Harnröhrenstrikturen der Frau: Aktuelles zu Diagnostik und Therapie

Zusammenfassung

Harnröhrenstrikturen der Frau sind ein seltenes Krankheitsbild mit individueller Symptomatik. Vor diesem Hintergrund mangelt es an klinischen Leitfäden, die sich mit Diagnostik und Therapie dieser Erkrankung befassen. Mittlerweile liegen einige Ergebnisse zu verschiedenen Operationstechniken vor, ein direkter inter-institutioneller Vergleich wird jedoch durch heterogene Patientenkohorten und kleine Fallzahlen erschwert. Die vorliegende Arbeit befasst sich mit einer aktuellen narrativen Literaturübersicht relevanter Artikel zur klinischen Diagnostik und zu den Therapiemöglichkeiten bei weiblicher Harnröhrenstriktur.

Iatrogene Ursachen wie eine vorangegangene Katheterisierung oder ein urogenitaler operativer Eingriff sind die häufigsten Gründe für die Entstehung einer Harnröhrenstriktur bei der Frau. Im klinischen Alltag stellt die körperliche Untersuchung einen wichtigen Grundstein in der Differentialdiagnostik dar, um bei Verdacht auf eine anatomisch-morphologische Ursache der Harnblasenentleerungsstörung weitere diagnostische Maßnahmen (Urethrozystoskopie, Urethrographie, MRT) einzuleiten. Therapeutisch sind minimal-invasive Eingriffe wie Harnröhrenbougierungen oder Urethrotomien oftmals nur mit kurzfristigem Erfolg assoziiert, sodass die offene Harnröhrenrekonstruktion mit langfristigeren Therapieerfolgen hier eine Sonderstellung einnimmt. Zur Verfügung stehen neben offenen Harnröhrenplastiken mit gestielten Lappen aus Vaginal- oder Labialschleimhaut auch die Verwendung freier Transplantate, vor allem dem Mundschleimhaut-Autotransplantat. Aufgrund der genannten Seltenheit der Erkrankung mit nur kleinen publizierten Fallserien ist jedoch eine Beurteilung der vergleichenden Wirksamkeit der verschiedenen Techniken nur schwer möglich. Wie bei allen seltenen Erkrankungen bedarf es hier der Etablierung von multizentrischen, großen Serien, um die Standards im perioperativen Vorgehen zu verbessern.

Abstract

Urethral strictures in women are rare and patients may present with varying symptoms. Hence, clinical guidelines regarding diagnostic algorithms and treatment approaches are scarce. Several small case series have presented results for several operative techniques, but patient cohorts are generally heterogeneous and relatively small, which hampers reliable comparability across institutions. The present narrative review aims to provide a contemporary overview of the literature regarding the clinical and therapeutical approach in women with urethral strictures.

Iatrogenic reasons such as previous catheterization or genitourinary surgical interventions are the most common cause of female urethral strictures. In daily clinical routine, physical examination is the cornerstone for differential diagnosis and may aid in the decision to expand diagnostic workup by urethrocystoscopy, urethrography, or magnetic resonance imaging in case of suspected anatomic or morphologic cause of voiding disorder. Endoscopic approaches such as dilation or urethrotomy only provide short-term symptomatic relief and open urethroplasty is more commonly associated with durable long-term success. Regarding the surgical approach, there are comparable operative techniques at hand, using vaginal or labial flaps or oral mucosal grafts. Given the relative rarity of female urethral strictures with only small case series published, a statement regarding the superiority of one approach over the other is hardly possible. As for all rare disorders, multi-institutional, large patient series are needed to generate reliable evidence and to improve standards in the perioperative care of women with urethral strictures.

Schlüsselwörter

Harnröhrenchirurgie - Blasenentleerungsstörungen - Urethroplastik - Urethrotomie - Harnröhrenbougierung

Keywords

Urethral Reconstruction - Voiding Disorders - Urethroplasty - Urethrotomy - Urethral Dilation

