Urethral reconstruction in the female may be done for a variety of conditions. These include urethral stricture, short or ablated urethra (congenital or acquired), sling erosion, urethral diverticulum, urethral prolapse, and urethrovaginal fistula. Procedures to treat urethral diverticulum, urethrovaginal fistula, bladder neck closure, and complications of incontinence surgery are covered elsewhere in this textbook. The focus of this chapter will be on surgical treatment of urethral strictures and urethral lengthening.

In the past two decades, the treatment of male urethral strictures has become more clearly defined, most recently with the establishment of Guidelines from the American Urological Association. However, the same cannot be said for urethral strictures in women. This may be due in part to the relative rarity of recognized urethral strictures in women. However, it may also be because in part, surgeries for female urethral stricture are less well described, most series are small, and many urologists have been content to treat women with repeated urethral dilations and/or self-catheterization, without attempting to cure a curable condition.

Because of the female urethra’s short length, its anatomic position behind the pubic arch, and its relative mobility, the incidence of stricture following pelvic trauma in females is lower than in males (range of 0%–6%). More commonly, stricture disease in women is seen following endoscopic or open urethral surgery, urethral dilatation, and pelvic radiation therapy for pelvic malignancies. Generally, procedures to treat urethral strictures are divided into endoscopic and open repairs, sometimes with the use of local tissue flaps or graft interposition. Because of the relatively short length of the female urethra (~4 cm), stricture excision and end-to-end urethroplasty is not always a feasible option. Although endoscopic treatment by urethrotomy (laser or cold knife) may be attempted for short strictures (≤1 cm), the failure rate is >50% ( ). In most cases, we prefer urethral reconstruction as the primary treatment for women seeking a long-term cure rather than chronic treatment by dilation.

To best understand options for urethral reconstruction, knowledge of urethral anatomy is essential. The female urethra is short compared with its male counterpart and is generally between 2 and 4 cm in length. It is made up of an inner layer of mucosal epithelium with numerous infoldings, creating an effective seal against the passive loss of urine. Beneath the mucosa lies a rich, vascular network of elastic tissue much like the corpus spongiosum. Finally, surrounding the spongy vascular tube is a collagen-rich fibromuscular envelope comprising the periurethral fascia. These three components of a normal urethra are crucial in maintaining continence and enabling dynamic function during increases in abdominal pressure as well as during normal micturition.

There are two primary fascial attachments that provide support to the urethra, the pubourethral ligament and the periurethral fascia that makes up the suburethral hammock that attaches to the arcus tendineus fascia pelvis on each side. The pubourethral ligaments are a band of fascial support the urethra dorsally between the vagina and pubic symphysis. These “ligaments” often serve as a point of anatomic demarcation of the mid- versus proximal urethra. The suburethral hammock is composed of two layers of fascial condensation, the endopelvic fascia and the pubocervical fascia, providing lateral attachment to the arcus tendineus. The midurethra is thought to be the center of continence where the striated sphincter complex maintains both active and passive tone.

When considering surgery for urethral structures, we find it convenient to divide the urethral into three segments, distal, mid-, and proximal, as the surgical techniques used to treat strictures in these three areas vary significantly ( ). Distal strictures including meatal stenosis are limited to the distal 2 cm of the urethra, usually distal to the continence mechanism. In the midurethra, one can have focal strictures, typically caused by trauma or radiation, as well as distal urethral ablation where it is necessary to construct a distal neourethra. Focal proximal urethral strictures are rare and are usually caused by trauma (including iatrogenic strictures). More commonly, proximal strictures are part of a more significant pan urethral process involving most or all of the urethra.