EURURO Vol. 73 No. 1

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1. Introduction
Female urethral stricture (FUS) is an uncommon condition.
Although its true incidence is largely unknown, it appears to
be relatively low
There is a certain controversy about its etiology, which is
largely due to the rarity of the disease. Multiple factors,
including infection, trauma, instrumentation, and prior
urethral surgery may be implicated.
There is no standardized definition or diagnostic criteria
for urethral stricture in women. The majority of published
studies perform a multitude of tests, and no author relies
on just one investigative modality. Therefore, making
an accurate diagnosis requires a high index of suspicion
because the presentation is often nonspecific.
Once FUS is diagnosed, there are two main treatment
methods: (1) urethral dilatation, and (2) urethroplasty
augmentation. In the case of the latter, this includes vaginal
and labial flap and graft urethroplasty, as well as oral graft
urethroplasty . However, there are no indications as to
which procedure to use for each case, and therefore it is
usually dependent on the surgeon’s expertise and personal
preference.
The success rates of the different procedures have also
been poorly described in the literature, and its follow-up is
usually of short duration. In general, meaningful outcome
procedures have not been used .
One of the most commonly used treatment methods is
the Blandy technique, popularized by McGuire et al .
This technique implies that the U-shaped vaginal wall flap is
inverted onto itself, making it a relatively simple procedure
with minimal morbidity. However, in our initial experience,
the technique results in a retrusive meatus and an inward
urinary stream.
The aim of this study is to present our experience on the
etiopathogenesis, diagnosis, and surgical management with
an alternative vaginal flap technique in a group of women
diagnosed with FUS at our institution, analyzing its safety,
effectiveness, and long-term outcome.
2. Patients and methods
2.1. Study population
A cross-sectional observational study was performed in a single
University Hospital. Nine female patients were diagnosed with urethral
stricture at our institution from 1999 to 2015, and had undergone open
surgery. These patients were contacted and agreed to undergo a follow-
up medical examination, signing an informed consent.
2.2. Preoperative evaluation
A standard preoperative evaluation was performed in all the patients,
including medical history, physical examination, urine culture,
flowmetry, postvoid residual urine measurement, urethral calibra-
tion, and voiding cystourethrography. Urodynamics and cystoscopy
was performed in cases where urethral caliber was superior to
14 Fr.
2.3. Surgical procedure
A ventral lateral-based anterior vaginal wall flap urethroplasty was
performed, based on Orandi’s technique for male strictures . After
intradural anesthesia, the patient was placed in a dorsal lithotomy
position. Then, urethral catheterization with a Foley 8-Fr catheter was
performed, or with a guidewire when the former was not possible. A
midline anterior vaginal wall incision was then carried out A),
followed by its mobilization. The side where the flap was to be taken
from was dissected, preserving as much vascularization as possible.
Then, the urethra was incised ventrally from the meatus to the point
where the stricture was completely open ).
A rectangular-shaped piece of vaginal wall was then selected,
depending on the length and caliber of the stricture ). After
mobilizing the outer external flap border, where a wide axial vascular
pedicle remains, the vaginal flap was then sutured to the margins of the
urethrotomy defect with an interrupted 3-0 polyglactin absorbable
suture. The inner vaginal flap was sutured to the closest urethral margin
). The outer vaginal edge was turned around and sutured to the
contralateral edge ). In cases where the meatus was not
strictured, the vaginal flap was carried down just to this limit.
Afterwards, the meatus was closed, remaining in an orthotopic position.
Finally, the vaginal mucosa was attached with a 2-0 Vicryl-rapid suture
). The patient was discharged from hospital within 24 h.
Antibiotics were given to the patients for 5 d and a Foley catheter
was maintained for 3 wk. Intravaginal estrogens were applied
preoperatively to two postmenopausal patients for 3 mo.
2.4. Postoperative follow-up
During the last postoperative review, symptom assessment, physical
examination, flowmetry, postvoid residual urine measurement, and
urethral calibration were performed. Personal assessment of the success
of the surgery was performed using the Perception Global Impression of
Improvement questionnaire (PGI-I) during this visit. The PGI-I question-
naire is a self-administered questionnaire based on an analogue scale
with seven questions regarding the current status compared with that
prior to treatment, ranging from excellent to poor.
Complications of the procedure was assessed from the patients’
medical records and directly from the patient during the last visit, and
classified according to the Clavien-Dindo classification .
2.5. Data analysis
A descriptive statistical assay was performed. A nonparametric test (sign
rank test) was used to compare the peak flow before and after surgery.
The effect of the surgical procedure was determined by median
differences and ratios.
3. Results
Eight women agreed to undergo a medical review. One
woman had died 5 yr after the urethroplasty due to an
unrelated disease. This patient had performed a clinical
review 2 mo before death. The mean age at the time of
surgery of the studied group was 56 yr (41–78 yr). The mean
follow-up was 80.77 mo (12–198 mo).
The average time of onset of symptoms was 12 yr
(3–30 yr) prior to surgery. The symptoms appeared in four
of the patients after a bladder catheterization (three from
surgery and one after complications while giving birth). The
remaining patients manifested FUS for unknown reasons,
although two patients described having complicated labors.
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