2009 The Authors; Journal compilation
Original Articles
2009 BJU International
DORSAL ONLAY LMG URETHROPLASTY IN WOMEN
SHARMA
et al.
BJUI
Dorsal onlay lingual mucosal graft urethroplasty
for urethral strictures in women
BJU INTERNATIONAL
Girish K. Sharma, Ashwani Pandey, Harbans Bansal, Sameer Swain,
Suren K. Das, Sameer Trivedi, Udai S. Dwivedi and Pratap B. Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Accepted for publication 5 June 2009
Study Type – Therapy (case series)
Level of Evidence 4
OBJECTIVE
To describe the technique and results of
dorsal onlay lingual mucosal graft (LMG)
urethroplasty for the definitive management
of urethral strictures in women.
2008. After a suprameatal inverted-U
incision, the dorsal aspect of the urethra was
dissected and urethrotomy was done at the
12 o’clock position across the strictured
segment. Tailored LMG harvested from the
ventrolateral aspect of the tongue was then
sutured to the urethrotomy wound over an
18 F silicone catheter.
RESULTS
PATIENTS AND METHODS
In all, 15 women (mean age 42 years) with a
history suggestive of urethral stricture who
had undergone multiple urethral dilatations
and/or urethrotomy were selected for dorsal
onlay LMG urethroplasty after thorough
evaluation, from October 2006 to March
INTRODUCTION
The incidence of lower urinary tract
obstruction, held responsible for LUTS in
women has been reported in 2.7–8% of cases
[1–3]. Urethral stricture accounts for 4–13%
of cases of female BOO presenting with LUTS
[4–6]. Strict diagnostic criteria of female
urethral stricture disease have not been
established because of its rarity. A female
urethral stricture has been defined as a fixed
anatomical narrowing of <14 F between
the bladder neck and distal urethra
responsible for symptoms and preventing
instrumentation. This 14 F threshold was
chosen as the lower limit value of ‘normal’
urethral diameter in young-adult women
based on lack of clinical finding of LUTS in
such candidates [7]. According to Defreitas
et al. in women, a detrusor pressure of
>25 cmH2O and a maximum urinary flow
rate (Qmax) of <12 mL/s is consistent with
obstruction [8].
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The preoperative mean maximum urinary
flow rate of 7.2 mL/s increased to 29.87 mL/
s, 26.95 mL/s and 26.86 mL/s with a ‘normal’
flow rate curve at 3, 6 and 12 months
follow-up, respectively. One patient at the 3month follow-up had submeatal stenosis
and required urethral dilatation thrice at
The aetiology of female urethral stricture is a
controversial subject; however, most urethral
strictures in females are of iatrogenic or
traumatic origin, e.g. after prolonged or
difficult catheterization, childbirth, pelvic
fracture, surgical repair of urethral
diverticulum, fistula or incontinence and after
pelvic radiation. While there are many reports
of female urethral stricture disease after
acute or chronic urethritis and cystitis but
many cases remain idiopathic [9]. In the
recent past, it was a common practice to use
urethral dilatation in women with LUTS
including for urgency, frequency and
recurrent UTI, and many cases of iatrogenic
urethral stricture are probably the result of
these unnecessary or overzealous dilatations
with subsequent fibrosis from bleeding and
extravasation [10].
The current opinion for the treatment of
female urethral stricture suggests judicious
application of urethral dilatation, or
monthly intervals. At the 1-year follow-up,
none of the present patients had any
neurosensory complications, urinary
incontinence, or long-term functional/
aesthetic complication at the donor site.
CONCLUSION
LMG urethroplasty using the dorsal onlay
technique should be offered for correction of
persistent female urethral stricture as it
provides a simple, safe and effective
approach with durable results.
KEYWORDS
female urethral stricture, lingual mucosal
graft, dorsal onlay lingual mucosal graft,
urethroplasty
urethrotomy as recurrence rates remain high
and this may exacerbate periurethral fibrosis,
therefore consideration should be given for
early open repair after recurrence following a
conservative approach [1,10].
