Bladder outlet obstruction in women is uncommon and often misdiagnosed, since it usually presents common symptoms, such as dysuria and lower urinary tract dysfunction. In women with this type of obstruction, the incidence of urethral stricture disease varies from 4% to 13%. The causes include trauma, iatrogenic injury, infection, malignancy, and radiation(1).The failure to admit a 14Fr catheter is widely accepted as a strong indication of urethral stricture, and radiologic urethral evaluation confirms it.
The management of female urethral stricture includes urethrotomy, urethral dilation, and urethroplasty. Urethral dilation and urethrotomy are the first-line treatments, although they do not usually provide long-lasting results. In the event that one of these treatments fails, urethroplasty is considered the definitive one(2).
Urethroplasty is, however, a more complex and delicate procedure that requires training and expertise. It can use vaginal or labial flap, vaginal wall graft, or buccal mucosa graft(3). In this stepwise video, it is presented a successful urethroplasty using a buccal mucosa graft.

The patient submitted to the procedure is a female 63-year-old who reported hesitancy, low flow, and incomplete voiding. Symptoms had gotten progressively worse over the past 15 years. In the physical evaluation, it was noticed a low-mobility urethra, where catheterization was only possible with a 6Fr catheter.
The patient had had a previous urethral dilation of up to an 18Fr catheter, with recurrence of the symptoms in a few weeks. Urodynamics could not be performed due to the impossibility of catheterization, and the 3D CT voiding cystourethrography showed urethral stenosis.
For the procedure, a supra-urethral incision in an inverted "U" shape was made with a cold blade scalpel. The largest size of Hegar dilator that could be inserted without resistance was 4. A polyurethane catheter was used to guide a careful resection of the dorsal portion of the urethra. Once the stenosis was identified and dissected, it was possible to insert a number 6 Hegar dilator.
A broad incision on the dorsal urethra was made through the stenotic area until a 20Fr patency was obtained. A 16Fr silicone catheter was placed, and the proximal urethra segments were shielded by 5-0 PDS. The buccal mucosa graft was harvested and prepared. Then, the graft was placed over the opened dorsal portion of the urethra and fixed with continuous bilateral sutures of 5-0 PDS.
After completion of the sutures, pubourethral ligaments were included to restore the urethral support. Next, 2-0 polyglactin paraurethral stitches were applied to the pubocervical fascia, close to the urethra, and fixed on the inferior aspect of the pubic bone bilaterally. This maneuver brought the distal urethra to its anatomic position. Finally, a new urethral meatus was created with 3-0 polyglactin simple stitches on the mucosa and initial incision.

The patient was discharged on the first postoperative day, and the urethral catheter was removed after 14 days. She had no significant complaints related to either the urethroplasty or the oral approach. At the follow-up three months later, the postoperative uroflowmetry showed Qmax of 17ml/s without post-void residual. The patient was satisfied, with no recurrence of the symptoms or local complications.

The buccal mucosa graft urethroplasty is an efficient method to treat female urethral strictures.

Faiena I, Koprowski C, Tunuguntla H. Female Urethral Reconstruction. J Urol. 2016;195(3):557-567. doi:10.1016/j.juro.2015.07.124
Osman NI, Mangera A, Chapple CR. A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol. 2013;64(6):965-973. doi:10.1016/j.eururo.2013.07.038
Agochukwu-Mmonu N, Srirangapatanam S, Cohen A, Breyer B. Female Urethral Strictures: Review of Diagnosis, Etiology, and Management. Curr Urol Rep. 2019;20(11):74. Published 2019 Nov 8. doi:10.1007/s11934-019-0933-1