In the following video, we present our technique for female urethroplasty using an oral labial mucosal graft in a ventral onlay fashion. Following appropriate outpatient workup to identify this female patient's urethral structure, surgical treatment options were discussed in detail and the patient consented to a urethroplasty. In this case, where the urethral structure was located at the bladder neck, a suprapubic tube had been placed two months prior to planned urethroplasty. Her dentition and oral mucosa was inspected to assess for healthy graft availability. She was taken to the operating room and underwent general anesthesia via nasotracheal intubation. She was placed in dorsal lithotomy position with careful attention to ensure all pressure points were appropriately padded. Her suprapubic tube was removed on the field and the case began with flexible cystoscopy via her matured suprapubic tube tract. The urethral structure was identified at the bladder neck. Flexible cystoscopy was then performed retrograde via urethra. A wire was passed through the stricture and into the bladder. The stricture in this case was approximately four French in caliber. A 16 French Foley catheter was used to drain the bladder via suprapubic tube tract and retraction was established using a weighted vaginal speculum and hook retractor. The wire remained in place per urethra. An inverted U incision was marked on the anterior vaginal wall with the most distal extent just proximal to the urethral meatus. Injectable saline was used for hydro dissection and then the incision was made using a number 15 blade. The vaginal flap was then developed sharply using metzenbaum scissors sparing only the periurethral fascia. Once the flap was dissected to the level of the bladder neck the stricture was localized using transillumination was performed to identify the proximal extent of the stricture. A 25 gauge needle was then passed across the midline of the urethral lumen at the proximal aspect of the stricture and under direct vision with the cystoscope. The cystoscope was then removed and the needle left in place to facilitate urethrotomy. Urethrotomy at the level of the stricture was then performed using a fresh number 15 blade. Urethrotomy is performed only at the level of the stricture by cutting down directly on top of the needle. Once the wire is identified in the urethral lumen the needle can be removed and a right angle clamp is placed in the urethral lumen to facilitate further urethrotomy. Retrograde cystoscopy is repeated and 20 french female urethral sound is then passed via meatus into the bladder to ensure the entire stricture has been incised and the remainder of the urethra has been removed. is of adequate caliber. Eversion of the urethral mucosa from the dorsal urethral plate to the spongiosum is then performed using 4-0 absorbable braided suture. Next, the stricture length is measured to establish the length of graft that will be needed. We typically harvest an oral labial graft that is 20% greater than the measured stricture length. Attention is then turned towards the mouth for the harvest of the oral labial mucosal graft. We harvest our graft from the mucosal lining of the inner lip known as the labial mucosa. Stay sutures of 2-0 silk are used to evert the lip outwards and provide exposure of our field. The harvest site is marked in this situation 2 centimeters long by 2 centimeters wide with careful attention to preserve the vermilion border and the labial frenulum. 1% lidocaine with epinephrine is then injected deep to the graft and a number 15 blade is used to incise the outline of the graft. Being careful to grasp only the edges with forceps, iris scissors are used to further dissect the graft off of the underlying fat. Once the graft is completely excised, it is placed on a silicone block, mucosal surface down, and iris scissors are used to remove excess fat. Selective electrocautery can be used to achieve hemostasis of the harvest site and the mouth is then packed with a gauze soaked in lidocaine plus epinephrine solution. Gown and gloves are changed and attention is returned to the urethra. We use 4-0 absorbable monofilament suture for the urethroplasty. A stitch is placed at the 12, 3, 6, and 9 o'clock positions in an out-to-in fashion incorporating a small bite of urethral mucosa. Once all four of these stitches are in place, the graft is brought onto the field and each stitch is passed through the graft in an in-to-out fashion such that the knots are extraluminal and the mucosal surface of the graft is intraluminal. These stitches are tied down and the excess suture is trimmed from the 3 and 9 o'clock position. The remaining suture from the 12 and 6 o'clock positions are then used to close both sides of the graft in a running fashion to complete the urethroplasty and are then tied down. So so A 16 French silver coated catheter modified to a counsel tip is then passed over the wire and into the bladder. The wires are moved and the balloon is inflated to 10 cc's. A 3-0 absorbable braided suture is then used to close periurethral tissue over the graft in an interrupted fashion. The vaginal flap is then closed with running 2-0 absorbable braided suture. A vaginal packing with estradiol vaginal cream is placed at the conclusion of the case. The patient is admitted overnight for pain control and observation and discharged the following day. Her suprapubic tube is kept to gravity drainage while her urethral catheter is capped and remains in place for three weeks to allow adequate healing. you

female urethroplasty

oral labial mucosal graft

ventral onlay

urethral structure

urethroplasty procedure