|Year : 2022 | Volume
| Issue : 1 | Page : 26-29
Outcome analysis of dorsal buccal mucosal graft urethroplasty in perimenopausal women with urethral stricture disease
A Bhalaguru Iyyan1, P Puvai Murugan1, Shree Vishnu Siddarth Rajagopal1, Sheik Asik Abu Sali2
1 Department of Urology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
|Date of Submission||08-Jun-2021|
|Date of Decision||31-Jul-2021|
|Date of Acceptance||24-Aug-2021|
|Date of Web Publication||02-Mar-2022|
Dr. P Puvai Murugan
Department of Urology, PSG Institute of Medical Science and Research, Peelamedu, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: To assess the clinical outcomes following dorsal buccal mucosal graft urethroplasty (BMGU) in perimenopausal women (PMW) suffering from urethral stricture disease. Materials and Methods: PMW (40–65 years) presenting with urinary symptoms were evaluated with uroflowmetry, voiding cystourethrogram (VCUG), and urethral calibration. PMW with maximum flow rate (Qmax) less than 10 ml/s or postvoid residual (PVR) volume greater than 50 ml, VCUG showing evidence of urethral stricture, and failure to calibrate with 14 Fr Foley catheter were included in the study. Patients with underactive bladder, carcinoma cervix, pelvic trauma, and oral submucosal fibrosis were excluded from the study. Patients satisfying inclusion and exclusion criteria underwent dorsal BMGU. Outcomes of the surgery were assessed by uroflowmetry at 3-monthly intervals. Results: The number of patients satisfying the inclusion and exclusion criteria between March 2014 and March 2020 was eight. The mean age of the patients was 52.1 years. The mean stricture length was 1.9 cm. The mean preoperative Qmax and PVR were 4.2 ml/s and 110 ml, respectively. The mean postoperative Qmax and PVR at 6 months were 15.4 ml/s and 39.1 ml, respectively. One patient had a recurrent stricture and underwent dilatation. Donor site complications were minor. The overall success rate of the procedure was 87%. Conclusion: Dorsal BMGU in females for urethral stricture disease offers successful urethral reconstruction and the advantage of least disruption of continence mechanism and resilience to hormonal changes in PMW.
Keywords: Buccal mucosal graft urethroplasty, perimenopausal urinary symptoms, urethral stricture in females
|How to cite this article:|
Iyyan A B, Murugan P P, Rajagopal SV, Sali SA. Outcome analysis of dorsal buccal mucosal graft urethroplasty in perimenopausal women with urethral stricture disease. Urol Sci 2022;33:26-9
|How to cite this URL:|
Iyyan A B, Murugan P P, Rajagopal SV, Sali SA. Outcome analysis of dorsal buccal mucosal graft urethroplasty in perimenopausal women with urethral stricture disease. Urol Sci [serial online] 2022 [cited 2023 Dec 3];33:26-9. Available from: https://www.e-urol-sci.com/text.asp?2022/33/1/26/338938
| Introduction|| |
Female urethral stricture is one of the distressing urological conditions affecting perimenopausal women (PMW). The incidence of bladder outlet obstruction in women with lower urinary tract symptoms is 3%–8%, and among them, 4%–13% suffer from urethral stricture. Most female urethral stricture disease is idiopathic. It was postulated that hormonal changes in PMW lead to atrophy and dryness in the perineum, affecting both the vagina and urethra., The treatment option available for these patients is urethral dilation using metal dilators, grafts, or flap urethroplasty. The recurrence stricture rate following urethral dilation is high, necessitating repeated urethral dilations once every 6 months or earlier. Epithelial involution, remodeling of the dermal matrix, and low-level chronic inflammation occur in the vagina of PMW due to hormonal changes. Hence, vaginal graft and flap would not be ideal for urethral reconstruction. The properties of buccal mucosa such as the absence of hair follicles, highly vascular lamina propria promoting early ingrowth, wet environment compatibility, resilience to hormonal changes, and ease of harvest with a concealed donor site scar make buccal mucosal graft urethroplasty (BMGU) a better option in these patients. This study evaluated the outcomes of dorsal BMGU in PMW with urethral stricture.
