Dorsal buccal graft urethroplasty in female urethral stricture disease: a multi-center experience

Female Urethroplasty with a Buccal Mucosa Graft using a Supraurethral Approach

INTRODUCTION AND HYPOTHESIS

In the setting of recurrent female urethral stricture, urethroplasty offer the best chance of cure. However, which approach (dorsal or ventral) and which tissue (buccal mucosa, vaginal graft, vaginal flap) remain areas of controversy. In this article and accompanying video, we describe female urethroplasty with a supraurethral approach using a buccal mucosa graft.

METHODS

A stricture of 3 cm in length was observed in the mid urethra. A supraurethral semi-lunar incision was made and dissection was performed up to the stricture. A dorsal urethrotomy was performed and a 3 × 2 cm oral mucosal graft was harvested from the left cheek. The mucosal graft was anastomosed to both urethral edges with running sutures. The graft was fixed to the supraurethral tissue with quilting sutures. A urethral catheter and a suprapubic catheter were left in place for 3 weeks.

RESULTS

Following removal of the catheters, the patient was able to void satisfactorily with no incontinence. No complications were observed in the urethral area or at the graft harvest site.

CONCLUSIONS

Buccal mucosa graft urethroplasty with a supraurethral approach is a reliable method in the treatment of female urethral stricture.

Female urethroplasty with dorsal onlay buccal mucosal graft: a single institution experience

PURPOSE

Female urethral stricture disease is frequently unrecognized or misdiagnosed, with controversy in the literature regarding the definition of strictures and approach to management. The purpose of this study is to report our institutional experience with female urethroplasty and add our experience to the growing body of research.

METHODS

We performed a retrospective review of patients undergoing female urethroplasty with dorsal onlay BMG at the University of Colorado between March 2015 and December 2021 performed by two surgeons (BF and JO). The primary outcome measure was surgical success, defined as no stricture recurrence. The secondary outcome measure was the incidence of de novo urinary incontinence.

RESULTS

23 patients were included in our data analysis. The median duration of lower urinary tract symptoms prior to urethroplasty was 16 years. 87% had undergone previous dilations. At a median follow-up of 12.2 months (range 1-81 months), four patients required a secondary procedure for obstruction with an overall success rate of 83%. One patient developed de novo stress urinary incontinence and one patient developed urge urinary incontinence. Subgroup analysis was performed comparing the patients that developed stricture recurrence (N = 4) to those that did not (N = 19). Those with stricture recurrence had a longer duration of symptoms and more dilations prior to urethroplasty.

CONCLUSION

Female urethroplasty with BMG is effective at treating female urethral stricture disease, with excellent outcomes at over a year of follow-up and minimal risk of stress incontinence postoperatively.

Female anterior wall onlay urethroplasty with lower lip buccal mucosal graft: Importance of the laterally extended incision

Objective

To describe the outcome of female anterior wall (pubic side) onlay urethroplasty with buccal mucosal graft using laterally extended surgical dissection in patients with previously failed minimally invasive techniques.

Methods

From January 2016 to April 2018, 17 symptomatic patients with previously failed minimally invasive procedures were enrolled in the study. The diagnosis of urethral stricture was confirmed based on a combination of patients' symptoms, post-void residual urine, video-urodynamics, and cystoscopy. Urethroplasty with lower lip mucosal graft was performed using the modified laterally extended dissection. Patients were evaluated pre-operatively and 12-month post-operatively with the American Urological Association symptom score, post-void residual urine, and maximum flow rate.

Results

Despite the previously failed minimally invasive procedures, urethroplasty with lower lip buccal graft and laterally extended dissection resulted in favorable outcomes (success rate=94%). The mean±standard deviation of American urological association symptom score improved from pre-operative levels at the 12-month post-operative follow-up (25.82±3.97 to 10.88±5.57); so did postvoid residual urine (71.12±74.98 mL to 15.00±28.30 mL), and maximum flow rate (7.88±1.72 mL/s to 25.82±5.59 mL/s) with all statistically significant (p<0.05).

Conclusion

The current study showed that female urethroplasty with buccal graft could be highly successful in experienced hands. An anterior approach could be superior to the posterior one due to higher mechanical support and lower sacculation rate. A laterally extended incision may improve visualization and better graft placement by providing wider working space. The results should be evaluated in the future studies with larger sample size.

