In this video, we present the surgical technique of female urethroplasty using the vaginal skin flap. This is a 63-year-old female who presented with overactive bladder symptoms and repeat episodes of acute urinary tension. The patient was known to have a urethral stricture for the past 10 years and for which she had failed multiple attempts for urethral dilations. She had been on self-catheterization twice weekly. Urethral history is pertinent for the patient's lichen planus of the mouth, and this contraindicated the use of a buccal mucosal graft. Voiding sister urethrogram and cystoscopy confirmed the tight 1-centimeter stricture just proximal to the external urethral meatus. The proximal end of the stricture is first localized using antigrade cystoscopy. The distal end of the stricture is then identified using a 32 French male urethral dilator. The limits of the stricture are marked on the vaginal surface to better plan the vaginal skin flap. The length of the stricture is approximately 1 centimeter, and this requires the use of a 4-by-2 centimeter flap. In this technique, a strip of vaginal tissue will be used as a flap. It will be denuded of vaginal epithelium nearly at the sagittal midline. The part of the flap distal to the denuded area is folded internally and used as an onlay for the urethroplasty. The proximal part of the flap is used then to close the vaginal defect overlying the urethral stricture site. After injection with local anesthetic, a 2-by-4 centimeter vaginal skin flap is created with the help of a scalpel and a medicine bound scissors. Approximately 1.5 centimeters away from the free flap edge, a 5-millimeter region of the strip is denuded, removing the vaginal epithelium and extended throughout the whole width of the flap. The urethra is then opened ventrally at the stricture site. Caution should be made not to transfix the urethra or injure the dorsal side. The tip of a metal dilator may be used to identify the lumen and avoid such a complication. Once the stricture is inside, a 16 French Foley catheter can be passed into the bladder. The distal edge of the flap is then folded, as previously described, and sutured mucosa to mucosa to the left edge of the urethrotomy. In this case, this was done using 5-0 PDS sutures. The edge of the flap just distal to the denuded area, marked here as A and B, is then sutured in a similar fashion to the right edge of the urethrotomy, marked as C and D. The vaginal skin defect is then closed. Operative time was 90 minutes, blood loss 150 cc, hospital stay one day, uterine catheter stayed in place for two weeks, and the suprapubic catheter for three weeks.

surgical technique

female urethroplasty

vaginal skin flap

overactive bladder symptoms

urethral stricture