PATIENTS AND METHODS
We selected 15 women with urethral stricture
disease, with a mean (range) age of 42
(25–65) years, for corrective surgery using
dorsal lingual mucosal graft (LMG) from
October 2006 to March 2008. All patients had
a history suggestive of urethral stricture
disease and were evaluated with a physical
examination: ultrasonography of the kidney,
ureter, and bladder region for upper tract
changes, urinary bladder appearance and the
postvoid residual urine volume (PVR); voiding
cysto-urethrography (VCUG) to show changes
in the upper tract and urinary bladder, bladder
neck and dilated urethra proximal to stricture
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S H A R M A ET AL.
segment; urethrocystoscopy using a
paediatric scope; and urodynamic studies in
selected cases.
Patients with a history of urethral, urinary
bladder and gynaecological malignancy were
not included in the present study. Other
exclusion criteria were leukoplakia,
submucosal fibrosis or malignancy of the oral
cavity, oral neuropathies, patients with
primary bladder neck obstruction or with a
history of anti-incontinence procedures.
In most of the women (nine of 15) stricture
was idiopathic, in three there was a history of
prolonged catheterization while obstetric
trauma and previous urethral caruncle
surgery were implicated in two and one
patients, respectively. All of these patients
with recurrent LUTS had had previous
interventions including multiple urethral
dilatations and/or urethrotomy with relief of
their symptoms for few weeks to months
followed by recurrence of their obstructive
voiding symptoms.
For the procedure, patients were asked to
maintain oral hygiene and were started on 5%
povidine iodine mouth gargling thrice daily,
48 h before surgery. The surgical procedure
was performed under combined spinal and
epidural block for postoperative maintenance
of analgesia and general anaesthesia was
given only at the time of LMG harvesting to
reduce the duration of general anaesthesia
with the oro-tracheal tube fixed at an angle in
the mouth on the right side.
After placing the patient in the dorsal
lithotomy position, povidine-iodine
preparation was used in the perineal area. A
6–10 F infant feeding tube or ureteric
catheter over a guidewire was inserted into
the urethra. Two traction sutures using 3/0
chromic catgut suture were applied at the 3
and 9 o’clock positions of the urethral margin.
An inverted-U incision was marked in the
suprameatal region from the 3 to 9 o’clock
position to expose the dorsal aspect of the
urethra (Fig. 1). The desired length of the
urethra was dissected free by sharply
dissecting the vulvar mucosa off the urethral
channel (Fig. 2) by developing a plane
between the urethra and clitoral cavernosal
tissue with care so as not to damage the bulb,
clitoral body crura and the anterior portion of
the striated sphincter that was reflected
upward. Dorsally the urethral wall was incised
from the meatus through the strictured
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segment at the 12 o’clock position until
reaching normal urethral mucosa, where a
4/0 polyglactin marker suture was placed. The
proximal ‘normal’ appearing urethra was then
calibrated and the length of the urethrotomy
wound measured to find the required length
of the LMG.
After oro-tracheal intubation, a mouth
opener was placed and oro-pharyngeal
packing was used to prevent aspiration. The
tongue was pulled out of the mouth with a
traction suture applied at tip of the tongue.
The required LMG length was then marked
with a mucosal deep incision of 10–15 mm
width on the ventro-lateral aspect of the
tongue starting from its posterior part. Two
stay sutures (4/0 chromic catgut suture) were
taken at the proximal margin of the LMG to
elevate it, and a full thickness LMG was then
harvested using a right-angled scissors. The
donor site was closed simultaneously with
4/0 polyglactin suture in a continuous
running fashion with interlocking, to achieve
haemostasis and good cosmesis (Fig. 3). The
harvested LMG was then processed by
removal of all the submucosal adventitial
tissue and tailored according to the required
length.
For the dorsal onlay LMG urethroplasty, the
mucosal aspect of the tailored LMG was
placed upon the urethral lumen as shown in
Figure 4. The LMG was fixed most proximally
with a pre-placed marking suture;
subsequently the graft was sutured to the
right and left urethral edge including bits of
tissue from the roof for proper dorsal fixation,
using interrupted 4/0 polyglactin suture with
particular attention to mucosa-to-mucosa
apposition, over an 18 F indwelling silicon
catheter. Before making the most distal
sutures, the graft was also fixed dorsally with
one suture midway and then distally it was
quilted to the clitoral body to cover the new
urethral roof. Then the vulvar mucosa was reapproximated with interposed lingual
mucosal graft by taking knots of interrupted
sutures outside the lumen (Fig. 5). A mild
compressive vaginal pack dressing was then
applied.
