Page 21 - Read Online

Page 4 of 11 de Toledo et al. Plast Aesthet Res 2022;9:5 https://dx.doi.org/10.20517/2347-9264.2021.103

reported a low success rate with one UD procedure, and half of those patients required an additional
dilation. Some authors reported a 67%-68% success rate with UD, but this may be attributed to a shorter
follow-up period [24,25] .

With the increasing interest in this uncommon problem, there has begun a paradigm shift that reflects
different training, and more surgeons are choosing to abandon the practice of serial dilations in favor of
performing definitive reconstructive repairs. Table 1 summarizes available original articles with outcomes
for women undergoing urethral dilation for urethral stricture over the last ten years. The mean success rate
in these studies was 54.4% at a mean follow-up of 34.1 months [21-25] .

Definitive management
It is important to distinguish between conservative vs. definitive treatment for FUS. As discussed earlier,
serial urethral dilation is an acceptable option for managing symptoms, but its high failure rate makes it a
substandard choice when considering definitive treatment. Furthermore, since there has been a growing
interest in the management of this rare pathology, some reconstructive urologists suggest that primary
[26]
urethroplasty can be considered a first-line option for FUS treatment .

The goals for female urethral reconstruction are to restore function, urinate without obstruction, maintain
continence, prevent vaginal voiding, and maintain sexual function. Although these goals are considered an
ideal scenario, there is a dearth of literature considering all five variables when analyzing outcomes.
Alternatives when considering a surgical approach are an augmented urethroplasty with a flap or graft vs. a
non-augmented urethroplasty: excision and primary anastomosis (EPA) or meatoplasty. The choice is based
upon stricture characteristics and surgeon preference as there is insufficient evidence to support one
[8]
technique over another, which is reflected in the European Guidelines .

Reports on EPA in female urethral strictures are few. However, it may be recommended in strictures due to
pelvic fracture and under a sine qua non condition that stricture is short and in the proximal or mid urethra.
In addition, there are reports of robotic-assisted techniques being utilized for patients with proximal short
traumatic stricture.

In cases where there is an isolated distal urethral stricture, meatoplasty should be considered. This usually
occurs after traumatic instrumentation, radiation therapy to the pelvis, and more commonly in
postmenopausal patients with vulvar and vaginal atrophy. Care needs to be taken not to make the incision
[27]
too ventral to prevent vaginal voiding. Rosenblum et al. suggest that circumferential, distal urethrectomy
and advancement meatoplasty work best for treating these distal strictures. This is also the preferred
technique of the authors.

Flaps
The utilization of tissue flaps for reconstruction is one of the oldest tools available for reconstructive
surgery, and it remains a valid option when considering approaches for urethroplasty in women. Various
authors have published their results using vaginal flaps, with a success rate that ranges between 60%-100%
according to our literature review [21,24-26,28-31] [Table 2]. However, there is wide variation, likely due to several
factors, including a range of follow-up (12 to 72 months), varied etiology, and surgical technique.

Flaps can be obtained from vaginal (U-shaped or C-shaped), labial, or vestibular tissue, and their versatility
allows them to be placed either in a ventral position (vaginal, labial tissue) or dorsally (vestibular tissue).
The anterior vaginal wall flap and lateral vaginal wall flap techniques have proven safety and efficacy,