Alan Wein: Hi, Alan Wein from UroToday, and it's really a great pleasure today to have my good friend and colleague, Vic Nitti as a guest. Vic is the Shlomo Raz chair in Urology, a professor of urology and OBGYN, and the head of Urogynecology and Reconstructive Pelvic surgery at UCLA. And today he's going to talk to us about female urethral stricture, diagnosis and management.

So Vic, take it away and then we'll have a few questions and a discussion at the end.

Victor Nitti: Thank you so much, Alan. I just have a few disclosures, none of which are relevant to this talk.

So, let's talk a little bit about female urethral strictures, and I think they are indeed a real entity. Here's some of the causes, I'm not going to go through each and every one of these, but sometimes the cause is obvious. Sometimes it's not so obvious. How do we diagnose a stricture? Well, sometimes the patient's history will raise a suspicion.

Sometimes our physical exam can lead us to a suspicion. Here's an area where the urethral, if we look at that picture, the urethral meatus looks a little bit small, but it's certainly not diagnostic.

Uroflow and post-void residual. We can attempt to catheterize and see if there's some resistance. Of course, we can do a voiding cystourethrogram. As you can see here, where there's significant dilation of the urethra or endoscopy.

Urodynamics is really done only in select cases, and I'll tell you that where it's most useful is when you don't suspect a stricture. So you're doing urodynamics for another reason. And here you can see this video urodynamics, high pressure, low flow, dilated urethra. Maybe this is a stricture, as opposed to a dysfunctional or discoordinated sphincter.

So usually we don't use urodynamics, but sometimes urodynamics brings us to the diagnosis. I like to summarize strictures by their location, meatus, distal, mid, and proximal because that's how we treat strictures.

Here are our treatments and none of these are wrong. So urethral dilation can be offered as a treatment either acutely, or chronically self-catheterization, urethrotomy, which is something I don't do much. And then of course there's urethroplasty.

Urethral dilation, if we go back in time, historically it was done for not really true strictures, urethral syndrome, et cetera, I don't think that's done much anymore. But if there is a true urethral stricture dilation maybe 50% of the time can take care of the problem if it's the first time.

But once you get past the first time, the chances that your dilation, whether it's combined with an incision or not, is very low, probably in the range of 25%. So it's really more of a chronic treatment.

There are different techniques that we can fix a urethra if we're going to do a urethroplasty. Sometimes when it's just a meatal stenosis, we can do a simple circumferential distal urethrectomy. Here's that same picture I showed before.

And you can see here we're just basically going to excise the distal urethra and do an advancement, very simple procedure that can absolutely be curative.
Sometimes when the stricture is a little more proximal, we can do sort of a little vaginal flap where we make an inverted U-incision, open the urethra at the six o'clock position through the stricture and advance that.

Again, a relatively simple procedure that can be done. And these have... If you look here at these small series, the outcomes are pretty good when we treat these surgically, in the range of 80-plus percent success rates. So that's pretty good. No need for chronic dilation if the patient decides that is what she'd like to do.

Sometimes when we have a mid-urethral stricture or a mid-urethral loss, we can also do some more complicated reconstructions where we can advance either the plate of the urethra on the dorsal side, or advance the vaginal wall and basically create a longer urethra.

This is particularly good with a short urethra if there's vaginal voiding or if one has incontinence due to a short urethra, and you can combine it with a pubovaginal sling. Here's the technique where there's only a dorsal plate, and you roll it. So a bit more complicated reconstructive techniques, but these work very well, and have good long-term outcomes.

And finally, we have the most versatile, which is a buccal mucosal graft. And this is where we're a little bit behind in treating women compared to how we treat men. I would say we're probably a decade or two behind how things have changed over time. But a buccal mucosal graft is very versatile. You can treat a stricture of the entire urethra or you can do just a proximal or mid-urethral stricture.

It can be done dorsally where there's a nice blood supply, or it can be done ventrally, bringing in a blood supply such as a Martius flap.

And here's just an example where we've opened up the urethra. You can see the urethra is splayed open, and then the graft is placed on top of it. You have a nice big urethral meatus, so more advanced reconstructive techniques, but they worked very well. And here's just some outcomes from a large systematic review.

