sphincter. The internal urethral sphincter is a collageno--muscular tissue cylinder that extends from the bladder neck down to the perineal membrane. It is lined by urothelium. The muscle fibers lie on, and intermingle with the collagen fibers in the mid-thickness of the cylinder. The muscle layer is controlled by alpha-sympathetic nerves T10-L2, and is connected above with the detrusor muscle.

The internal urethral sphincter is intimately lying on the anterior vaginal wall.

II -The acquired factor: (Second stage of micturition)
This is an acquired behavior gained by learning and training in early childhood how to maintain a high alpha sympathetic tone at the internal urethral sphincter keeping it closed all the time until voiding is needed or desired.

A tough and a strong anterior vaginal wall is the major support for the overlying internal urethral sphincter and the lower portion of the posterior wall of the urinary bladder. A weak overstretched and lax anterior vaginal wall will fall down; prolapse, with its overlying internal urethral sphincter, and lower part of the posterior wall of the urinary bladder. The strength and the toughness of the vaginal walls depend on its rich compact collageno-elastic tissue cylinder. The compact tough collagen bundles, which give strength to the vaginal walls, are essential elements of keeping the vagina in its normal upward position without descending or falling down. As an example, a hard-cover book will stand upright on a shelf, while a paper-cover book will fall down.

Prolonged labor, difficult labor, multiple frequent labors, and operative deliveries cause stretching, attenuation, split and actual lacerations of the collagen bundles of the vagina causing weakness and laxity of the vaginal walls. The insult will affect the anterior vaginal wall more common in women with gynecoid pelvis, and platypelloid pelvis with wide subpubic arch, while an android pelvis with a narrow subpubic arch displaces the fetal head posterior injuring more the posterior vaginal wall. An anthropoid pelvis, large fetal head, or bigger diameters, and or large fetus will damage both the anterior and posterior vaginal walls.

After menopause, there is further slowly progressive collagen attenuation caused by hormone deficiency, which will aggravate the vaginal wall weakness.

Another factor which may add to the etiology of the vaginal wall weakness is repeated vaginal infections which will cause degeneration of its collagen.

The weakness and rupture of the vaginal collagenous sheet will manifest itself in the transverse axis of the vagina. (Figures: 6, 7, 8 & 9).

This is seen clinically and on imaging:

1 - at first, there will be loss of the nulliparous H-shape vagina which changes into a transverse slit in parous women. (Figure: 7 & 8)
2 - Then, further weakness, will lead to loss of vaginal rugae; the vaginal wall will be smooth without folds.
3 - Further weakness and rupture of the vaginal collagen will induce vaginal wall descent.

In the transverse axis of the vagina, the central midsegment suffers more damage than the periphery. This is a mechanical effect. In addition, the attenuated anterior vaginal wall will suffer an extra load, the overlying urinary bladder and internal urethral sphincter.

The stretching, attenuation, degeneration, split and lacerations which affect the anterior vaginal wall will, without doubt, affect the intimately overlying internal urethral sphincter causing rupture of its posterior wall, figure: 18. This will lead to a defective weak internal urethral sphincter with lowered urethral closing pressure, and subsequent urinary incontinence on provocation. Depending on the level and extent of the lacerations along the length of the collageno-muscular cylinder of the internal urethral sphincter, stress urinary incontinence, SUI, detrusor overactivity, DO, or mixed type of urinary incontinence is the result.

Urethro-vaginoplasty operation, would be beneficial for the treatment of urinary incontinence, SUI, DO, and mixed type; whether there is anterior vaginal wall descent or not.

Collagen is the most abundant protein in humans. Collagen accounts for one third of human protein by mass.

Collagen fibers are usually found in bundles of fibers and provide strength to the tissues. Each fiber is made up of fibrils, chemically it has a high content of hydroxy-proline and hydroxy-lysine. Many different types of collagen are identified on the basis of their molecular structure.

Type I is the most abundant being found in the dermis, bone, dentin, tendons, fascia, sclera, and organ capsules.

A strong and intact collagen sheath and capsule is the tough skeleton of soft tissue organs.

Understanding the mechanism of micturition and the factors controlling urinary continence, voiding troubles can be better understood and managed.

Functional disturbances, and/or structural damage of the internal urethral sphincter will lead to Urinary incontinence. (4 -11)

I- Functional disturbances:
1 - Failure to gain the acquired behavior to maintain high alpha sympathetic tone at the internal urethral sphincter, complete, or partial failure, will lead to Nocturnal Enuresis.
2 - Sympathetic over activity, e.g., painful lesions e.g., episiotomy; spinal cord lesions that lead to pelvic parasympathetic palsy sparing the thoraco-lumbar sympathetic activity, e.g., disseminated sclerosis, DS, systemic lupus erythromatosis, SLE, or spinal cord injury, will lead to retention of urine and overflow incontinence.
3 - Sympathetic failure e.g., severe fear, use of alpha sympathetic blocker drugs, deep anesthesia will lead to transient urinary incontinence.

