Female Urethral Reconstruction Research Articles

(089) Regional Vestibulectomy and Buccal Mucosal Graft Reconstruction for Refractory Neuroproliferative Vestibulodynia

Abstract Introduction Buccal mucosal grafts (BGM) are widely used in male urethral reconstruction and have more recently been reported for female urethral reconstruction. We report the first case of using a buccal mucosa graft (BMG) to cover the excised 12:00 vestibule in a 19 year old woman with lifelong persistent genital arousal disorder (PGAD) presumed secondary to congenital neuro-proliferative vestibulodynia. She presented to our clinic at 17 and underwent lysis of clitoral adhesions, excision of the core 12:00 region with primary closure, and complete vestibulectomy with vaginal advancement flap. Her vestibular specimen positively stained for CD117 and PGP9.5 consistent with excess mast cells and nerves, respectively. Post-operatively, there was marked reduction of vestibular pain in the 1:00 to 11:00 region posteriorly, however she had persistent PGAD and significant residual tenderness to cotton-tipped swab testing at the 12:00 region. Her PGAD was medically managed successfully with tramadol, clonazepam and low dose zolpidem. Desiring to eliminate the need for systemic medications, the patient returned to the clinic at age 19. Again, local anesthesia applied to the clitoris and 12:00 vestibule region resulted in clinically significant PGAD symptom reduction and 12:00 vestibulodynia. We discussed repeat clitoral lysis and re-excision of the 12:00 region with BMG reconstruction. Objective To report on a novel technique using BMG for 12:00 region vestibular reconstruction in one woman with distressing vestibulodynia and PGAD. Methods Pre-operative counseling included discussion of routine surgical risks, benefits, alternatives, with additional possible complications including failure of the procedure to relieve PGAD or vestibulodynia, graft contracture, buccal harvest site contracture, sexual dysfunction, and genital disfigurement. The patient gave consent for the procedure and underwent a repeat lysis of clitoral adhesions and 12:00 regional subepithelial vestibulectomy. The defect measured 2.5 cm x 2.5 cm. A non-tubularized onlay patch of buccal mucosa was harvested and used for vestibular reconstruction. The procedures were performed by a single surgeon. The patient was discharged the same day. Results The patient’s post-operative course was notable for acute urinary retention in the recovery room. She was discharged with a foley catheter and passed a voiding trial on post-op day 1. Her pain was well-controlled with non-opioid medications and she was able to resume a soft food diet immediately after surgery. At post-op week 5, the clitoral area, buccal harvest site, and graft site were healed without complication. The patient reports that her 12:00 pain to touch has resolved. Her PGAD has decreased slightly, although she has not yet attempted to discontinue oral medications. Conclusions For this patient, regional vestibulectomy with BMG to the 12:00 region of the vestibule appears to have been a safe and feasible technique for refractory neuroproliferative vestibulodynia. Given that the vestibule is of endodermal origin derived from the urogenital sinus, and neuroproliferation may represent a congenital anomaly, there is a rationale to replace urogenital sinus endoderm with a non-urogenital sinus endoderm such as buccal mucosa. Pre-operative counseling should include surgery specific adverse events like mouth opening restriction and genital disfigurement. Longer follow up and larger studies are needed. Disclosure No

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.

Female Urethroplasty: Outcomes of Different Techniques in a Single Center.

Introduction: Female urethral strictures and injuries are relatively uncommon compared to males. A wide range of possible causes and treatment modalities have been described. Lately female urethral reconstruction is gaining attention and is fortunately no longer a neglected topic within the reconstructive urology. As such, we aimed to describe our surgical techniques and outcomes for female urethroplasty from a tertiary center. Materials and Methods: Records of female patients who underwent a urethroplasty between July 2018 and May 2021 in our tertiary referral center were reviewed. Patients were subdivided in two groups: patients who suffered from a urethral injury and received an early repair urethroplasty, and patients with a true urethral stricture who received a delayed urethroplasty. Preprocedural, surgical and postoperative data were collected and analyzed with descriptive statistics. Results: A total of five patients in group 1 and nine patients in group 2 were included. Etiology of the urethral injury in group 1 was iatrogenic in 80% and transitional cell carcinoma of the urethra in 20% of cases. A patency rate of 100% at a follow-up of 30 months was achieved with the different techniques. In group 2 etiology was idiopathic (44%), iatrogenic (44%) and due to external trauma in 12% of cases. Urethroplasty technique consisted of primary repair or dorsal onlay of a buccal mucosal graft. Patency rate was 100% at a median follow-up of 13 months. Three patients suffered from postoperative urinary incontinence, one in group 1 and two in group 2. Conclusion: Female urethroplasty is a relatively rare entity within reconstructive urethral surgery. This case series of 14 patients demonstrates that with appropriate surgical techniques, a high patency rate with a low complication rate can be achieved. Further prospective studies with standardized diagnostic workup and follow-up should be performed in order to optimize management strategy.