FIG. 1. Inverted-U incision in suprameatal region
from the 3 to 9 o’clock position.
FIG. 2. Plane of dissection between the dorsal aspect
of the urethra and the overlying clitoral cavernosal
tissue and the dorsal urethral incision.
FIG. 3. Tailored LMG and closed LMG-harvest site
with continuous suturing.
FIG. 4. Mucosal aspect of tailored LMG is placed for
apposition of margins of LMG with urethrotomy
wound.
RESULTS
After 15 days the patients underwent a trail
of voiding and VCUG to establish a ‘normal’
urethra. Patients were then followed at 3, 6
and 12 months with uroflometry and a
detailed questionnaire about relief of voiding
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DORSAL ONLAY LMG URETHROPLASTY IN WOMEN
FIG. 5. External meatus appearance at the end of the
urethroplasty.
symptoms and urinary incontinence if any.
VCUG was advised at the 6- and 12-month
follow-ups and urethrocystoscopy performed
if required at of the follow-up visits. The
criteria for a successful reconstruction was a
Qmax of ≥15 mL/s with a normal appearing
flow rate curve in asymptomatic patients with
no postoperative requirement of any kind for
instrumentation and a normal VCUG.
generalized consensus for the best size of
catheter to be used and the best regimen of
CISC in these patients [7].
Several materials have been tried for
substitution urethroplasty or total urethral
reconstruction and essentially they fall into
two groups, i.e. a vascularized flap from the
local genital region or free grafts. Difficulties
arise where suitable local tissue is lacking
as in women with low oestrogen level
physiological states or in women with lichen
sclerosus where the perivulvar skin becomes
fragile, thin and atrophic with scarring
leading to fusion of the labia minora and
narrowing of the introitus [11].
Although few studies are available on female
urethral stricture disease, reports by various
authors during the last 5–6 years, suggest
that surgical repair of the stricture eliminates
or decreases the number of repeated urethral
dilatations and urethrotomies, especially in
women who are not compliant with CISC.
The mean urethral stricture and harvested
graft length in the present series was 2.45 cm
and 2.95 cm, respectively. The preoperative
mean Qmax of 7.2 mL/s increased to 29.87 mL/
s, 26.95 mL/s and 26.86 mL/s with normal
flow rate curves at the 3-, 6- and 12-month
follow-ups, respectively. One patient had
wound infection and was managed
conservatively. At the 3-month follow-up, this
patient had recurrence of obstructive voiding
symptoms with a Qmax of <15 mL/s and upon
evaluation was found to have submeatal
stenosis. This patient required urethral
dilatations at monthly intervals, which
resolved the voiding symptoms and the Qmax
improved from 11 mL/s to 22 mL/s at the
6 month follow-up with no PVR and a normal
VCUG. At the 1-year follow-up, none of
the present patients complained of any
neurosensory complication, urinary voiding
symptoms or urinary incontinence, or any
long-term functional or aesthetic
complications at the donor site.
In 2002, Tanello et al. [12] described the use of
a pedicle flap from the labia minora in the
treatment of urethral strictures in two
women. Although the series was small, the
outcomes were good with resolution of the
strictures. In a larger series, Montorsi et al.
[13] described the use of a pedicle flap from
the vaginal vestibule for patch urethroplasty
in 17 women with significant improvement in
voiding symptoms in 15 (88%) of their cases.
Schwender et al. [1] created a vaginal flap in
an inverted U-shape, with its apex at the
urethral meatus to repair urethral strictures in
eight women. They advocated it to be a
simpler procedure, as it did not require tissue
tunnelling or flap rotation apart from a little
distortion of the vagina and paravaginal
tissue. The mean calibre of the urethra in their
series increased from 9.25 F to 16.5 F with
subjective relief of voiding symptoms in a
mean follow-up of 2.5 years and only one
patient required a repeat dilatation, at
3 weeks after the primary procedure.
