Female Urethral StrictureReconstruction

At first, it is important to rule out a primary or direct extension malignancy etiology for the stricture. Urethral cancers are rare, and present as a palpable urethral mass or induration and/or for smelling urethral discharge in women older than 50. In contrast to male urethral strictures, where a treatment plan and outcomes are more readily available, the female urethral stricture algorithm is not well defined. Nonmalignant causes of female stricture disease most commonly are observed after pelvic radiation for GYN malignancy (e. g., cervical) and iatrogenic (e. g., diverticulectomy or instrumentation). In general, stricture repairs can be either open or endoscopic. Because the female urethra is relatively short (roughly 4 cm), stricture excision and primary anastomosis is typically not feasible.

5.2.1. Distal Urethral Stricture

Women with stenoses or stricture of the distal urethra typically present with obstructive voiding. Such distal strictures typically occur after traumatic instrumentation of the urethra, endoscopic procedures, after radiotherapy to the pelvis of vulva, and more commonly in postmenopausal women with vulvar dystrophy or significant vaginal atrophy. Female urethral strictures are very uncommon and typically managed by recurrent urethrotomy and urethral dilation.

Meatotomy can be performed to treat distal strictures by simple incision of the meatus. In general,

Circumferential and distal urethrectomy and advancement meatoplasty works well for distal urethral strictures (a distal stricture being within 5 to 10 mm of the meatus). Interrupted absorbable sutures are first placed at four quadrants, into the more proximal, healthy urethral mucosa (proximal to the strictured segment), so that the mucosa does not retract (Fig. 27.6). A circumferential excision of the distal urethra and meatus is performed sharply and the cut edges sutured to the vaginal epithelium. A Foley catheter is typically left indwelling for 1-3 days. As an adjunct to promote healing, daily intravaginal estrogens cream placement is often helpful.

5.2.2. Mid-Urethral Strictures Endoscopic Repair

Midurethral strictures can be managed by visual internal urethrotomy. Incisions in the scar tissue are usually made at the 3- and 9-o’clock position, with an occasional additional 12-o’clock incision. After urethrotomy, a urethral catheter is typically maintained for several days to a week. Some advocate clean intermittent catheterization after urethrotomy to help prolong or “prevent” that risk of stricture recurrence. However, in general, the concept that self catheterization will help stabilize a stricture is often untrue; time until stricture recurrence is only delayed as long as the catheterization is still regularly preformed. We thus do not commonly recommend self-catheterization.

Fig. 27.6. Distal Urethral Stricture Repair. A. Four quadrant traction stitches are placed in the urethra proximal to the stricture to prevent retraction. B. Stricture is circumferentially excised and the healthy proximal urethra sutured to the vaginal epithelium. (From Rosenblum N, Nitti VW: Female urethral reconstruction. Atlas Urol Clin NA 12:213-223, 2004)

Obliterative mid-urethral strictures that are not amenable to a simple urethrotomy have been managed in a few cases with a “cut to the light” procedure. This procedure often is performed (from above and below) with simultaneous above and below cystoscopy, under direct visualization and fluoroscopic guidance. Two surgeons are typically needed, and finding the “true” lumen is often difficult or unclear. Such procedures require prolonged Foley catheter drainage to ensure urethral epitheliazation. Furthermore, post procedure, indefinite intermittent catheterization will usually be needed, otherwise the stricture will recur. Graft Urethroplasty

Buccal mucosa grafts for male urethral reconstruction have been successful and durable and thus intuitively should work well for female strictures.  Dorsal Placement The patient is placed lithotomy and a guidewire is placed across the stricture. The dorsal aspect of the distal urethra is then dissected from the surrounding tissue through a suprameatal incision and the urethral wall incised dorsally at the 12-o’clock position until normal urethral tissue and lumen size are reached. Mean incision urethral length is 2-3 cm from the meatus (15). The proximal urethra is then calibrated with a large (30-Fr) bougie. We prefer to harvest our free graft from the inner cheek. As for male urethroplasty the buccal graft needs to be defatted and thinned to facilitate ‘take” in a vascular host bed.  Ventral Placement The urethra can also be reconstructed with a ventral buccal graft. However, the main disadvantage of placing the graft ventrally is the greater risk for urethrovaginal fistula formation (16). Further argument favoring dorsal graft placement is that if an antiincontinence procedure is ultimately needed, it will be easier and more effective if the ventral aspect of the urethra is intact and the anterior vaginal wall is free from prior dissection (Fig. 27.7).

Park and Hendren (17) reported on their experience with a tubularized full thickness buccal graft (for cases where the local tissue was fibrotic and unsuitable for creating a supple new urethra). However, as a concept, tubularized grafts usually

Fig. 27.7. Buccal Graft Urethroplasty A. Schematic of a mid-urethral stricture. B. Dorsal urethral stricturotomy. C. Buccal graft sutured into the incised defect. (From Ref. [5])

Do poorly because there is often insufficient well vascularized tissue to circumferentially cover the graft. As an alternative to the ventral buccal graft, McKinney used a ventrally placed, full thickness vaginal wall graft for urethral reconstruction (18).

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