RECONSTRUCTIVE UROLOGY

Female Urethral Strictures: Successful Management with Long-term Clean Intermittent Catheterization after Urethral Dilatation
Smith AL, Ferlise VJ, Rovner ES
Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
BJU Int. 2006; 98: 96-9

• Objective: To report our experience in the diagnosis and treatment of urethral stricture in women.
• Patients and Methods: A retrospective review of records and video-urodynamics identified women treated for urethral stricture between 1999 and 2004 at one institution by one surgeon. Urethral stricture was defined as a fixed anatomical narrowing between the bladder neck and distal urethra of <14 F preventing catheterization, and the diagnosis was confirmed by cysto-urethroscopy, and/or video-urodynamics. Women with a history of external beam radiotherapy to the pelvis, or of gynaecological, urethral or bladder malignancy, were excluded, and the women had a urethral biopsy to exclude a malignant cause of the stricture. Initial treatment consisted of urethral dilatation to > or = 30 F. After a period of indwelling catheterization, the women were placed on clean intermittent self-catheterization (CISC) at least once daily, and monitored every 3-6 months. At each follow-up, the urethra was catheterized to exclude recurrence. American Urological Association (AUA) symptom scores were obtained at presentation and at the initial 3 month follow-up.
• Results: Seven women met the criteria for urethral stricture, and were followed for a mean (range) of 21 (6-34) months. All were initially maintained on daily CISC, and some were gradually reduced to weekly CISC for the duration of follow-up. No patient had a recurrent stricture while on CISC, and none has had a urethral reconstruction to manage their condition. AUA symptom scores improved in all of the women by a mean of 10.7 points. No complications related to catheterization were noted.
• Conclusion: Urethral stricture is rare in women. Long-term CISC in these women is safe and effective, and can avoid the need for major reconstructive surgery.

Technique and Results of Urethroplasty for Female Stricture Disease
Schwender CE, Ng L, McGuire E, Gormley EA
Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
J Urol. 2006; 175: 976-80

• Purpose: Urethral stricture disease in females is uncommon and is often treated with repeat dilation or internal urethrotomies. Various surgical techniques to repair strictures have been described with successful results. However, these techniques are cumbersome to use. The vaginal inlay flap is simple and easy to learn. To our knowledge this is the first report of its use and clinical results in a series of patients from 2 institutions. Materials and Methods: Eight symptomatic women with a history of traumatic or difficult catheterization, a history of at least 1 urethral dilation or urethrotomy and difficult or a failed attempt at catheter placement underwent urethroplasty. The technique consisted of incising the posterior aspect of the stricture and advancing a vaginal inlay flap. A retrospective chart review was performed.
• Results: Followup was 1 to 9 years. All patients had subjective relief of symptoms and could easily catheterize with a 14Fr catheter. Average caliber of the urethra increased from 9.25Fr to 16.5Fr and post-void residual urine decreased from 130 to 15 cc. One patient with a hypotonic bladder was in retention, which resolved during 3 months. One patient underwent repeat dilation once 3 weeks after the primary procedure with no recurrence. No patient had stress urinary incontinence. There were no immediate or delayed serious complications.
• Conclusions: Urethral stricture disease in females is an uncommon entity that can cause voiding symptoms, recurrent infections, retention and renal impairment. This method of surgical repair offers a durable result and has a low incidence of complications.
  
  
• Editorial Comment
  Although the urethral stricture in female is uncommon recently two papers with a different therapeutic approach were published. In the first study progressively the stricture was dilated with up to a 30F sound. In the follow-up of up to 39 months the patients performed clean intermittent self-catheterization. Three of them (38%) needed additional re-dilatation (Smith et al.). Probably the dilatation up to 30F causes a rupture of the stricture and it needs to be asked if this cause new fibroses in even the former normal urethra. The re-stricture might be avoided by the regular dilatation by the clean intermittent self-catheterization.
  The surgical urethroplasty performed by Swender et al. with an intraoperative urethral diameter of 22F, remains in a urethral diameter in mean 16.5F after a follow-up of up to 9 years similar to the published data of Montorsi et al. of 17 women with a follow-up of 12 months (1). Except one patient none of the women needed a further treatment. All were able to perform clean intermittent self-catheterization. On the other hand the dilatation did not cause in any of the cases urinary stress incontinence whereas after the urethroplasty two patients had had stress incontinence (see Swinder et al., Table 2).
  Parameters are probably needed to decide who is suitable for dilatation and who for the urethroplasty to improve the outcome further. Perhaps, we are too conservative when contemplating surgical correction for female urethral stricture. On the other hand, although simple techniques are at hand, skilled surgical expertise is requested to protect the sphincteric mechanism (2). The videourodynamics and intraurethral ultrasound might become diagnostic tools in order to choose the best approach, but successful application of surgery calls for adequate clinical experience (3).

References
1. Montorsi F, Salonia A, Centemero A, Guazzoni G, Nava L, Da Pozzo LF, Cestari A, Colombo R, Barbagli G, Rigatti P: Vestibular flap urethroplasty for strictures of the female urethra. Impact on symptoms and flow patterns. Urol Int. 2002; 69: 12-6.
2. Heit M: Intraurethral ultrasonography: correlation of urethral anatomy with functional urodynamic parameters in stress incontinent women. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11: 204-11.
3. Schaer GN, Schmid T, Peschers U, Delancey JO: Intraurethral ultrasound correlated with urethral histology. Obstet Gynecol. 1998 ; 91: 60-4.

Dr. Karl-Dietrich Sievert, Dr. Christel Reisenauer,
Dr. Barbara Winter & Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany