Dorsal Buccal Mucosa Graft

Urethroplasty for Female Urethral Strictures

Roberto Migliari,* Pierluigi Leone, Elisa Berdondini, M. De Angelis, Guido Barbagli
and Enzo Palminteri
From the Department of Urology, Ospedale Santa Maria alla Gruccia, Montevarchi and Center for Urethral Reconstructive Surgery
(EB, GB, EP), Arezzo, Italy

Purpose: We describe the feasibility and complications of dorsal buccal mucosa graft urethroplasty in female patients with
urethral stenosis.
Materials and Methods: From April 2005 to July 2005, 3 women 45 to 65 years old (average age 53.7) with urethral
stricture disease underwent urethral reconstruction using a dorsal buccal mucosa graft. Stricture etiology was unknown in
1 patient, ischemic in 1 and iatrogenic in 1. Buccal mucosa graft length was 5 to 6 cm and width was 2 to 3 cm. The urethra
was freed dorsally until the bladder neck and then opened on the roof. The buccal mucosa patch was sutured to the margins
of the opened urethra and the new roof of the augmented urethra was quilted to the clitoris corpora.
Results: In all cases voiding urethrogram after catheter removal showed a good urethral shape with absent urinary leakage.
No urinary incontinence was evident postoperatively. On urodynamic investigation all patients showed an unobstructed
Blaivas-Groutz nomogram. Two patients complained about irritative voiding symptoms at catheter removal, which subsided
completely and spontaneously after a week.
Conclusions: The dorsal approach with buccal mucosa graft allowed us to reconstruct an adequate urethra in females,
decreasing the risks of incontinence and fistula.

Key Words: urethra, urethral stricture, mouth mucosa, female, transplants

rethral strictures in women have long been debated went urethral reconstruction using dorsal BMG. All patients

U with regard to their etiology and impact on voiding

patterns.1,2 Some groups suggest that most female
urethral strictures are iatrogenic and apart from radiation
complained of preoperative recurrent urinary infection,
straining and a burning sensation during voiding, terminal
dribbling and decreased flow.
inducing urethral fibrosis they may be the consequence of Stricture etiology was unknown in 1 patient, ischemic in
prolonged urethral catheterization or surgical repair of di- 1 due to prolonged catheterization for coma reversal and
verticulum, fistula or anti-incontinence procedures.3–7 Often iatrogenic in 1 due to diverticulum repair. Two patients who
overzealous urethral dilation with subsequent fibrosis due to refused daily clean intermittent catheterization underwent
bleeding and extravasation are among the most frequent multiple prior dilations, which failed before surgical treat-
causes of iatrogenic urethral strictures. Surgical treatment ment. Only 1 patient elected to start a regular program of
in these cases is still debated. It varies from a simple vaginal clean intermittent catheterization, which was interrupted
flap to pedicle labial skin tube urethroplasty wrapped with after 3 months. One patient had experienced failure after
labial fat or omentum depending on stricture complex- previous urethroplasty.
ity.8 –12 To evaluate stricture length all patients were evaluated
BMG represents the gold standard for urethral recon- preoperatively with voiding cystourethrography (fig. 1). In
struction in males with complex hypospadias or urethral all patients urodynamic evaluation showed a stable bladder
strictures.13,14 In male strictures graft urethroplasty using a with low flow and low detrusor pressure with Qmax less
dorsal approach to the urethra has shown improved urethral than 12 ml per second and detrusor pressure at Qmax more
reconstruction due to a decrease in fistulas and graft weak- than 20 cm H2O. Post-void residual volume was 90 to 200
ening by urethral diverticula.15 We suggest the technique of ml. At clinical evaluation the urethral meatus was fibrotic,
urethral stricture correction in females using BMG for ure- while the urethra was rigid and stenotic. No patients com-
throplasty with a dorsal approach. plained of urinary stress incontinence.

MATERIALS AND METHODS

Surgical Technique
From April 2005 to July 2005, 3 women 45 to 65 years old With the patient under general anesthesia in the dorsal
(average age 53.7) with urethral stricture disease under- lithotomy position a 10Fr silicone urethral catheter is posi-
tioned. BMG is harvested from the right inner cheek. The
BMG is 5 to 6 cm long and 2 to 3 cm wide. All patients
Submitted for publication December 14, 2005.
* Correspondence: Via Carpaccio, 9, 52100 Arezzo, Italy (e-mail: undergo free graft urethroplasty using the dorsal approach
[Link]@[Link]). to the urethral lumen.

0022-5347/06/1764-1473/0 1473 Vol. 176, 1473-1476, October 2006

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/[Link].2006.06.043
1474 BUCCAL MUCOSA GRAFT URETHROPLASTY FOR FEMALE URETHRAL STRICTURES

FIG. 3. Buccal mucosa graft tailored about 1.5 cm wide and 4 cm

long is positioned on dorsal part of opened urethra.

