Female Urethroplasty(For Urethral Stricture)

Female Urethroplasty(For Urethral Stricture)

Female urethral stricture is an usually underdiagnosed condition. It occurs in 2.7% to 8% of females presenting with lower urinary tract symptoms and surgical treatment is still debatable. Any strict diagnostic criteria has not been documented for female urethral stricture because of its rare incidence. However, Defreitas et al. stated that a detrusor pressure (Pdet) of 25 cm of H2O and maximum urinary flow rate (Qmax) of less than 12 ml/s is consistent with obstruction. The most common aetiology for female urethral stricture may be infection, repeated instrumentation, trauma, previous surgeries for incontinence or diverticula, radiation for pelvic malignancy, and idiopathic. As similar to the male urethral stricture disease, results of repeated urethral dilatation and internal urethrotomy are not good in females also as subsequent fibrosis occurs due to bleeding and extravasation. Surgery is often the answer in such cases in the form of meatoplasty for distal urethral strictures and grafts or flaps for mid-and proximal-urethral stricture. Several methods of female urethroplasty have been reported in various small series.

An external file that holds a picture, illustration, etc. Object name is IJU-29-124-g001.jpg

Micturating cystourethrogram showing urethral stricture with proximal dilatation (white arrow)

The procedure requires the patient to be placed in the dorsal lithotomy position. The operative field, including the vagina, is cleaned and draped with strict aseptic measures. The anus is adequately covered and sealed from the operative area. Cystoscopy is done with 6 Fr pediatric cystoscope to see the stricture area and assess its length from bladder neck. Normal saline mixed with 1% adrenaline is injected in periurethral tissues and urethra is dissected dorsally and laterally from 3 to 9’ 0 clock position by an inverted U-shaped incision [Figure 2a]. Stay sutures are taken at urethral angles to help in dissection. Sharp dissection is done with scissors. Dissection is done with care so as not to damage the bulbs and the clitoral body by staying close to the fibrous tissue of the urethra. An 18 Fr Foley is inserted upto the stricture segment and urethra is dissected proximally above the stricture in retropubic space [Figure 2b]. A full-thickness urethrotomy is then made over the stricture site at 12’ 0 clock position with a surgical blade and then extended with scissors upto proximal and distal healthy area which may extend even upto urethral meatus [Figure 2c]. Urethra is now again calibrated with an 18 Fr Foley catheter to ascertain that there is no proximal stenosis beyond the incised strictured site. Saline is injected in submucosal plane in lateral vaginal wall and full-thickness vaginal graft is harvested and defattened [Figure [Figure3a3a and andb].b]. The dimensions of the harvested graft are in accordance with the length of the stricture plus additional healthy margin. Then an 18 Fr silastic catheter is placed in urethra over which vaginal graft has to be sutured to urethrotomy site. The vaginal graft is then sutured on the dorsal surface of urethra as onlay graft with 4-0 PDS sutures in interrupted fashion [Figure 4]. First suture is taken at the apex of urethra and then onto the graft and tied. Then suturing of right and left margin of urethra is done with vaginal graft and urethra is sutured back to its normal position with 4-0 PDS suture [Figure 5]. Distally the vaginal mucosa may be tailored and split to achieve a normal meatal slit-like appearance if urethrotomy has been extended to external meatus.

An external file that holds a picture, illustration, etc. Object name is IJU-29-124-g003.jpg

(a) Line diagram showing inverted U-shaped incision over urethra (b) Development of retropubic space (blue arrow) on the dorsal aspect of urethra with stay sutures at urethral angles (white arrow) (c) Line diagram showing mid-urethral stricture, dorsal urethrotomy, and dorsal vaginal graft placement

An external file that holds a picture, illustration, etc. Object name is IJU-29-124-g004.jpg

(a) Vaginal graft harvesting shown by white arrow and urethral meatus by (blue arrow) (b) Line diagram showing vaginal graft harvesting

An external file that holds a picture, illustration, etc. Object name is IJU-29-124-g005.jpg

Vaginal graft sutured as dorsal onlay (blue arrow) over urethrotomy site

An external file that holds a picture, illustration, etc. Object name is IJU-29-124-g006.jpg

Final post operative appearance after suturing urethra back to its normal position

Mean hospital stay was 2.5 days (2-7 days). After 14 days patient is again called for voiding cystourethrography and catheter removal.

Our follow-up protocol includes every 3 monthly assessment of voiding and storage lower urinary tract symptoms, uroflowmetry, and one weekly self-calibration. Patient is followed-up for a minimum of 2 years after which she may be shifted to a less rigorous 6 monthly or an yearly follow-up.