Dorsal oral mucosa graft urethroplasty for female urethral stricture reconstruction: A narrative review

Female urethral stricture is currently a challenging situation. In general, urethra dilatation can be selected for treatment, but the complications and high recurrence rate urge doctors to consider other treatments. Recently, dorsal oral mucosa graft urethroplasty is concerned by more and more surgeons, but there are not enough reports so far. A comprehensive search of dorsal oral mucosa graft urethroplasty was performed. According to the existing literature, there are applications of buccal mucosa and lingual mucosa, and compared with other kinds of grafts, the success rate is higher. However, there is a lack of multicenter, large sample and long follow-up studies. And there is still no enough comparative study between different types of oral mucosa. In summary, dorsal oral mucosa graft urethroplasty is an effective option for the management of female urethral stricture. More multicenter and large sample studies with long-term follow-up data are needed.

An Update on Female Urethral Stricture Disease

PURPOSE OF REVIEW

To provide an overview of female urethral stricture disease and updates on surgical outcomes.

RECENT FINDINGS

In a large retrospective case series, women reported significant improvements in urinary symptoms and quality of life following treatment of their urethral stricture. Both vaginal flap and buccal mucosal graft urethroplasty have higher short- and long-term success rates than urethral dilation. Female urethral stricture disease is rare and surgical reconstruction has the highest likelihood of long-term success. Due to the complexity of reconstruction, referral to a reconstructive trained urologist should be considered.

Histologic Analysis of Urethral Stricture in 9 Patients Following Dorsal Vaginal Graft Urethroplasty

OBJECTIVE

To present the pathologic analysis of female urethral strictures obtained during reconstructive urethroplasty.

METHODS

Nine separate female urethral tissue specimens were obtained during dorsal vaginal graft urethroplasty by a single surgeon (S.P.P.). Samples were serially sectioned and fixed in 10% formalin 6 to 12 hours before routine processing in paraffin blocks. Serial 5-µm sections were subjected to H&E, Masson trichrome, and elastin staining. End point analysis included evaluation for epithelial hyperplasia and cell type, mucosal edema, degree of fibroblast/inflammatory cell infiltrate, and elastin fiber density and distribution.

RESULTS

Nine specimens were examined. Six specimens had epithelial linings of stratified squamous epithelium overlying fibrosis (67%), 1 had mixed squamous and urothelial epithelium, and 2 had only urothelial epithelium. Two specimens (29%) showed acute injury with prominent squamous papillary hyperplasia, focal erosion, and patchy mucosal hemorrhage. Areas of urethral stricture were variably thickened, with increased, densely packed collagen fibers and associated mucosal lymphocytic inflammation ranging from mild and patchy to focally dense with lymphoid aggregates. The highest elastin fiber density appeared to be associated with vessels and overlying muscle bundles in the submucosa.

CONCLUSIONS

Further elucidation of histopathologic characteristics may illuminate more appropriate therapeutic pathways for female urethral stricture disease management.

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females.

EVIDENCE ACQUISITION

The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.

Quality of life is improved after urethroplasty in women with urethral stricture

INTRODUCTION AND HYPOTHESIS

To evaluate the quality of life (QoL) in women who underwent urethroplasty for urethral stricture.

METHODS

Twenty-two women who underwent ventral labium minus graft urethroplasty were included. Patients were assessed with uroflowmetry, urethral caliber and post-voiding residual urine (PVR). American Urological Association (AUA) symptom score, Urogenital Distress Inventory (UDI)-6 and Short Form-36 (SF-36) were used to evaluate QoL. Preoperative values were compared with patients' last visit data. The cure of the surgery was defined as a maximum flow rate > 15 ml/s in uroflowmetry and no need for any further intervention.

RESULTS

Median age was 55 (40-66) years. Cure was achieved in 20 (90.3%) patients with median 37 (13-52) months follow-up duration. The median Qmax increased from 4 (0-5) ml/s to 27.5 (8-55) ml/s (p < 0.001). Median post-void residual volume (PVR) decreased from 52.5 (0-120) ml to 20(0-60) ml (p = 0.011). Both AUA symptom score [from median 30 (24-35) to 4.5 (0-20), p < 0.001] and AUA-QoL score [from median 5 (4-6) to 0(0-3), p < 0.001] decreased after surgery. Median UDI summary score at the last follow-up was 0 (0-44.4), which was 33.3 (22.2-61.05) at baseline visit. Improvement was observed in all domains except the 'Energy/Fatigue' domain of the SF-36.

