Female Urethral Reconstruction

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.

Distal Urethral Reconstruction

Meatal stenosis and stricture of the distal urethra can be asymptomatic but often present with lower urinary tract symptoms (decreased force of stream, prolonged or incomplete emptying, frequency/urgency). This can be seen following traumatic urethral instrumentation, including catheterization; endoscopic procedures; radiation therapy to the pelvis or vulva for gynecologic, colorectal, or urologic malignancy; and in postmenopausal women with significant vaginal atrophy from estrogen deficiency or with vulvar dystrophy. Meatal stenosis can also be a congenital disorder. The diagnosis of a functional urethral stricture can be made with a combination of history (symptoms), physical examination (obvious scarring and/or the inability to pass a urethral catheter), noninvasive uroflowmetry, endoscopy, and radiography (voiding cystourethrogram), depending on the clinical presentation. In cases of uncertainty as to whether a stricture is causing true obstruction, videourodynamics can be helpful.

The two most common types of urethral reconstruction that we perform are distal circumferential urethrectomy with advancement meatoplasty and the proximally based ventral flap or Blandy urethroplasty. Distal urethrectomy is ideally suited for meatal stenosis and strictures at the very distal urethra while the proximally based ventral flap urethroplasty can be used for strictures up to 2 cm from the meatus.

Distal Urethrectomy With Advancement Meatoplasty

Meatotomy can be performed to treat distal stenosis by simple ventral incision of the meatus and suturing the cut end of the meatus to the vaginal wall. However, in our experience, circumferential, distal urethrectomy and advancement meatoplasty works best for meatal stenosis and very distal strictures.

The extent of the stricture is identified. If desired, interrupted absorbable sutures can be placed in the more proximal, healthy urethral mucosa (at least 2 mm proximal to the strictured segment), at the 6 and 12 o’clock position so that the mucosa does not retract inward. Identification of healthy mucosa can be aided with a nasal speculum. In cases of a severely narrowed urethral meatus, an initial ventral incision may be necessary to identify the extent of the stricture). Fig. 87.1 is an example of a symptomatic meatal stenosis.


Meatal stenosis causing symptoms of decreased force of stream, and urinary frequency and urgency in a postmenopausal woman. Note the fibrotic ring around the meatal opening.

Operative Description

  • 1.

    A circumferential incision is made around the urethra near the mucosal/epithelial junction ( Fig. 87.2, A ) and the urethra and periurethral fascia are mobilized for about 1 cm or the length of the stricture ( Fig. 87.2, B ).

    FIGURE 87.2

    Distal urethrectomy and advancement meatoplasty. ( A ) Circumferential incision is made around the urethra about 2 mm from the mucosal-epithelial border. ( B ) The urethra and periurethral fascia are mobilized away from the vaginal-vestibular epithelium for about 2 cm to allow excision of the diseased distal urethra and advancement of healthy urethral mucosa. ( C ) Prior to excision of the distal urethra, four quadrant sutures are placed in the urethral mucosa, proximal to the scarred segment. ( D ) After excision of the distal urethra, the four quadrant sutures are placed through the periurethral fascia and vaginal-vestibular epithelium creating the neomeatus. ( E ) The reconstruction of the neomeatus is completed by placing sutures between the quadrant sutures.

  • 2.

    Stay sutures (usually 4-0 monocryl or polyglycolic acid) can be placed in two or four quadrants, prior to excision of the distal urethra. These should be placed proximal to the structure into healthy urethral mucosa ( Fig. 87.2, C ).

  • 3.

    After excision of the scarred distal urethra, the quadrant sutures can be placed through the vaginal epithelium creating the neomeatus ( Fig. 87.2, D ) and healthy urethral mucosa is then advanced and circumferentially sutured to the vaginal epithelium in an interrupted fashion ( Fig. 87.2, E ). This creates a neomeatus with well-vascularized, nondiseased mucosa.

  • 4.

    There can be some edema in the immediate postoperative period so a urethral catheter may be left in place for 1–3 days.

Proximally Based Ventral Flap Urethroplasty

The proximally based ventral flap urethroplasty can be preformed for strictures as far proximal as 2 cm from the urethral meatus. The operation was originally described, but never reported, by Blandy. It was subsequently reported on by . The proximally based ventral flap urethroplasty recreates the ventral portion of the urethral meatus and replaces the distal ventral urethra with a flap of vaginal wall.

Operative Description

Jan 2, 2020 | Posted by in UROLOGY | Comments Off on Female Urethral Reconstruction

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