| Materials and Methods|| |
PMW presenting with voiding urinary symptoms (slow stream of urine, straining to void), recurrent urinary tract infection were evaluated using uroflowmetry and postvoid residual urine (PVR) volume assessment using ultrasound. Patients with a maximum flow rate (Qmax) less than 10 ml/s or PVR greater than 50 ml were further evaluated using voiding cystourethrogram (VCUG), urodynamic and calibration studies.
Women aged between 40 and 65 years presenting with voiding symptoms and Qmax less than 10 ml/s or PVR more than 50 ml, VCUG showing evidence of urethral stricture [Figure 1], and failed calibration with 14 Fr Foley catheter were included in the study. Patients with an underactive bladder (urodynamic study showing detrusor pressure at Qmax less than 20 cm water in voiding phase), carcinoma cervix, pelvic trauma history, and oral submucosal fibrosis were excluded from this study.
This study was approved by the institutional ethics committee (PSG Institute of Medical Sciences and Research, Approval number: 21/007). After taking informed consent, patients who met the inclusion and exclusion criteria were scheduled for dorsal BMGU. Under general anesthesia with nasal intubation, patient in the lithotomy position, urethroscopy was conducted using 6/7.5 Fr ureteroscope (Karl Storz®, Germany) to assess the stricture length and its distance from bladder's neck. Vaginal packing was done. After taking stay sutures at a 3 o' clock and 9 o' clock position in the external urethral meatus, an inverted U-shaped incision [Figure 2]a was made from 9 o' clock to 3 o' clock position. Urethra and periurethral tissue were dissected sharply with fine scissors. Care was taken to safeguard the clitoral body. A 16 Fr Foley catheter was inserted up to the stricture; urethrotomy was made at 12 o' clock position over the stricture [Figure 2]b and extended distally to the meatus. Buccal mucosa was harvested from a cheek after infiltrating diluted adrenaline with saline in the submucosal plane and taking care not to injure the Stensen's duct. The raw area was primarily closed using 3-“0”chromic catgut (CHROMIC GUT® Ethicon Inc., USA). The harvested buccal mucosa was then sutured to the urethral plate over the 16 Fr Foley catheter using 4-“0” polydioxanone (PDS® Ethicon Inc., USA) sutures starting from the apex of the urethra to the graft [Figure 2]c. Suturing of the right and left margins of the urethra with the buccal mucosal graft was done using 4-0 PDS [Figure 2]d. The excess graft was excised and neomeatus created [Figure 2]e. Vulval mucosa was approximated with 4-0 PDS. Foley catheter was removed on the 21st day; uroflowmetry and VCUG were done on the same day. The patients were followed up with uroflowmetry every 3 months. The surgery was considered successful if Qmax was more than 10 ml/s and PVR was less than 50 ml.
|Figure 2: (a) Inverted U-shaped incision, (b) urethrotomy at 12 o' clock position, (c and d) buccal mucosal graft anastomosis with urethral plate, (e) neomeatus|
Click here to view
| Results|| |
The total number of patients meeting the inclusion and exclusion criteria between March 2014 and March 2020 was eight. The demographic characteristics of the patients are presented in [Table 1]. The mean age of the patients is 52.1 years. The presenting symptoms include a slow stream of urination (87%), urinary frequency, urgency, and nocturia (75%), urinary tract infection (63%), overflow incontinence (12%), and urinary retention (12%). The mean preoperative Qmax was 4.2 ml/s while residual urine volume was 110 ml. The mean stricture length was 1.9 cm. The stricture was panurethral in one, distal in five, and mid-urethral in two patients. Four patients had undergone urethral dilatation previously for the same symptoms. In terms of associated comorbidities, four had hypothyroidism, three had diabetes, two had hypertension, and one had chronic obstructive pulmonary disease.