II- Structural damage of the internal urethral sphincter:
1 - Whole thickness damage, this leads to genito-urinary fistula and subsequently to True urinary incontinence.
2 - Partial thickness damage, (2 sites)
(a) - Damage that occurs from outside, this is more common; is mostly caused by child birth trauma; this will cause weakness of the internal urethral sphincter, with subsequent S.U.I., D.O.,&/or Mixed urinary incontinence.
(b) - Damage that occurs from inside, less common; this will lead to urethral diverticulum, and subsequently will lead to post-voiding dribbling.

SUI, DO, (DI) and Mixed-type of urinary Incontinence are caused by weakness of the internal urethral sphincter. The weakness is mostly due to traumatic injury of the internal urethral sphincter causing: rupture, and/or split of the collagenous tissue cylinder, the essential constituent of the internal urethral sphincter.

The torn weak internal urethral sphincter with a lower urethral closing pressure will, on sudden increases of intra-abdominal pressure, intra- vesical pressure, give way, with resultant leakage of urine.

Leakage of urine will induce a rapid reactive sympathetic activity that will increase the sympathetic tone at the internal urethral sphincter preventing further loss of urine (1, 2, 5, 6, 7, 8, 9, 10&11)

The extent and the site, (the level along the cylinder), of the damage in the internal sphincter will determine the type and the degree of the urinary incontinence, and the morphological changes seen on imaging the urethral sphincter.

1 - If the rupture affects the whole length it will lead mixed urinary incontinence and to apparent shortening of the functional urethral length and irregularity in shape on imaging.

2 - If it affects the upper part only this will lead to loss of urethro-vesical angle, (funneling of the bladder neck), urethral hyper mobility. As urine enters the urethra on increases of intravesical pressure it will lead to an abrupt and strong desire to void, detrusor overactivity, DO.

3 - If it affects the lower part only; this will appear as Flask-shape on imaging by three-dimension-ultrasound, and it will lead to genuine stress urinary incontinence.

Stress urinary incontinence, detrusor overactivity, and mixed type of incontinence had been big problems to manage. So many different trials to understand the pathogenesis of the incontinence, and many different operations are introduced to treat such ambiguous troublesome conditions.

We claim that urinary incontinence is due to a weak defective internal urethral sphincter (1, 2, 4-11). Weakness of the sphincter is due to an injury to the collagenous tissue cylinder, the essential constituent of the internal urethral sphincter, and which gives its high wall tension necessary to create the high urethral closure pressure. The most common cause of the defect is traumatic rupture, and/or split of the collagenous cylinder. Other causes include atrophy, and degeneration caused by other factors, e.g., infection, senility, and/or estrogen deficiency.

Weakness of the internal sphincter would reduce the wall tension and subsequently the urethral closure pressure, so that sudden increases of the intra-abdominal pressure would overcome the weak sphincter leading to leakage of urine. This leakage of urine will initiate a quick reactive sympathetic activity that increases the internal sphincter tone preventing further leakage (1, 2, 5, 6, 7, 8, 9, 10 &11).

“Urethro-vaginoplasty”, figures, 9, 10, 11 & 12, a new vaginal operation had been innovated to treat urinary incontinence, SUI, DO and mixed type with, or without anterior vaginal wall descent. It is a simple vaginal operation which depends on mending the rupture in the internal urethral sphincter, by “urethro-raphy” at first then treating the anterior vaginal wall descent if present, and adding extra support, and strength to the internal urethral sphincter, by overlapping longitudinally the two vaginal flaps of the bisected anterior vaginal wall. The aim is to restore the strength and toughness, to both the vagina and the internal urethral sphincter to allow the internal urethral sphincter to maintain urinary continence.

It is worthwhile mentioning that “Urethro-raphy” is different from Kelly, Kelly- Kennedy plication operation in the pathogenesis of the incontinence, the aim of the procedure, the technique of the operation and the post-operative sequel. Kelly and Kelly-Kennedy plication operations aim at elevating the bladder neck to a high retro-pubic position; and narrowing the funneled bladder neck by plicating sutures. This is done by deeply infolding, plicating and suturing together the adjacent pelvic, sub-pubic and peri--urethral fasciae by several mattress sutures (12 &13). On the other hand we claim that SUI, DI and mixed incontinence are due to a weak torn internal urethral sphincter. Our aim in performing “Urethro-raphy” operation is to restore an intact and strong internal urethral sphincter with compact, thick tough walls with high wall tension. This is achieved by identifying the rupture in the wall of the internal sphincter and mending it by approximating the torn edges together by simple interrupted sutures. The false impression of urethral hyper mobility and funneling of the bladder neck is caused by the damaged torn weak wall of the upper part of the internal urethral sphincter. Reconstruction and repair of the torn wall will restore the normal shape and station of the bladder neck and urethra.