CONCLUSIONS

Urethroplasty is an effective surgical method to improve patients' QoL which is impaired because of female urethral stricture.

Dorsal Onlay Oral Mucosa Graft Urethroplasty for Female Urethral Stricture

OBJECTIVE

To describe and assess the outcomes of dorsal onlay oral mucosa graft urethroplasty for female urethral stricture.

METHODS

We retrospectively reviewed the charts of all female patients who underwent dorsal onlay oral (buccal or lingual) mucosa urethroplasty for urethral stricture between 2011 and 2020 at two academic institutions. The primary endpoint was clinical success defined as any subjective improvement in LUTS self-assessed by the patients 1-3 months after catheter removal. Four surgeons performed the urethroplasties using a standardized technique: suprameatal incision, dissection and longitudinal opening of the dorsal aspect of the urethra, harvest of the oral mucosa graft, graft onlay sutured into the urethral opening.

RESULTS

Nineteen patients were included. The clinical success rate was 94.7% at 1-3 months and 90.9% at 1 year. After a median follow-up of 12 months (range 1-49) there was one recurrence (5.3%), clinical success was achieved in 17 patients (89.5%) and both the maximum urinary flow rate and post void residual were significantly improved (15.2 vs 7.4 ml/s preoperatively; P = .008 and 71.5 vs 161.1 ml preoperatively; P = .001 respectively). The de novo stress urinary incontinence rate was 15.7% at 1-3 months and 9.1% at 1 year.

CONCLUSION

Dorsal onlay oral mucosa graft urethroplasty for female urethral stricture appears feasible across multiple surgeons and is associated with a low perioperative morbidity, satisfactory functional outcomes and a low recurrence rate. Other series with larger sample size and longer follow-up are needed to confirm these findings.

Update on female urethral reconstruction

PURPOSE OF REVIEW

Female urethral stricture (FUS) is not frequent but can be the cause of significant morbidity. A somewhat overlooked condition for years, it has received significant attention in recent times. In this review, we update the current evidence surrounding FUS management.

RECENT FINDINGS

It is estimated that FUS is present in about 1% of all women having check-ups for lower urinary tract symptoms. Etiology is considered as idiopathic in half of the cases, iatrogenic in one-third, whereas infection/inflammation and trauma account for the rest. Symptoms presented are usually nonspecific and nondiagnostic. Pelvic examination, uroflowmetry, endoscopy, and urethrography are the most frequently employed diagnostic tools. Urodynamics/video-urodynamics can be used to document obstruction and to differentiate true anatomic strictures from functional disorders. Urethral dilation (UD) is the most frequent management procedure, sometimes followed by self-dilation, but recurrence is high, at over 50%. By contrast, reconstructive surgery is far more efficient, with overall curative rates of around 90%.

SUMMARY

A high index of suspicion is required to identify FUS patients. UD is advised as a first approach but after one or two failed attempts, reconstruction at a referral center should be considered.

The outcomes of three buccal mucosal graft urethroplasty techniques in women with urethral stricture disease

AIM

The purpose of this paper is to present the outcomes of three buccal mucosal graft (BMG) urethroplasty techniques in female patients with urethral strictures.

METHODS

We included all patients who had BMG urethroplasty for female urethral strictures (FUS) disease between January 2015 and June 2020. Patient age, comorbidities, stricture etiology, stricture length, the number of previous treatments, preoperative and postoperative uroflowmetry data, postvoid residual volumes, and the operation and postoperative course details were documented.

RESULTS

A total of 34 patients were included in this study. There were 8 patients in vaginal-sparing inlay BMG, 12 for ventral onlay BMG, and 14 for Aybek-Zumrutbas (AZ) technique groups. The mean age of the study population was 56.1 years. The length of urethral strictures varied between one and 4.5 cm. All patients had a previous history of endoscopic treatment or dilatations. The preoperative mean maximal flow rate (Qmax) was 6.9 ml/s. The median postoperative follow-up time was 24.6 months. Twelve months after surgery, the mean Qmax was 25 (range: 14-32) ml/s. There were no significant complications in any patients. The success rates were 83.3% for ventral onlay BMG, 87.5% for vaginal-sparing, and 100% for AZ technique.

