Female urethroplasty: contemporary thinking

Comparison Of Ventral Inlay and Dorsal Onlay Urethroplasty For Female Urethral Stricture

OBJECTIVE

To compare the outcomes of Ventral inlay buccal mucosal graft urethroplasty (VIBMGU) with dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) for the treatment of Female urethral stricture (FUS).

MATERIAL AND METHODS

This study included women who underwent either VIBMGU or DOBMGU between January 2016 and June 2023. The preoperative AUA symptom scores, maximal urinary flow rate (Qmax), post-void residual volume (PVR) on ultrasonography, and length and location of the stricture were obtained from a prospectively maintained electronic database. The data obtained from the patient's last visit was compared with the preoperative values for this study. The primary outcome was the success rate. The secondary outcomes were changes in AUA score, PVR, and Qmax. The patient's last follow-up visit was considered for the duration of the follow-up.

RESULTS

Seventy-three patients were treated for BMGU for FUS. Forty-six patients underwent VIBMGU, and 27 patients underwent DOBMGU. The median duration of follow-up was 27.5 11.00-55.00) versus 14 (7.00-17.00) months respectively. The success rates of VIBMGU and DOBMGU were 89.13% and 88.89% respectively. There was a reduction in AUA scores and PVR and an improvement in Qmax postoperatively in both groups. The difference in the reduction in AUA scores between the VIBMGU and DOBMGU groups was statistically significant. The difference was not statistically significant in terms of reduction in PVR and improvement in Qmax between the two groups.

CONCLUSION

The ventral inlay technique can provide equal results to the dorsal technique with the added advantage of vaginal sparing. This is the single largest series in the literature on female urethral stricture with the largest follow-up period of 90 months.

Female ventral-onlay buccal mucosal graft urethroplasty supported with martius labial fat pad flap: early results

PURPOSE

There is a growing interest in reconstructive urology and female urethroplasty. We aimed to report our experience in ventral-onlay buccal mucosa graft (BMG) urethroplasty supported with Martius flap (MF) in treating female urethral stricture disease.

METHODS

We retrospectively evaluated data of 18 female patients (ages 35-78) who were diagnosed with urethral stricture disease and underwent ventral-onlay BMG urethroplasty supported with MF by single surgeon in a tertiary referral centre between February 2019 and October 2022. Detailed history, international prostate symptom score (IPSS), pelvic examination, urine flow rate (rate and pattern), post void residual (PVR), storage and voiding phase urodynamic study, and voiding cystourethrography were recorded. At the last visit; the number of urethral dilatations before urethroplasty, time from urethral dilation to urethroplasty, hospital stay, urethral catheterization time, postoperative IPSS, PVR and uroflowmetry values were recorded.

RESULTS

The presenting symptoms were obstructive voiding symptoms in 16 patients. While the mean number of urethral dilatation was 2.11 ± 1.93 (1-7), the mean time from dilatation to urethroplasty was 5.83 ± 5.00 (1-19 months) months. Maximum flow rate increased from 8.36 ± 3.26 ml/sec in preoperative uroflowmetry to 21.45 ± 5.27 ml/sec at the last follow-up (p < 0.001). Post-void residual urine (PVR) decreased from preoperative mean 116.66 ± 105.88 cc to 26.94 ± 22.69 cc postoperatively (p < 0.004). None of the patients developed stricture recurrence, incontinence or vaginal fistula until the last follow-up. The mean follow-up period was 17.28 ± 11.65 (1-35) months.

CONCLUSIONS

A ventral-onlay BMG urethroplasty supported with MF represents an effective and reproducible treatment option for FUS in the present study.

Surgery for female urethral stricture

BACKGROUND

Female urethral stricture (FUS) is a rare entity that causes great morbidity and suffering in those affected. As the available scientific data is sparce, there are no formal guidelines or standard of care for this disease.

METHODS

This is a narrative review of the surgical management for female urethral stricture. The literature review was performed on PubMed. Articles were limited to English, but there was no limitation in terms of date.

