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Urethroplasty of female distal urethra
URETHROPLASTY SIDNEY
R. WEINBERG,
ALBERT
KOVETZ,
GERALD MAUD
BERTONI, BERTONI,
OF FEMALE
DISTAL
URETHRA*
M.D.
M.D. M.D. M.D.
From the Division of Urology, Departments of Surgery and Pathology, The Jewish Hospital and Medical Center of Brooklyn, State University of New York, and Downstate Medical Center, Brooklyn, New York
ABSTRACTResults of experiences with urethroplasty for the repair of urethral meatal stricture of the female are reported. Discussion of the indications, results of the surgery, and afive-yearfollow-up study of the procedure is presented. Results are satisfactory, especially in children. A study of the resected pathologic specimens demonstrates in$ammation rather than fibrosis is the basic cause of urethral meatal stricture.
Urinary
tract symptoms, such as dysuria, freand alteration of suprapubic pain, quency, urinary stream, are common in female patients of all ages often without upper urinary tract disease. In adults this syndrome is often caused by hyperplastic urethritis often with a urethral caruncle and a stricture of the distal meatus.’ In children it is usually caused by distal urethral stenosis alone. During the past five years we have treated 98 female patients of all ages by excision of the urethral meatal ring, freeing of adhesions in the submucosal layer of the urethrovaginal septum, and excision of the distal quarter of the urethral mucosa. In the majority there has been a marked improvement of symptoms. We have also studied the histopathologic aspects of the resected tissue of the urethra by hematoxylin-eosin and trichrome stains and have found that fibrotic tissue was minimal and that the alteration was due in most instances to submucosal and mucosal inflammatory changes. In our experience, most of the children were first seen because of urinary tract infection, the adults because of urinary symptoms. On examination, definite stricture of urethra by calibrations *This material was presented as a scientific exhibit at the meeting of the American Urological Association, Washington, D.C., May, 1972.
UROLOGY
/
JUNE 1973
/
VOLUME I, NUMBER 6
with bougie a boule was found. The criterion in children is to define urethral stricture when there is definite blanching on calibration (Fig. 1A and B). Previous studies by Immergut, Culp, and Flocks,2 as well as Fisher et aL3 have demonstrated that the urethral meatus of all females, even the newborn, should be able to accommodate a no. 16 French bougie. We have used this criterion to determine if a definite stricture is present, and that is our only diagnostic standard, regardless of the findings noted on voiding cystography, which is done for all patients to rule out ureterovesical reflux. Most of the patients, both children and adults, were treated at the initial visit by dilatation with straight sounds to no. 30 French bougie. Those who improved clinically and bacteriologically were many. It has been estimated that an initial dilatation alone will cure only 40 per cent of the patients.4 The procedure described herein was performed only in those who failed to respond and in whom infection and/or symptoms developed for the second time. Surgical
Technique
The patient is placed in lithotomy position. The labia are retracted laterally with silk sutures. A U-shape incision is made in the meatus (Fig.
589
FIGURE 1. (A) Blanching blanching as acorn-tipped
on calibration of urethra in three-year-old girl at no. 12 French catheter. catheter is withdrawn. (C) U-shaped incision into child’s meatal ring.
(B) Increased
FIGURE 2. (A) Excision of distal urethral mucosa. (B) Surgical specimen: resected urethral meatus and distal one quarter of urethral mucosa. (C) Suture of urethral mucosa to vagina.
590
UROLOGY
/ JUNE1973 / VOLUME&NUMBER6
1C). With an iris scissors, dissection of the distal one third of the urethral mucosa and surrounding connective tissue is performed by freeing all adhesions in the urethrovaginal septum. Ligature of blood vessels is not necessary if the right plane is found. The dissection is carried until normal suburethral tissue is found. A stay suture is placed at the upper edge of the urethral mucosa and resection of the distal urethral mucosa beyond to the stay suture is performed (Fig. 2A and B). The mucosa is secured back to the vaginal wall with interrupted mattress sutures of 3-O chromic catgut (Fig. 2C). No catheter is left indwelling. Only an occasional postoperative catheterization was necessary. Adult patients were discharged in twenty-four to forty-eight hours; the children were sent home the same day. Results This technique is similar to that described by Harvard,s except that he makes the incision from the 9 to 3 o’clock position and uses a postoperative catheter for twenty-four hours. Our incision is higher from the 11 to 10 o’clock position, and it can be completely circumferential; also we do not use a postoperative catheter. Richardson6 has had extensive experience with external urethroplasty in women. Although his technique differs somewhat from ours, the results of both series are approximately the same. All patients who had been operated on were sent a questionnaire for information as to results of the surgery. From 50 returns on 98 patients treated from 1965 to 1971, the following statistics were tabulated: 80 per cent had good results; 10 per cent had distal urethral stricture associated with permanent cystitis and require continuing treatment; and 10 per cent reported poor results or their answers were equivocal. None of the patients had urinary incontinence as a result of urethroplasty. The patients with continuing symptoms were mainly women with chronic interstitial cystitis. Many of these were greatly improved as to urinary frequency. Pathologic
Aspects
