The choice of surgical technique is dictated by a number of factors including (1) the experience and expertise of the surgeon, (2) the desires of the patient, (3) the patient’s age and comorbidities, (4) lower urinary tract and renal function, (5) the presence of concomitant conditions such as pelvic organ prolapse or abdominal or pelvic disease requiring surgical correction, (6) prior abdominal and pelvic surgical procedures, and (7) sexual function:

Before proceeding with the vaginal incision, it is critical to choose the site and shape of the initial incision for the urethral reconstruction. We have previously described several methods of urethral reconstruction for stricture, and in the majority of the cases, the repair can be accomplished with a single transvaginal operation [1].

All surgical approaches follow the same rules: fine sharp dissection is preferable and homeostasis is maintained. Sharp dissection permits the development of correct planes and excision of the dense fibrotic tissue and may prevent inadvertent injury to the bladder or sphincter. The urethra should be opened proximal enough to clearly see the extent of the urethral stricture when present. If the edges of the stricture are uncertain, we place progressively larger bougie-a-boule sounds into the urethra past the area of suspected stricture. As the sound is pulled back it will catch on the stricture. The urethrotomy is extended until the bougies can be withdrawn without resistance. In addition to aiding visualization, attention to homeostasis may prevent hematoma and breakdown of the sutures lines. When excessive bleeding is encountered, pressure should be applied until the bleeding stops or bleeding vessels individually clamped and sutured or coagulated. Frantic efforts to control hemorrhage without clearly identifying the bleeding vessels may lead to unnecessary injury to adjacent organs.

In preparing for vaginal surgery, the patient is placed in a dorsal lithotomy position with the least degree of Trendelenburg that is necessary for adequate exposure. Draping should permit access to the vagina as well as abdominal area (when concomitant surgery is planned). At the onset of surgery, the bladder is drained via a transurethral catheter and palpation of the balloon allows identification of the bladder neck. If suprapubic cystotomy, pubovaginal sling, or rectus muscle graft is planned, these should be done prior to the vaginal reconstructive surgery to avoid subsequent damage to the reconstruction during dissection for these procedures. For pubovaginal slings, though, the sutures should not be tied until the reconstruction has been completed so that tension can be judged.

In cases of minimal urethral disruption, such as small urethrovaginal fistula or diverticulum, the defect can be circumscribed and closed over a catheter with tension-free, interrupted sutures of 3–4:O chromic catgut. An inverted U anterior vaginal wall flap is usually adequate for closure, but sometimes a lateral vaginal flap may be more appropriate.

If urethral injury is extensive and sufficient vaginal wall tissue exists, vaginal wall flaps may be considered. Flap-based urethroplasty techniques have been demonstrated to be effective and improve the outcome in the urethrovaginal fistulas and are the treatment of choice for most female urethral strictures that are distal to the sphincter mechanism [2–4]. In one such technique, the anterior vaginal wall can be mobilized and a rectangular incision around the urethral defect is made. A lateral vaginal wall flap is advanced, rolled over the catheter, and sutured to the contralateral side, without tension, to form the entire posterior urethral wall. However, if the extent of urethral injury and lack of vaginal tissue preclude simple repair, use of an advancement flap may be required. Another choice is to create a labia minora flap. An oval-shaped incision is made in an adjacent hair-free portion of the labia minora and carried through the underlying tissue and a pedicle is raised on a posterior- or anterior-based blood supply. This island flap is tunneled beneath the vaginal wall, rotated, and sutured over the catheter, so the vaginal epithelial surface creates the inner wall of the urethra. Rarely, it is not possible to close the defect in the vaginal wall primarily and in such instances, it is possible to create a labia majora flap to cover the wound. We have only needed a gracilis flap on one occasion and have never used any other major kind of flap (rectus, Singapore, etc.), but of course, those are available if needed [1].