Again, not huge numbers of patients, but very high success rates. Here's a couple of more contemporary studies, again, one that we did with our colleagues in France when I was in New York, and another one from the UK, showing good results at about a year.

And this is something that the SUFU Research Network did retrospective study, but basically showing that yes, you can treat things endoscopically, but urethral reconstruction over time has better long-term cure rates with relatively low incontinence rates.

So I want to just summarize by saying female urethral strictures are a real entity. A high index of suspicion helps with diagnosis. You can offer dilation, but we do have surgical techniques that are more curative in the right hands, no comparative studies, but still some good options to treat these surgically. Thank you.
Alan Wein: Great. That was terrific. So we classically think of the point of continence in the female urethra as the mid-urethra. That's what all the textbooks tell us.

So I mean, I gather obviously you wouldn't do these surgeries if the risk of incontinence is very high. I mean, what is the risk of incontinence? And if it's under 20, 30%, why are these people not incontinent?

Victor Nitti: Well, I think what I've learned from doing these procedures is that we know less about the female continence mechanism than we think we do because we can completely filet the urethra open dorsally-

Alan Wein: Exactly.

Victor Nitti: Put a graft on top of it. And incontinence rates are in the relatively low single digits. So there's something more to continence that I don't think we fully understand.

Alan Wein: In the male, now, people are talking a lot about the Optilume catheter for BPH and also for urethral stricture disease. I mean, first of all, how well does it work in men? And are any people using it in women?

Victor Nitti: So in men, it works reasonably well. I think it takes dilation and DVIU and brings it a little bit closer to outcomes. For surgical treatment, you could take 50% and maybe it brings it to 70% success. In women. The problem in women is it hasn't been studied. And the other thing is in women, the portion of the urethra where the stricture occurs is functional urethra.

In men, it's more of a conduit, so we don't really know what happens when you circumferentially treat the sphincter by dilating it and putting a chemotherapeutic agent in it. It may actually be dangerous. Also, the balloons are pretty big for what a female urethra is. So I think if somebody's going to look at it has to... in my opinion, it has to be studied.

I think it's a little bit dangerous to just go ahead and do it without knowing what the outcome is. That's my thought. I may be completely wrong on that, but it's not something that I've adapted as of this time.

Alan Wein: You're not very wrong very often, Vic.

Victor Nitti: I don't know about that.

Alan Wein: Any tips for dealing with post-radiation strictures?

Victor Nitti: Well, I mean, of course whenever somebody's radiated, it's a less than optimal situation. And I see radiated strictures all the time. And the things you have to consider above what I just spoke about is the bladder may be radiated too. So you have to make sure you have a healthy bladder.

However you do that, it might require urodynamics to evaluate the bladder, not obstruction. And then you have to realize that your reconstructive techniques are probably going to have a little bit lower success rate because that tissue is just not as good.

Radiated patients are always challenging. And then the other thing is the urethra itself may be deficient from radiation. So incontinence rates to start and even after therapy may be higher than what we expect in the non-radiated patient.

Alan Wein: And man, it's pretty easy to do an antegrade and a retrograde study. You fill the bladder up, you have them void, you do a retrograde, your urethrogram. Is there anything like that in women that you do? In other words, how do you make the diagnosis of a urethral stricture as opposed to, let's say a bladder neck contracture in a woman?

Victor Nitti: So I mean, to me the most accurate way to do it is endoscopically, but it often requires a small... You don't want to dilate the stricture with a big scope. So I'll often use pediatric instruments, a voiding cystourethrogram can be done. There's no good retrograde studies. A voiding cystourethrogram can be done, but you have to be careful not to dilate the stricture so that for that 10 minutes right after it that you're doing your study, it actually looks better than it really is.

So for me, endoscopic exam with clinical parameters is the best way, but there isn't an ideal way.

Alan Wein: Got you. Well, that was terrific. I think you answered all our questions and it sounds like if I get one of these in the office tomorrow, I'll buy them a plane ticket to Los Angeles.

Take care, Vic.

Victor Nitti: Oh, thank you, Alan, my pleasure.