Female urethral stricture (FUS) has been a hitherto ignored and largely undiscussed topic in the urological literature.(1) Many women with primary lower urinary tract symptoms have been subjected to indiscriminate use of periodic urethral dilatation, fascinatingly leading to short- term symptomatic improvement. These incorrect practices can result in the patients primarily having urethras with reasonable calibres developing “secondary strictures”. Over time, patients may become dependent on the periodic dilatations.(2,3) As mentioned, visualising the unhealthy or pale mucosa along with a reduced calibre on cystourethroscopy (6 Fr) is essential to confirm the diagnosis of FUS.(1)
Over the past decade, there have been a plethora of manuscripts on urethral reconstruction for FUS.(3,4) This surge in interest is likely due to a better understanding of the FUS as a distinct clinical entity, driven by an increase in both the number and the expertise of the reconstructive surgeons specialising in male urethroplasty. Increased incidence of FUS, due to increasing interventions (catheterisations/ instrumentations), could also be a reason. Despite this growing body of evidence, most of the studies are retrospective, with small sample sizes, and providing a low quality of evidence. Additionally, a few review articles have also been published.(5,6)
There has been a shift from periodic urethral dilatations to urethral reconstruction using various grafts and flaps with emerging data on superior long-term outcomes. The Dorsal Onlay Buccal Mucosal Graft Urethroplasty (DO-BMGU) is the most widely performed urethroplasty.(1) We present our decade-long experience of Ventral Inlay Buccal Mucosal Graft Urethroplasty (VI-BMGU) at our centre.
Initially, the urethral mucosa is incised at the six o’clock position all along the length of the urethra until splaying happens, and a nasal speculum is introduced. Buccal Mucosal Graft (BMG) is laid in an on-lay fashion and is fixed with two proximal sutures using PDS 4-0. It is further secured with distal sutures. 18F silicone foley is placed. (Figure 2) The catheter is removed after 21 days. However, we are removing it after seven days in our recent cases with no significant worsening of outcomes. Patients are followed up periodically using Americal Urological Association (AUA) symptom scores, peak flow rates (Qmax), and PVR on ultrasound. Suspected recurrences are confirmed on cystourethroscopy.
Forty-six patients underwent VIBMGU, with a median follow-up of 27.5 (11-55) months. Most of them were idiopathic (86.13%), while 10.87% were iatrogenic. Nineteen (41.3%) patients had a history of dilatation. The overall success rate was 89.13%, with five failures. There was a statistically significant improvement in AUA symptom scores, Qmax and PVR.
VI-BMGU is a valid treatment option for FUS with durable long-term success rates and added advantages of vaginal sparing and avoidance of dissection around clitoral neurovascular bundle.
Outcomes of Ventral inlay BMG urethroplasty in females | |
Parameter | VI-BMG (n=46) |
Success | 41 (89.13%) |
Median follow-up (mo) | 27.5 (11-55) |
Idiopathic | 41 (86.13%) |
Iatrogenic | 5 (10.87%) |
History of dilation | 19 (41.30%) |
Early recurrence (<12mo) | 2 |
Late recurrence (12-24mo) | 1 |
Late recurrence (12-60mo) | 2 |
Figure 2: Key steps of Female Ventral BMG urethroplasty
Authored by Dr Swarnendu Mandal, AIIMS, Bhubaneswar, Odisha
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