Deciphering the enigma of female urethral strictures: A systematic review and meta‐analysis of management modalities

Abstract

Objective: To evaluate the management methods of female urethral stricture (FUS) and analyze the outcomes of surgical treatments. A meta-analysis was done in an attempt to identify the best approach of urethroplasty and the graft-of-choice. Materials and Methods: A systematic search of Pubmed/Medline and Embase databases was performed according to the Preferred Reporting Items For Systematic Review And Meta-Analysis statement, for articles reporting on FUS management in the last decade. The Newcastle-Ottawa scale was used to assess the quality of 28 included non-randomized studies. The data on FUS management was summarized and pooled success rates (taken as symptom improvement and no need for further instrumentation) were compared. The secondary outcome was to establish a diagnostic modality of choice and define a "successful-outcome" of repair. Results: The outcome was separately reported for 554 women undergoing surgical intervention for FUS in the literature. The criteria defining FUS were varied. A combination of tests was used for diagnosis as none was singularly conclusive. A total of 301 patients had previous urethral instrumentations. The pooled success rate of urethral dilatation (234 women) was 49% at a mean follow-up of 32 months; flap urethroplasty (108 cases) was 92% at a mean followup of 42 months; buccal mucosal graft (BMG) urethroplasty (133 cases) was 89% at a mean follow-up of 19 months; vaginal graft augmentation (44 cases) was 87% at a mean follow-up of 15 months; and labial graft reconstruction (19 cases) was 89% at a mean follow-up of 18.4 months. The dorsal approach of graft augmentation met with 88% (95% confidence interval [CI] 0.79-0.95) success compared with 95% (95% CI 0.86-1) for the ventral approach. Conclusion: FUS is a rare condition requiring a meticulous diagnostic workup using multiple tests. All urethroplasties have shown better pooled success rates (86%-93%) compared with dilatation (49%). BMG is equally effective as vaginal graft urethroplasty.

Treatment of Urethral Stricture Disease in Women: Nonsystematic Review of Surgical Techniques and Intraoperative Considerations

“…All articles identified in previous systematic reviews (Osman 2013 et al and Sarin 2020 et al) were included. 3 , 9 …”

“…One recent systematic review by Sarin et al reports endoscopic treatment success rate as 49%. 3 , 9 , 16 There is a lack of data of urethrotomy for FUS, which is likely due to the increased risk of sphincter compromise and new onset incontinence. 17 , 18 One contemporary retrospective analysis in 2019 by Sharifian et al reviewed 23 patients who had an internal urethrotomy with a 66% success rate and a rate of new onset stress urinary incontinence (SUI) of 9.5%.…”

“…For graft urethroplasties, success rates ranged from 86 to 93%. 3 There are a variety of techniques described each with theoretic advantages, but given that the sample sizes of studies have continued to be low, no single technique has proven to be superior.…”

“…8% were related to infection and inflammation and 6.6% related to trauma. 3 Iatrogenic injury includes anterior vaginal or urethral surgery, urethral catheterization and irradiation for pelvic malignancies. 2 Surgeries can include transurethral operations and open procedures such as excision of a synthetic midurethral sling or a diverticulectomy.…”

“…Meanwhile other supplementary tests include maximum urinary flow rate, post void residual, MRI, CT, micturating cystourethrogram, video cystometrogram and retrograde urethrogram. 3 …”