Update on female urethral reconstruction.

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. 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%. 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.

Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (FUSD); our institutional experience.

Female urethral stricture is a poorly studied disease entity. To date, its management has been poorly evaluated, with small numbers and various definitions of success. Treatment options traditionally have been urethral dilatation and/or self-catheterization with success rates ranging from only 14 to 49%. However, there has been increasing use of urethroplasty due to the improved success rate (70 to 100%). In this study we assessed the outcome of dorsal buccal mucosal grafts in female urethral stricture disease. In our study we prospectively analyzed 25 female patients treated from 2014 to 2019 at our institute; ages ranged from 26 to 66years. Dorsal buccal mucosal graft urethroplasty was performed in all patients. The pathology of female urethral stricture disease is unknown, and neither the pre- nor the intraoperative assessment allows determining the precise location and extent or the severity of urethral damage; therefore, we advocate extensive grafting of the entire urethra. Patients were followed every 3 months during the 1st year and then biannually with lower urinary tract symptom, uroflowmetry and post-void residual urine assessments. Stricture recurrence (failure) was defined as recurrence of symptoms, no change or reversal in Qmax and post-void residual urine values and failure of negotiation of a 17-Fr cystoscope. Success rate of our surgical intervention was > 90%. We observed that the mid-urethra was the most common location of the stricture. Stricture location was confined to the distal urethra in 12%, the mid-urethra in 16%, spanned the distal mid-urethra in 16%, spanned the mid-proximal urethra in 40% and spanned the pan-urethra in 16%. Mean stricture length was 1.8 (0.7-2.1)cm. Mean pre- versus postoperative Qmax was 5ml/s versus 23.3ml/s and mean residual urine was 178ml versus 18.5ml. Two patients had stricture recurrence at 3months post-intervention. Dorsal buccal mucosal graft currently represents a prime choice for female urethral stricture reconstruction, keeping in view the advantages of the procedure such as easy availability of the graft and fewer donor site comorbidities. We emphasize upfront urethroplasty and extensive urethral grafting.

Female bladder outlet obstruction and urethral reconstruction

Female bladder outlet obstruction and urethral reconstruction

Дивертикул уретры у женщины

Urethral diverticulum is one of the rarest female urological diseases, which is characterized by various manifestations, ranging from an asymptomatic to severe urinary disorders, pain and dyspareunia. The aim of this work is to present a clinical observation of female urethral diverticulum with a description and discussion of its etiology, diagnosis, and treatment. Clinical observation is dedicated to 40-year-old woman with complaints of pain in the urethral area. The patient underwent ureteral stenting followed by a diverticulectomy. Vaginal diverticulectomy is the gold standard for treatment. The specialist performing such interventions should be aware for possible intraoperative complications. It seems appropriate to perform the surgical treatment of female urethral diverticulum in specialized centers with an experience in female urethral reconstruction.

Female urethroplasty: contemporary thinking.