CONCLUSIONS

All three BMG urethroplasty techniques applied in this study had a success rate of over 80% in a median follow-up of approximately 2 years. In females, urethroplasty with BMG provided high rates of cure, and the recently described two techniques (vaginal-sparing inlay BMG, and AZ technique) showed promise in FUS treatment.

Surgical interventions in female urethral strictures: a comprehensive literature review

INTRODUCTION AND HYPOTHESIS

Female urethral stricture (FUS) is an uncommon entity. Although there is no clinical consensus on the best modality of treatment, several studies have been published describing different techniques of FUS management. We carried out a literature review of the different surgical techniques used in the management of FUS and their results.

METHODS

We performed a systematic search of the PubMed and EMBASE databases and several cross-references. We grouped the data available from the studies into four general treatment categories.

RESULTS

We reported 35 studies (488 patients) with outcome measures; 53.48% of cases were presumably idiopathic in origin. A history of prior intervention was described in 91.29% of cases. As a surgical intervention, urethral dilatation (UD) had the lowest success rate of only 41.25%. In contrast, local flaps performed better (92.54% success rate) than local or oral grafts (87.30% and 89.94%, respectively). Only 9.43% of patients experienced mild to moderate post-surgery de novo incontinence; most of them recovered with pelvic floor exercises.

CONCLUSION

In practice, UD is tried first for FUS, at least once, before urethroplasty. In case of failure or short recurrence following UD, urethroplasty should not be delayed. In experienced hands, urethroplasty has a better outcome.

Treatment of Urethral Stricture Disease in Women: Nonsystematic Review of Surgical Techniques and Intraoperative Considerations

Female urethral strictures are rare, but underdiagnosed pathologies that can cause voiding dysfunction. These strictures are best managed with open reconstruction, as endoscopic treatments have high rates of failure. A flap urethroplasty can be performed with vaginal, labial or bladder tissue. Meanwhile, graft urethroplasties can utilize vaginal, labial, buccal or lingual tissue. It is important to consider the etiology and type of stricture, local vascularity, and prior attempts at repair when selecting the type of repair. Multiple different techniques have been described with theoretical advantages to each one. While some studies have reviewed a few of the reconstructive techniques to treat female urethral strictures, no single study has accounted for each individual technique. In this review, we discuss techniques captured by a number of systematic reviews and other articles. We will herein focus on reviewing and describing each unique technique of reconstruction in the setting of female urethral stricture.

[Contemporary management of urethral strictures in women]

Urethral strictures in women are rare and patients may present with varying symptoms. Hence, clinical guidelines regarding diagnostic algorithms and treatment approaches are scarce. Several small case series have presented results for several operative techniques, but patient cohorts are generally heterogeneous and relatively small, which hampers reliable comparability across institutions. The present narrative review aims to provide a contemporary overview of the literature regarding the clinical and therapeutical approach in women with urethral strictures.Iatrogenic reasons such as previous catheterization or genitourinary surgical interventions are the most common cause of female urethral strictures. In daily clinical routine, physical examination is the cornerstone for differential diagnosis and may aid in the decision to expand diagnostic workup by urethrocystoscopy, urethrography, or magnetic resonance imaging in case of suspected anatomic or morphologic cause of voiding disorder. Endoscopic approaches such as dilation or urethrotomy only provide short-term symptomatic relief and open urethroplasty is more commonly associated with durable long-term success. Regarding the surgical approach, there are comparable operative techniques at hand, using vaginal or labial flaps or oral mucosal grafts. Given the relative rarity of female urethral strictures with only small case series published, a statement regarding the superiority of one approach over the other is hardly possible. As for all rare disorders, multi-institutional, large patient series are needed to generate reliable evidence and to improve standards in the perioperative care of women with urethral strictures.

Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (FUSD); our institutional experience

INTRODUCTION AND HYPOTHESIS

Female urethral stricture is a poorly studied disease entity. To date, its management has been poorly evaluated, with small numbers and various definitions of success. Treatment options traditionally have been urethral dilatation and/or self-catheterization with success rates ranging from only 14 to 49%. However, there has been increasing use of urethroplasty due to the improved success rate (70 to 100%). In this study we assessed the outcome of dorsal buccal mucosal grafts in female urethral stricture disease.