Publication History

Article published online:
15 April 2021

• Literatur

• 1 Bayne DB, Gaither TW, Awad MA. et al. Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up. Transl Androl Urol 2017; 6: 288-294 DOI: 10.21037/tau.2017.03.55.
• 2 Nitti VW, Tu LM, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol 1999; 161: 1535-1540 DOI: 10.1016/S0022-5347(05)68947-1.
• 3 Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: Definition and characteristics. Neurourol Urodyn 2000; 19: 213-220 DOI: 10.1002/(sici)1520-6777(2000)19:3<213::aid-nau2>3.0.co;2-u.
• 4 Hsiao S-M, Lin H-H, Kuo H-C. Videourodynamic Studies of Women with Voiding Dysfunction. Sci Rep 2017; 7: 6845 DOI: 10.1038/s41598-017-07163-2.
• 5 Lyon RP, Tanagho EA. Distal Urethral Stenosis in Little Girls. J Urol 1965; 93: 379-387 DOI: 10.1016/s0022-5347(17)63782-0.
• 6 Mattelaer JJ, Debruyne FM. Distal urethral stenosis in young girls. Urol Int 1974; 29: 389-398 DOI: 10.1159/000279937.
• 7 Hampson LA, Myers JB, Vanni AJ. et al. Dorsal buccal graft urethroplasty in female urethral stricture disease: a multi-center experience. Transl Androl Urol 2019; 8: S6-S12 DOI: 10.21037/tau.2019.03.02.
• 8 el-Sayed RF, Morsy MM, el-Mashed SM. et al. Anatomy of the urethral supporting ligaments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women. AJR Am J Roentgenol 2007; 189: 1145-1157 DOI: 10.2214/ajr.07.2215.
• 9 Morgan DM, Iyengar J, DeLancey JOL. A technique to evaluate the thickness and density of nonvascular smooth muscle in the suburethral fibromuscular layer. Am J Obstet Gynecol 2003; 188: 1183-1185 DOI: 10.1067/mob.[phone].
• 10 Thomaz RP, Colla C, Darski C. et al. Influence of pelvic floor muscle fatigue on stress urinary incontinence: a systematic review. Int Urogynecol J 2017; 29: 197-204 DOI: 10.1007/s00192-017-3538-6.
• 11 Clobes A, DeLancey JO, Morgan DM. Urethral circular smooth muscle in young and old women. Am J Obstet Gynecol 2008; 198: 587.e581-585 DOI: 10.1016/j.ajog.2008.03.009.
• 12 O'Connell HE, Sanjeevan KV, Hutson JM. Anatomy of the clitoris. J Urol 2005; 174: 1189-1195 DOI: 10.1097/01.ju.0000173639.38898.cd.
• 13 Spilotros M, Malde S, Solomon E. et al. Female urethral stricture: a contemporary series. World J Urol 2016; 35: 991-995 DOI: 10.1007/s00345-016-1947-7.
• 14 Anast J, Brandes SB, Klutke C. Female Urethral Reconstruction. Brandes SB. Urethral Reconstructive Surgery. Totowa, NJ: Humana Press; 2008: 303-313 DOI: 10.1007/978-1-59745-103-1_27
• 15 Blaivas JG, Santos JA, Tsui JF. et al. Management of Urethral Stricture in Women. J Urol 2012; 188: 1778-1782 DOI: 10.1016/j.juro.2012.07.042.
• 16 Flisser AJ, Blaivas JG. Outcome of Urethral Reconstructive Surgery in a Series of 74 Women. J Urol 2003; 169: 2246-2249 DOI: 10.1097/01.ju.0000061763.88247.16.
• 17 Perry MO, Husmann DA. Urethral Injuries in Female Subjects Following Pelvic Fractures. J Urol 1992; 147: 139-143 DOI: 10.1016/S0022-5347(17)37162-8.
• 18 Indudhara R, Vaidyanathan S, Radotra BD. Urethral tuberculosis. Urol Int 1992; 48: 436-438 DOI: 10.1159/000282372.
• 19 Levy A, Browne B, Fredrick A. et al. Insights into the Pathophysiology of Urethral Stricture Disease due to Lichen Sclerosus: Comparison of Pathological Markers in Lichen Sclerosus Induced Strictures vs Nonlichen Sclerosus Induced Strictures. J Urol 2019; 201: 1158-1163 DOI: 10.1097/ju.0000000000000155.
• 20 Harari SE, Cheng L, Osunkoya AO. Primary mucinous adenocarcinoma of the female urethra: a contemporary clinicopathologic analysis. Human Pathol 2016; 47: 132-137 DOI: 10.1016/j.humpath.2015.09.014.
• 21 Desai S, Libertino JA, Zinman L. Primary carcinoma of the female urethra. J Urol 1973; 110: 693-695 DOI: 10.1016/s0022-5347(17)60317-3.
