Female Urethral Reconstruction

Purpose: Female urethral reconstruction can be used successfully to treat a heterogeneous group of urethral disorders through an expanding number of unique approaches. Understanding the diverse etiologies of female urethral stricture and loss is essential in evaluating and diagnosing patients. Although there is an appreciable body of literature addressing female urethral reconstruction individually, there is a paucity of resources that approach this issue holistically. We discuss the relevant female urethral anatomy, pathophysiology, diagnosis and evaluation of female urethral disorders, and current reconstructive techniques, as well as published outcomes data and potential future directions for female urethral reconstruction. Materials and Methods: We reviewed articles published in English and indexed in the PubMed (R), Embase (R) and Google Scholar (TM) databases, and consulted textbooks. Key search terms used were female, urethra, urethral reconstruction, urethroplasty, pathology, stricture, vaginal flap, bladder flap, graft, dilation, pubovaginal sling, catheterization, imaging, tissue engineering and bioscaffold. We created a synopsis of relevant articles, including original research studies and reviews. Results: Urethral tissue loss and strictures are caused by traumatic injuries, iatrogenic injuries and, rarely, infections and malignancies. A comprehensive patient history and physical examination are critical for diagnosis. Flexible cystoscopy, voiding cystourethrography and endovaginal magnetic resonance imaging can help to determine the surgical method of repair. Minimally invasive approaches to female urethral reconstruction are associated with poor outcomes. Definitive treatment options for repair of female urethral stricture include vaginal flap/wall urethroplasty, graft urethroplasty and distal urethrectomy with advancement meatoplasty. Repair techniques for urethral loss include primary closure, vaginal flap/wall urethroplasty and bladder flap urethroplasty. Vaginal flap approaches with well vascularized grafts and buccal mucosal grafts have high success rates. Tissue engineered grafts are being investigated as a novel treatment modality. Conclusions: Female urethral reconstruction is complex, and one must carefully evaluate patients afflicted with urethral disorders. Urethral stricture and urethral loss have different etiologies. Variations of a standard approach might best address the condition of an individual patient. Long-term outcomes data are not available for contemporary techniques of female urethral reconstruction. The highest success rates have been reported with vaginal flap and buccal mucosal graft urethroplasty. Further studies focusing on newer reconstruction techniques and long-term outcomes are warranted.