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Received: November 18, 2022. Accepted: January 14, 2023
Published by Oxford University Press and JSCR Publishing Ltd.© The Author(s) 2023.
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Journal of Surgical Case Reports, 2023, 2,1–3
https://doi.org/10.1093/jscr/rjad025
Case Report
Case Report
Ventral-inlay buccal mucosal graft urethroplasty
in a 44-year old female patient with recurrent
urethral stricture
Orlando Burkhardt *, Hans-Peter Schmid, Daniel Engeler and Valentin Zumstein
Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
*Correspondence address. Department of Urology, School of Medicine, University of St. Gallen, Rorschacherstrasse 95, 9000 St. Gallen, Switzerland.
Tel : +41 792 912 821; E-mail: o.burkhardt@burkhardt-home.ch
Abstract
Female urethral stricture is a rare manifestation of bladder outlet obstruction in women. According to the current guidelines of the
European Association of Urology, urethral dilatation should be offered as first line treatment. Intermittent self-dilatation (ISD) in case
of recurrence is recommended. However, if patients wish definitive surgical treatment or are not able to perform ISD, urethroplasty can
be considered. So far, there are little data available on urethroplasty in female patients. We present a case of a 44-year old female patient
with a postoperative urethral stricture who underwent ventral-inlay buccal mucosal graft urethroplasty due to inability to perform ISD.
INTRODUCTION
Female urethral strictures account for ∼4–13% of women with
bladder outlet obstruction and therefore is thought to be a rare
disease [1]. Though, since strictures present with frequency,
urgency, poor flow, incomplete bladder emptying and consecutive
urinary tract infections, quality of life can be severely impaired.
According to the guidelines of the European Association of
Urology (EAU) dilatation of the urethra up to 30–41 Fr with
subsequent intermittent self-dilatation (ISD) or planned repeated
dilatation in case of recurrence is the recommended first line
treatment strategy [1–4]. However, in patients with recurrent
strictures who wish definitive treatment and/or are unable to
continue ISD due to physical inability or pain, urethroplasty can
be performed. A variety of techniques, primarily using grafts, have
been proposed [2,5]. Currently, there is no recommendation on
which technique should be performed. In fact the technique of
urethroplasty should be chosen according to surgeons expertise,
availability and quality of the graft material. Since female urethral
strictures are rare and the vast majority of symptomatic patients
is treated by dilatation without any further surgical interventions,
we present a case in which we performed a ventral-inlay buccal
mucosal graft urethroplasty.
CASE REPORT
A 44-year old female patient presented with frequency, urgency
and severe painful micturition 1 year after excision of a urethral
caruncle. Clinical examinations revealed a reduced urinary f low
rate (Qmax 7.6 ml/s), relevant post void residual volume of 110 ml
and an International Consultation on Incontinence Questionnaire
Female Lower Urinary Tract Symptoms Score (ICIQ-FLUTS Score)
of 22 points (filling symptoms 10 points, voiding symptoms 12
points and incontinence symptoms 0 points). Urethrocystoscopy
showed a pre sphincteric stricture that could not be passed with
the 17 Fr flexible cystoscope. Therefore, dilatation of the urethra
up to 30 Fr was performed. After the procedure, urinary flow rate
was sufficient and frequency/urgency dissolved completely for
a few days. Unfortunately, the stricture recurred 2 weeks later
and the patient complained about the same initial symptoms. ISD
was no treatment option in this patient due to severe pain during
dilatation. We therefore discussed a ventral-inlay buccal mucosal
graft urethroplasty for definitive treatment.
The patient was placed in a lithotomy position and a nasal
speculum was used to expose the extend of the urethral stricture
(Fig. 1a). A ventral urethrotomy at 6 o’clock was performed using
a 15-blade scalpel transecting the urethral mucosa and the under-
lying fibrotic tissue creating an ∼1.5 cm long triangular defect
(Fig. 1b). Three 5-0 polydioxanone suture (PDS) simple interrupted
sutures were prepa red at 5, 6 and 7 o’clock (Fig. 1c). The normal 5-0
PDS needle was bend into a J-shape to facilitate taking stitches. An
∼2cm×1.5 cm buccal mucosal graft was harvested and prepared
for ventral-inlay fixation (Fig. 2a and b). The graft was placed and
fixed to the urethra using the three prepared sutures. Additional
lateral stitches were taken for definitive fixation (Fig. 2c). A 12-
Fr silicon Foley’s catheter was placed to drain the bladder. The
catheter remained in place until Day 10 after the procedure.
After catheter removal on Day 10, the patient showed a maxi-
mum urinary flow rate of Qmax 28 ml/s. Post void residual volume
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2|O. Burkhardt et al.
Figure 1. Exposure of the urethral stricture using a nasal speculum (a); after urethrotomy at 6 o’clock (b); prepared 5-0 PDS sutures at 5, 6 and 7
o’clock (c).
Figure 2. Planning of buccal mucosal graft harvesting (a); harvested buccal mucosal graft (b); after complete fixation of the graft (c).
decreased from 110 ml preoperatively to 50 ml. At 6 weeks Qmax
remained stable and postvoid residual volume decreased to 15 ml.
ICIQ-FLUTS score decreased from 22 to 7 points (filling symptoms
1 point, voiding symptoms 0 points, incontinence symptoms 6
points). Unfortunately, the patient reported a slight postoperative
urge incontinence with the need of 1 pad per 24 h. The patient
had a history of overactive bladder and received intravesical Botox
injection 2 years before the buccal mucosal graft urethroplasty.
Therefore, we planned another injection 2–3 months postopera-
tively. In addition, pelvic f loor physiotherapy was instructed. How-
ever, there were no signs of postoperative stress urinary inconti-
nence. Thus, we consider the postoperative incontinence rather
associated with the overactive bladder than as a postoperative
symptom after buccal mucosal graft urethroplasty.
DISCUSSION
A variety of techniques of surgical management of female ure-
thral strictures have been proposed. However, there is no rec-
ommendation on which technique should be performed in each
case [1]. Nayak et al.[5] presented a small case series of 12
female patients with urethral strictures undergoing a ventral-
inlay buccal mucosal graft urethroplasty. They reported a success
rate of the procedure of 92% within a follow-up period up to
28 months and discussed several potential advantages of the
ventral-inlay approach.Since vaginal and urethral dissection and
manipulation are not necessary in this technique, postoperative
pain and the risk of urethrovaginal fistula is reduced compared to
other techniques. Furthermore, compared to the dorsal approach,
transection of the pubourethral ligament can be avoided and
therefore lower rates of postoperative stress urinary incontinence
can be expected. However, long-term follow data are still miss-
ing. In our patient suffering primarily from painful micturition,
urgency and frequency, we aimed to choose a technique with as
little manipulation as possible and decided to perform a ventral-
inlay buccal mucosal graft urethroplasty. The procedure in our
patient showed excellent functional outcome with a sufficient
maximum urinary f low rate, absence of pain and no urinary
incontinence 6 weeks postoperatively.
Ventral-inlay buccal mucosal graft urethroplasty seems to be a
safe and feasible alternative to the recommended first line treat-
ment with dilatation in female patients with recurrent urethral
strictures and/or inability to perform ISD.
CONFLICT OF INTEREST STATEMENT
None declared.
FUNDING
None.
DATA AVAILABILITY
The data underlying this article are available in the article.
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Ventral-inlay buccal mucosal graft urethroplasty |3
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3. Popat S, Zimmern PE. Long-term management of luminal ure-
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5. Nayak P, Mandal S, Das M. Ventral-inlay buccal mucosal graft
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