Introduction: Female urethral strictures are rare, and there is no consensus on proper surgical treatment. The literature is primarily limited to case reports and small case series. Surgical treatment has frequently been extrapolated from male urethroplasty techniques. However, female urethroplasty differs significantly from male urethroplasty because it is performed directly across the urinary sphincter. We describe our rationale and technique for female ventral urethroplasty utilizing a modified Martius flap.
Methods: A 50-year-old female with a chronic proximal to mid-urethral stricture requiring daily intermittent catheterization to maintain urethral patency underwent a ventral Modified Martius Flap Urethroplasty. Following guidewire and open-ended ureteral stent placement across the stricture, an inverted U-flap incision was made from the distal urethra to the bladder neck. A full thickness incision into the urethral lumen was made, extending past the bladder neck, and sounded with a 30 French urethral sound. A 5x2 cm portion of non-hair bearing inner labia tissue was harvested and mobilized on the anterior pedicle of a Martius flap. This was then tunneled under the vaginal wall and rotated over the area of the urethral defect. The flap was sutured in place with two 4-0 vicryl running suture lines, covering the entire gap in the urethra with good mucosal apposition. The remaining fatty tissue of the Martius flap was rotated over the suture lines, adding an extra layer to the repair. The inverted U flap incision was closed over the repair with 2-0 vicryl suture. The skin edges of the Martius flap harvest site were then closed in two layers with a deep 2-0 vicryl layer and a superficial 4-0 monocryl subcuticular suture, resulting in a cosmetic closure.
Results: Postoperative VCUG revealed an open bladder neck and no recurrent stricture. Uroflow peak flow was 20cc/s. The patient had no complaints of stress incontinence (SUI) and a negative cough leak test at 1 month follow-up. At 6 months follow-up, the patient continued to deny any SUI and had no obstructive voiding complaints with PVR=2cc. She had mild postoperative dyspareunia which had resolved by the 6-month follow-up appointment.
Conclusions: Our technique using a ventral approach to female urethroplasty with a modified Martius flap is feasible and effective in the management of female urethral stricture disease. This approach offers potentially less damage to the sphincter, avoids possible clitoral nerve injury, allows for better maintenance of urethral support, and is an approach familiar to most FPMRS surgeons.