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to present a novel modification of surgical technique to treat female urethral stricture ( fus ) by a vaginal - sparing ventral buccal mucosal urethroplasty .
a variety of surgical techniques have been described to date , yet a lack of consensus on the optimal procedure persists .
, the patient had undergone at least 25 formal urethral dilations and periods of self - dilation . in lithotomy position , the urethra was dilated to accommodate forceps , and ventral urethrotomy carried out sharply , exposing a bed of periurethral tissue .
buccal mucosa was harvested , and a ventral inlay technique facilitated by a nasal speculum , was used to place the graft from the proximal urethra / bladder neck to urethral meatus without a vaginal incision .
the vaginal - sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow - up .
flexible cystoscopy demonstrated patency of the repair at 6 months . at 10 months of follow - up ,
this case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for fus . by avoiding incision of the vaginal mucosa ,
benefits may include reduced : morbidity , urinary incontinence , and wound complications including urethro - vaginal fistula .
female urethral stricture ( fus ) represents an uncommon clinical problem , with a paucity of data to guide clinicians on its optimal management .
while the causes of fus may be diverse , commonly cited causes include iatrogenic injury , trauma , and malignancy . in women with bladder outlet obstruction , the incidence of fus as
symptoms may include frequency , urgency , dysuria , hesitancy , poor stream , incontinence , and recurrent urinary tract infection .
because of overlapping symptoms with other urologic conditions , and its rarity , the clinician should have a high degree of suspicion for urethral stricture as a cause of lower urinary tract symptoms in women .
fus remains without a standardized definition , and studies to date have relied on retrospectively collected data , without uniform methods of collecting and reporting findings .
a variety of investigative modalities have been advocated in the work - up of fus , including : uroflowmetry , measurement of postvoid residual , retrograde urethrogram , voiding cystourethrogram , cystoscopy , and urodynamic studes .
historically a mainstay of management for recurrent fus , urethral dilation is known to have poor long - term efficacy .
the successful management of fus with long - term clean intermittent catheterization has been reported in a small series .
this technique fails to provide a definitive management option , though may be an appropriate option for some .
osman et al .   recently performed a literature review , which examined urethroplasty for fus .
while long - term data is limited , they reported an 80%94% mean success rate across all techniques .
to date , there is minimal reported evidence for the reconstruction of fus by ventral buccal mucosal graft urethroplasty .
we aim to describe a novel modification of this technique , employing a vaginal - sparing approach .
, the patient had undergone at least 25 formal urethral dilations and periods of self - dilation . self - dilation was becoming increasingly difficult , and negatively affecting quality of life .
the patient desired a more definitive option and the decision was made to proceed with buccal mucosal graft urethroplasty .
the patient was placed lithotomy position , and the urethra was dilated using hegar dilators , calibrating to 40 french .
adequate urethral dilation allows for accommodation of tissue forceps or nasal speculum to facilitate the procedure .
a ventral urethrotomy was carried out sharply using an 11-blade scalpel at the 6 o'clock position , exposing a bed of periurethral tissue ( fig .
care was taken to ensure the incision did not extend to the mucosa , sparing the anterior vaginal wall .
it was ensured that this ventral periurethral bed of tissue displayed adequate vascularity , and appeared healthy enough to accommodate placement of a graft .
an approximately 4 cm by 1 cm strip of buccal mucosa was removed , which was adequate to bridge the length of the urethral defect .
a ventral inlay technique was used to place the graft from the bladder neck to urethral meatus .
three apical bladder neck / proximal urethral sutures ( 4 - 0 vicryl ) were placed , facilitated by a nasal speculum .
the needle was modified by the surgeon into a " j - shaped " bend , to assist passage .
once the 3 sutures were in place , they were sewn to the corresponding proximal portion of the buccal graft , and parachuted into position ( fig .
2 ) . interrupted 4 - 0 vicryl sutures were utilized to circumferentially anastomose the graft to the edges of the urethrotomy ( fig .
several interrupted quilting sutures using 5 - 0 vicryl rapide were placed to secure the graft to its underlying periurethral bed .
flexible cystoscopy at 6 months demonstrated patency of the repair . at 10 months of follow - up ,
a complete video overview of the procedure is attached in the supplemental information ( fig . 4 ; supplementary video clip ) .
the first report of successful vaginal flap reconstruction as an alternative to bladder flap was by blaivas in 1989 . in 2002 , tanello et al .  
described the labia minora pedicle flap , while montorsi et al .   reported on vestibular flap urethroplasty for the management of fus .
there have been subsequent studies examining vaginal flaps using a ventral inlay technique for the management of fus . while patient numbers were small and studies retrospective in nature , success rates are good , varying between 83%100% . in these procedures , either a u - shaped or c - shaped inlay flap was employed with advancement of the flap into a ventral location .
tsivian and sidi   first described the dorsal onlay graft urethroplasty for fus , in a series of 3 patients , employing vaginal or buccal mucosal graft .