MATERIALS AND METHODS

In our study we prospectively analyzed 25 female patients treated from 2014 to 2019 at our institute; ages ranged from 26 to 66 years. Dorsal buccal mucosal graft urethroplasty was performed in all patients. The pathology of female urethral stricture disease is unknown, and neither the pre- nor the intraoperative assessment allows determining the precise location and extent or the severity of urethral damage; therefore, we advocate extensive grafting of the entire urethra. Patients were followed every 3 months during the 1st year and then biannually with lower urinary tract symptom, uroflowmetry and post-void residual urine assessments. Stricture recurrence (failure) was defined as recurrence of symptoms, no change or reversal in Q_max and post-void residual urine values and failure of negotiation of a 17-Fr cystoscope.

RESULTS

Success rate of our surgical intervention was > 90%. We observed that the mid-urethra was the most common location of the stricture. Stricture location was confined to the distal urethra in 12%, the mid-urethra in 16%, spanned the distal mid-urethra in 16%, spanned the mid-proximal urethra in 40% and spanned the pan-urethra in 16%. Mean stricture length was 1.8 (0.7-2.1) cm. Mean pre- versus postoperative Qmax was 5 ml/s versus 23.3 ml/s and mean residual urine was 178 ml versus 18.5 ml. Two patients had stricture recurrence at 3 months post-intervention.

CONCLUSION

Dorsal buccal mucosal graft currently represents a prime choice for female urethral stricture reconstruction, keeping in view the advantages of the procedure such as easy availability of the graft and fewer donor site comorbidities. We emphasize upfront urethroplasty and extensive urethral grafting.

Female Urethral Stricture Management: The Initial Experience of an Female Pelvic Medicine and Reconstructive Surgery-Trained Urologist

OBJECTIVE

Given the rarity of female urethral strictures (the cause of <1% of female lower urinary tract symptoms), most trainees have little experience diagnosing and managing the problem as they begin practice. Presented are the female urethral stricture outcomes of an attending surgeon after the completion of a female pelvic medicine and reconstructive surgery fellowship.

METHODS

With institutional review board approval, a retrospective review of all cases of suspected female urethral stricture through the first 7 years of practice was completed.

RESULTS

Over the study period, 13 women were treated for urethral stricture. One underwent simple meatotomy, 9 underwent vaginal wall flap (Blandy) urethroplasty, and 3 underwent urethral dilation only because they were not reconstructive candidates (1 due to severe radiation damage and 2 with panurethral strictures that included the bladder neck). Women undergoing urethral dilations (n = 3) have all required subsequent dilations, whereas those undergoing reconstructive procedures have not required further intervention (all with max flow rates greater than 17 mL/s at last follow-up [median = 35 months, range = 10-70]).

CONCLUSION

Over the course of 7 years, our limited experience suggests that (a) urethral dilation is not usually successful but surgical reconstruction is, (b) preoperative urethral rest before reconstruction may reduce failure rates, (c) staging a stricture in the operating room is the best route to confirm the diagnosis, (d) de novo stress urinary incontinence seems to rarely if ever occur after female urethroplasty, and (e) postoperative follow-up with simple uroflow and postvoid residual testing suffices.

Changes in patient reported outcome measures after treatment for female urethral stricture

INTRODUCTION

There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture.

METHODS

American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed.

RESULTS

Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01).

CONCLUSION

Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Dorsal vaginal graft urethroplasty in female urethral stricture: a contemporary series

Background

Bladder outlet obstruction (BOO) is an uncommon entity in women. The incidence is only 2.7–8% of women referred for voiding symptoms. It is common to treat female urethral strictures by repeated urethral dilatations with subsequent self-intermittent catheterisation, which often leads to stricture recurrence. We aim to review the technique and outcomes of Dorsal vaginal graft Urethroplasty (DVGU) to manage urethral strictures in females.

Methods

This study is a retrospective chart review of 24 women with urethral stricture who underwent dorsal vaginal graft urethroplasty by a single surgeon. 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.

