Female urethral stricture (FUS) is one of the least understood diseases in urology. The incidence of FUS is reported to be low (0.1-1%) and 4-10% among females with bladder outlet obstruction. However, the true incidence of FUS is still unknown. The lack of uniform criteria for diagnosing FUS poses a major challenge for urologists worldwide. The first description of vaginal flap urethroplasty was by Hariss in 1935. It took a long time for urologists to acknowledge female urethral reconstructive procedures due to their difficulty and imminent threat to functional and sexual complications. Urethral dilatation has remained the first and most frequent treatment method for female urethral stricture. Recently, dorsal onlay buccal mucosal graft urethroplasty has become a popular and preferred choice of urethral stricture repair. Another surgical repair, Ventral inlay buccal mucosal graft urethroplasty, has also shown promising outcomes in limited series. The main advantage of the Ventral inlay buccal mucosal graft urethroplasty technique over dorsal onlay buccal mucosal graft urethroplasty is preserving the neurovascular bundle. In our study, we aim to compare the outcomes of Ventral inlay buccal mucosal graft urethroplasty with dorsal onlay buccal mucosal graft urethroplasty for the treatment of Female urethral stricture.

This retrospective study included women who underwent either Ventral inlay buccal mucosal graft urethroplasty or dorsal onlay buccal mucosal graft urethroplasty between January 2016 and March 2023. The screening criteria involved an AUA symptom score >7 or a maximum urinary flow rate (Qmax) of <12 ml/s or thick trabeculated bladder on ultrasonography with post-void residual volume (PVR) > 100ml with inability/difficulty (snugly fit) to calibrate with 12 Fr catheter. To confirm the diagnosis of FUS, a cystourethroscopy with a 30o 6 Fr pediatric scope (Olympus A3765A) was done to see scarred urethral mucosa and narrowed lumen. The length and location of the stricture on cystoscopy were noted and all data were prospectively maintained in an  electronic database. The primary outcome was the success rate. The secondary outcomes were changes in AUA score, PVR, and Qmax. The data obtained from the patient’s last visit was compared with the preoperative values for this study. The patient's last follow-up visit was considered for the duration of the follow-up, with minimum 1-year follow-up required for inclusion in this analysis. The patients were followed up at postoperative 3, 6, and 12 months, and later, according to the surgeon or patient’s preference. The AUA symptom score, PVR, and Qmax were recorded at each visit and entered prospectively in an electronic database.

Seventy-three patients were treated for BMGU for FUS. Forty-six patients underwent Ventral inlay buccal mucosal graft urethroplasty, and 27 patients underwent dorsal onlay buccal mucosal graft urethroplasty. The median stricture length was 20 mm (15-30) versus 25 mm (10-40). The mean duration of follow-up was 27.5 versus 14 months respectively. The success rates of Ventral inlay buccal mucosal graft urethroplasty and Dorsal onlay buccal mucosal graft urethroplasty were 89.13% (41/46) and 88.89% (24/27) respectively. The recurrence was seen in 5/46 patients who underwent Ventral inlay buccal mucosal graft urethroplasty and 3/27 in the dorsal onlay buccal mucosal graft urethroplasty group.  There was a reduction in AUA scores and PVR and an improvement in Qmax postoperatively in both groups. The difference in the reduction in AUA scores between the Ventral inlay buccal mucosal graft urethroplasty and Dorsal onlay buccal mucosal graft urethroplasty groups was statistically significant(p=0.007). The difference was not statistically significant in terms of reduction in PVR and improvement in Qmax between the two groups.

This retrospective long term follow up study showed than urethroplasty in female urethral stricture had high success rates  with no significant difference between the two techniques. Recurrence rates were low in both groups. Both techniques also led to improvements in AUA scores and PVR, with no significant difference between the two groups in terms of PVR and Qmax improvement.
However, there was a statistically significant difference in the reduction of AUA scores between the two groups, favoring the Ventral inlay technique. This suggests that Ventral inlay buccal mucosal graft urethroplasty may offer slightly better symptomatic improvement compared to dorsal onlay buccal mucosal graft urethroplasty.

The ventral inlay technique can provide equal results to the dorsal technique with the added advantage of vaginal sparing. This is the single largest series in literature on female urethral stricture with the largest follow-up period of 75 months.

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Faiena I, Koprowski C, Tunuguntla H. Female Urethral Reconstruction. J Urol. 2016;195(3):557-567. doi:10.1016/j.juro.2015.07.124
Waterloos M, Verla W. Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease. Biomed Res Int. 2019;2019:6715257. Published 2019 Feb 18. doi:10.1155/2019/6715257

Continence 12S (2024) 101573
DOI: 10.1016/j.cont.2024.101573