subsequent studies have built upon this experience with dorsal onlay buccal mucosal graft urethroplasty with variations in surgical technique .
while these studies have been encouraging in their results , their patient numbers remain small , and data retrospective .
the ventral approach to buccal mucosal graft urethroplasty has been reported by berglund et al . , who noted long - term success in one of 2 women for which the technique was employed .
they employed a midline vaginal incision to expose the underlying urethra by dissecting free the anterior vaginal wall .
they reported excellent results , with the benefit of the option to reinforce the reconstruction with a martius flap .
the rationale for our approach is based on the technique described for male ventral oral mucosal onlay graft urethroplasty , and its associated good results . when compared to the dorsal onlay technique for repair of fus by buccal mucosal graft urethroplasty , the vaginal sparing approach we utilized has several potential advantages .
in addition , this technique avoids dissection and possible disruption to the nerve and vascular supply to the clitoris as well as clitoral bulbar tissue , potentially avoiding intraoperative bleeding and postoperative sexual dysfunction . in comparison to published ventral techniques , the vaginal - sparing modification as described also portends some potential benefits . by avoidance of vaginal incision ,
it may also help to avoid issues of postrative urethrovaginal and vesicovaginal fistula , by circumventing vaginal incision altogether .
the vaginal - sparing modification also avoids dissection of the anterior vaginal wall , and could mirror the benefits of the dorsal onlay technique by protecting this tissue for any future anti - incontinence procedure that may be necessary . compared to the dorsal approach , which requires mobilization of the urethra , the ventral vaginal - sparing approach may avoid division of the pubo - urethral ligament , and potentially reduce the risk of stress urinary incontinence .
prior anatomic studies have revealed that the striated muscle fibres of the female external urinary sphincter are attenuated in the ventral ( or posterior ) position , especially in the elderly , and relatively thicker on the dorsal ( anterior ) aspect .
while stress urinary incontinence is rare after urethroplasty for fus , it remains unknown whether the dorsal or ventral approach would prove a preferential approach from the standpoint of disruption of the external urethral sphincter .
given that the striated muscle is relatively deficient posteriorly , the ventral approach may have a theoretically benefit in this regard .
the disadvantages to this operative technique include the morbidity of buccal mucosal graft harvest , which is avoided in the vaginal flap technique .
it is possible that a graft wider than 1 cm may be necessary for severe strictures with a more deficient graft bed .
oral mucosal grafts tend to be well tolerated , however , with minimal morbidity and complications .
also , the lack of long - term follow - up precludes any definitive statement of its continuing efficacy .
while it is clear that no particular technique has demonstrated superiority in the literature to date , the vaginal - sparing modification may prove advantageous . as methods for definitive reconstruction for fus continue to evolve
, surgeons should continue to innovate and search for the most effective techniques , while aiming to minimize patient morbidity and potential complications .
a multidisciplinary approach may be prudent at some centres , as male reconstructive surgeons often has extensive experience harvesting and working with buccal mucosa , while female reconstructive surgeons may tend to be most comfortable with the vaginal anatomy and dissection .
an individualized approach tailoring the most appropriate procedure for a given patient should be advocated .
this novel modification of technique may help add to the surgical armamentarium of the reconstructive urologist in managing fus .
the rarity of fus contributes to the challenges of conducting larger studies to compare different techniques , and continued academic inquiry into this field will remain important going forward .
accompanying videos can be found in the ' urology in motion ' section of the journal homepage ( www.icurology.org ) .
the supplementary video clips can also be accessed by scanning a qr code located on the fig .
purposeto present a novel modification of surgical technique to treat female urethral stricture ( fus ) by a vaginal - sparing ventral buccal mucosal urethroplasty . 
 recurrent fus represents an uncommon , though difficult clinical scenario to manage definitively . 
 a variety of surgical techniques have been described to date , yet a lack of consensus on the optimal procedure persists.materials and methodswe present a 51-year - old female with urethral stricture involving the entire urethra . 
 suspected etiology was iatrogenic from cystoscopy 17 years prior . since then 
 , the patient had undergone at least 25 formal urethral dilations and periods of self - dilation . in lithotomy position , the urethra was dilated to accommodate forceps , and ventral urethrotomy carried out sharply , exposing a bed of periurethral tissue . 
 buccal mucosa was harvested , and a ventral inlay technique facilitated by a nasal speculum , was used to place the graft from the proximal urethra / bladder neck to urethral meatus without a vaginal incision . 
 graft was sutured into place , and urethral foley catheter inserted.resultsthe vaginal - sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow - up . 
 flexible cystoscopy demonstrated patency of the repair at 6 months . at 10 months of follow - up , 
 the patient was voiding well , with no urinary incontinence . 
 no further interventions have been required.conclusionsthis case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for fus . by avoiding incision of the vaginal mucosa , 
 benefits may include reduced : morbidity , urinary incontinence , and wound complications including urethro - vaginal fistula .