The urethral mucosa near the meatus is formed by squamous epithelium and changes to pseudostratified columnar epithelium and transitional epithelium as the bladder neck is approached. There are numerous periurethral gland-like tubules; the most distal are known as Skene’s
UROLOGY
/ JUNE 1973 / VOLUME I, NUMBER 6
glands. The mucosa is arranged as longitudinal folds which appear as crypts on cross section. The surgical specimens were stained with both classical hematoxylin-eosin and trichrome stains for fibrous tissue. In both the adult and pediatric patients the lesion was consistent with hyperplastic urethritis. It is necessary to emphasize hyperplasia of the squamous epithelium (Fig. 3). When this occurs in the urethral fold, it can completely obliterate the size of the lumen and distensibility of the urethra, thereby producing symptoms of obstruction. The trichrome stain failed to show the expected increase in fibrous tissue in the submucosal layers, and no fibrous ring was found. This is in accord with the findings of Lyons and Tanagho.4 It is reasonable to assume that the squamous hyperplasia is the result of acute and chronic inflammation which is demonstrated by vascular engorgement and the presence of polymorphonuclear leucocytes and lymphocytes in the submucosa. Summary Urethroplasty in the female is superior to continued urethral dilatations or internal urethrotomy for the treatment of distal urethral stenosis.7 Since the pathologic alterations, especially in children, are confined to the distal urethral meatus, they remove the etiologic lesion without involving the posterior urethra and causing the extensive bleeding that often results after internal urethrotomy. 555 Prospect Place Brooklyn, New York 11238 (DR. WEINBERG) References 1. HYAMS, J. A., and WEINBERG, S. Ft.: Hyperplastic changes at the vesical neck in the female, J. Urol. 51: 1944. 2. IMMERGUT, M., CULP, D., and FLOCKS, Il. H.: The urethral caliber in normal female children, ibid. 97: 693 (1967). 3. FISHER, R. E., TANAGHO, E. A., LYONS, R. P., and Urethral calibrations in newborn girls, TOOLERY, W. H.: ibid. 102: 67 (1969). LYONS, R. P., and TANAGHO, E. A.: Distal urethral stenosis in little girls, ibid. 93: 379 (1965). HARVARD, B. M.: Revision of the external urinary meatus in girls: A clinical appraisal, ibid. 103: 236 (1970). RICHARDSON, F. H: External urethroplasty in women: Technique and clinical evaluation, ibid. 101: 719 (1969). IMMERGUT, M. A., and GILBERT, E. C.: The clinical response of women to internal urethrotomy, ibid. 109: 90 (1973).
591
R. WEINBERG,
ALBERT
KOVETZ,
GERALD MAUD
BERTONI, BERTONI,
OF FEMALE
DISTAL
URETHRA*
M.D.
M.D. M.D. M.D.
From the Division of Urology, Departments of Surgery and Pathology, The Jewish Hospital and Medical Center of Brooklyn, State University of New York, and Downstate Medical Center, Brooklyn, New York
ABSTRACTResults of experiences with urethroplasty for the repair of urethral meatal stricture of the female are reported. Discussion of the indications, results of the surgery, and afive-yearfollow-up study of the procedure is presented. Results are satisfactory, especially in children. A study of the resected pathologic specimens demonstrates in$ammation rather than fibrosis is the basic cause of urethral meatal stricture.
Urinary
tract symptoms, such as dysuria, freand alteration of suprapubic pain, quency, urinary stream, are common in female patients of all ages often without upper urinary tract disease. In adults this syndrome is often caused by hyperplastic urethritis often with a urethral caruncle and a stricture of the distal meatus.’ In children it is usually caused by distal urethral stenosis alone. During the past five years we have treated 98 female patients of all ages by excision of the urethral meatal ring, freeing of adhesions in the submucosal layer of the urethrovaginal septum, and excision of the distal quarter of the urethral mucosa. In the majority there has been a marked improvement of symptoms. We have also studied the histopathologic aspects of the resected tissue of the urethra by hematoxylin-eosin and trichrome stains and have found that fibrotic tissue was minimal and that the alteration was due in most instances to submucosal and mucosal inflammatory changes. In our experience, most of the children were first seen because of urinary tract infection, the adults because of urinary symptoms. On examination, definite stricture of urethra by calibrations *This material was presented as a scientific exhibit at the meeting of the American Urological Association, Washington, D.C., May, 1972.
UROLOGY
/
JUNE 1973
/
VOLUME I, NUMBER 6
with bougie a boule was found. The criterion in children is to define urethral stricture when there is definite blanching on calibration (Fig. 1A and B). Previous studies by Immergut, Culp, and Flocks,2 as well as Fisher et aL3 have demonstrated that the urethral meatus of all females, even the newborn, should be able to accommodate a no. 16 French bougie. We have used this criterion to determine if a definite stricture is present, and that is our only diagnostic standard, regardless of the findings noted on voiding cystography, which is done for all patients to rule out ureterovesical reflux. Most of the patients, both children and adults, were treated at the initial visit by dilatation with straight sounds to no. 30 French bougie. Those who improved clinically and bacteriologically were many. It has been estimated that an initial dilatation alone will cure only 40 per cent of the patients.4 The procedure described herein was performed only in those who failed to respond and in whom infection and/or symptoms developed for the second time. Surgical
Technique
The patient is placed in lithotomy position. The labia are retracted laterally with silk sutures. A U-shape incision is made in the meatus (Fig.