Urethral damage associated with erosion of synthetic material poses unique considerations and the repairs can be even more challenging [5]. Most authors agree that eroded synthetic slings require complete removal of the sling from the urethra and bladder. The literature on the surgical management of erosions suggests midline anterior vaginal wall incision at the erosion site, bilateral dissection into the retropubic space, and removal of the entire synthetic sling including sutures, and when possible, bone anchors if they were used [6]. In our experience, especially with transobturator techniques, attempting to remove the entire sling leads to difficult and morbid surgery and should probably be reserved for those who failed at first attempt. Once the sling has been excised, the urethra can usually be repaired primarily. If this is not feasible, any of the techniques described above may be considered.

For patients with distal urethral strictures, ventral urethroplasty using vaginal and labial skin flaps is, in our judgment, the least morbid technique . This approach is utilized in patients with mid-to-distal urethral strictures and an intact bladder neck and urinary sphincter mechanism. However, ventral urethrotomy risks urethral sphincter damage and de novo urinary incontinence when the stricture involves the proximal urethra or when sphincteric incontinence was present preoperatively. In cases of documented preoperative sphincteric incontinence, the dorsal approach offers easier access to the bladder neck and permits an easier concomitant anti-incontinence procedure.

Unlike the dorsal approach, ventral urethroplasty may redirect the urethra and the urinary stream anteriorly or posteriorly. When the urethra is too short, a vaginally directed urinary stream that causes post-void dribbling may occur. In some patients, there has been spontaneous resolution; in others, reconstructive surgery to lengthen the urethra may be required [7]. If the urethra is too long, there may be an excessive arc to the stream and the patient may actually void over the toilet bowl. This is easily corrected with a ventral meatotomy.

Vaginal tissue from the labia minor has be reported as a free inlay graft with minimal short-term complications [8]. Several groups have proposed a dorsal onlay urethroplasty using buccal mucosa graft [9, 10], labia minora skin graft [11], or vestibular flap [12]. The dorsal technique has several advantages, but requires different surgical expertise, utilizing many of the surgical principles derived from urethral reconstruction in men. A surgical plane is developed between the urethra and overlying clitoral cavernous tissue. Care should be taken during the dissection of the dorsal urethra to avoid injury to the clitoral bulb, body or crura, and the clitoral neurovascular bundle and minimize excessive bleeding. The clitoro-urethrovaginal complex is supplied by pudendal neurovascular bundles which arise from pelvic side walls and bifurcate into clitoral and perineal divisions. The clitoral neurovascular bundle ascends along the ischiopubic ramus and adjacent clitoral crura on both sides, runs under the surface of the symphysis pubis in the midline, and then travels along the cephaled surface of the clitoral body towards the glans (Fig. 19.5). The nerves of the clitoral neurovascular bundle are not large enough to be seen on the MRI. However, the histological dissections show that they accompany the vessels [13].

From a practical standpoint, it is fairly straightforward to avoid these structures during the dissection by confining the dissection to the dorsal urethra. We are not aware of any reports of injury to the clitoral structures, nor have there been any reports of orgasmic changes. Our experience corroborates these findings.

Not infrequently during the dissection troublesome bleeding is encountered, but we caution against blind coagulation or suture ligature. All that is usually necessary is to place a gauze pack between the dorsal urethra and pubis, extending into the retropubic space for compression. Positioning the graft on the dorsal surface preserves intact ventral midurethra and provides a better vascular bed for a graft. In our judgment, doing so minimizes the likelihood of requiring an incontinence procedure. However, unlike the ventral approach, dorsal dissection is infrequently performed in pelvic reconstructive surgery , and for most surgeons, the anatomy is not well known. Further, most pelvic surgeons are unfamiliar with the techniques of graft reconstruction that are done much more commonly in men .

One of the challenges of urethral reconstruction is achieving a long and stricture-free lumen that allows nonobstructive voiding and maintains continence. Due to the variable etiology of the urethral pathology, local tissue may not be available for the urethral repair. In cases of extensive posttraumatic or postsurgical urethral fibrosis, congenital malformations, and recurrent urethral strictures , reconstructing the urethra with a free graft provides an alternative to a vaginal flap or bladder flap.