Female Pelvic Surgery

13. Urethroplasty for Female Urethral Stricture

Chad Baxter 

(1)

Department of Urology, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA

Chad Baxter

Email: cbaxter@mednet.ucla.edu

Introduction

Female urethral stricture disease has been historically treated with urethral dilation, which has demonstrated high recurrence rates. There is growing evidence that formal urethroplasty should be pursued early in the care of female urethral stricture disease as surgery can provide durable results [1]. This chapter presents the various techniques for female urethroplasty that are presented in the recent literature.

Background

Urethral stricture disease, while sometimes idiopathic, is commonly iatrogenic. Urethral dilations, catheterization, urinary tract endoscopy, urethral surgery, and radiation are all implicated. Urethral strictures may occur as a consequence of urethral infection, urethral diverticulum, atrophy with subsequent fibrosis, primary urethral carcinomas, leiomyomas, teratomas, and trauma [28].

Female urethral stricture disease is rarely diagnosed and rarely reported in the contemporary urological literature. All causes of bladder outlet obstruction have an estimated incidence of 3–8 % of women presenting with obstructive symptoms [9].

Of these women with obstruction, even fewer have proven urethral stricture. Estimates range between 4 and 13 %. Thus the true incidence of urethral stricture appears to lie between 0.1 and 1 % [1012].

Despite the low incidence of urethral stricture disease, urethral dilation and urethrotomy have historically been employed to manage a wide variety of lower urinary tract symptoms in women [111315]. McLean and Emmett reported that the first urethral dilation took place in 1923, and, by the 1960s, series with as many as 800 patients were being reported [15]. Dilation of the female urethra has been advocated to treat recurrent urinary tract infections, bladder pain syndromes, urinary urgency, urinary frequency, overactive bladder, and interstitial cystitis symptoms [1314]. Contemporary literature has demonstrated that urethral dilation has no benefit and may be harmful for patients in the absence of demonstrable urethral stricture disease [16].

Santucci and the Urologic Diseases in America Project reported in 2008 that urethral dilation for various lower urinary tract symptoms appears ineffective, common, costly, and mostly unnecessary [16]. They note that while there were less than 40 reports of true female urethral strictures in the contemporary literature at that time, more than 1.2 million office visits for female urethral stricture occurred in the United States between 1992 and 2000 at a cost of $61 million per year. Since the first case report in 1828 [17], no more than 200 cases have been reported in the English language literature. The majority of reports describe small, single-surgeon series and lack objective preoperative or postoperative measures of success.

Given the low number of reported urethroplasties, there exists no consensus for surgical treatment and several different surgical techniques have been reported and will be reviewed here.

Evaluation

As Blaivas et al. note, the diagnosis of urethral stricture in women requires a high index of suspicion. Similar to other forms of bladder outlet obstruction such as prolapse, bladder neck dysfunction, and detrusor external sphincter dyssynergia, symptoms of urethral stricture may include urinary frequency, dysuria, weak or dribbling stream, and recurrent urinary tract infections. Cystoscopy provides the most reliable assessment, though some experts advocate urethral calibration as well. Urethral calibration may offer information of scar density through haptic feedback [1]. Periurethral fibrosis may also be measured by translabial or transvaginal ultrasound, though the efficacy of ultrasound for this purpose in women is not well defined. Detrusor pressure-flow studies allow determination of bladder outlet obstruction and may be graded according to the Blaivas–Groutz nomogram [11] and voiding cystourethrogram or cystoscopy allows one to determine the location of obstruction (Fig. 13.1).

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Fig. 13.1

Voiding cystourethrogram showing proximal urethral dilatation with distal urethra narrowing and distortion of bladder morphology from spherical to oblong (Both: Used with permission from Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: Definition and Characteristics. Neurourol Urodyn 2000, 19:213–220)

Preoperative Considerations

Female urethroplasty can be categorized by the surgical approach, nature of any needed tissue graft, and whether to perform concomitant bladder outlet procedure. The urethra is approached either dorsally or ventrally. A dorsal approach is perhaps less familiar to many urologists and care must be taken to avoid injury to the crura and body of the clitoris. A dorsal approach may also facilitate later anti-incontinence procedures, prevent sacculation of the reconstructed urethra, and minimize risk of urethrovaginal fistula or hypospadias [18]. A ventral approach, conversely, is familiar to urologists experienced in many of the transvaginal anti-incontinence procedures and allows for easier visualization of the urethra to the level of the bladder neck.