RESULTS

Management of FUS is divided between endoscopic and open surgical repair. Urethral dilation with or without urethrectomy can be offered as a first-line treatment. However, the rate of success of this procedure remains inferior to open surgical repair, and its efficacy decreases with the number of previous dilations. For distal urethral strictures, distal urethrectomy and advancement meatoplasty may be considered. Vaginal flaps are readily available, easy to harvest, well-vascularized, and allow for a dorsal or ventral orientation urethroplasty. The results of this procedure are promising, but most studies are small and retrospective. Labia flaps are easily accessible, wet, hairless, and elastic. The main limitations with the use of vaginal or labial tissues are co-existing conditions such as lichen sclerosis or vaginal atrophy, which may affect future results. Vaginal and labial graft urethroplasty can be used when it is not possible to mobilize an adequate flap. Stricture-free rates of this technique are variable. In cases of more severe stricture, an augmentation urethroplasty using buccal mucosa graft may be necessary. The techniques used in FUS replicate those for male urethral strictures, where both ventral and dorsal approaches can be utilized.

CONCLUSIONS

Although there is growing interest in the field, the optimal management of FUS remains to be determined.

Trends in Male and Female Urethral Endoscopic Management and Urethroplasty Using the TriNetX Database

BACKGROUND

How quickly providers adapt to new practice guidelines is not well known. The objective of this study was to evaluate temporal trends in the performance of urethral endoscopic management and urethroplasty surrounding the release of the American Urological Association (AUA) Male Urethral Stricture Guidelines in 2017. We also evaluate in parallel trends in female urethral stricture disease, where AUA guidelines are not present. We hypothesized that the ratio of urethroplasty versus urethral endoscopic management in both males and females is increasing and that guidelines do not result in immediate changes in management trends.

METHODS

Endoscopic management and urethroplasty data were collected from the TriNetX database on adult males and females five years before (starting 1 January 2012) and after (ending 31 December 2022) the 2017 AUA guidelines. Cohorts were built using Current Procedural Terminology (CPT) codes and grouped into urethral endoscopic management (Males: CPT 52275, 52281, 52282, 53600, 53601, 53620, 53621; Females: CPT 52270, 53660, 53661, 53665) or urethroplasty (Males: CPT 53000, 53010, 53400, 53410, 53415, 53420, 53450, 53460; Females: CPT 53430). Data on patient age, race, and geographic distribution were also collected.

RESULTS

In total, 27,623 (Males: 25,039; Females: 2584) endoscopic managements and 11,771 (Males: 11,105; Females: 666) urethroplasties were reviewed across 51 Health Care Organizations. The mean age of endoscopic management and urethroplasty patients was 67.1 and 55.7, respectively (p < 0.01). The urethroplasty-to-endoscopic management ratio decreased for males between 2012 and 2013 and then steadily increased until 2017. The ratio steadily increased for females from 2012 to 2017. The urethroplasty-to-endoscopic management ratio showed a slight decline from 2017 to 2020 across both males and females before rising again through 2022 to a study high (Males: 0.62; Females: 0.63). Regional differences were identified, with the West having the highest urethroplasty-to-endoscopic management ratios for both males and females, the Northeast having the lowest urethroplasty-to-endoscopic management ratio for males, and the Midwest having the lowest ratio for females.

CONCLUSIONS

The utilization of urethroplasty for males and females is increasing. An immediate benefit on post-guideline urethroplasty rates was not observed, and the utilization of female urethroplasty increased despite the absence of AUA guidelines. These illustrate that the impact of guideline dissemination takes time and supports the need for continued provider outreach and education on urethral stricture disease and management.

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.

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.

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.

Does successful urethral calibration rule out significant female urethral stenosis? confronting the confounder- an outcome analysis of successfully treated female urethral strictures

Objective:

The diagnosis and treatment of female urethral stricture disease (FUSD) are practiced variably due to the scarcity of data on evaluation, variable definitions, and lack of long-term surgical outcomes. FUSD is difficult to rule out solely on the basis of a successful calibration with 14F catheter. In this study, we have tried to characterize the variable clinical presentation of FUSD, the diagnostic utility of calibration, videourodynamic study(VUDS), and urethroscopy in planning surgical management.

