Buccal mucosa proves efficacious for the treatment of strictures of the female urethra

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Jun 27 2006

As uncommon as the female urethral stricture is for the general urologist, they present a challenge for the reconstructive urologist.

Many of these patients present with a history of having undergone multiple prior dilations and/or endoscopic urethrotomies, and the ideal durable repair necessitates the use of an interposition graft or flap. Several methods of repair have been reported including the use of anterior vaginal wall flaps, labia minora flaps, vaginal vestibule flaps, and porcine acellular matrix. These techniques are less successful in the setting of inadequate or unhealthy vaginal wall tissue.

Much success has been reported with the use of buccal mucosa grafts for the treatment of male urethral stricture disease. Given the success of this graft material in this setting, a group from the Cleveland Clinic adapted the use of the graft for the repair of two women presenting with recurrent mid to distal urethral strictures. The report, authored by R. K. Bergland, Raymond Rackley and colleagues, is published in the May 2006 issue of Urology.

In the report, two female patients underwent single-stage urethral reconstruction using a ventral buccal mucosa onlay. The patients were aged 50 and 46 years. The diagnosis of urethral stricture was made from the findings on pressure-flow urodynamics of a maximal “free” urinary flow less than 12 mL/s and a bladder pressure or greater than 20 cm H2O during voiding , as well as the findings on cystoscopy of a urethral narrowing analogous in appearance to that found in men with stricture.

The operative procedure involved harvesting a 2.0 cm to 2.5 cm wide buccal graft from the inner cheek. A longitudinal incision was made in the vagina from the distal urethra to the bladder neck. An incision is then made in the urethra, opening it ventrally at the 6 o’clock position through the meatus and into healthy tissue proximally. The graft is then sutured in place with 5-0 polyglyconate sutures, with the mucosal surface pointing into the lumen. One patient had a 4 cm long and one had a 5 cm long graft. The repair is then covered with mobilized periurethral soft tissue or a Martius flap if needed. The vaginal wall is then closed and an 18F silicone urethral catheter and a 22F suprapubic tube are left in place. The urethral catheter is left in place for 6 weeks until a VCUG is done to assure adequate healing and urethral patentcy.

At follow-up of 12 and 30 months, both patients were stricture free and both were continent. One patient was found to have a meatal stenosis distal to the graft site 5 months after her surgery which was treated with a meatal dilation and she has been symptom free for 25 months. The repair of a recurrent female urethral stricture is an uncommon and complex procedure with no accepted standard approach. In this small series, a ventral onlay buccal mucosa onlay proved to be successful and should be considered for recurrent mid to distal female urethral strictures.

By Michael J. Metro, MD

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