Female urethral stricture disease is a rare entity. To date, its diagnosis and treatment have been poorly studied, with small numbers, and variable definitions of success. With growing interest in this area of reconstructive urology, there is an increased number of surgical techniques. In this article, we review current trends, definitions, etiologies and surgical techniques available for management of FUSD. We completed a review of publications in: English; Pubmed, and Google scholar. Key words identified for review were, female urethra stricture, female urethroplasty and female urethral dilation, female pelvic fracture, and female urethral reconstruction. Papers were reviewed, and references of relevant papers reviewed. Iatrogenic injury is the most common cause of female urethral stricture disease. Assessment requires a thorough patient history, examination and either flexible cystoscopy and/or fluoroscopic urodynamics to determine the most appropriate surgical approach for stricture repair. Multiple open urethroplasty techniques are described with various grafts and flaps, with good medium-term success. Minimally invasive techniques remain well-employed but have poor long-term success, with increased failure with multiple attempts at treatment. Female urethral stricture disease is a complex clinical entity that requires a measured and thorough evaluation. Individualized approach should be undertaken reviewing the patient's symptoms, the stricture's etiology, surrounding vaginal tissue health and stricture location. Promising medium-term success rates with vaginal flaps and buccal mucosal graft urethroplasty have been reported, with disappointing long-term results from repeated urethral dilation. Further research comparing techniques and defining successful long-term outcomes is required.

1019 - Female urethral reconstruction: Etiology and outcomes

1019 - Female urethral reconstruction: Etiology and outcomes

Reconstruction of Female Urethra with Tubularized Anterior Vaginal Flap.

Female urethral injury is a rare disease. Causes of urethral injuries are prolonged obstructed labour, gynaecological surgeries like vaginoplasty and post traumatic urethral injuries. The present study was conducted to evaluate outcome of female urethral reconstruction using tubularized anterior vaginal wall flap covered with fibroadipose martius flap and autologous fascia sling in patients with urethral loss. Aim of study was to evaluate outcome of reconstruction of female urethra with tubularized anterior vaginal flap. Retrospective analysis of all the patients with complete urethral loss was done from August 2008 to July 2015. Total seven patients were included in study. All patients presenting with total urethral loss were included. These patients were treated with tubularized anterior vaginal flap. Neourethra was covered with Martius labial flap and autologous fascia lata or rectus abdominis fascia sling. Most common cause of urethral loss was obstructed labour (57.1%). Postoperatively patients were assessed for continence, urine flow rate, ultrasound for upper urinary tract and post void residue. Mean operative time was 180 minutes (160-200 minutes) and Intraoperative blood loss was 220ml (170-260 ml). Mean postoperative hospital stay was eight days (seven to nine days) Mean post surgery maximum urine flow rate was more than 15ml/sec (6.7-18.2ml/sec) and mean post void residual urine was 22.5ml (10-50ml). Median follow-up time was 35 months. All patients were catheter free and continent post three weeks of surgery except one patient who developed mild stress urinary incontinence. One patient developed urethral stenosis which was managed by intermittent serial urethral dilatation. Female neourethral reconstruction with tabularized anterior vaginal flap and autologous pubovaginal sling is feasible in patients of total urethral loss with success rate of approximately 86%. It should be considered in patients of complete urethral loss with adequate healthy vaginal tissue.

MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2014MP9-10 ASSESSMENT OF FEMALE URETHRAL STRICTURE RECONSTRUCTION: BUCCAL MUCOSA GRAFT AND VAGINAL FLAP Casey Kowalik, John Stoffel, Leonard Zinman, Alex Vanni, and Jill C. Buckley Casey KowalikCasey Kowalik More articles by this author , John StoffelJohn Stoffel More articles by this author , Leonard ZinmanLeonard Zinman More articles by this author , Alex VanniAlex Vanni More articles by this author , and Jill C. BuckleyJill C. Buckley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.498AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The management of female urethral strictures is challenging given the variable presenting symptoms and extremely low incidence. Our objective was to evaluate the safety, operative technique and outcomes of women following urethral reconstruction with either a vaginal flap urethroplasty (VFU) or dorsal buccal mucosa graft (BMG). METHODS We retrospectively identified 10 women undergoing urethral reconstruction between February 2007 and October 2012. All patients had active urinary symptoms and/or urodynamic study indicating bladder outlet obstruction, confirmed by cystoscopy. Recurrent stricture was defined by a urethral diameter less than 17fr. Follow-up included urethral calibration (>16fr), symptom assessment, voiding cystourethrogram, and cystoscopy when there was difficulty voiding or symptoms recurred. RESULTS Mean age was 49 years (range 32-74). For urethral reconstruction, 6 patients had a VFU and 4 had a dorsal BMG. Location was mid in 6 and distal in 4 women. The indication for urethral reconstruction was urethral stricture in 9 patients. One woman had a traumatic 2 cm ventral urethral laceration associated with a pelvic fracture. Average stricture length was 1.25 cm (range 0.2-2). All patients with urethral stricture had previously undergone multiple urethral dilations. There were no major post-operative complications. Patients with available data (BMG patients) demonstrated improvement with a median pre-operative maximum flow of 4.5 mL/sec to a median post-operative maximum flow of 10.5 mL/sec. The median post-void residual was 163 mL prior to reconstruction and 25mL at follow-up. Two patients undergoing VFU underwent dilation at an average of 27 months following reconstruction for recurrent stricture with an average follow-up of 41 months. No patients undergoing dorsal BMG had a recurrent stricture or experienced urinary incontinence at an average follow-up of 24 months. CONCLUSIONS Female urethral reconstruction, either VFU or dorsal BMG, is a safe procedure with high success and significant improvements in quality of life. Outcomes of dorsal BMG are promising, demonstrating improved clinical and physiological parameters with maintenance of urinary continence. Women should be offered urethral reconstruction as a definitive management option rather than repeated urethral dilations. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e125 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Casey Kowalik More articles by this author John Stoffel More articles by this author Leonard Zinman More articles by this author Alex Vanni More articles by this author Jill C. Buckley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intermediate Outcomes After Female Urethral Reconstruction: Graft vs Flap