Graft tissue may be either a local rotational flap, pedicle flap, or free flap harvested from vaginal, labial, or oral mucosa. Free or pedicle flaps may minimize distortion of local tissue compared to rotational flaps, but are also associated with harvest site morbidity including paresthesia, anesthesia, and altered cosmesis.

The decision to perform a concomitant anti-incontinence procedure should be based on preoperative evidence of stress incontinence or, in the opinion of some experts, in the presence of contrast entering the urethra to the level of the stricture during fluoroscopic imaging while performing a Valsalva maneuver and cough [1]. Many experts advocate dorsal, as opposed to ventral, urethroplasty techniques to facilitate concomitant or delayed placement of ventral urethral sling [18].

Given the infrequent occurrence of urethral strictures and more infrequent reports of their repair in the literature, there is a paucity of data precluding a recommendation of one approach or graft over another.

Postoperative Care

Duration of catheterization, use of imaging, and antibiotic therapy differs among reported series of urethral reconstructions. Many surgeons advocate leaving a catheter indwelling for 2–4 weeks, obtaining a voiding cystourethrogram at time of catheter removal, and maintaining antibiotics, usually low dose Ciprofloxacin or trimethoprim-sulfamethoxazole, for the duration of catheterization.

Surgical Techniques

Ventral Incision and Anastomosis

Short strictures located primarily on the ventral aspect of the urethral lumen may be incised longitudinally with transverse closure consistent with the Heineke–Mikulicz principle. Long or circumferential dense scar may be recalcitrant to this technique:

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Excision and end-to-end anastomosis is not often used due to the risk of urethral ischemia distal to the excision. Rovner reported that this approach was useful in treating complex urethral diverticulae [19].

Vaginal Inlay Flap

Vaginal inlay flaps have been separately reported by several investigators [2021]:

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Free Labia Minora Skin Flap

The free labia minora skin flap is an alternative to the vaginal inlay flap and is well described by Rehder et al. [22]:

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Consideration should be given to placing a Martius flap harvested through either a separate vulvar incision or from the lateral aspect of the anterior vaginal wall flap incision.

Pedicle Flap from the Labia Minora

This procedure is similar to the free labial graft, except that the donor tissue is isolated on a pedicle and tunneled under the vulvovaginal wall to the site of urethral dissection (Fig. 13.4a–d). The remainder of the urethroplasty is similarly performed [23].

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Fig. 13.4

(ad) (a) Graft site is marked. (b) The graft is harvested taking care to preserve the pedical. (cd) The graft is tunneled and affixed to the urethra

Ventral Buccal Graft

Buccal grafts, widely used in male anterior urethral reconstruction, are well described for female urethral reconstruction by Bergland et al. [24]:

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Dorsal Buccal Graft [18]

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Dorsal Vestibular Flap Urethroplasty [26]

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Free Vaginal Wall In-Lay Graft [27]

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Summary

Female urethral stricture disease is an infrequently reported entity despite more than 100,000 physician office visits each year in the United States for symptoms mimicking the condition. The vast majority of female patients with obstructive voiding symptoms have a dynamic dysfunction as opposed to a fixed urethral stricture. Presumed fixed urethral obstruction has been historically managed by urethral dilation and rarely endoscopic urethrotomy. In patients with proven urethral stricture disease, minimally invasive treatments including dilation and endoscopic incision generally fail with early recurrence and the need for additional procedures or intermittent catheterization. Urethroplasty appears to be a viable option for definitive therapy. Given the low number of reported urethral strictures, small series in even the most specialized urology practices, and variety of surgical techniques, the optimal treatment is not yet known. The dorsal approach to the proximal female urethra may be associated with a greater postoperative incidence of stress urinary incontinence when compared to ventral approaches, but this remains to be proven. Anti-incontinence procedures such as urethral sling placement or suspensions are not routinely performed concomitant to urethroplasty, but again evidence for this recommendation is lacking. Local tissue flaps, when available, appear to be very effective. When local tissue is inadequate, distal grafts, e.g., buccal mucosa, appear efficacious.

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