• 22 Yamashita T, Masuda H, Yano M. et al. Female Urethral Fibroepithelial Polyp With Stricture. J Urol 2004; 171: 357-357 DOI: 10.1097/01.ju.0000101514.52796.4e.
• 23 Migliari R, Leone P, Berdondini E. et al. Dorsal buccal mucosa graft urethroplasty for female urethral strictures. J Urol 2006; 176: 1473-1476 DOI: 10.1016/j.juro.2006.06.043.
• 24 Waterloos M, Verla W. Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease. Biomed Res Int 2019; DOI: 10.1155/2019/6715257.
• 25 Romero Pérez P, Mira Llinares A. [Renal and ureteral complications of urethral stenosis]. Actas Urol Esp 1995; 19: 432-440
• 26 Faiena I, Koprowski C, Tunuguntla H. Female Urethral Reconstruction. J Urol 2016; 195: 557-567 DOI: 10.1016/j.juro.2015.07.124.
• 27 Keegan KA, Nanigian DK, Stone AR. Female urethral stricture disease. Curr Urol Rep 2008; 9: 419-423 DOI: 10.1007/s11934-008-0071-7.
• 28 Defreitas GA, Zimmern PE, Lemack GE. et al. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64: 675-679 DOI: 10.1016/j.urology.2004.04.089.
• 29 Kawashima A, Sandler CM, Wasserman NF. et al. Imaging of Urethral Disease: A Pictorial Review. Radiographics 2004; 24: S195-S216 DOI: 10.1148/rg.24si045504.
• 30 Portnoy O, Kitrey N, Eshed I. et al. Correlation between MRI and double-balloon urethrography findings in the diagnosis of female periurethral lesions. Eur J Radiol 2013; 82: 2183-2188 DOI: 10.1016/j.ejrad.2013.08.005.
• 31 Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol 1999; 162: 2066-2069 DOI: 10.1016/s0022-5347(05)68102-5.
• 32 Theisen KM, Kadow BT, Rusilko PJ. Three-Dimensional Imaging of Urethral Stricture Disease and Urethral Pathology for Operative Planning. Curr Urol Rep 2016; 17: 54 DOI: 10.1007/s11934-016-0616-0.
• 33 Lorenzo AJ, Zimmern P, Lemack GE. et al. Endorectal coil magnetic resonance imaging for diagnosis of urethral and periurethral pathologic findings in women. Urology 2003; 61: 1129-1133 DOI: 10.1016/s0090-4295(03)00260-7.
• 34 Elsayes KM, Mukundan G, Narra VR. et al. Endovaginal magnetic resonance imaging of the female urethra. J Comput Assist Tomogr 2006; 30: 1-6 DOI: 10.1097/01.rct.0000187420.61062.f9.
• 35 Smith AL, Ferlise VJ, Rovner ES. Female urethral strictures: successful management with long-term clean intermittent catheterization after urethral dilatation. BJU Int 2006; 98: 96-99 DOI: 10.1111/j.1464-410X.2006.06206.x.
• 36 Osman NI, Mangera A, Chapple CR. A Systematic Review of Surgical Techniques Used in the Treatment of Female Urethral Stricture. Eur Urol 2013; 64: 965-973 DOI: 10.1016/j.eururo.2013.07.038.
• 37 Buckley JC, Heyns C, Gilling P. et al. SIU/ICUD Consultation on Urethral Strictures: Dilation, Internal Urethrotomy, and Stenting of Male Anterior Urethral Strictures. Urology 2014; 83: S18-S22 DOI: 10.1016/j.urology.2013.08.075.
• 38 Rosenblum N, Nitti VW. Female Urethral Reconstruction. Urol Clin North Am 2011; 38 DOI: 10.1016/j.ucl.2010.12.008.
• 39 Steenkamp JW, Heyns CF, de Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: a prospective, randomized comparison. J Urol 1997; 157: 98-101
• 40 Santucci R, Eisenberg L. Urethrotomy Has a Much Lower Success Rate Than Previously Reported. J Urol 2010; 183: 1859-1862 DOI: 10.1016/j.juro.2010.01.020.
• 41 Kirtschig G, Becker K, Gunthert A. et al. Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2015; 29: E1-E43 DOI: 10.1111/jdv.13136.
• 42 Stewart L, McCammon K, Metro M. et al. SIU/ICUD Consultation on Urethral Strictures: Anterior Urethra-Lichen Sclerosus. Urology 2014; 83: S27-S30 DOI: 10.1016/j.urology.2013.09.013.
• 43 Pandher BS, Rustin MHA, Kaisary AV. Treatment of balanitis xerotica obliterans with topical tacrolimus. J Urol 2003; 170: 923-923 DOI: 10.1097/01.ju.0000080958.11761.7b.
