Female urethral stricture (FUS) accounts for 4-13% of all cases of bladder outlet obstruction in women. Urethral dilation typically has a low success rate whereas dorsal onlay urethroplasty with buccal mucosal graft (BMG) often succeeds in 86-94%, with no reported cases of de novo stress incontinence. However, anatomical-based surgical principles are still lacking to make this technique more widespread amongst urologists. Our aim is to show a detailed anatomically based video of a step by step technique so that it may be widely reproduced.

A 53-year-old woman who underwent hysterectomy in 2006 was unable to be catheterized intraoperatively. Several urethral dilations were subsequently performed between 2007 and 2010 because of recurrent straining to void and severe voiding symptoms. Eventually, placement of a suprapubic catheter (SPC) was required. Imaging demonstrated bilateral hydronephrosis with a thickened detrusor while a distal-and-mid FUS and a bladder diverticulum were found on antegrade cystoscopy and cystourethrogram.

As shown in the video, the meatus was healthy. A dorsal inverted U-shaped incision was performed between the clitoris and the meatus. Perineal membrane and deeper layers were dissected with scissors and scalpel. Dorsal urethrotomy was performed at 12’-o-clock until a 30 Fr bougie-a-boule was able to pass easily. The stricture was 4 cm long. A unilateral BMG was harvested in the standard fashion. The graft was sutured with 3 interrupted 5-0 PDS at the proximal apex of the urethrotomy. Afterwards, 5-0 PDS running sutures were placed on each side, including lateral urethropelvic ligament. The graft was also quilted with interrupted sutures dorsally. The U-shaped incision was then closed with interrupted 4-0 polyglactin. A 16 Fr urethral catheter was placed for 14 days. Blood loss was <100 ml. Complete stress continence was preserved. Follow-up at 10 and 21 months after surgery showed uroflowmetry with Qmax of 26 and 19 ml/sec respectively and she only referred nocturnal urge-incontinence responding to oxibutinin BID. Figures show multiple lateral and ventral supporting structures which are always spared in this technique.

The dorsal approach with buccal mucosa to female urethroplasty can be successful and it simultaneously preserves continence likely due to preservation of the ventrolateral urethral support, as per the “hammock principle”.

Gomez RG, Segura FJ, Saavedra A, Campos R. Female urethral reconstruction: dorsal buccal mucosa graft onlay. World J Urol. 2019. DOI: 10.1007/s00345-019-02958-6