Introduction: Bladder outlet obstruction (BOO) is an uncommon entity in women; it occurs in only 2.7 – 8% of women referred for voiding symptoms. Of these, the subgroup of female urethral stricture (FUS) is even rarer, covering only 4-13% of female BOO [1]. Due to agreed-upon criteria for diagnosing FUS, urologists often use different criteria such as symptoms, uroflow rate, cystoscopy, radiography and sometimes urodynamic parameters [2,3]. Repeated urethral dilatation for FUS has largely been replaced with different female urethroplasty techniques with different grafts [4,5]. Both dorsal Onlay urethroplasty and ventral inlay techniques are acceptable for FUS repair. Here, we aim to analyse the outcome of dorsal Onlay vaginal graft urethroplasty (Do-VGU) and Ventral Inlay buccal mucosal graft Graft urethroplasty (Vi-BMGU).

A retrospective chart review of prospectively maintained data was performed on 24 women who underwent Do-VGU in one institute (A) by a single surgeon from January 2015 to October 2017. Patients were selected based on history, physical examination, uroflowmetry, urethral calibration, urethroscopy, and voiding cystourethrography. We compared the pre-and postoperative values of variables such as the peak flow (Qmax), post-void residual (PVR), and self-reporting satisfaction score.

Subsequently, in a second Institute (B), a similar retrospective analysis of prospectively maintained data was performed on 21 patients who underwent Vi-BMGU between May 2016 and January 2020 with a minimum follow-up of 2 years. The primary outcome was the long-term success after 2 to 5 years of surgery. Patients were followed with the American Urological Association (AUA) symptom score, uroflowmetry, and post-void residual (PVR) urine measurement. Failure (recurrence) was defined by an increase in the AUA symptoms score by 3 on subsequent follow-up visits, maximum flow rate (Qmax) <12 cc/s, and inability to calibrate with an 18 Fr catheter.

Forty-five patients with FUS were included in this study that include 24 patients in institute A and 21, in group B. In institute A, the patients’ mean (range) age was 46.54 (38–55) years. The mean PVR was 6.35 ml/s and 148.12 ml/s, respectively. The mean Qmax before and after surgery was 6.35–25.12 ml/s, respectively (p < 0.05). The mean PVR decreased from 148.12 ml (preoperative) to 41.67 ml (postoperative) (p < 0.05). Before and after surgery, the mean calibration size was 12.76 F and 24.50 F, respectively (p < 0.05).  Three women (12.5%) had stricture recurrence. Two of them stabilised with initial soft dilatation, and the third woman required continued self-catheterisation. Overall, the success rate was 87.5%, with a mean (range) follow-up of 22.62 (12–36) months.

In Institute B, twenty-one patients were included. The Median follow-up was 42 months (range: 24-64
months). The AUA symptom scores, Qmax, and PVR improved in all except 3 patients. The median AUA score fell from 27 (range 18-34) at diagnosis to 9 (range 6-24) at the last follow-up. Similarly, the median PVR values decreased from 138 ml (34-290) to 24 ml (19-360) and the mean Qmax improved from 7.7 § 2.2 ml/s to 22.6 § 5 ml/s. None experienced urinary incontinence. There were 2 failures, 1 at 6 months and the other at 24 months. The overall success rate was 90.5 %. Success rates on life table analysis were 95%, 85%, 85%, 85%, and 85% after 1, 2, 3, 4 and 5 years, respectively.

The outcome of both dorsal and ventral female urethroplasty is comparable, with a reasonable success rate. The dorsal technique with vaginal graft is simple and practical and avoids general anaesthesia without the risk of a fistula formation. Both can be considered as a first-line option for definitive repair.

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