RECONSTRUCTIVE UROLOGY

doi: 10.1590/S1677-55382010000600025

Vaginal flap urethroplasty for wide female stricture disease
Simonato A, Varca V, Esposito M, Carmignani G
Clinica Urologica L. Giuliani, Ospedale San Martino, Università degli Studi di Genova, Genova, Italy
J Urol. 2010; 184: 1381-5

• Purpose: As in men, female urethral stricture disease is often treated with repeat urethral dilation or internal urethrotomy but not always with good results. In nonresponsive cases surgical treatment may be useful but only a few cases are reported in the literature. We present our single institution experience with urethral reconstruction in 6 patients using an alternative vaginal inlay flap technique inspired by the Orandi technique.
  Materials and Methods: We treated 6 women with urethral stricture. In 5 patients stricture involved the entire middle and distal urethra, and in 1 it also involved the proximal urethra with bilateral hydronephrosis. Patients underwent urethral reconstruction using a vaginal flap with a lateral vascular pedicle that maintains the vascular axis. The flap was partially de-epithelialized to favor tissue cicatrix formation where the sutures are placed and avoid fistula formation.
  Results: Mean followup was 70.8 months. Normal micturition was achieved after catheter removal in all patients. Post-void residual urine was measured postoperatively in 3 patients. One patient had significant post-void residual urine and required intermittent self-catheterization. The remaining 5 patients required no additional treatment.
  Conclusions: Using the vaginal wall to reconstruct large segments of the female urethra is simple and appears to have good results. Our technique preserves the vascular axis of the flap and protects the sutures. More contributions to the existing literature are needed before any further conclusions can be drawn.

• 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