Female urethral strictures (FUS) are an uncommonly recognized condition. A FUS is often defined as a fixed narrowing of the urethra causing symptoms. The symptoms of FUS can include any number of lower urinary tract symptoms (LUTS). These cab include recurrent urinary tract infections, urethral pain, dysuria, urgency, dribbling, weak stream, retention and an elevated postvoid residual (PVR). These wide variety of symptoms can partially explain why FUS is often difficult to diagnosis.   Historically, the mainstay of treatment included urethral dilation. Different treatments have been described in the past with varied results. These included repeated dilation, reconstruction with local flaps, and grafting techniques. New evidence has shown that repeated urethral dilation has uniformly showed poor long term results. 
We present our multi institutional experience of substitution buccal graft urethroplasty for female urethral stricture disease.

This is a multi-institutional retrospective review of all female patients with FUS from January 2016 - December 2020. Institutional ethics were obtained and followed in accordance with the ethical standards of the institutional review board. There were 25 females with FUS that underwent a single stage ventral substitution buccal graft urethroplasty. The median age was 50 years (IQR 60-39). The cause of the stricture was idiopathic in 14 (56%), lichen sclerosus in 5 (20%), complex vaginal delivery 2 (8%), prior urethral surgery 2 (8%), recurrent infection 1 (4%), and pelvic fracture 1 (4%). All 25 patients, had received prior treatment for their FUS. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation.

The overall mean (range) follow up was 22 months (12-60) months. Of the 25 patients, there were no failures. The initial median urethral stricture calibre was 6F (0-10F). The stricture site was panurethral in 8, and distal in 2. The median intraoperative stricture length was 30mm (15-35mm). There were no episodes of SUI or fistula. There was 1 patient treated with a post-operative UTI. One patient was lost to follow up at 12 months.

We have demonstrated the superior efficacy and safety of substitution graft urethroplasty in female urethral stricture disease. Many females with this condition that are undergoing repeated dilatations may be a candidate for this procedure. We have shown that it can have long standing beneficial improvements and avoid repeated interventions. Complications are minimal and the procedure is well tolerated.  This technique can be used by many reconstructive surgeons for those patients who have failed endoscopic treatments and wish to have a more successful and lasting solution.

The ventral substitution graft urethroplasty technique for female urethral stricture represents a significant improvement in the treatment of female urethral stricture, whilst minimizing recurrence and complications.