Technique of urethroplasty for female stricture disease described

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The incidence of obstruction from any cause occurs in approximately 2.7% to 8% of women presenting with lower urinary tract symptoms.

The most common cause is clearly the result of anti-incontinence procedures, but distal urethral stricture disease does occur usually as a result of prior urethral dilation, difficult catheterization with resultant fibrosis, urethral surgery, or trauma. In the past, it was common practice to perform urethral dilations on women who complained of lower urinary tract symptoms. There is no evidence to suggest that this intervention works and many cases of true urethral stricture are likely a result of these unnecessary dilations. The diagnosis is suggested by the presence of lower urinary tract symptoms and the diagnosis can be made with urethral calibration and the inability to place a catheter greater than 12 Fr. Videourodynamics may show an open bladder neck, a relaxed sphincter and a distal narrowed area in the urethra.

Treatment of urethral stricture disease in women has focused on dilations or internal urethrotomy. These procedures carry a low long-term success rate as they do in men and often require frequent and emergent or semi-emergent visits to the urologist office. The literature describes few methods for definitive repair. In a recent report by Ed McGuire and colleagues from the University of Michigan, the authors describe the use of the Blandy urethroplasty and report on their results with the procedure in 8 women. The report is published in the March 2006 issue of the Journal of Urology.

The technique of the vaginal inlay flap Blandy urethroplasty is described. The procedure involves the development of an inverted U shaped vaginal flap with its apex at the urethral meatus. After the plane is developed between the urethra which has been catheterized with a 14 Fr Foley, the stricture is incised at 6 o’clock and, once the entire structure is open, the vaginal flap is apex is sutured to the proximal urethrotomy and the flap is folded over, advanced into, and used to augment the urethra by approximating the urethral mucosa edges to the vaginal flap edges with interrupted sutures. A 16 Fr Foley catheter is placed and left in place for 7 to 10 days. Following catheter removal, patients are started on daily CIC with a 14 Fr catheter.

Analysis of results showed that all patients had subjective relief of their voiding dysfunction. Follow-up was 2 months to 9 years (mean 2.5 years). Only one patient required a repeat dilation which was done 3 weeks after the initial procedure. A stricture was found at the bladder neck in this instance and not at the site of the prior stricture. There were no immediate or delayed complications.

Surgical management of urethral stricture disease in women has been addressed in the last 2 to 4 years in the literature and supports primary surgical repair. It appears that surgery eliminates or dramatically decreases the number of costly and painful repeat office visits for dilation and urethrotomy. The procedure described showed a low complication rate, good medium-term success and the diagnosis of urethral stricture disease in women should be considered when encountering the troubled patient with “urethral syndrome”.

By Michael J. Metro, MD

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