DISCUSSION
Since the first reported use of buccal mucosa
(BM) in urethroplasty for male stricture by el
Kasaby et al. [14], and given the success of
BM grafts (BMG) in male urethroplasty in
numerous reports, authors have applied this
technique to female urethral stricture disease
[10,15,16].
Typically, a minimally invasive procedure in
the form of urethral dilatation followed by
clean intermittent self-catheterization (CISC)
is the initial procedure offered to women with
urethral stricture disease, but the incidence of
short-term recurrences of stricture after this
method is high, because of lack of compliance
with CISC. Apart from this, there is no
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Berglund et al. [16] presented the first series
of two women treated with a ventral BMG for
urethral stricture, although one had
recurrence of LUTS requiring meatal
dilatation. Tsivian and Sidi [15] treated three
women with recurrent urethral stricture by
dorsal graft urethroplasty using vaginal
mucosa in two and BMG in one. All the
women had normal voiding after catheter
removal and no further intervention was
required during 1, 8, and 27 months of
follow-up in that series. Migliari et al. [10]
performed a similar procedure using dorsal
BMG onlay in three women with urethral
strictures and reported good results with
unobstructed Blaivas-Groutz nomograms on
follow-up urodynamics.
The mucosa covering the ventro-lateral
aspect of the tongue has no particular
functional features, is thin, smooth, and
identical in structure to that lining the rest of
the mucosa of the oral cavity. Considering
these favourable properties of LM, Simonato
et al. [17] used LMG for managing urethral
stricture in eight men and reported successful
reconstruction in seven at the 1-year followup. Since then reports of LMG urethroplasty
in male anterior urethral stricture disease
from our centre have been published [18–21].
In the present study, we chose LM as the graft
material because of our previous experience
with LMG harvesting with minimal morbidity
and good results for urethroplasty in men.
LM fulfills all the requirements of an optimal
graft material for substitution urethroplasty,
i.e. like BM, LM is easily accessible, hairless,
naturally wet, has favourable immunological
properties (resistance to infection) and
optimal tissue characteristic (thick epithelium,
high elastic fibre content, thin lamina propria,
rich vascularization thus favouring imbibition,
inosculation and re-vascularization) [17].
• LMG can be easily harvested as the tongue
can be pulled to the operative field outside
the oral cavity.
• A mucosal strip of up to 7–8 cm long can
be harvested from one ventro-lateral aspect
of tongue in continuity with minimal-to-no
donor-site morbidity [18].
Distinct advantages of a harvesting LMG
instead of a BMG are the complete avoidance
of injury to the parotid duct and mental nerve
and avoidance of deviation of the angle of the
mouth and retraction of the lip.
Recently, small series using the dorsal
approach for female urethroplasty by Migliari
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S H A R M A ET AL.
et al. [10] and Tsivian and Sidi [15] showed
that possible injury to the neurovascular
bundles of the clitoris is avoidable, as they are
quite far from the dissection area and the
striated urogenital sphincter in the dorsal
approach is preserved by reflecting it upward.
On the dorsal aspect, the urethra is only
juxtaposed to the clitoral structure, which is
carefully preserved during dissection. The
advantages of using the dorsal approach in
female urethroplasty are:
• Sacculation of the graft is minimized [10].
• The graft is well supported mechanically
and rests on a well-vascularized bed.
• Graft apposition on the dorsal aspect of the
urethra leads to physiological urethral
reconstruction with resultant urinary stream
directed away from the vagina [10].
• Prevents the possibility of urethrovaginal
fistula formation [15].
• The ventral aspect of the urethra is left
intact thus leaving the possibility of midurethral anti-incontinence procedures in the
event of any future incontinence.
In conclusion, LMG urethroplasty using the
dorsal onlay technique should be offered for
correction of persistent female urethral
stricture as it provides a simple, safe and
effective approach with durable results and
no increased risk of urinary incontinence.
However, long-term studies in randomized
controlled settings are required to evaluate its
efficacy as a procedure for early intervention
rather than as a last resort in the
management of female urethral stricture
disease.
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CONFLICT OF INTEREST
None declared.
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REFERENCES
13
1
Schwender CE, Ng L, McGuire E,
Gromley EA. Technique and results of
urethroplasty for female stricture disease.