The bladder neck is identified by the catheter balloon. A

5-zero stitch is placed on the dorsal surface of the urethra as
close as possible to the bladder neck to mark it. An incision
is made through the entire thickness of the dorsal urethra
(mucosa and spongiosal tissue) from meatus to bladder neck.
By traction with 6 stitches on the edges of the opened ure-
thra the ventral urethral plate is well exposed (fig. 3).
Subsequently the BMG is sutured to the right margin of
FIG. 1. Case 2. Preoperative voiding cystourethrography
the urethral plate and then to the left margin (fig. 4). The
augmented dorsal urethra is quilted to the clitoris body to
cover the new urethral roof. Distal the BMG is tailored and
The dorsal part of the urethra is exposed by a reversed split to achieve a normal meatal slit-like appearance. Fi-
U-shape incision over the meatus starting from the 3 o’clock nally, the vulvar mucosa is reapproximated with 5-zero
to the 9 o’clock position. The vulvar mucosa is separated poliglecaprone sutures.
from the urethral channel and a plane is developed between Patients were discharged home after 2 days. After 15
the underlying urethra and overlying clitoral cavernous tis- days the catheter was removed. Voiding cystourethrography
sue to free the entire length of the urethra (fig. 2). Dissection showed a normal-appearing urethra.
is done with care taken not to damage the bulbs and the
clitoral body crura by staying close to the fibrous tissue of RESULTS
the urethra. During dissection the anterior portion of the
striated urethral sphincter is identified and moved upward. In all cases voiding urethrogram after catheter removal
showed a good urethral shape with absent urinary leakage.

FIG. 4. Left side of buccal mucosa graft is sutured to epithelial

FIG. 2. Whole dorsal part of urethra is dissected free from surround- margin of opened urethra using 6-zero interrupted stitches with
ing tissue. Note anterior part of striated urethral sphincter. knots inside lumen.
 BUCCAL MUCOSA GRAFT URETHROPLASTY FOR FEMALE URETHRAL STRICTURES 1475

On uroflowmetry normal voiding was achieved and no uri- does not cause an increased risk of urinary inconti-
nary incontinence was evident. Two patients complained nence.18 –20
about irritative voiding symptoms at catheter removal, In the recent past a dorsal approach to male urethral
which subsided completely and spontaneously after a week. reconstruction has been proposed.15 The dorsal graft is me-
On urodynamic investigation all patients had an unob- chanically supported by the corpora cavernosa and receives
structed Blaivas-Groutz nomogram with Qmax more than its vascular supply from the surrounding corpus spongio-
12 ml per second and detrusor pressure at Qmax less than sum. This avoids graft weakening due to diverticula and
20 cm H2O. After 6 months the patients were well, residual decreases the risk of fistula.
urine was absent and cosmetic results were satisfactory. Similarly in women dorsal onlay graft urethroplasty of-
fers strong mechanical support, which allows it to fold on
itself, decreasing the chance of neovascularization as well as
DISCUSSION the caliber of the reconstructed urethra. Moreover, saccula-
tion at the graft side, which might further compromise the
Recently normal clitoral anatomy in healthy volunteers has state of the adjacent urethra, facilitating recurrent stricture
been well revealed by magnetic resonance imaging using fat disease, is avoided. Graft apposition on the dorsal surface of
saturation techniques without any contrast agents and this the urethra leads to physiological urethral reconstruction,
study complements cadaveric studies of clitoral anat- providing the possibility of modeling a urethral meatus that
omy.16,17 The bright erectile tissue of the clitoris surrounds is directed upward. It leads to more physiological voiding
the urethrovaginal complex anterolaterally and provides because the urinary stream is directed upward and not
strong dorsal support to the urethra. The clitoral bulbs on toward the vagina. Another positive aspect of this urethro-
either side continue anterior to the urethra and meet to- plasty is that it maintains the ventral part of the mid ure-
gether ventral to the urethra. Dissection studies show that thra intact, leaving the possibility of an anti-incontinence
they are not continuous across the midline. The exact role of procedure on the mid urethra.
the bulbs in urethral support and sexual function is not clear Although it requires optical magnification, this procedure
even if recent studies suggest that they have a significant is easy to perform. In cases of stenosis of the distal urethra
role in urethral continence. A concern about the dorsal ap- or external meatus as well as in cases of longer urethral
proach to the urethra is in regard to a possible lesion of the stenosis involving the mid urethra our dorsal onlay urethro-
neurovascular bundles to the clitoris. The large clitoral neu- plasty technique provides a simple, safe and effective ther-
rovascular bundles ascend along the ischiopubic ramus to apeutic alternative, especially when vaginal fibrosis limits
the under surface of the pubic symphysis in the midline, the use of a pedicled flap. The innovation of dorsal free graft
from which they run along the cephalad surface of the clito- repair may be tested in larger series and long-term followup
ral body toward the glans. Therefore, they are quite far from to evaluate whether a free buccal mucosal graft for female
the dissection area. urethral strictures may be offered as a primary procedure
Several histological studies as well as microdissection17 and whether it is anatomically healthier in the dorsal rather
of the female urethra revealed that the female urethra has 2 than in the ventral position.
thick muscular layers, that is an inner longitudinal layer
and an outer oblique or circular layer. The 2 layers are direct
continuations of the detrusor muscle. The urethral muscu- Abbreviations and Acronyms
lature is thickest close to the bladder and the mid urethra,
and it decreases as it is followed distally. The inner and BMG ⫽ buccal mucosa graft
Qmax ⫽ maximum urine flow
outer layers end sharply in the distal fourth of the urethra
by gaining insertion into dense collagenous tissue. From this
level down to the external meatus the urethral wall is com- REFERENCES
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