Hypothesis / aims of study
Female urethral stricture (FUS) is an uncommon condition with a significant impact on quality of life (QoL), accounting for a significant minority of recurrent infections and lower urinary tract symptoms (LUTS). The most common causes are iatrogenic injury and trauma. FUS if often addressed by intermittent self catheterization (ISC), dilation or endoscopic urethrotomy, with high failure rates due to recurrence and urethral pain. Urethroplasty is a suitable treatment option, and a number of different techniques have been proposed. We aim to describe a dorsal buccal mucosal graft urethroplasty (BMGU) in an elderly woman.
Study design, materials and methods
Non-systematic literature review of English articles published in the PubMed database using the query "female urethroplasty". All abstracts were read and 9 articles were included.
We also describe the first case of female urethroplasty performed at our Institution.
A fit 72 year old female was referred to our clinic due to FUS involving the entire urethra, supposedly after traumatic catheterization 27 years prior. The patient underwent over 100 urethral dilations since then. ISC were increasingly painful, impairing her QoL. As the patient desired a more definitive treatment, she was referred to our clinic and offered BMGU.
The patient was placed in lithotomy position, and the urethra was calibrated to 30 French (Fr), in order to accommodate a nasal speculum. Labial retraction sutures were placed.
A suprameatal inverted U-shaped incision was performed, and the urethra dissected, exposing healthy periurethral tissue. A 12 o’clock dorsal urethrotomy was completed.
A 40x10mm strip of buccal mucosa, which was adequate to cover the urethral defect, was harvested from the patient’s left cheek, and the defect closed with a running suture.
A dorsal onlay technique was used to suture the graft from the bladder neck to the urethral meatus – the proximal sutures were parachuted into position, using offset needle drivers. Continuous 4-0 monocryl sutures bridged the urethotomy edges, and interrupted sutures were placed in the meatal border. Tissues were closed and an 18Fr urethral Foley catheter inserted.
Operative time was 98 minutes, and estimated blood loss was 40mL. The patient was discharged home the postoperative day 2. The urethral catheter was removed 3 weeks postoperatively.
The patient was assessed monthly postoperatively. There were no perioperative complications. At 18 months of follow-up, the patient was voiding well, with neither voiding LUTS nor urinary incontinence. Free uroflowmetry showed unobstructed flow and null post void residue, significantly better than her previous studies. No further intervention has been required.
Interpretation of results
Surgical management of FUS includes several techniques and currently there are no comparative prospective studies, hampering the establishment of a therapeutic algorithm.
International retrospective case series of female BMGU are limited to small and heterogeneous sample sizes with short follow-ups. Furthermore, the definitions of FUS are not consistent.
BMGU outcomes have been reported in different studies, adding to about 200 patients, with a weighted mean success rate of over 85% at an average follow-up of 18-24 months.
Both dorsal and ventral BMGU are gaining popularity and are considered acceptable treatment options with few complications. Potential benefits of the dorsal BMGU include avoiding the complications associated with a vaginal incision. On the other hand, ventral BMGU avoids dissection of clitoral neurovascular structures and pubo-urethral ligaments, and reduces the odds of urethral sphincter injury. To date neither technique has proved superiority over the other.
The treatment of FUS remains controversial, as the reconstructive surgical management is relatively recent. However, it is recognized conservative strategies will largely fail, due to periurethral fibrosis. Recent studies show encouraging results regarding urethroplasty, but data is scarce and mostly retrospective, and no particular technique has demonstrated superiority. Therefore, a tailored approach is advised to minimize patient morbidity. BMGU can be considered a first-line treatment option in experienced centres.