J Urol 2006; 175: 976–80
1312
Carr LK, Webster GD. Bladder outlet
obstruction in women. Urol Clin North Am
1996; 23: 385–91
Massey JA, Abrams PH. Obstructed
voiding in the female. Br J Urol 1988; 61:
36–9
Nitti VW, Tu LM, Gitlin J. Diagnosing
bladder outlet obstruction in women.
J Urol 1999; 161: 1535–40
Groutz A, Blaivas JG, Chaikin DC.
Bladder outlet obstruction in women:
definition and characteristics. Neurourol
Urodyn 2000; 19: 213–20
Kuo HC. Videourodynamic characteristics
and lower urinary tract symptoms of
female bladder outlet obstruction.
Urology 2005; 66: 1005–9
Smith AL, Ferlise VJ, Rovner ES.
Female urethral strictures: successful
management with long-term clean
intermittent catheterization after urethral
dilatation. BJU Int 2006; 98: 96–9
Defreitas GA, Zimmern PE, Lemack GE,
Shariat SF. Refining diagnosis of
anatomic female bladder outlet
obstruction: comparison of pressure-flow
study parameters in clinically obstructed
women with those of normal controls.
Urology 2004; 64: 675–81
Keegan KA, Nanigian DK, Stone AR.
Female urethral stricture disease. Curr
Urol Rep 2008; 9: 419–23
Migliari R, Leone P, Berdondini E,
Angelis MD, Barbagli G, Palminteri E.
Dorsal buccal mucosa graft urethroplasty
for female urethral strictures. J Urol 2006;
176: 1473–6
Pugliese JM, Morey AF, Peterson AC.
Lichen sclerosus: review of literature
and current recommendations for
management. J Urol 2007; 178: 2268–76
Tanello M, Frego E, Simeone C, Cosciani
Cunico S. Use of pedicle flap from the
labia minora for repair of female urethral
stricture. Urol Int 2002; 69: 95–8
Montorsi F, Salonia A, Centemero A
et al. Vestibular flap urethroplasty for
strictures of the female urethra. Impact
on symptoms and flow patterns. Urol Int
2002; 69: 12–6
14 el-Kasaby AW, Fath-Alla M, Noweir
AM, el-Halaby MR, Zakaria W,
el-Beialy MH. The use of buccal mucosa
patch graft in the management of
anterior urethral strictures. J Urol 1993;
149: 276–8
15 Tsivian A, Sidi AA. Dorsal graft
urethroplasty for female urethral
stricture. J Urol 2006; 176: 611–3
16 Berglund RK, Vasavada S, Angermeier
K, Rackley R. Buccal mucosa graft
urethroplasty for recurrent stricture of
female urethra. Urology 2006; 67: 1069–
71
17 Simonato A, Gregori A, Lissiani A et al.
The tongue as an alternative donor site
for graft urethroplasty: a pilot study.
J Urol 2006; 175: 589–92
18 Kumar A, Goyal NK, Das SK, Trivedi S,
Dwivedi US, Singh PB. Oral
complications after lingual mucosal graft
harvest for urethroplasty. ANZ J Surg
2007; 77: 970–3
19 Kumar A, Das SK, Sharma GK et al.
Lingual mucosal graft substitution
urethroplasty for anterior urethral
strictures: our technique of graft
harvesting. World J Urol 2008; 26: 275–
80
20 Das SK, Kumar A, Sharma GK et al.
Lingual mucosal graft urethroplasty for
anterior urethral strictures. Urology 2009;
73: 105–8
21 Singh PB, Das SK, Kumar A et al. Dorsal
onlay lingual mucosal graft urethroplasty:
comparison of two technqiues. Int J Urol
2008; 15: 1002–5
Correspondence: Girish K. Sharma,
Department of Urology, Institute of Medical
Sciences, Banaras Hindu University, Varanasi,
Uttar Pradesh, India.
e-mail: [email protected]
Abbreviations: LM(G), lingual mucosa(l)
(graft); BM(G), buccal mucosa(l) (graft); Qmax,
maximum urinary flow rate; VCUG, voiding
cysto-urethrography; PVR, postvoid residual
urine volume; CISC, clean intermittent selfcatheterization.
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2009 THE AUTHORS
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