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Augmenting the female urethra: status of lingual graft

Dr Lalit Kumar, IMS, BHU, Varanasi.

Use of lingual graft for female urethral strictures was first reported by Sharma et al in 2009.(1) They evaluated 15 women who underwent dorsal onlay lingual graft urethroplasty and reported a 93.3% success rate at 1 year. The authors chose to use the lingual graft based upon their prior experience with the graft in men and the minimal morbidity associated with it. Few others have also reported similarly good outcomes.(2)  

The lingual mucosa is easily accessible, naturally wet, hairless and has favourable tissue characteristics, similar to the buccal mucosa, making it an optimal option for substitution urethroplasty. In addition, the tongue can be pulled out of the oral cavity, making it easy to harvest the graft as compared to the buccal mucosa, especially in patients with restricted mouth opening, and primary closure of the harvest site results in minimal donor site morbidity, despite providing a 7-8 cm long graft, which is more than enough for the female urethra. Besides, the risk of injury to the parotid duct and the mental nerve is non-existent and the deviation of angle of mouth or restricted mouth opening, as seen in some cases with buccal or labial graft, is completely avoided. A distinct advantage of lingual graft is that this site is not affected by submucosal fibrosis associated with tobacco chewing, a problem fairly common in some parts of our country, although less so in females. As compared to the vaginal graft, the lingual mucosa can be confidently harvested in females of any age, whereas the quality of the vaginal graft depends on the estrogen status of the patient and may not available in females suffering from atrophic vaginitis or lichen sclerosis. The down side of lingual graft is that harvesting it bilaterally may result in restricted tongue movement and alteration in speech.(3) Also, harvesting the lingual graft usually requires general anaesthesia with oral or nasal intubation, whereas, the buccal graft can be harvested under local anaesthesia.

High quality studies comparing the outcomes of substitution urethroplasty in females with lingual graft to either buccal or vaginal graft are not available. Several studies have reported equivalent surgical outcomes with lingual and buccal graft when used for substitution urethroplasty in men, and these findings can be used as a proxy in females.(3) Kore and Martins compared the outcomes of dorsal only substitution urethroplasty with buccal graft and vaginal graft in females and reported similar success rates in both the groups.(4) Thus, it is safe to say that the lingual graft performs similar to buccal and the vaginal graft and therefore, the lingual graft can be considered a viable option for substitution urethroplasty in females and can be the only available site in a few with vaginal and oral diseases.

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