Severe Urethral Stenosis/Complete Urethral Obliteration

Abstract

While urethral strictures do occur in women, fortunately, complete obliteration of the urethral lumen is unusual. This dramatic situation is typically a result of severe trauma to the urethra such as that which may occur due to urethral or pelvic floor surgery, endoscopy or instrumentation, radiation of the tissues or, in third world countries, obstructed childbirth. The condition often requires extensive reconstruction, including the harvesting and application of sophisticated grafts, and therefore necessitates the involvement of a surgeon with special expertise in complex urethral reconstructive techniques. This chapter provides an overview of the aetiology, evaluation, surgical approaches and often protracted and challenging courses encountered by those who provide care for severe urethral stenosis and complete luminal obliteration.

Commentary by Jaspreet S. Sandhu, Memorial Sloan-Kettering Cancer Center, Department of Surgery, Urology Service, New York, NY, USA

Commentary

• Jaspreet S. Sandhu 

This chapter presents a case-based review of severe female urethral stricture disease including a detailed summary of available female urethral reconstructive techniques. These techniques range from endoscopic management such as internal urethrotomy or urethral dilation followed by intermittent self-catheterisation to flap or graft-based urethroplasty.

The authors correctly state that a common aetiology of female urethral strictures in the western world is iatrogenic, specifically following urethral surgery (e.g. urethral diverticulectomy or removal of mid-urethral sling). Pelvic radiation, such as that for gynaecological or colorectal malignancies, is another common cause for female strictures. It is also noted that, unlike in males, pelvic fractures are not a common aetiology of female urethral strictures.

The history and physical exam are extremely important in women presenting with symptoms of urethral stricture. Specifically, urethral cancer should be on the differential diagnosis in women with no obvious cause for urethral stricture based on history. A physical exam or pelvic imaging finding of a urethral mass or urethral thickening in this setting should prompt a urethral biopsy and if cancer is found, the patient should be managed by an oncologist. At our centre, we have diagnosed urethral cancers in multiple women who presented with recurrent urinary tract infections and/or difficulty voiding.

Treatment options for female stricture disease are varied and are reviewed nicely in this chapter. Minimally invasive methods such as urethral dilation or internal urethrotomy are often the first-line treatment and can sometimes be the only treatment needed, specifically if intermittent self-catheterisation is added [15]. Vaginal wall and other flaps have been described with reasonable efficacy. More recently, buccal mucosal grafts have been used with similar efficacy. The small number of patients in these series, however, limits our ability to conclude if one technique is better than another or even if flaps or graft are better than endoscopic management. The fact that the two meta-analyses referenced in this chapter were compilations of studies that average 5–7 patients each is concerning. Furthermore, a recent report on the experience of 6 surgeons with dorsal buccal graft urethroplasty in female urethral stricture disease included approximately 6 cases per surgeon over a 9-year period [72]. Not only is the number of patients in these series low, follow-up remains limited. As more surgeons gain experience and offer these techniques, more robust reporting is expected and perhaps, one technique will prove better than others.

Female urethral strictures associated with previous pelvic radiation are a uniquely difficult problem to treat. It appears that more women are presenting with urethral strictures after radiotherapy; yet, there is very little reported in literature on this topic. In our experience, urethral strictures post-radiotherapy are best managed with minimally invasive methods. These patients tend to have severely ischaemic tissue resulting in diminished wound healing and complications after surgery are difficult to treat and can potentially be devastating. Specifically, urinary incontinence or vesicovaginal fistula rates are likely higher after urethroplasty in radiated patients. If these are subsequently treated, the surgeon is dealing with a radiated and previously operated field and sometimes, these patients are left with a urinary diversion as their only option.

Finally, a urinary diversion or a suprapubic-tube placement are important techniques to use as a ‘back-up’ for patients with severe female urethral stricture disease. Permanent supra-pubic tubes are not ideal, but some patients prefer the simplicity of this method and are comfortable with frequent scheduled replacements of these catheters.

A simple cystectomy may be performed with a urinary diversion regardless of whether it is a continent cutaneous diversion or an ileal conduit urinary diversion. While a cystectomy with urinary diversion is technically straightforward, it is important to note that these patients have a high rate of subsequent complications particularly if the cystectomy is for benign disease [73] as in the setting of severe female urethral strictures. Cutaneous continence mechanisms, such as those based on the Mitrofanoff principle, can be added to an existing bladder in the setting of complete urethral occlusion. However, it should be noted that women that presented with urinary incontinence also need a bladder neck closure. A previous history of radiation can cause a bladder neck closure to subsequently fail; in which case, these women either need a tight pubo-vaginal sling or a cystectomy with urinary diversion.

Female urethral stricture disease is being recognised as an important malady that needs treatment. This chapter provides an excellent review of the surgical techniques currently available for treating this disease. Because of the limited evidence base, it is extremely important to take into account patient preference and goals of care and discuss the risks and possible complications of treatment with patients in a shared decision-making model.