Urethral Dilatation Incision or Reconstruction

True urethral strictures in females are rare, but can occur as a result of chronic urethral infections, trauma from iatrogenic urethral dilations, and postreconstructive ure-thral surgery. In these cases, the narrowing of the urethra is easily recognized endoscopically. Although urethral dilations have been used in the past, idiopathic and post-surgical strictures can be treated with periodic self-catheterization or permanent CIC, transurethral incision, or urethral reconstruction as reported in males with similar conditions. As reported in the management of male urethral strictures, CIC can be used as a modality to self-obturate strictures and prevent stricture recurrences in females. Adjuvant topical estrogen replacement may complement this manipulative therapy.

Urethral dilatation has been used for many years as a treatment for recurrent cystitis, pelvic or bladder and ure-thral pain, and for nonspecific voiding dysfunction including bladder emptying dysfunction in women. Although frequently used to treat urethral syndrome or primary bladder neck obstruction in the female, this procedure often results in only temporary symptomatic relief and over time it may result in bladder outlet obstruction secondary to transmural urethral stenosis or stricture formation. The obstruction is caused by periurethral fibrosis and scarring of the urethral wall that results from multiple episodes of postdilatation bleeding or extravasation of urine into the periurethral tissues. This may result in rigidity of the urethral wall and narrowing of the urethral lumen.

Management of the postdilatation obstruction and ure-thral stenosis in females is challenging in that the goal of providing low-resistance bladder emptying must be

Figure 10-2.1. Buccal mucosa graft for urethral reconstruction.

weighed against the complication of developing urinary incontinence. Curative therapy ranges from transurethral incision of the urethra to various forms of urethral reconstruction depending on the degree (mucosal vs transmural) and the area involved. For urethral reconstructions without bladder neck involvement, there is usually sufficient tissue of the anterior vaginal wall to use as pedicle flaps for reconstruction. If the vaginal tissue is extensively scarred, ischemic, or atrophied, other potential donor sites should be considered. These may include labial and perineal pedicle flaps, and rarely the use of rectus and gracilis pedicle flaps. We prefer to use buccal mucosa grafts (Figure 10-2.1) for urethral reconstruction in women when the anterior vaginal wall tissue is not applicable for reconstruction or the urethral defect is too large. This obviates the more disfiguring and morbid complications of muscle flaps or anterior bladder flap repairs (Barnes' bladder flap urethroplasty) obtained through an abdominal incision.

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