Female Urethroplasty for a Childbirth Related Stricture: A Case Report
Marjan Waterloos1, Wesley Verla2, Anne Françoise Spinoit2 and Nicolaas Lumen2*
1Department of Urology, Algemeen Ziekenhuis Maria Middelares, Belgium
2 Department of Urology, Ghent University Hospital, Belgium
Submission: December 14, 2018; Published: December 20, 2018
*Corresponding author: Nicolaas Lumen, Department of Urology, Ghent University Hospital, Belgium.
How to cite this article: Marjan W, Wesley V, Anne F S, Nicolaas L. Female Urethroplasty for a Childbirth Related Stricture: A Case Report. JOJ Case Stud. 2018; 9(4): 555767. DOI: 10.19080/JOJCS.2018.09.555767.
This article describes a case report of a female who suffered a 23-year long history of urethral stricture disease after a childbirth injury to the urethral meatus and anterior vaginal wall. Despite different attempts of urethral dilations and urethrotomies, the stricture and the obstructive complaints persisted affecting the patient’s quality of life. The patients were finally treated with a dorsal only urethroplasty using a buccal mucosa graft. This was combined with local resection of abundant inflammatory scar tissue at the ventral vaginal wall and urethral meatus. This case report will emphasize on the clinical decision making and the tools used for this as well as on the surgical technique and postoperative care.
Reports on diagnosis and treatment of female urethral strictures are rare in urologic literature, as opposed to male urethral stricture disease. Nevertheless, female urethral stricture disease might cause severe obstructive and irritative voiding symptoms as well with a substantial impact on the patient’s quality of life. There are no exact data on the incidence of female urethral stricture disease [1-3]. There is no international consensus nor any guideline on how to diagnose or treat female urethral strictures. Herein, we describe the case of a female suffering a long-standing history of urethral stricture disease finally treated with dorsal onlay buccal mucosa graft urethroplasty with emphasis on the diagnostic work-out, surgical technique and postoperative care.
A 51-year old female consulted a reconstructive urologist (M.W.) with complaints of painful micturition, incomplete emptying of the bladder, recurrent urinary tract infections, a weak urinary stream and urgency but without any incontinence. She suffered an anterior vaginal laceration extending into the urethral meatus during childbirth 23 years ago. This injury was primarily sutured but no further details on the technique could be obtained from her medical file. Shortly thereafter, she
developed the above-mentioned complaints. Numerous (>10) dilations and internal urethrotomies have been performed with only a short temporarily relief of the symptoms.
Clinical gynecological examination revealed abundant
inflammatory and indurated tissue just below the urethral
meatus (Figure 1). This scar tissue was painful during digital
Uroflowmetry showed a plateau-shaped obstructive
voiding curve with a maximum urinary flow of 11ml/s. Cystourethroscopy
was poorly supported because of local pain and
not possible because the stricture started directly at the meatus.
A 10Fr urethral catheter could not be passed into the bladder.
Voiding cysto-urethrography (VCUG) was performed after a 5Fr
feeding tube was introduced into the bladder. VCUG showed a
distal urethral and meatal stricture with a remarkable dilation
of the proximal urethra (Figure 2). Pelvic MRI was performed to
exclude any peri-urethral abnormalities. Especially, we wanted
to exclude an infected urethral diverticulum or a peri-urethral
abscess because of the observed local inflammation. However,
MRI was negative for this (Figure 3).
After counseling the patient, it was decided to perform
a dorsal onlay urethroplasty with a buccal mucosa graft and
excision of the inflammatory scar tissue surrounding the ventral
circumference of the urethral meatus. A preoperative urine
culture was sterile.
The operation was performed by 2 urethral surgeons (M.W.
and N.L.). Prophylactic antibiotics were administrated (1g
cefazoline) at induction of general anesthesia. The patient was
placed in the lithotomy position with the hips and knees 90°
flexion and the legs 45° abduction. The buttock was slightly
over the end of the operation table. The feet and lower legs were
placed in supportive boots (Figure 4). The surgical field was
disinfected using a povidone-iodine solution. Nasal intubation
was performed, and the oral cavity was disinfected with
chloramine solution in aqua. The labia minora were retracted by
a self-retaining hook retractor in order to have a good exposure
of the vestibulum, the urethral meatus and the vaginal introitus.
A guidewire (5Fr feeding tube) was placed through the urethra
inside the bladder in order to avoid creation of false passage
during opening of the stricture (Figure 5).
A semi-lunar suprameatal incision was made (Figure 5).
