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| Dorsal onlay buccal mucosal graft urethroplasty for female urethral stricture: Techniques and outcomes |
Vinod Kumar Prabhuswamy*( ),Harsha Hiriyur Somashekarappa,Pradeepa Melinamane Ganeshappa,Kumar Prabhu,Venkatesh Krishnamoorthy
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| NU Hospitals, Padmanabhanagar, Bangalore, Karnataka, India |
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Abstract Objective: Female urethral stricture (FUS) accounts for about 4%-13% of cases of female bladder outlet obstruction. FUS was and is still managed by repeated dilatations and/or direct visual internal urethrotomy. There are many alternative options for reconstruction like buccal or vaginal mucosal graft urethroplasty. Our aim was to describe the technique of dorsal onlay buccal mucosal graft (BMG) urethroplasty for FUS and present the outcomes. Methods: Between January 2014 and December 2021, 37 patients who underwent dorsal onlay BMG urethroplasty were included in the study. Their pre-operative diagnosis was confirmed with uroflowmetry, micturating cystourethrogram, urethral calibration, and on table cystoscopy. Bladder catheter was removed after 2 weeks. Patients were followed up at 3 months, 6 months, 1 year, and then annually with urine analysis, uroflowmetry, and post-void residual assessment. We defined success as a maximum flow rate (Qmax) above 15 mL/s without the need for an additional instrumentation. Results: The mean age of patients was 47.8 (standard deviation [SD] 11.3) years. Twenty patients had previously undergone urethral dilatations. The mean pre-operative Qmax was 7.79 (SD 3.73) mL/s. However, the mean Qmax improved to 23.20 (SD 8.25) mL/s after surgery. The mean post-void residual urine after surgery was 30.50 (SD 10.70) mL. This reduced from a mean value of 139.00 (SD 147.24) mL before surgery. The mean follow-up was 30.2 (SD 18.3, range 18-44) months. There was no post-operative incontinence. There were Clavien-Dindo Grade 1 complications in 6 out of 37 (16.2 %) patients during hospital stay. The only long-term complication was recurrence of stricture in 4 (10.8%) patients. Conclusion: Dorsal onlay BMG urethroplasty in females is a safe, effective technique which can avoid repeated painful dilatations and multiple urethrotomies. One should always consider reconstruction in FUS without any fear of incontinence.
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Received: 17 January 2023
Available online: 20 October 2024
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Corresponding Authors:
*E-mail address: vinodkumarbmc144@gmail.com (V.K. Prabhuswamy).
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Micturating cystourethrogram showed proximal urethral dilatation and distal urethral narrowing, and two small radio-opaque markers were placed on either side of the meatus.
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Urethral mobilization. (A) The plane was created below the clitoral cavernosal bed; (B) The stricture was incised (between forceps) at a 12-o'clock position till the adequate caliber was reached.
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Buccal mucosal graft fixed to the apex of the urethrotomy.
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Final post-operative appearance of meatus after dorsal onlay buccal mucosal graft urethroplasty.
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| Parameter | Patient, n (%) | | Presenting symptom | | | Poor flow | 19 (51.4) | | Straining to void | 7 (18.9) | | Urinary frequency | 4 (10.8) | | Recurrent urinary tract infection | 4 (10.8) | | Acute urinary retention | 3 (8.1) | | Medical comorbidity | | | Hypertension | 13 (35.1) | | Diabetes mellitus | 8 (21.6) | | Dyslipidemia | 3 (8.1) | | Hypothyroidism | 4 (10.8) | | Bronchial asthma | 1 (2.7) | | Obesity | 3 (8.1) | | Location of the stricture | | | Distal 1/3 and meatus | 22 (59.5) | | Distal 2/3 | 7 (18.9) | | Mid urethral | 8 (21.6) | | Clavien-Dindo complication (Grade 1) | 6 (16.2) | | Oral pain | 3 (8.1) | | Post Dural puncture headache | 2 (5.4) | | Fever | 1 (2.7) |
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Presenting symptoms with medical comorbidities, location of the stricture, and post-operative complications.
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| Study | Technique | Patient, n | Follow-up, mean, month | Stricture-free rate, % | New onset SUI, n | | Berglund et al., 2006 [14] | Ventral BMG onlay | 2 | 24 | 50 | 0 | | Hoag and Chee, 2017 [13] | Ventral BMG inlay | 1 | 10 | 100 | 0 | | Mukhtar et al., 2017 [15] | Ventral BMG onlay | 22 | 21.5 | 95 | 1 | | Petrikovets et al., 2019 [16] | Ventral BMG onlay | 1 | 4 | 100 | 0 | | Ozlulerden et al., 2020 [17] | Ventral BMG onlay | 7 | 6 | 100 | 0 | | Migliari et al., 2006 [19] | Dorsal onlay BMG | 3 | 6 | 100 | 0 | | Sharma et al., 2010 [21] | Dorsal lingual graft onlay | 15 | 12 | 93 | 0 | | Castillo et al., 2011 [22] | Dorsal BMG onlay | 2 | 18 | 100 | 0 | | ?nol et al., 2011 [23] | Dorsal, ventral, circumference in two patients each | 6 | 17 | 100 | 0 | | Blaivas et al., 2012 [24] | Dorsal BMG onlay | 3 | 25 | 100 | 0 | | Goel et al., 2014 [25] | Dorsal BMG onlay | 8 | 15 | 63 | 0 | | Kowalik et al., 2014 [26] | Dorsal BMG onlay | 4 | 24 | 100 | 0 | | Powell and Daniels, 2017 [27] | Dorsal BMG onlay | 6 | 18.5 | 77 | 0 | | Hampson et al., 2019 [28] | Dorsal BMG onlay | 39 | 32 | 77 | 0 | | Our study | Dorsal BMG onlay | 37 | 30 | 89 | 0 |
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Studies comparing different methods of BMG urethroplasty.
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