(Poster 127) Buccal Grafts to Repair Complex Urogenital Conditions in Women: A Case Series

Objectives: Buccal mucosal grafts are well described for repair of urethral strictures and male genitourinary pathologies, but their use in other complex female urogenital disorders remains limited. There is a paucity of published data on buccal graft urethroplasty for urethrovaginal fistula, urethral diverticulum, or female urethral mesh exposure. This study presents three cases of buccal graft urethroplasty for management of complex female urogenital conditions.

Methods: We included three female patients who underwent buccal graft urethroplasty at our institution.

Patient 1: A 52-year-old with a history of urethral diverticulum repair with subsequent urethrovaginal fistula repair and total abdominal hysterectomy with recurrent urethrovaginal fistula seen on CT urogram. Intraoperative findings showed a fistula 1.5-2cm from the urethrovesical junction at 7 o’clock. A three-layer primary closure and Martius flap were completed prior to buccal graft placement.

Patient 2: A 50-year-old with a history of total abdominal hysterectomy complicated by a pelvic abscess, urethral diverticulum repair and subsequent urethrovaginal fistula repair with pubovaginal sling placement, who was diagnosed with a recurrent urethral diverticulum on cystourethroscopy. A three-layer primary closure was performed in addition to the buccal graft.

Patient 3: A 60-year-old with a history of multiple urethral diverticulum repairs and two mid-urethral slings, who was found to have distal urethral mesh exposure on cystourethroscopy. Intraoperative findings demonstrated a one centimeter area of mesh exposure into the urethra. After excision of the mesh, the buccal graft was placed and the vaginal epithelial defect closed.

All patients underwent repair of their respective pathologies followed by buccal mucosal graft placement. Buccal grafts ranging from 1–2 × 5 centimeters (width × length) were harvested from each patient. Each graft was attached utilizing a previously published minimally-invasive technique utilizing a laparoscopic suturing device and clip system. A foley catheter was placed at completion of each procedure and removed 3-6 weeks postoperatively. Repeat cystourethroscopy was performed between 3-5 months post-procedure to ensure expulsion of the titanium clips.

Results: There were no significant complications. Two patients experienced postoperative urinary tract infection. One patient had persistent stress urinary incontinence subsequently treated with a fascial sling. There has been no recurrence of pathology in the range of 3-24 months since their respective procedures.

Conclusions: A buccal graft urethroplasty was effective in facilitating the repair of a urethrovaginal fistula, urethral diverticulum and urethral mesh exposure in three female patients. Buccal grafts are unique in their accessibility, resistance to infection, and the compatibility of the oral mucosa with the urethral environment providing an additional tissue layer to promote healing. The buccal graft urethroplasty utilizing a minimally invasive technique ultimately shows promise for the management of complex female urogenital pathologies.