The plane between the clitoris bodies and the dorsal urethra was carefully dissected. The pubic bone was digitally palpated
and marked the point of proximal dissection. The urethra was
progressively opened at the dorsal side and stay sutures were
immediately placed at the urethral edges (every centimeter)
to facilitate further identification of the urethral mucosa. The
stricture was further opened until healthy proximal urethra
was encountered which allowed passage of a 25Fr metal sound
The ventral scar tissue was locally excised until healthy
urethral and vaginal mucosa were left over at the ventral aspect
of the meatus. The edges were approximated to each other using
monocryl™ 4.0 separate sutures. At that stage, a Doyen’s blade
was placed at the posterior vaginal wall to further expose the
anterior vaginal wall (Figure 7).
A graft was harvested according to the dimensions of the
stricture. In this case, a slightly triangular graft was harvested
of 3cm long and 2.5cm width. A mouth retractor was used, and
the dimensions of the graft were projected at the inner surface
of the left cheek with respect for the orifice of Stenon’s duct. The
buccal mucosa was infiltrated with a diluted solution of xylocain
with adrenalin as a measure of hydrodissection. Dissection was performed using Jones scissors in a submucosal plane above
the buccinator muscle. Hemostasis was achieved using bipolar
coagulation and the donor area was further left open. The graft
was carefully defatted on a silicone plate and meshed. During
preparation of the graft, the graft was held wet constantly. A stay
suture was placed at the distal end of the graft (Figure 7b).
The graft was transferred to the acceptor area, presented on
the silicone plate. The proximal end of the graft (the tip) was
sutured to the proximal end of the opened urethra with 2 sutures
monocryl™ 4.0. The mucosal surface of the graft was turned
towards the urethral lumen and the knots of the suture were
outside the lumen. These monocryl™ sutures were further used
to approximate the edges of the graft to the edges of the opened
urethra on both sides in a running suture fashion from proximal
to distal. This suturing also included the peri-urethral tissues
in order to have a good fixation of the graft to the surrounding
tissues. In addition to this, the graft was centrally quilted to
the clitoral bodies with separate monocryl™ 4.0 sutures. At the
meatus, the distal end of the graft was sutured to suprameatal
incision using separate stitches monocryl™ 4.0 (Figure 8).
At the end of the operation, a 20Fr catheter was inserted,
and a fatty gauze was wrapped around this catheter and pushed
against the grafted meatus. A vaginal packing was inserted as
well for hemostatic reasons (Figure 9). The oral cavity was
checked for bleeding before extubation. Operation time (skin-toskin)
was 125 minutes.
At the recovery, amoxicillin + clavulanic acid 3 x 500mg and
oxybutynin 3 x 5mg daily were initiated until catheter removal.
After 3h, patient went back to the standard hospital room. The
oral cavity was washed morning and evening, and after every
meal with corsodyl™ during 2 weeks. The vaginal packing was
removed after one day. The patient was discharged at the 2nd
postoperative day without any problems. The catheter was
removed after 2 weeks with VCUG showing a patent urethra and
no signs of extravasation (Figure 10). Upon clinical examination,
there were no wound healing problems. The resected tissue was
inflammatory but not malignant upon pathological examination.
At the next postoperative visit (after 3 months), patient
reported no voiding difficulties and absence of pain. There was
no incontinence. She was very satisfied with the result. Clinical
examination showed no abnormalities and a well healed graft in
the urethral meatus (Figure 11). The urethra allowed passage
of a 14Fr cystoscope without signs of narrowing. The patient
provided written informed consent for anonymous publication
of this case report.
Only 10% of women who consult a urologist with obstructive
voiding will have a true (“anatomical”) urethral stricture [1-
3]. In this case, stricture etiology was the consequence of
childbirth injury. Obsteteric urethral injuries are an import
etiology of female stricture formation [2,4]. Frequently reported
complaints are a weak urinary stream, sensation of incomplete
voiding, straining, frequency and nocturia [5,6]. As in this case,
many women also experience pain during micturition, urgency
[1,3,6,7] and suffer recurrent urinary tract infections [3,5,6,8]. In
women with lower urinary tract symptoms, uroflowmetry must
be part of the diagnostic work-out and a plateau-shaped curve
is suggestive for a stricture . A gynecological examination is
indispensable as it might directly reveal a meatal stenosis and
the presence of lichen sclerosus, pelvic organ prolapses or periurethral
abnormalities. This examination must also emphasize
on the quality of local tissues which might be used for urethral
reconstruction [1,2]. In this case, the presence of inflammatory
scar tissue at the ventral aspect of the meatus revealed during
gynecologic examination was important for the choice of
technique. In the present case, a 10Fr catheter could not be
passed through the stricture. Although there is no strict definition
about the caliber of the urethral diameter, the inability to pass
a 14Fr catheter is generally considered pathognomonic for the
presence of a urethral stricture [3,10,11]. Cysto-urethroscopy is
not possible in case of meatal or very distal urethral strictures
, but it might directly visualize a more proximal stricture
without providing information about the stricture length.