• 44 Agochukwu-Mmonu N, Srirangapatanam S, Cohen A. et al. Female Urethral Strictures: Review of Diagnosis, Etiology, and Management. Curr Urol Rep 2019; 20: 74 DOI: 10.1007/s11934-019-0933-1.
• 45 Gormley EA. Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn 2010; 29: S42-S45 DOI: 10.1002/nau.20814.
• 46 Simonato A, Varca V, Esposito M. et al. Vaginal Flap Urethroplasty for Wide Female Stricture Disease. J Urol 2010; 184: 1381-1385 DOI: 10.1016/j.juro.2010.06.042.
• 47 Gozzi C, Roosen A, Bastian PJ. et al. Volar onlay urethroplasty for reconstruction of female urethra in recurrent stricture disease. BJU Int 2011; 107: 1964-1966 DOI: 10.1111/j.1464-410X.2010.09790.x.
• 48 Petrou SP, Rogers AE, Parker AS. et al. Dorsal vaginal graft urethroplasty for female urethral stricture disease. BJU Int 2012; 110: E1090-E1095 DOI: 10.1111/j.1464-410X.2012.11233.x.
• 49 Rehder P, Glodny B, Pichler R. et al. Dorsal urethroplasty with labia minora skin graft for female urethral strictures. BJU Int 2010; 106: 1211-1214 DOI: 10.1111/j.1464-410X.2010.09240.x.
• 50 Tsivian A, Sidi AA. Dorsal graft urethroplasty for female urethral stricture. J Urol 2006; 176: 611-613 DOI: 10.1016/j.juro.2006.03.055.
• 51 Vetterlein MW, Loewe C, Zumstein V. et al. Characterization of a Standardized Postoperative Radiographic and Functional Voiding Trial after 1-Stage Bulbar Ventral Onlay Buccal Mucosal Graft Urethroplasty and the Impact on Stricture Recurrence-Free Survival. J Urol 2019; 201: 563-570 DOI: 10.1016/j.juro.2018.09.041.
• 52 Vetterlein MW, Stahlberg J, Zumstein V. et al. The Impact of Surgical Sequence on Stricture Recurrence after Anterior 1-Stage Buccal Mucosal Graft Urethroplasty: Comparative Effectiveness of Initial, Repeat and Secondary Procedures. J Urol 2018; 200: 1308-1314 DOI: 10.1016/j.juro.2018.06.067.
• 53 Zumstein V, Dahlem R, Kluth LA. et al. A critical outcome analysis of Asopa single-stage dorsal inlay substitution urethroplasty for penile urethral stricture. World J Urol 2020; 38: 1283-1294 DOI: 10.1007/s00345-019-02871-y.
• 54 Zumstein V, Dahlem R, Maurer V. et al. Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options. World J Urol 2019; 38: 2609-2620 DOI: 10.1007/s00345-019-03035-8.
• 55 Berglund RK, Vasavada S, Angermeier K. et al. Buccal mucosa graft urethroplasty for recurrent stricture of female urethra. Urology 2006; 67: 1069-1071 DOI: 10.1016/j.urology.2005.12.010.
• 56 Waterloos M, Verla W. Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease. Biomed Res Int 2019; 2019: 1-13 DOI: 10.1155/2019/6715257.
• 57 Castillo OA, Sepúlveda F, Feria-Flores MA. Uretroplastia con injerto dorsal de mucosa oral en estenosis uretral femenina. Actas Urol Esp 2011; 35: 246-249 DOI: 10.1016/j.acuro.2010.09.010.
• 58 Önol FF, Antar B, Köse O. et al. Techniques and Results of Urethroplasty for Female Urethral Strictures: Our Experience With 17 Patients. Urology 2011; 77: 1318-1324 DOI: 10.1016/j.urology.2011.01.017.
• 59 Sharma GK, Pandey A, Bansal H. et al. Dorsal onlay lingual mucosal graft urethroplasty for urethral strictures in women. BJU Int 2010; 105: 1309-1312 DOI: 10.1111/j.1464-410X.2009.08951.x.
• 60 Dublin N, Stewart LH. Oral complications after buccal mucosal graft harvest for urethroplasty. BJU Int 2004; 94: 867-869 DOI: 10.1111/j.1464-410X.2004.05048.x.
• 61 Lane GI, Smith AL, Stambakio H. et al. Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network. Neurourol Urodyn 2020; 39: 2433-2441 DOI: 10.1002/nau.24507.
• 62 Gunnemann A, Liedl B, Palma P. et al. Die Harnröhrenenge und Blasenhalsstenose der Frau – Fakt oder Mythos – Was ist zu tun?. Aktuelle Urol 2015; 46: 382-387 DOI: 10.1055/s-0035-1559624.