Reconstruction of neourethra and vagina, and repair of vagino-rectal fistula using minor labial skin and gracilis muscle flap

Injuries to the female urethra, vagina and rectum, especially in the childhood, are rarely encountered in pelvic trauma. This video shows a case of successfully managed complicated annular urethrovaginal stricture and urethro-vagino-rectal fistula. A 15 year old girl who sustained a car accident 7 years previousely has been suffering from persistent urinary incontinence, perineal wetting, voiding difficulty and fecaluria due to annular stricture of distal urethra and vagina associated with urethro-vagino-rectal fistula Physical examinaton, excretory urogram and endovision cystourethroscopy reveal fusion of symphysis pubis, defect in distal urethra and vaginal introitus and also show an annular scar and urethro-vagino-rectal fistula. The two-stage-surgery was contemplated. The first stage is for "The transpubectomy reconstruction of distal urethra and vagina and repair of vagina-rectal fistula using minor labial skin and gracilis muscle flap". Temporary sigmoid loop colostomy is also performed. The second stage is for the closure cf colostomy afterward The patient is placed in dorsal lithotomy position in the first stage. For the dissection of the annular urethrovaginal stricture and vaginorectal fistula, an inverted V shaped incision connecting both ischial tuberosities and scarred annular stricture site is made. Through both upper and lower pubic approaches, the segment of pubic bone is removed and enough operating space for the neourethra and distal vaginal introitus is secured. The clearly visualized fistula opening is closed. A 3×5 cm sized minor labial skin flap is fashioned and tubularized to reconstruct the distal urethra. The preserved proximal stump of vagina is brought with the unfolded minor labial skin flap. Well vascularized gracilis muscle flap is interposed around neourethra and vagina and over the closed vaginorectal fistula. Temporary sigmoid loop colostomy is made. Postoperative urethrocystogram and endovision findings show patent neourethra. Vaginal introitus is properly patent and cosmetically good in appearance. Vaginorectal fistula is healed. On uroflowmetry, continent self voiding of bell shaped pattern with an average flow rate 23.7 ml/sec was recorded. In conclusion, the above outlined surgical procedure provided a reliable technique for the complicated urethro-vagino-rectal trauma repair in a female child.