Voiding cysto-urethrography (VCUG) is more informative about
the stricture location and stricture length. Filling of the bladder
is accomplished by either suprapubic access, if a suprapubic
catheter has been placed, or by passing a small-caliber (e.g. 5Fr
feeding tube) catheter through the stricture inside the bladder.
During voiding, the urethra proximal to the stricture will show
dilation with abrupt narrowing at the stricture site [5,12]. This so
called “wine glass image” was clearly visible upon VCUG (Figure
2) and directly disappeared postoperatively (Figure 10). In case
of any doubt of concomitant abnormalities (urethral diverticula,
abscess formation, etc.), pelvic MRI is advised to diagnose or rule
this out [2,9,11].
No guidelines exist on which diagnostic modalities must be
used during the work-out , but before start of urethroplasty,
the surgeon should have sufficient information on the presence,
extent and location of the stricture as well as on the quality
of surrounding structures in order to be prepared for the
The patient in the present case underwent numerous
dilations and internal urethrotomies. This initial trial with
endoluminal treatments is common practice in female urethral
stricture disease despite disappointing long-term results.
Based on a systematic review of Osman et al., the composite
success rate was only 47% but should be considered even too
optimistic as most of these women underwent intermittent
catheterization which is a surrogate form of dilations . All
types of urethroplasty are associated with a higher success rate.
Vaginal flap urethroplasty, vaginal/labial graft urethroplasty
and oral mucosa graft urethroplasty have a composite success
rate of respectively 91%, 80% and 94% . No large and
well-conducted comparative trials have been performed to
evaluate whether one technique is superior to another, whether
the dorsal location is better than the ventral one or whether
a specific type of graft performs better than the others. As a
consequence no, general recommendations exist on which
technique to choose . In this case, we opted for buccal
mucosa. This was in part the preference of the surgeon who
is familiar with harvesting buccal mucosa for male urethral
stricture disease. Vaginal mucosa seemed not suitable as the
local vaginal tissues were inflammatory. The dorsal approach
was opted here above the ventral approach. Again, because
of the inflammatory vaginal tissue at the ventral aspect of the
urethra, we estimated that the dorsal side of the urethra would
be a more secure graft bed. Furthermore, because of pain, we
opted to resect this abnormal tissue and we feared for paucity
of local tissue to cover an eventually placed ventral graft. In
this case, a Martius fat flap would be an option but this add
to the morbidity of the operation (labial hematoma, cosmetic
labial problems, decreased sensitivity, local pain) and was not
preferred by the patient after discussing the options [14,15].
On the other hand, ventral procedures are reported technically
easier to perform . Nevertheless, we experienced no specific
technical challenges during the dorsal approach performed
herein. Another theoretic advantage of the ventral approach
is the reduced risk of stress urinary continence because of the
omega-shape of the female urethral sphincter with its ventral
midline deficiency [3,9]. However, this hypothesis seems to be
solely theoretical as no excess in stress urinary incontinence has
been reported with dorsal procedures so far . Our patient
also reported no incontinence, despite this dorsal approach.
Another concern with the dorsal approach is the risk of bleeding
and damage to the clitoral bodies . The fear of injury to the
clitoral neurovascular bundle seems not to be justified .
We experienced no problems with this during the operation
herein reported. In this case, the graft was meshed to allow
fluid evacuation and quilted against the graft bed to ensure
a close contact between the graft and the graft bed. A close
contact between the graft and a well-vascularized graft bed is an
important prerequisite in graft urethroplasty ..
This case shows that a surgeon performing female
urethroplasty should master different techniques in order to be
able to adapt his technique to the local circumstances. In this
case we opted for a dorsal approach because of poor quality of
the ventral tissues. However, in case of the opposite situation,
a ventral approach might be more suitable. Therefore, these
techniques should not be regarded as competitive to each
other but more complementary in the armamentarium of the
reconstructive surgeon. The duration of urethral catheterization
varies among series but is usually 2-3 weeks [7,9,13]. In this case, we maintained the catheter for 2 weeks and used VCUG
upon catheter removal to exclude extravasation. This is inspired
from our experience in males . Vaginal packing during 24h
is also advised by others for hemostatic reasons . Longer
follow-up of this case is needed because grafts might have the
tendency to retract with time and long-term results in male have
showed a steady deterioration .
This case showed the initial success of dorsal onlay
urethroplasty with a buccal mucosa graft in a female with a
urethral stricture refractory to endoluminal treatments. Longer
follow-up and larger, preferable comparative series are needed to
define the exact place of this technique in female urethroplasty.