589
FIGURE 1. (A) Blanching blanching as acorn-tipped
on calibration of urethra in three-year-old girl at no. 12 French catheter. catheter is withdrawn. (C) U-shaped incision into child’s meatal ring.
(B) Increased
FIGURE 2. (A) Excision of distal urethral mucosa. (B) Surgical specimen: resected urethral meatus and distal one quarter of urethral mucosa. (C) Suture of urethral mucosa to vagina.
590
UROLOGY
/ JUNE1973 / VOLUME&NUMBER6
1C). With an iris scissors, dissection of the distal one third of the urethral mucosa and surrounding connective tissue is performed by freeing all adhesions in the urethrovaginal septum. Ligature of blood vessels is not necessary if the right plane is found. The dissection is carried until normal suburethral tissue is found. A stay suture is placed at the upper edge of the urethral mucosa and resection of the distal urethral mucosa beyond to the stay suture is performed (Fig. 2A and B). The mucosa is secured back to the vaginal wall with interrupted mattress sutures of 3-O chromic catgut (Fig. 2C). No catheter is left indwelling. Only an occasional postoperative catheterization was necessary. Adult patients were discharged in twenty-four to forty-eight hours; the children were sent home the same day. Results This technique is similar to that described by Harvard,s except that he makes the incision from the 9 to 3 o’clock position and uses a postoperative catheter for twenty-four hours. Our incision is higher from the 11 to 10 o’clock position, and it can be completely circumferential; also we do not use a postoperative catheter. Richardson6 has had extensive experience with external urethroplasty in women. Although his technique differs somewhat from ours, the results of both series are approximately the same. All patients who had been operated on were sent a questionnaire for information as to results of the surgery. From 50 returns on 98 patients treated from 1965 to 1971, the following statistics were tabulated: 80 per cent had good results; 10 per cent had distal urethral stricture associated with permanent cystitis and require continuing treatment; and 10 per cent reported poor results or their answers were equivocal. None of the patients had urinary incontinence as a result of urethroplasty. The patients with continuing symptoms were mainly women with chronic interstitial cystitis. Many of these were greatly improved as to urinary frequency. Pathologic
Aspects
The urethral mucosa near the meatus is formed by squamous epithelium and changes to pseudostratified columnar epithelium and transitional epithelium as the bladder neck is approached. There are numerous periurethral gland-like tubules; the most distal are known as Skene’s
UROLOGY
/ JUNE 1973 / VOLUME I, NUMBER 6
glands. The mucosa is arranged as longitudinal folds which appear as crypts on cross section. The surgical specimens were stained with both classical hematoxylin-eosin and trichrome stains for fibrous tissue. In both the adult and pediatric patients the lesion was consistent with hyperplastic urethritis. It is necessary to emphasize hyperplasia of the squamous epithelium (Fig. 3). When this occurs in the urethral fold, it can completely obliterate the size of the lumen and distensibility of the urethra, thereby producing symptoms of obstruction. The trichrome stain failed to show the expected increase in fibrous tissue in the submucosal layers, and no fibrous ring was found. This is in accord with the findings of Lyons and Tanagho.4 It is reasonable to assume that the squamous hyperplasia is the result of acute and chronic inflammation which is demonstrated by vascular engorgement and the presence of polymorphonuclear leucocytes and lymphocytes in the submucosa. Summary Urethroplasty in the female is superior to continued urethral dilatations or internal urethrotomy for the treatment of distal urethral stenosis.7 Since the pathologic alterations, especially in children, are confined to the distal urethral meatus, they remove the etiologic lesion without involving the posterior urethra and causing the extensive bleeding that often results after internal urethrotomy. 555 Prospect Place Brooklyn, New York 11238 (DR. WEINBERG) References 1. HYAMS, J. A., and WEINBERG, S. Ft.: Hyperplastic changes at the vesical neck in the female, J. Urol. 51: 1944. 2. IMMERGUT, M., CULP, D., and FLOCKS, Il. H.: The urethral caliber in normal female children, ibid. 97: 693 (1967). 3. FISHER, R. E., TANAGHO, E. A., LYONS, R. P., and Urethral calibrations in newborn girls, TOOLERY, W. H.: ibid. 102: 67 (1969). LYONS, R. P., and TANAGHO, E. A.: Distal urethral stenosis in little girls, ibid. 93: 379 (1965). HARVARD, B. M.: Revision of the external urinary meatus in girls: A clinical appraisal, ibid. 103: 236 (1970). RICHARDSON, F. H: External urethroplasty in women: Technique and clinical evaluation, ibid. 101: 719 (1969). IMMERGUT, M. A., and GILBERT, E. C.: The clinical response of women to internal urethrotomy, ibid. 109: 90 (1973).
591