DOI: https://doi.org/10.53350/pjmhs221651519 ORIGINAL ARTICLE P J M H S Vol. 16, No. 05, May 2022 1519 Dorsal Onlay Urethroplasty Using Buccal Mucosal Graft and Vaginal Wall Graft for Female Urethral Stricture; Outcome of a Tertiary Care Hospital RAZA UL HASSAN 1 , SHAHID SIRAJ 2 , AJMAL KHAN 3 , AMJAD SALEEM 4 , IFTIKHAR AHMAD 5 , RAJA NAEEM 6 1, 3, 4, 5, 6 PGR Urology, Pakistan Institute of Medical Sciences Islamabad 2 Registrar Urology, Pakistan Institute of Medical Sciences Islamabad Corresponding author: Ajmal Khan, Email: Drkhanajmal@gmail.com, Cell: +92 345 9330044 ABSTRACT Background: Normally female urethral stricture (FUS) is uncommon and underdiagnosed condition. It is raising a diagnostic challenge for the physicians. It is the one of the rarely known urological entity. Urethral dilatation is the traditionally used treatment for urethral stricture (FUS). The female urethroplasty have shown the promising outcomes. Objective: The objective of the study was to compare the outcome of the dorsal onlay urethoplasty FU obtained by using buccal mucosal graft and vaginal wall graft. The FU is more effective treatment for female urethral stricture (FUS) as compared to the repeated dilatation. Study design: It is a retrospective study with the statistical approach, conducted at Urology Department, Pakistan Institute of Medical Sciences Islamabad from June 2021 to November 2021. Material and Methods: The women who underwent the dorsal onlay urethropasty at the urology department of the hospital were included in the study. The outcomes of BMG and VWG were compared. The re-intervention was marked as failure. The association symptom score, postvoid residual urine (PVR), cystourethrogram, cystoscopy and uretheral calibration were included in the assessment. Operating time, catheter time, etiology, location, length, prior interventions and suprapubic cystostomy were the other parameters that was also reported. For the statistical analysis the Mann-Whitney test, t-test and proportion test was performed. Results: The calculated mean age of the patients included in the group was 48 years. Its range was between the 26 to 76 years. The women visited the urology department of the hospital from June 2021 to June 2022. The average follow-up was for 26 months. The AUA symptoms changes from 22 to 6, Qmax from 4ml/s to 26ml/s and RVR from 185ml to 7ml. The operating time was the only parameter showed the difference, while other remained the same. The 94% was the overall urethral patency rate. Conclusion: For the substitution of dorsal onlay urethroplasty the use of VWG and BMG is highly recommended. It is an efficient and reliable treatment method. There are very low chances of complication and it has an easy protocol. Apparently, no specific change was observed in the FUS treatment by BMG and VWG. Keywords: Female urethral stricture (FUS), buccal mucosal graft, vaginal wall graft, postvoid residual urine (PVR), dorsal onlay urethroplasty. INTRODUCTION Female urethral stricture is one of the rarely reported condition. The one of the challenging condition for the physicians is the diagnosis of bladder outlet obstruction. The repeated instrumentation has impacted the etiology of the FUS. It became iatrogenic 1 . The breach in the mucosa is as a result of the repeated instrumentation trauma. The extravasation that resulted in the fibrosis ultimately leads to the stricture formation.The incidence of urethral stricture in the women is reported to be range from 4 to 13%. The 2.7% to 8% of the women having low urinary tract symptoms usually diagnosed with the FUS 2-3 . The diverticulum surgery, difficult catheterization, prior urethral dilatation, pelvic fracture and exposure to radiations can cause the formation of urethral stricture. Limited knowledge is present on the diagnosis criteria, optimum management algorithm and follow-ups. The diagnostic criteria are not documented for this disease. The need of the hour is to improve the treatment efficacy and diagnostic techniques for the disease. The recurrent urianary tract infection, voiding and storage lower urinary tract symptoms are observed in the patients suffering from FUS 4 . This can ultimately leads to the renal failure that affect the quality of life badly. In most of the cases the stricture is usually located distally to the external ureatheral sphincter. The measurement of residual volume and uroflometry are normally used for the local examinations 5-6 . The internal urethrotomies and urethral dilatation are traditionally used for the treatment of the female urethral stricture. The physicians are considering surgical reconstruction for the treatment of FUS. The promising results are observed by the substitution urethroplasty aided with the local flaps and different grafts. The two types of substitution are onlay and inlay 7-8 . The dilatation and intermittent catheterization also yield good results but with the higher reported complications. However the results obtained from the dorsal onlay urethroplasty aided with the buccal mucosal graph and vaginal wall graph were compared. These treatment are proved to be more effective with better results and less reported complications 9-10 . MATERIAL AND METHODS The study was conducted on the 79 women, out of which 42 was diagnosed with urethral stricture at the Urology department of our teaching hospital from June 2021 to June 2022. Only 35 patients were included in the study. The ethical committee of the hospital approved the study. The informed consent was taken from all the participants. For the diagnostic criteria the urinary flow less than 10mi/s, inability of the patient to calibrate urethra with 10 Fr catheter, and narrowing of urethra with proximal dilatation on micturating cystourethrogram were considers. The data about the history, physical examination, micturating cystourethrogram, uroflowmetry, and residual volume were collected. The incomplete voiding and poor flow were observed in the most of patients while recurrent urinary tract infection was reported in four patients and the other four had complaint of frequency and urgency. The flimsy stricture were observed in the 5 patients. The acute urinary retention were observed in the three patients. The clinical examination, urological association symptom score, uroflowmetry urethral calibration and PVR. The cystoscopy was used for the final diagnosis. The SPSS was used for the statistical analysis. RESULTS For this study, the mean age was calculated (48 years), and the range was 26 to 76 years. Among the two groups, the patients of the BMG group were younger having average age of 44 than VWG group having mean age of 54. All the interventions were noticed before further proceeding for stricture localization, etiology length,