The mean operative time was 130 min, and the mean estimated blood loss was 80 ml. The postoperative complications are listed in [Table 2]. Clitoral edema was the most common complication, and it subsided with anti-inflammatory agents. The mean duration of follow-up was 30 months (range 8–56). Postoperative voiding parameters are listed in [Table 3]. One patient had a recurrence after 1 year, and it was managed by urethral dilatation. None of the patients developed de novo urinary incontinence.
| Discussion|| |
The normal adult female urethra is usually 30 Fr in caliber. When the urethral lumen size in adults reduces to less than 10 Fr, urinary flow becomes obstructive at normal voiding pressures. Urethral stricture is a fixed anatomical narrowing of the urethra, and the lumen will not accommodate instrumentation without disrupting the urethral mucosal lining. The underlying pathology of urethral narrowing is periurethral fibrosis. Symptoms such as straining to void, slow urinary stream, increased micturition frequency, urinary hesitancy, dysuria, hematuria, recurrent urinary tract infection, and urethral pain occur due to fibrotic narrowing. The potential long-term consequences of urethral stricture in women include detrusor decompensation, urinary retention, and upper urinary tract deterioration.
VCUG is a useful tool in the evaluation of urethral stricture in females. It gives information regarding the size and location of the stricture, bladder diverticula, and vesicoureteric reflux. Functional or physiological narrowing of the urethra as in striated sphincter dyssynergia or dysfunctional voiding may mimic urethral stricture in VCUG. Hence, results in VCUG need to be aligned with cystourethroscopy, urethral calibration, or video urodynamic study to establish urethral stricture diagnosis.,
Treatment of urethral stricture is to relieve the obstruction and its associated symptoms while maintaining continence. The female urethra although short when compared to the male urethra, has complex anatomical relations that help to maintain continence. The pubourethral and periurethral pelvic ligaments together provide hammock-like support that maintains the resting angle of the urethra at 45°. Further, the horseshoe-shaped external urethral sphincter and compressor urethral muscle originating from the ischiopubic rami are responsible for the continence mechanism. Understanding these mechanisms is important before urethral surgery as any accidental injury to these structures would lead to disastrous postoperative incontinence. Dorsal placement of graft leads to the least disruption of these continence mechanisms. As observed in our study, de novo stress incontinence has not been reported following dorsal BMGU in the literature. Graft survival is also enhanced by strong mechanical and vascular support from the clitoral cavernous tissue. The dorsal placement of the graft also prevents the chance of urethrovaginal fistula formation. Further, as the ventral aspect of the urethra is left intact, future or concomitant mid-urethral anti-incontinence procedures can be conducted.
The success rate of dorsal BMGU in our series is 87.5%, with a median follow-up of 30 months. Similar studies have reported success rates ranging from 62.5% to 100%.,,, This wide variation in success rate is probably because of variation in follow-up periods and outcomes regarded as a success. Petrou et al. showed that, for proximal urethral stricture, pubic bone could be used as a guide for identifying the bladder neck and as a landmark for proximal dissection end point. Mittal et al. reported better pain alleviation and sexual outcomes with limited urethral dissection and avoidance of graft quilting to the clitoris. Manasa et al. objectively assessed sexual function before and after urethroplasty by a dorsal approach using a validated questionnaire and reported no negative impact on sexual function after urethroplasty. Donor site morbidities include postoperative pain, restricted mouth opening, numbness at the donor site, and parotid swelling. They usually resolve in few weeks.
The study's limitations include a relatively small sample size and the need for a longer follow-up of the patients.
| Conclusion|| |
In summary, dorsal BMGU offers not only successful urethral reconstruction but also the advantage of least disruption of continence mechanism and resilience to hormonal changes in PMW with urethral stricture.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, et al
. Genitourinary syndrome of menopause: An overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol 2016;215:704-11.
Keegan KA, Nanigian DK, Stone AR. Female urethral stricture disease. Curr Urol Rep 2008;9:419-23.
