RECONSTRUCTIVE UROLOGY

doi: 10.1590/S1677-55382010000600024

Volar onlay urethroplasty for reconstruction of female urethra in recurrent stricture disease
Gozzi C, Roosen A, Bastian PJ, Karl A, Stief C, Tritschler S
Department of Urology, Klinikum Großhadern, Ludwig Maximilians University of Munich, Munich, Germany
BJU Int. 2010 Nov 17 [Epub ahead of print]

• Objective: To report our experience with a new and simple method of urethral repair with a volar onlay of free labium minus graft. Strictures of the female urethra are rare, and it is well accepted that the therapeutic options of dilation and urethrotomy are not lasting solutions as a result of their high recurrence rates. However, there is no consensus regarding the best way to reconstruct the female urethra in the case of stricture disease.
  Patients and Methods: Four consecutive female patients with a long lasting history of recurrent urethral strictures underwent open urethroplasty with a volar situated free split thickness epidermal graft from the labium minus. The surgical technique is described and a short-term follow-up is presented.
  Results: Operating time was 40–140 min (mean 105 min), and the graft measured between 2 × 1.5 cm and 3 × 2.5 cm. Follow-up time was 11–19 months. Maximum urinary flow rate could be improved from a baseline of 9.4–11.2 mL/s (preoperatively, after intermittent use of dilation) to 19–23 mL/s. Postvoid residual urine volume was 0-50 mL preoperatively and no postvoid residual urine volume postoperatively. Urinary catheters were removed after 21 days. Urinary stress incontinence did not occur postoperatively. There were found no complications related to the graft donor site.
  Conclusions: The reported data concerning a new therapeutic approach for the treatment of recurrent female urethral stricture show that a volar onlay urethroplasty represents a feasible, safe and simple surgical method. Larger series with long-term follow-up are needed for further evaluation.

• Editorial Comment
  Repair of female urethral stricture disease is difficult. First, the disease is less common than male urethral stricture disease making the surgeon less familiar with the technique. Second, the shorter urethra and proximity to the vaginal mucosa allows for little margin of error. Perhaps the multitude of surgical approaches described attests to the quest to find a universally acceptable approach. Dividing the urethra along its volar aspect (the vaginal rather than clitoral body side) is preferable for many reasons. First, it avoids the majority of the sphincter fibers. These fibers follow an omega shape and are more prominent on the clitoral side. Second, a volar dissection is familiar to most urologists as the dissection for most anti-incontinence procedures is done in this area. Third, it avoids dissection of the urethra off the clitoral bodies – a dissection unfamiliar to urologists.
  These two articles present descriptions of modifications of the volar urethroplasty in women. In Gozzi et al, the authors describe a suburethral incision followed by dissection of the vaginal flap off the urethra, a volar urethrotomy and excision of all scarred tissue. A labia minora graft is then harvested, thinned, and grafted ventrally, using the periurethral tissue as a graft bed. The vaginal flap is closed. In contrast, the Simonato et al group describes an approach that borrows heavily from the Orandi urethroplasty well-known in reconstruction of penile urethral stricture disease. A laterally-based vaginal flap is created and the middle portion is de-epithelialized. This essentially creates a medially located island flap which is then rolled onto the ventral urethrotomy. The remaining (lateral) vaginal flap is closed over the urethra.
  Both of these approaches are attractive in the fact that they use a volar approach and borrow from reconstructive principles used in male urethral stricture surgery. Both approaches are most appropriate in the distal to middle third of the urethra. The proximal third remains a higher risk area due to the deeper dissection and the prominence of bladder neck sphincter fibers. Small patient numbers and limited follow-up may limit the external validity of the results of these two series.

Dr. Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.edu