The efficacy of construction of neourethra using a bladder anterior wall for treatment of female total urethral stricture or atresia

Abstract

Objective To explore the efficacy of constructing the neourethra using a bladder anterior wall for the treatment of female total urethral stricture or atresia. Methods We retrospectively reviewed 11 female patients with total urethral stricture or oblitalition, who were underwent a procedure of reconstructive neourethra using a bladder anterior wall, from January 2009 to November 2015. Of the 11 patients , urethral stricture was associated with vesicovaginal fistula and a severe hydrocolpos in the proximal vagina because of vaginal anterior strictures or atresia in four girls. The mean age was 16 years (ranging 5-48 years) in all patients. The etiology was posttraumatic urethral injuries after pelvic fracture in 9 patients, radical urethral resection because of urethral cancer in 1 patient and congenital bladder exstrophy with an absent urethra in 1 patient. All patients underwent a procedure of neourethral construction under general anesthesia. The bladder anterior wall, which was about 2.0 to 2.5 cm in width and 4.0~4.5cm in length, was separated from bladder neck to middle partion of the anterior bladder wall. The bladder flap was tubularized around a 12-14 French catheter using continuous 4-0 polyglycolic acid sutures for the mucosa and interrupted sutures of 3-0 polyglycolic acid for the muscle. The tubularized flap was then flipped caudally to the site of the original external urethral meatus to form a new urethra. 4 patients with severe stenosis or oblitalition of the distal vagina underwent a procedure of vaginoplasty at same time, including island vulvar flaps enlarging vaginoplasty in two girls and reconstructive vaginal orifice using the proximal enlargedvagina wall in other two girls. Results There were no serious complications postoperatively. The catheter was removed 3~4 weeks after the operation. 7 patients were completely continent with excellent voiding, 3 patients had stress incontinence. One patient experienced dysuria. And the urethroscopy in this case showed that the mucosal prolapse was present at the 12 to 3 o'clock position on the neck of the bladder, which caused urinary obstruction. Endoscopic resection of the prolapsed mucosa was performed. The patient could easily void without incontinence after the operation. The patients were followed up a median of 38 months, (ranging 6-72 months). 2 patients experienced dysuria 3 and 4 months after operation, separatively. Examination showed that the mucosal prolapse was present at the position on the neck of the bladder in one patient and urethral meatal stenosis in another patient. The two patients were separatively underwent a procedure of endoscopic resection of the prolapsed mucosa and meatal urethroplasty, using vulvar flap. All of them could easily void without incontinence after the operation. Of the 3 patients with stress urinary incontinence, one underwent a procedure of TVT-O one year later, and after which continence was achieved with good voiding; the other two cases were awaiting for reoperation. Four cases of postoperative vaginal fluid disappeared with unobstructed micturition. Conclusions Female neo-urethral reconstruction using the bladder anterior wall flap was a reliable technique for the management of complete urethral stricture or obliteration. Key words: Female; Bladder wall flap; Urethra; Reconstruction