Results

Mean (range) age of the patients 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). Self-reported satisfaction score (Patient Global impression of improvement) showed that five (5) patients scored 1 (very much better), sixteen (16) patients scored 2 (much better) and three (3) patients scored 3 (a little better). Three women (12.5%) had stricture recurrence. Two of them got stabilised with initial soft dilatation, and the third women required continued self-catheterisation. Overall, the success rate was 87.5% with a mean (range) follow-up of 22.62 (12–36) months.

Conclusion

Dorsal onlay vaginal graft urethroplasty is a simple, safe and practical approach to treat female urethral stricture with a reasonable success rate. It can be considered as a first-line option for definitive repair.

Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture

OBJECTIVES

Female urethral stricture is a rare disease. Urethroplasty with different techniques using grafts or flaps are successful treatment options. The objective of this study was to present our experience with ventral onlay buccal mucosa graft urethroplasty for the treatment of female urethral stricture disease.

METHODS

Eight female patients treated with ventral onlay buccal mucosa graft urethroplasty were identified retrospectively. Patient evaluation included physical examination, uroflowmetry with postvoid residual urine measurement, videourodynamics and urethrocystoscopy. Stricture was identified by videourethrography and/or urethrocystoscopy. Urodynamic evidence of stricture was considered as a persistent low maximum flow rate of <12 mL/s combined with detrusor pressure at maximum measured flow rate of >20 cmH₂ O in the pressure flow study.

RESULTS

The mean age was 50.5 ± 4.14 years. Stricture etiology was idiopathic (62.5%) or iatrogenic (37.5%). Two patients (25%) had undergone prior urethral dilations before buccal mucosa graft urethroplasty. Mean stricture length was 1.62 ± 0.44 cm. Stricture location was as follows: four distal urethra (50%), two mid-distal (25%) and two mid-urethra (25%). The mean postoperative follow-up period was 16.37 ± 5.75 months, and the during follow-up success rate was 100%. No complication, such as incontinence or vaginal fistula, was noted, except dyspareunia developed in one patient (12.5%).

CONCLUSIONS

Ventral onlay buccal mucosa graft urethroplasty is a safe and effective treatment option for female urethral stricture. Unnecessary dilation should not be carried out and buccal mucosa graft urethroplasty in expert centers should be recommended to these patients.

Deciphering the enigma of female urethral strictures: A systematic review and meta-analysis of management modalities

OBJECTIVE

To evaluate the management methods of female urethral stricture (FUS) and analyze the outcomes of surgical treatments. A meta-analysis was done in an attempt to identify the best approach of urethroplasty and the graft-of-choice.

MATERIALS AND METHODS

A systematic search of Pubmed/Medline and Embase databases was performed according to the Preferred Reporting Items For Systematic Review And Meta-Analysis statement, for articles reporting on FUS management in the last decade. The Newcastle-Ottawa scale was used to assess the quality of 28 included non-randomized studies. The data on FUS management was summarized and pooled success rates (taken as symptom improvement and no need for further instrumentation) were compared. The secondary outcome was to establish a diagnostic modality of choice and define a "successful-outcome" of repair.

RESULTS

The outcome was separately reported for 554 women undergoing surgical intervention for FUS in the literature. The criteria defining FUS were varied. A combination of tests was used for diagnosis as none was singularly conclusive. A total of 301 patients had previous urethral instrumentations. The pooled success rate of urethral dilatation (234 women) was 49% at a mean follow-up of 32 months; flap urethroplasty (108 cases) was 92% at a mean follow-up of 42 months; buccal mucosal graft (BMG) urethroplasty (133 cases) was 89% at a mean follow-up of 19 months; vaginal graft augmentation (44 cases) was 87% at a mean follow-up of 15 months; and labial graft reconstruction (19 cases) was 89% at a mean follow-up of 18.4 months. The dorsal approach of graft augmentation met with 88% (95% confidence interval [CI] 0.79-0.95) success compared with 95% (95% CI 0.86-1) for the ventral approach.

CONCLUSION

FUS is a rare condition requiring a meticulous diagnostic workup using multiple tests. All urethroplasties have shown better pooled success rates (86%-93%) compared with dilatation (49%). BMG is equally effective as vaginal graft urethroplasty.

Treatment of urethral stricture disease in women: A multi‐institutional collaborative project from the SUFU research network

AIM

Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches.

METHODS

This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence.

RESULTS

Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence.

CONCLUSION

This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.