Urethral tissue loss can result from traumatic or iatrogenic injuries and, less frequently, from infections or malignancies. Diagnosis depends on a comprehensive history and careful physical examination.
Existing surgical options include primary closure, vaginal wall or bladder flap urethroplasty, and buccal mucosal grafting. Vaginal flaps with well-vascularized grafts have demonstrated high success rates [1]. The use of synthetic materials should be avoided in complex urethral reconstruction [2].
When postoperative stress incontinence persists, options such as autologous slings [2], biological grafts (Pelvicol®) [3], or a Burch colposuspension may be considered.
The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits painless and unobstructed passage of urine [2].
We describe a modified minimally invasive reconstructive surgical technique for the management of stress urinary incontinence (ALPP > 100 cm H₂O) in a 68‑year‑old woman presenting with complete loss of the ventral urethral plate, secondary to iatrogenic injury after explantation of an extruded tension-free vaginal tape (TVT) sling. This report aims to contribute to the refinement of reconstructive strategies and the development of future guidelines in such clinical contexts.

The surgical objective was to reconstruct a functional urethra that would ensure adequate urinary flow, restore continence, and provide a solid anatomical base for any future intervention. 

In postmenopausal patients, topical vaginal estrogen therapy should be initiated 8 weeks prior to surgery and continued for at least 6 months postoperatively, provided there are no contraindications.

Ventral urethral reconstruction was performed through a U-shaped incision along the labia minora surrounding the urethral defect (Fig. 1). A well-vascularized vaginal flap was mobilized and advanced to the midline over a urethral catheter, thereby restoring the urethral plate (Fig. 2). The vaginal mucosa was closed in the midline without tension, re-establishing normal anatomy (Fig. 3a and 3b). Whenever possible, the different layers of the reconstruction should be closed with non-overlapping suture lines.

The procedure was completed without complications. A satisfactory urethral caliber and length were obtained (Fig.4). Urinary continence was achieved and maintained, with no need for additional procedures during more than five years of follow-up.

Female urethral reconstruction success depends on anatomical precision, use of healthy and well-vascularized local tissue, and avoidance of synthetic materials. In selected patients, urethral reconstruction alone may restore continence without additional anti-incontinence surgery.

When feasible, urethral reconstruction using adjacent vaginal flaps represents an effective and durable option. Delaying any further intervention for persistent incontinence allows for optimal evaluation of the primary outcome. Future studies are required to evaluate long-term results and evolving reconstructive techniques.

Faiena I, Koprowski C, Tunuguntla H. Female Urethral Reconstruction. J Urol. 2016.
Martins FE, Rodrigues RN. Reconstrução Uretral na Mulher. Acta Urológica. 2008;25(1):29–37.
Cadilhe JP. Clinical Challenge – Case Study No. 28. European Urology Today, May 2012.