Female urethral stricture: A multi-centre experience and lessons learnt

Objectives

To review demographics, surgical techniques and outcomes of female patients undergoing buccal mucosal graft substitution urethroplasty.

Materials and methods

An international multi-institutional study was performed through a retrospective review of a prospectively managed database of female urethroplasty outcomes at two sites from December 2016 to June 2023. Institutions included a high-volume tertiary referral centre performing 500 urethroplasties annually, and a regional centre with a fellowship-trained urethroplasty surgeon performing ~50 urethroplasties annually. Female urethroplasty accounted for 2% of urethroplasties performed, utilising dorsal onlay, ventral inlay and double-face techniques.

Results

Forty-two patients underwent female urethroplasty between 2016 and 2023; 20 dorsal onlay grafts, 14 ventral inlay grafts and 8 double-face urethroplasty. The mean age was 45 years (SD 12.07) and mean follow-up 27 months (SD 17.22). The most common aetiology was idiopathic in 59%. The most common presenting symptom was obstructive lower urinary tract symptoms in 86%. Urethral dilatations were the most common treatment before urethroplasty, with a mean of 9 (SD 1.2) dilations pre-urethroplasty. Stricture locations seen were; proximal 7%, proximal to mid-14%, mid-31%, mid to distal 10% and distal 38%. A total of 88% were successful overall; dorsal onlay was 100%, ventral inlay urethroplasties 71% and double-face 88%. Mean Qmax improvement was 291% at 6 months. In those who required dilatations or further surgery postoperatively (n = 5); four were ventral inlay (one mid-distal, three distal), and one double-face distal stricture. All patients including those requiring secondary treatments were continent and did not require intermittent self-catheterisation or suprapubic catheter insertion.

Conclusion

Urethroplasty is an effective long-term therapeutic option for managing female urethral strictures. Dorsal onlay urethroplasty demonstrated the highest success rate, and stands out as a versatile technique, addressing distal to proximal urethral strictures. However, the chosen urethroplasty technique should be tailored to the characteristics of the stricture, patient and surgeons experience.