Insights on female urethroplasty patients from the EAU Section of Genitourinary Reconstructive Surgeons Female Reconstruction Group (EFG)

The EAU Section of Genitourinary Reconstructive Surgeons formed the ESGURS Female Reconstruction Group (EFG) in 2022 to enhance multicentric collaboration. The significance of such a collaboration is highlighted by the low prevalence and specialised nature of many female reconstructive disorders.

The first project of this group was to generate more evidence on urethroplasty outcomes in females with a urethral stricture. Data from female patients undergoing a urethroplasty for a urethral stricture, from 7 referral centres for urethral reconstruction, were grouped and analysed. Patients were divided into 3 groups according to the reconstructive procedure they underwent: ventral onlay flap urethroplasty (VOFU), ventral onlay graft urethroplasty (VOGU), or dorsal onlay graft urethroplasty (DOGU). The outcomes of specific interest were stricture-free survival and prognostic factors. 

A total of 165 women with urethral strictures were included — the largest cohort of female urethroplasty patients in the current literature. The surgical techniques performed were VOFU in 17 (10%) patients, VOGU in 115 (70%) patients, and DOGU in 33 (20%) patients. Buccal mucosa grafts were the most frequently used across the cohort (84%). Stricture-free survival at one year was 88% overall, 73% in the VOFU group, 91% in the VOGU group, and 84% in the DOGU group. There was no statistically significant difference among the different groups.

Regarding prognostic factors, two interesting findings emerged. First, and unsurprisingly, prior radiotherapy was identified as an independent predictor for stricture recurrence. Second, a surgical volume of 30 cases or more was associated with improved stricture-free survival, indicating a positive impact of surgical experience on outcomes.

The EFG will continue its collaborative efforts, with new research initiatives already underway. The value of this collaboration is underscored by the low prevalence of female disorders requiring reconstructive surgery. Only through data pooling and multicentre cooperation can robust evidence be generated to guide clinical practice.

Figure 1 Ventral Onlay Graft Urethroplasty (VOGU)

1. Ventral stricturotomy into a healthy urethra. Harvesting of a buccal mucosal patch to allow the creation of a 30Ch urethra, and suturing into the stricturotomy with a continuous 4/0 polyfilament resorbable suture.
2. A right-sided modified Martius labial fat pad flap has been harvested on its posterior pedicle and transposed into the vaginal wound. The labial fat pad flap has been sutured to the right paravaginal fascia.
3. The modified Martius labial fat pad flap has been quilted to the buccal mucosal graft and sutured to the left paravaginal fascia.
4. The result at the end of the surgery

Figure 2: Dorsal Onlay Graft Urethroplasty (DOGU)

1. Dissection of the dorsal part of the urethra up to the bladder neck
2. Dorsal incision of the stricture until healthy urethra is encountered
3. A shield-shaped buccal mucosal graft is transferred to the site of the stricture and sutured in with a running suture Monocryl 4-0. Dorsal quilting is performed to enhance graft ingrowth.
4. The result at the end of the surgery

1. Riechardt S, Waterloos M, Lumen N, Campos-Juanatey F, Dimitropoulos K, Martins FE, et al. European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients. Eur Urol Focus [Internet]. 2021;1–7. Available from: https://doi.org/10.1016/j.euf.2021.07.013

1. AZ Maria Middelares Gent, Department of Urology, Ghent, Belgium
2. Ghent University Hospital, Department of Urology, Ghent, Belgium
3. University College Hospitals London, London, United Kingdom
4. Molinette Hospital, Department of Urology, Città della Salute e della Scienza, University of Turin, Turin, Italy
5. Sakarya University, Department of Urology, Sakarya, Turkey
6. Shaare Zedek Medical Center, Department of Reconstructive and Functional Urology, Jerusalem, Israel
7. University Medical Center Hamburg-Eppendorf, Hamburg, Germany