To evaluate the outcomes of women after urethral reconstruction with a vaginal flap urethroplasty (VFU) or dorsal buccal mucosal graft (BMG). We retrospectively identified 10 women undergoing urethral reconstruction between February 2007 and October 2012. All patients had evidence of urethral stricture on cystoscopy and/or urodynamic study indicating bladder outlet obstruction. Recurrent stricture was defined using the same criteria. Follow-up included urethral calibration (>16F), symptom assessment, voiding cystourethrogram, and cystoscopy when there was difficulty voiding or symptoms recurred. Mean age was 49 years (range, 32-74). The indication for urethral reconstruction was urethral stricture in 9 patients. One woman had a traumatic 2-cm ventral urethral laceration associated with a pelvic fracture. Location was mid in 6 and distal in 4 women. Average stricture length was 1.25 cm (range, 0.2-2). All patients with urethral stricture had previously undergone multiple urethral dilations. There were no major postoperative complications. Two patients undergoing VFU had a recurrent stricture requiring dilation. No patients undergoing dorsal BMG had a recurrent stricture. Female urethral reconstruction, either VFU or dorsal BMG, is a safe and successful procedure that should be offered to women with urethral strictures. The dorsal BMG approach is well tolerated and results are promising, but longer-term follow-up is needed. Women should be offered urethral reconstruction as a definitive management option rather than repeated urethral dilations.

Use of Martius flap in the complex female urethral surgery.

IntroductionObjectives were to evaluate safety and patient reported perception of the Martius fibroadipose flap for complex female urethra reconstruction.Material and methodsPatients operated with a Martius flap were contacted again via telephone to rate their self–perception on cosmetic appearance, pain or numbness of the flap harvest site.Results37 women (mean age of 46.8 yrs.) were operated with Martius flaps. Complications were limited to bleeding from the flap bed in 19% (7/37); hematomas – 5.4% (2/37); and lymphorrhea from the labial incision in 13.5% (5/37) and labial wound infection in 5.4% of cases (2/37). For self–perception 65% of patients (24/37) were phone interviewed (mean follow up – 54.2 months). Only 17% of women (4/24) complained to cosmetic problems. Two patients (8%) complained to a periodical mild pain. And 12.5% (3/24) of the women had decreased sensation or numbness at the labia.ConclusionsMartius flap is safe and it is not causing significant complications during female urethral reconstruction. However, an informed consent for decreased sensation and numbness at the flap harvesting area should be obtained.