Materials and Methods:

A retrospective review of records of 16 patients who underwent surgical management of FUSD was analyzed. The clinical history, examination findings, and the results of all the investigations (including uroflowmetry, VUDS findings, urethroscopy) they underwent, the procedures they had undergone, and the follow-up data were studied.

Results:

A total of 16 patients underwent surgical management of FUSD. 13 out of 16 patients had successful calibration with 14F catheter on the initial presentation. These 13 patients on VUDS demonstrated significant BOO and had variable stigmata of stricture on urethroscopy. The mean IPSS, flow rate, and PVR at presentation and after urethroplasty were 23.88±4.95, 7.72±4.25mL/s, 117.06±74.46mL and 3.50±3.44, 22.34±4.80mL/s, and 12.50±8.50mL, respectively. (p <0.05). The mean flow rate after endo dilation(17F) (n=12) was 11.4±2.5mL/s while after urethroplasty improved to 20.30±4.19mL/s and was statistically significant(p <0.05).

Conclusions:

An adept correlation between clinical assessment, urethroscopy findings, and VUDS is key in objectively identifying FUSD and planning surgical management. A good caliber of the urethra is not sufficient enough to rule out a significant obstruction due to FUSD. Early urethroplasty provides significantly better outcomes in patients who have failed dilation as a treatment.

Novel operative technique of advancement urethral meatoplasty utilizing buccal mucosa for Vulvar Paget's disease with urethral invasion: two case reports

BACKGROUND

Vulvar Paget's disease (VPD) is a rare malignant disorder originating in the external genitalia. It occasionally invades into urethral or vaginal mucosa of female, making surgical treatment more complicating. In case of urethral invasion of Paget's cells, systematic mapping biopsy of urethral mucosa is the standard of care to determine the range of surgical resection. Resection of urethral mucosa and simple skin grafting often result in urethral stricture after surgery, which severely deteriorates patient's quality of life.

CASE PRESENTATION

We applied a new technique of advancement urethral meatoplasty using buccal mucosa, in two Japanese cases of VPD with urethral invasion. After broad resection of vulvar skin together with the urethral mucosa, buccal mucosa was implanted between advanced urethral mucosa and skin graft. In both cases, we could prevent urethral stricture one year and two years after surgery, respectively.

CONCLUSION

This technique prevented urethral stricture after surgery and could be a useful technique as part of urethroplasty for VPD.

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.

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.

Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft

Introduction:

Both dorsal and ventral approaches are acceptable options for the surgical reconstruction of female urethral strictures (FUS), but damage to the sphincter and the clitoral nerves resulting in sexual dysfunction is the chief argument against the dorsal approach. Most of the reported case series are retrospective and none has evaluated sexual functions. This study prospectively evaluates the early sexual and functional results after dorsal onlay vaginal graft urethroplasty (DVGU) for FUS.

Materials and Methods:

All women with a history of obstructive voiding symptoms and previous urethral dilatation were evaluated with urodynamic study, voiding cystourethrography, and cystoscopy for the presence of FUS, which was defined as visual demonstration of anatomical narrowing on urethro-cystoscopy. DVGU was offered as a definitive management for all those identified with FUS. Surgical outcomes were assessed at 3 and 6 months with the International Prostate Symptom Score (IPSS), uroflowmetry, and postvoid residual (PVR) estimation. For sexually active females, sexual function was assessed using the Female Sexual Function Inventory (FSFI) score both preoperatively and at 3 months following surgery.

Results:

Seventy-one women were evaluated. FUS was identified in 29 women (flimsy in 12 and dense in 17). Thirteen women with dense strictures underwent DVGU. The mean improvement in the IPSS score, Q_max, and PVR was 12.6, 16.64 ml/s, and 103.08 ml at 3 months, respectively. The FSFI score improved with a mean of 6.42 points after urethroplasty. None of the patients developed incontinence. There were three failures after a mean follow-up of 8.5 months.

Conclusion:

The early functional results after DVGU are good without any negative impact on the continence or the sexual functions.