Investig Clin Urol.  2016 Jul;57(4):298-302. 10.4111/icu.2016.57.4.298.

Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: A novel modification of surgical technique

• Hoag N
• Gani J
• Chee J

• KMID: 2426508
• DOI: http://doi.org/10.4111/icu.2016.57.4.298

Abstract

PURPOSE
To present a novel modification of surgical technique to treat female urethral stricture (FUS) by a vaginal-sparing ventral buccal mucosal urethroplasty. Recurrent FUS represents an uncommon, though difficult clinical scenario to manage definitively. A variety of surgical techniques have been described to date, yet a lack of consensus on the optimal procedure persists.
MATERIALS AND METHODS
We present a 51-year-old female with urethral stricture involving the entire urethra. Suspected etiology was iatrogenic from cystoscopy 17 years prior. Since then, the patient had undergone at least 25 formal urethral dilations and periods of self-dilation. In lithotomy position, the urethra was dilated to accommodate forceps, and ventral urethrotomy carried out sharply, exposing a bed of periurethral tissue. Buccal mucosa was harvested, and a ventral inlay technique facilitated by a nasal speculum, was used to place the graft from the proximal urethra/bladder neck to urethral meatus without a vaginal incision. Graft was sutured into place, and urethral Foley catheter inserted.
RESULTS
The vaginal-sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow-up. Flexible cystoscopy demonstrated patency of the repair at 6 months. At 10 months of follow-up, the patient was voiding well, with no urinary incontinence. No further interventions have been required.
CONCLUSIONS
This case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for FUS. By avoiding incision of the vaginal mucosa, benefits may include reduced: morbidity, urinary incontinence, and wound complications including urethro-vaginal fistula.

Keyword

Buccal mucosa; Female; Reconstructive surgical procedures; Urethral stricture

MeSH Terms

Cystoscopy/adverse effects
Dilatation/methods
Female
Follow-Up Studies
Humans
Middle Aged
Mouth Mucosa/*transplantation
Tissue and Organ Harvesting/methods
Urethra/*surgery
Urethral Stricture/etiology/*surgery

Figure

• 

  Fig. 1 Intraoperative photograph demonstrating dilated urethra to accommodate nasal speculum, and ventral urethrotomy carried out sharply with 11-blade scalpel.

• 

  Fig. 2 Intraoperative photograph demonstrating three apical/proximal urethral sutures, sutured to corresponding proximal end of harvested buccal mucosal graft before parachuting into position.

• 

  Fig. 3 Intraoperative photograph, with nasal speculum inserted into the urethra, demonstrating ventral placement of buccal mucosal graft, sutured into appropriate position from proximal to distal urethra.

• 

  Fig. 4 Video demonstrating vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/9s1AzELqJEE.

Reference

1. Faiena I, Koprowski C, Tunuguntla H. Female urethral reconstruction. J Urol. 2016; 195:557–567.

2. Nitti VW, Tu LM, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol. 1999; 161:1535–1540.

3. Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: definition and characteristics. Neurourol Urodyn. 2000; 19:213–220.

4. Kuo HC. Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction. Urology. 2005; 66:1005–1009.

5. Keegan KA, Nanigian DK, Stone AR. Female urethral stricture disease. Curr Urol Rep. 2008; 9:419–423.

6. Osman NI, Mangera A, Chapple CR. A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol. 2013; 64:965–973.

7. Santucci R, Chen M. Evaluation and treatment of female urethral stricture disease. Curr Bladder Dysfunct Rep. 2013; 8:123–127.

8. Blaivas JG, Santos JA, Tsui JF, Deibert CM, Rutman MP, Purohit RS, et al. Management of urethral stricture in women. J Urol. 2012; 188:1778–1782.

9. Smith AL, Ferlise VJ, Rovner ES. Female urethral strictures: successful management with long-term clean intermittent catheterization after urethral dilatation. BJU Int. 2006; 98:96–99.

10. Morey AF, McAninch JW. Technique of harvesting buccal mucosa for urethral reconstruction. J Urol. 1996; 155:1696–1697.

11. Barbagli G, Sansalone S, Romano G, Lazzeri M. Ventral onlay oral mucosal graft bulbar urethroplasty. BJU Int. 2011; 108:1218–1231.

12. Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol. 1989; 141:542–545.

13. Tanello M, Frego E, Simeone C, Cosciani Cunico S. Use of pedicle flap from the labia minora for the repair of female urethral strictures. Urol Int. 2002; 69:95–98.

14. Montorsi F, Salonia A, Centemero A, Guazzoni G, Nava L, Da Pozzo LF, et al. Vestibular flap urethroplasty for strictures of the female urethra. Impact on symptoms and flow patterns. Urol Int. 2002; 69:12–16.

15. Gormley EA. Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn. 2010; 29:Suppl 1. S42–S45.

16. Simonato A, Varca V, Esposito M, Carmignani G. Vaginal flap urethroplasty for wide female stricture disease. J Urol. 2010; 184:1381–1385.

17. Tsivian A, Sidi AA. Dorsal graft urethroplasty for female urethral stricture. J Urol. 2006; 176:611–613.

18. Singh M, Kapoor R, Kapoor D, Kapoor R, Srivastav A, Chipde S. Dorsal onlay vaginal graft urethroplasty for female urethral stricture. Indian J Urol. 2013; 29:124–128.

19. Sharma GK, Pandey A, Bansal H, Swain S, Das SK, Trivedi S, et al. Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women. BJU Int. 2010; 105:1309–1312.

20. Onol FF, Antar B, Kose O, Erdem MR, Onol şY. Techniques and results of urethroplasty for female urethral strictures: our experience with 17 patients. Urology. 2011; 77:1318–1324.

21. Berglund RK, Vasavada S, Angermeier K, Rackley R. Buccal mucosa graft urethroplasty for recurrent stricture of female urethra. Urology. 2006; 67:1069–1071.

22. Barbagli G, Montorsi F, Guazzoni G, Larcher A, Fossati N, Sansalone S, et al. Ventral oral mucosal onlay graft urethroplasty in nontraumatic bulbar urethral strictures: surgical technique and multivariable analysis of results in 214 patients. Eur Urol. 2013; 64:440–447.

23. Migliari R, Leone P, Berdondini E, De Angelis M, Barbagli G, Palminteri E. Dorsal buccal mucosa graft urethroplasty for female urethral strictures. J Urol. 2006; 176(4 Pt 1):1473–1476.

24. Haderer JM, Pannu HK, Genadry R, Hutchins GM. Controversies in female urethral anatomy and their significance for understanding urinary continence: observations and literature review. Int Urogynecol J Pelvic Floor Dysfunct. 2002; 13:236–252.

25. Barbagli G, Vallasciani S, Romano G, Fabbri F, Guazzoni G, Lazzeri M. Morbidity of oral mucosa graft harvesting from a single cheek. Eur Urol. 2010; 58:33–41.