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reduced urethral caliber ( 12 Fr) that significantly reduced
maximum urinary flow ( 11 ml/sg). Voiding cystoure-
thrography confirmed the stenosis and its characteristics.
The patient’s clinical history, along with the combination of
tests the performed, make a proper diagnosis highly likely,
not requiring further testing.
In cases where there is a mild stricture with urethral
calibration doubtfully normal, the diagnosis becomes very
difficult. Two of our patients presented 16 Fr and 18 Fr of
urethral caliber, respectively. What constitutes an abnor-
mal urethra in women is a matter of controversy. In
previous studies, Powell and Powell
[15]and Montorsi et al
[3]applied a 20-Fr caliber as diagnostic criteria. However,
other authors reported that the caliber should be equal to or
less than 17 Fr
[16], or even
<
14 Fr
[17,18]for FUS to be
considered. This debate is also observed in studies with
healthy women. In this population certain studies have
observed average calibers of 22 Fr
[19]and 23.7 1.9 Fr
[20], yet other authors have suggested that a normal urethra
should accommodate a 30-Fr catheter
[21] .This lack of
agreement in both healthy and affected women is likely to be
in part due to the subjective nature of urethral calibration.
In cases where there is doubt, urethroscopy and
urodynamic evaluation may help in the diagnosis. In the
first case, the feel of scar tissue in a urethra that cannot
admit a 17-Fr flexible cystoscope is considered as a method
of diagnosing stricture
[16]. However, in our study,
urethroscopy was not conclusive for the two patients that
we analyzed. As for the urodynamic evaluation, in one case
this was also not decisive, as obstruction criteria were not
present. In the other doubtful case, detrusor pressure at
maximum flow was abnormally elevated. In this regard,
Goel et al
[18]observed a preoperative mean maximum
detrusor pressure at maximum flow of 142.7 cm H
2
O
(87–240 cm H
2
O). Blaivas et al
[16]observed that 10 out of
14 patients satisfied videourodynamic studies criteria for
obstruction and four had impaired detrusor contractility.
Kuo
[22]found a mean detrusor pressure of 60.9 34.2 cm
H
2
O and mean Q
max
of 8.6 3.8 ml/s. However, there is no
consensus regarding the urodynamic diagnostic criteria for
bladder outlet obstruction due to the considerable variation in
normal female voiding function
[22,23].
Voiding cystourethrogarphy, however, allowed us to
properly diagnose urethral stenosis in the two doubtful cases.
In our study, cystourethrography gave rise to two possible
results. The most frequent was a narrow segment in the
urethra, with proximal urethral and bladder neck ballooning.
In the other cases, the whole urethra was rigid. As far as we
know, this is the first report that describes this observation.
Because urethral strictures are so uncommon and high
quality studies are sparse, the indications for treatment
modalities are not well defined. Treatment options include
urethral dilatation and urethroplasty. Although there is
limited data, the majority of the published reports suggest
that urethral dilatation is only effective for a short period of
time
[8,16–18,24] .However, Romman et al
[25]reported a
51% success rate with a mean follow-up of 46 37 mo. In
our study, none of the patients treated with urethral dilatation
had such a sustained response. It is difficult to decide when to
undertake surgery. In our case, we used the criteria of short-
term dilatation efficacy and continuous discomfort.
Urethroplasty techniques include vaginal and labial flap
and graft urethroplasty, as well as oral graft urethroplasty
either using a dorsal or ventral approach. The reports using
these approaches indicated positive results with minimal
complications
[2–9].
Palou et al
[2]were the first to use a proximal-based
vaginal flap for female urethral stenosis. This was our first
choice for female urethral stricture repair. However, our
patients reported an inward urinary stream. Onol et al
[8]observed the same complication in two of their patients,
although it improved within 6 mo. In our case, we decided
to use a lateral-based anterior vaginal wall flap, based on
the Orandi technique for male urethroplasty
[12]. Using this
technique, the meatus remains in an orthotopic position,
with no effect on the direction of the urinary stream. We
believe this report to be the first to perform an augmenta-
tion urethroplasty in this manner.
Simonato et al
[17]described a vaginal flap urethroplasty
technique using a lateral vascular pedicle. In this case, the
flap is partially de-epithelialized and the apex is inverted
onto itself, suturing the more distal flap portion to the left
side of the open urethra. The authors claimed that de-
epithelialization of this area favored scar tissue formation.
The results of the study were very positive, although the
procedure seemed definitely more complex.
The technique described in our study is simple to
perform and does not require tissue tunneling or flap
rotation, unlike other flap procedures
[3,4]. There is little
distortion of the vagina, the vascular axis is preserved, and
the flap is located in a position that is familiar to urologists
performing pelvic floor surgery.
No complications were observed during or after the
procedure, and no recurrence was reported in the follow-
ups. However, this study was performed on a low number of
patients, due to the rarity of the condition, and does not
allow for definite conclusions. Goel et al
[18]reported two
recurrences in eight patients operated with onlay buccal
mucosa grafting at 12 mo and another one at 18 mo.
Kowalik et al
[26]reported two recurrences at 20 mo and
34 mo using the Blandy technique, while Blaivas et al
[16]had two recurrences after 6 yr with the same technique.
The negative symptoms and the urinary tract infection had
disappeared in all our patients presumably as a result of
stricture relief and its consequences. Maximum flow im-
proved very significantly, with a median increase of 16.5 ml/s
and ratio of 3:25, respectively. Patient-related outcomes
evaluated using the PGI-I questionnaire were also very
satisfactory, with all the patients feeling much better after
the surgery.
No patient developed incontinence, despite the fact that
the repair extended up to the bladder neck in three cases.
Osman et al
[10] ,in a systematic review concerning FUS, did
not report of any case where incontinence appeared after
urethroplasty. Blaivas et al
[16]added a concomitant
pubovaginal sling in five out of nine patients, as they were
considered to be at high risk of sphincteric incontinence.
According to our experience, we would recommend to
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