Outcome of female urethral reconstruction: a 12-year experience

To report our experience over 12 years in female urethral reconstruction with either anterior bladder tube (Tanagho) or labia minora pedicled tube. This retrospective study included 16 patients with posttraumatic urethral loss. The patients were divided into two groups. Group I: included 6 patients managed with combined vaginal and abdominal approach using a proximally based anterior bladder tube (Tanagho) and Group II: included 10 patients underwent repair with labial fat pad flap with concomitant TOT sling. Outcomes included the success or failure of anatomical repair and continence, which was assessed during patient follow up by voiding diary, 24-h pad test and uroflowmetry. A total of 15 patients were followed for a mean of 42 months postoperatively, and only one patient was lost to follow up. Total continence was achieved in 10 patients (66.6 %) [4/6 patients (66.6 %) in group I and 6/9 patients (66.6 %) in group II]. Partial continence (i.e., one or two pad per day) was achieved in 2 patients (13.3 %). Failure occurs in 3 cases (20 %) [one case in group I and two cases in group II]. All our patients had a smooth postoperative course. In the labia pedicled tube, meatal stenosis was encountered in one patient and transient postoperative urine retention in 2 patients. Successful anatomical repair was achieved in all our patients. Both Bladder tube and labia minora pedicled tube with sling procedure have high success rate with only minor complications and are equally effective in the management of females with total urethral loss. Due to the small number of patients in this study, we still need to extend our study to verify our results.

Management of Urethral Stricture in Women

We describe the diagnosis and treatment of urethral strictures in women. We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Post-traumatic female urethral reconstruction

Post-traumatic urethral damage resulting in urethrovaginal fistulas or strictures, though rare, should be suspected in patients who have unexpected urinary incontinence or lower urinary tract symptoms after pelvic surgery, pelvic fracture, a long-term indwelling urethral catheter, or pelvic radiation. Careful physical examination and cystourethroscopy are critical to diagnose and assess the extent of the fistula. A concomitant vesicovaginal or ureterovaginal fistula should also be ruled out. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits volitional, painless, and unobstructed passage of urine. An autologous pubovaginal sling, with or without a Martius flap at time of reconstruction, should be considered. The three approaches to urethral reconstruction are anterior bladder flaps, posterior bladder flaps, and vaginal wall flaps. We believe vaginal flaps are usually the best option. Options for vaginal repair of fistula include primary closure, peninsula flaps, bilateral labial pedicle flaps, and labial island flaps. Outcomes are optimized by using exacting surgical principles during repair and careful postoperative management by an experienced reconstructive surgeon.

Female urethral reconstruction

The female urethra is relatively short compared with its male counterpart and is generally between 2 and 4 cm in length. It is made up of an inner layer of mucosal epithelium with numerous infoldings that create an effective seal against the passive loss of urine. Beneath the mucosa lies a rich, vascular network of elastic tissue that is much like the corpus spongiosum. Surrounding the spongy vascular tube is a collagen-rich fibromuscular envelope comprising the periurethral fascia. These three components of a normal urethra are crucial in maintaining continence and enabling dynamic function during increases in abdominal pressure and during normal micturition. Two fascial attachments suport the urethra: the pubourethral and urethropelvic ligaments. The pubourethral ligaments are a band of fascial support located superiorly between the urethra and pubic symphysis. These ligaments often serve as a point of anatomic division between the proximal and distal urethra. The urethropelvic ligaments are comprised of two layers of fascial condensation, the endopelvic fascia and the pubocervical fascia, whichprovide lateral attachment to the arcus tendineus. Themidurethra is believed to be the center of continence where the striated sphincter complex maintains active and passive tone. A basic understanding of female urethral anatomy is necessary to approach urethral reconstruction from an anatomic standpoint. This article reviews the techniques of female urethral reconstruction based on these anatomic divisions: proximal and bladder neck, midurethra, and distal urethra.

Experiences With Female Urethral Reconstruction

Experiences With Female Urethral Reconstruction

Urethral diverticulum in the female.

Urethral diverticulum is one of the rarest female urological diseases, which is characterized by various manifestations, ranging from an asymptomatic to severe urinary disorders, pain and dyspareunia. The aim of this work is to present a clinical observation of female urethral diverticulum with a description and discussion of its etiology, diagnosis, and treatment. Clinical observation is dedicated to 40-year-old woman with complaints of pain in the urethral area. The patient underwent ureteral stenting followed by a diverticulectomy. Vaginal diverticulectomy is the gold standard for treatment. The specialist performing such interventions should be aware for possible intraoperative complications. It seems appropriate to perform the surgical treatment of female urethral diverticulum in specialized centers with an experience in female urethral reconstruction.