Does successful urethral calibration rule out significant female urethral stenosis? confronting the confounder- an outcome analysis of successfully treated female urethral strictures

Abstract

Objective: The diagnosis and treatment of female urethral stricture disease (FUSD) are practiced variably due to the scarcity of data on evaluation, variable definitions, and lack of long-term surgical outcomes. FUSD is difficult to rule out solely on the basis of a successful calibration with 14F catheter. In this study, we have tried to characterize the variable clinical presentation of FUSD, the diagnostic utility of calibration, videourodynamic study(VUDS), and urethroscopy in planning surgical management.

Materials and methods: A retrospective review of records of 16 patients who underwent surgical management of FUSD was analyzed. The clinical history, examination findings, and the results of all the investigations (including uroflowmetry, VUDS findings, urethroscopy) they underwent, the procedures they had undergone ,and the follow-up data were studied.

Results: A total of 16 patients underwent surgical management of FUSD. 13 out of 16 patients had successful calibration with 14F catheter on the initial presentation. These 13 patients on VUDS demonstrated significant BOO and had variable stigmata of stricture on urethroscopy. The mean IPSS, flow rate, and PVR at presentation and after urethroplasty were 23.88±4.95, 7.72±4.25mL/s, 117.06±74.46mL and 3.50±3.44, 22.34±4.80mL/s, and 12.50±8.50mL, respectively. (p < 0.05). The mean flow rate after endo dilation(17F) (n=12) was 11.4±2.5mL/s while after urethroplasty improved to 20.30±4.19mL/s and was statistically significant(p < 0.05).

Conclusions: An adept correlation between clinical assessment, urethroscopy findings, and VUDS is key in objectively identifying FUSD and planning surgical management. A good caliber of the urethra is not sufficient enough to rule out a significant obstruction due to FUSD. Early urethroplasty provides significantly better outcomes in patients who have failed dilation as a treatment.

Keywords: Urinary Bladder; Female; Urethral Stricture.

Figure 1. Management protocol for patients suspected with FUSD.

Figure 2. Surgical steps in dorsal onlay graft urethroplasty. 2A- Harvesting of vaginal graft from posterior lateral vaginal wall and closure of harvest site. 2B-Dorsal dissection of urethra from clitoral bed up to the bladder neck after detachment of pubourethral ligament. 2C- Dorsal urethrotomy extending well beyond the stricture and preplaced sutures taken through apex of the laid open urethra and the vaginal graft. 2D- Finally constructed neomeatus.

Figure 3. 43-year-old lady with IPSS (27) with successful calibration with 14F, showing VUDS and urethroscopic correlation with a pDet@Qmax 67cmH2O, flat fixed flow curve, proximal urethral ballooning, stigmata of stricture as a flimsy ring with poor distensibility of urethra, Qmax after endodilation~14mL/s and after urethroplasty ~30mL/s.

Figure 4. 54-year-old lady with IPSS (28) with successful calibration showing VUDS and urethroscopic correlation with pDet@Qmax 90cmH2O, inability to void with proximal urethral ballooning evident during VUDS, stigmata of stricture as a whitish mucosal discoloration and rigidity and poor distensibility on urethroscopy, Qmax after endodilation was ~5mL/s and after urethroplasty ~24mL/s.