Goldstein I. Recognizing and treating urogenital atrophy in postmenopausal women. J Womens Health (Larchmt) 2010;19:425-32.
Goldstein I, Dicks B, Kim NN, Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med 2013;1:44-53.
Santucci RA, Payne CK, Anger JT, Saigal CS; Urologic Diseases in America Project. Office dilation of the female urethra: A quality of care problem in the field of urology. J Urol 2008;180:2068-75.
Binder RL, Freedman MA, Sharma KB, Farage MA, Wang Y, Combs C, et al
. Histological and gene expression analysis of the effects of menopause status and hormone therapy on the vaginal introitus and labia majora. J Clin Med Res 2019;11:745-59.
Filipas D, Fisch M, Fichtner J, Fitzpatrick J, Berg K, Störkel S, et al
. The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine. BJU Int 1999;84:108-11.
Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomology. Neurourol Urodyn 2000;19:553-64.
Brannan D. Stricture of the female urethra. J Urol 1951;66:242-53.
Tanagho EA, McCurry E. Pressure and flow rate as related to lumen calibre and entrance infection in girls. J Urol 1971;105:583-6.
Smith LA, Ferlise JV, Rovner ES. Female urethral strictures: Successful management with long-term clean intermittent catheterization after urethral dilatation. BJU Int 2006;98:96-9.
Tanello M, Frego E, Simeone C, Cunico SC. Use of pedicle flap from the labia minor for the repair of female urethral strictures. Urol Int 2002; 69: 95-8.
Kawashima A, Sandler CM, Wasserman NF, LeRoy AJ, King BF Jr., Goldman SM. Imaging of urethral disease: A pictorial review. Radiographics 2004;24 Suppl 1:S195-216.
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.
Aldamanhori R, Inman R. The treatment of complex female urethral pathology. Asian J Urol 2018;5:160-3.
Osman NI, Chapple CR. Contemporary surgical management of female urethral stricture disease. Curr Opin Urol 2015;25:341-5.
Yucel S, Baskin LS. An anatomical description of the male and female urethral sphincter complex. J Urol 2004;171:1890-7.
Hampson LA, Myers JB, Vanni AJ, Virasoro R, Smith TG 3rd
, Capiel L, et al
. Dorsal buccal graft urethroplasty in female urethral stricture disease: A multi-center experience. Transl Androl Urol 2019;8:S6-12.
Gomez RG, Segura FJ, Saavedra A, Campos RA. Female urethral reconstruction: Dorsal buccal mucosa graft onlay. World J Urol 2020;38:3047-54.
Tsivian A, Sidi AA. Dorsal graft urethroplasty for female urethral stricture. J Urol 2006;176:611-3.
Goel A, Paul S, Dalela D, Sankhwar P, Sankhwar SN, Singh V. Dorsal onlay buccal mucosal graft urethroplasty in female urethral stricture disease: A single-center experience. Int Urogynecol J 2014;25:525-30.
Sharma GK, Pandey A, Bansal H, Swain S, Das SK, Trivedi S, et al
. Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women. BJU Int 2010;105:1309-12.
Petrou SP, Rogers AE, Parker AS, Green KM, McRoberts JW. Dorsal vaginal graft urethroplasty for female urethral stricture disease. BJU Int 2012;110:E1090-5.
Mittal A, Sarin I, Bahuguna G, Narain TA, Bhirud DP, Ranjan SK, et al
. Technical modifications in dorsal onlay female urethroplasty: Time to make way for amendments. Turk J Urol 2021;47:170-4.
Manasa T, Khattar N, Tripathi M, Varshney A, Goel H, Sood R. Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft. Indian J Urol 2019;35:267-72.
] [Full text]
Castagnetti M, Ghirardo V, Capizzi A, Andretta M, Rigamonti W. Donor site outcome after oral mucosa harvest for urethroplasty in children and adults. J Urol 2008;180:2624-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]