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      Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft

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          Abstract

          Introduction:

          Both dorsal and ventral approaches are acceptable options for the surgical reconstruction of female urethral strictures (FUS), but damage to the sphincter and the clitoral nerves resulting in sexual dysfunction is the chief argument against the dorsal approach. Most of the reported case series are retrospective and none has evaluated sexual functions. This study prospectively evaluates the early sexual and functional results after dorsal onlay vaginal graft urethroplasty (DVGU) for FUS.

          Materials and Methods:

          All women with a history of obstructive voiding symptoms and previous urethral dilatation were evaluated with urodynamic study, voiding cystourethrography, and cystoscopy for the presence of FUS, which was defined as visual demonstration of anatomical narrowing on urethro-cystoscopy. DVGU was offered as a definitive management for all those identified with FUS. Surgical outcomes were assessed at 3 and 6 months with the International Prostate Symptom Score (IPSS), uroflowmetry, and postvoid residual (PVR) estimation. For sexually active females, sexual function was assessed using the Female Sexual Function Inventory (FSFI) score both preoperatively and at 3 months following surgery.

          Results:

          Seventy-one women were evaluated. FUS was identified in 29 women (flimsy in 12 and dense in 17). Thirteen women with dense strictures underwent DVGU. The mean improvement in the IPSS score, Q max, and PVR was 12.6, 16.64 ml/s, and 103.08 ml at 3 months, respectively. The FSFI score improved with a mean of 6.42 points after urethroplasty. None of the patients developed incontinence. There were three failures after a mean follow-up of 8.5 months.

          Conclusion:

          The early functional results after DVGU are good without any negative impact on the continence or the sexual functions.

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          Most cited references13

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          Anatomy of the clitoris.

          We present a comprehensive account of clitoral anatomy, including its component structures, neurovascular supply, relationship to adjacent structures (the urethra, vagina and vestibular glands, and connective tissue supports), histology and immunohistochemistry. We related recent anatomical findings to the historical literature to determine when data on accurate anatomy became available. An extensive review of the current and historical literature was done. The studies reviewed included dissection and microdissection, magnetic resonance imaging (MRI), 3-dimensional sectional anatomy reconstruction, histology and immunohistochemical studies. The clitoris is a multiplanar structure with a broad attachment to the pubic arch and via extensive supporting tissue to the mons pubis and labia. Centrally it is attached to the urethra and vagina. Its components include the erectile bodies (paired bulbs and paired corpora, which are continuous with the crura) and the glans clitoris. The glans is a midline, densely neural, non-erectile structure that is the only external manifestation of the clitoris. All other components are composed of erectile tissue with the composition of the bulbar erectile tissue differing from that of the corpora. The clitoral and perineal neurovascular bundles are large, paired terminations of the pudendal neurovascular bundles. The clitoral neurovascular bundles ascend along the ischiopubic rami to meet each other and pass along the superior surface of the clitoral body supplying the clitoris. The neural trunks pass largely intact into the glans. These nerves are at least 2 mm in diameter even in infancy. The cavernous or autonomic neural anatomy is microscopic and difficult to define consistently. MRI complements dissection studies and clarifies the anatomy. Clitoral pharmacology and histology appears to parallel those of penile tissue, although the clinical impact is vastly different. Typical textbook descriptions of the clitoris lack detail and include inaccuracies. It is impossible to convey clitoral anatomy in a single diagram showing only 1 plane, as is typically provided in textbooks, which reveal it as a flat structure. MRI provides a multiplanar representation of clitoral anatomy in the live state, which is a major advantage, and complements dissection materials. The work of Kobelt in the early 19th century provides a most comprehensive and accurate description of clitoral anatomy, and modern study provides objective images and few novel findings. The bulbs appear to be part of the clitoris. They are spongy in character and in continuity with the other parts of the clitoris. The distal urethra and vagina are intimately related structures, although they are not erectile in character. They form a tissue cluster with the clitoris. This cluster appears to be the locus of female sexual function and orgasm.
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            Clitoral anatomy in nulliparous, healthy, premenopausal volunteers using unenhanced magnetic resonance imaging.

            We determined the magnetic resonance imaging (MRI) characteristics of normal clitoral anatomy.
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              A systematic review of surgical techniques used in the treatment of female urethral stricture.

              Female urethral stricture (FUS) is a rare and challenging clinical entity. Several new surgical techniques have been described for the treatment of FUS, although with the limited number of reports, there is no consensus on best management.
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                Author and article information

                Journal
                Indian J Urol
                Indian J Urol
                IJU
                Indian Journal of Urology : IJU : Journal of the Urological Society of India
                Wolters Kluwer - Medknow (India )
                0970-1591
                1998-3824
                Oct-Dec 2019
                : 35
                : 4
                : 267-272
                Affiliations
                [1]Department of Urology, MS Ramaiah Medical College, Bengaluru, Karnataka, India
                [1 ]Department of Urology, Medanta - The Medicity, Gurgaon, Haryana, India
                [2 ]Department of Urology, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
                Author notes
                Article
                IJU-35-267
                10.4103/iju.IJU_134_19
                6792406
                31619864
                a4b6dd35-dd75-4e61-a6d7-4105381653d6
                Copyright: © 2019 Indian Journal of Urology

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 05 May 2019
                : 12 August 2019
                Categories
                Original Article

                Urology
                Urology

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