In some patients suffering from SUI, the urodynamic studies show high urethral closure pressure at rest (14-24). This is seen in cases where there is just splitting of the compact collagenous tissue cylinder, without any observable defective rupture in this compact layer, leaving the internal sphincter with high wall tension at rest. However, on stress the split weak wall yields leading to leakage of urine. This defect can be better assessed by 3DUS studies.

We evaluated our patients pre, and post operative by clinical assessment, by urodynamic studies, and by transvaginal 3DUS for up to 12 months.

There are highly significant differences in the symptoms, signs, urodynamic, and 3DUS parameters.

The immediate results are encouraging, and in the follow up period, further improvement occurred. This can be explained by later healing of the collagenous tissue cylinder in some patients. The healing of the repaired wall of the internal sphincter and anterior vaginal wall is affected by many factors, e.g. by the patient age, the tissues state, its vascular supply, any infection, and the trophic effects of estrogen.

Senility and hormone deficiency weakens the collagenous tissue, and this may explain the failure in some patients. In a trial to improve the results, we tried local application of estrogen but we are, still analyzing the results. Theoretically, local estrogen application will promote pelvic tissue healing, as pelvic tissues are hormone dependant, with minimal systemic effects. The dose and the duration of application have to be determined.

Also, it might be worth trying to put longitudinally a tape or a mesh of synthetic material, e.g. Dacron, Teflon or Proline, instead of the vaginal double-flapping, especially in cases of atrophic vaginal wall.

“Urethro-vaginoplasty” is a novel, simple effective vaginal operation where we mend and repair the internal urethral sphincter and add strength and good support by double-flapped anterior vaginal wall. This in addition, will correct anterior vaginal wall laxity, and descent, if present. Thus, the sphincter restores its integrity, toughness and strength. This allows the internal sphincter to perform its physiological function in keeping urinary continence, and a narrow, tough unprolapsed vagina ensues.

Figure 1: Three-dimension trans-vaginal ultra-sound picture, by integrated 3D- 4D unit, of a patient suffering from severe degree of mixed type of urinary incontinence. The internal urethral sphincter is torn, showing funneling, and flask-shape appearance.

Figure 2: 3-D US, trans-vaginal pictures of patients with severe SUI, (A) showing the internal urethral sphincter is torn along the whole length, with wide, irregular and collapsed urethra, while (B) showing the main trauma is affecting, more the lower part of the internal urethral sphincter, giving it a flask-shaped; done by integrated 3-D - 4-D unit.

Figure 3: Trans-perineal three-dimension ultra-sound picture, by integrated 3D- 4D unit, of a patient suffering from severe mixed UI, and vaginal wall descent.

Figure 4: Trans-perineal 3-D ultra-sonic picture, by integrated 3-D- 4-D unit, showing descent of both anterior and posterior vaginal walls.

Figure 5: MRI pictures, sagittal section, of a normal tough, strong and unprolapsed vagina, in comparison with torn, lax, descending anterior vaginal wall and torn internal urethral sphincter.

Figure 6: MRI picture, coronal section, showing the rupture that affects the vagina is more manifest on the transverse axis.

Figure 7: MRI pictures of cross sections in the pelvis showing the effects of injury on the transverse axis of the vagina and the internal urethral sphincter, the stages of stretching, attenuation and laxity of the vagina changing its cross section from H-shape in (A) into transverse slit in (B) and to more stretching and relaxation with injury to the collagen sheet (C), to more injury and damage to both the internal urethral sphincter, and the vaginal walls with more stretching, attenuation and descent of the vaginal walls as seen in (D).

Figure 8: MRI pictures of normal vagina, and internal urethral sphincter, on the left, they are both intact. On the right, the vaginal wall are torn, more in the central midpart than the periphery, the intimately overlying internal urethral sphincter is torn as well.

Figure 9: The rupture in the internal urethral sphincter is seen.

Figure 10: Urethro-raphy is done by finely mending the torn wall of the internal urethral sphincter.

Figure 11: Urethro-raphy is done by finely mending the torn wall of the internal urethral sphincter.

Figure 12: Repairing anterior vaginal wall descent, and adding extra strength and support to the mended internal urethral sphincter is done. This is accomplished by bringing the right vaginal flap beneath the left vaginal flap. This is done by several consecutive longitudinal mattress sutures, as seen in (A); far-near-near-far, then fixing the free edge of the left vaginal flap as seen in (C) by several interrupted sutures to the far lateral intact right surface of the vagina, as seen in (D).

Figure 13: Histo-pathological section stained by Masson’s trichrome, which stains collagen greenish-blue, of a normal vagina, it shows compact collagen bundles, with no lacerations.

Figure 14: Histo-pathological section stained by Masson’s trichrome, of a weak, lax vagina; it shows loose collagen bundles, with lacerations.

Figure 15: Histo-pathological section stained by Masson’s trichrome; comparison of a normal strong vagina with strong compact collagen, weak, lax vagina; it shows loose collagen bundles, with lacerations.

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