Dorsal Vaginal Flap Urethroplasty (Female)
Dorsal vaginal flap urethroplasty is a reconstructive technique for female urethral stricture disease that uses autologous vaginal tissue placed on the dorsal (12-o'clock) aspect of the urethra to augment the strictured segment. It is considered a first-line definitive surgical option when conservative measures (dilation, intermittent self-catheterization) have failed.[1][2]
Indications and Patient Selection
Female urethral stricture is rare but underrecognized, presenting with obstructive voiding symptoms, incomplete emptying, and elevated post-void residuals.[1][3] Preoperative evaluation typically includes history, physical examination, fluorourodynamics, urethral calibration, flexible cystoscopy, and voiding cystourethrography.[1][4] Adequate vaginal mucosal tissue must be confirmed prior to offering this approach.[3]
Surgical Technique
The dorsal approach, originally described by Tsivian and Sidi, involves the following key steps.[1][3]
- Dorsal urethral dissection and mobilization — the urethra is dissected from the dorsal aspect, preserving the clitoral neurovascular bundle and sexual function.[5]
- Stricturotomy — the urethra is incised dorsally through the entire length of the stricture.
- Graft harvest — a vaginal mucosal graft or flap is harvested from the anterior vaginal wall, with careful site selection to avoid excessive vaginal narrowing.[3]
- Graft preparation — underlying fibromuscular tissue is removed from the graft.[3]
- Dorsal onlay placement — the graft is sutured tension-free to the incised urethral edges, augmenting the urethral lumen.
A meatal-sparing modification has been described for mid- and proximal urethral strictures: the urethra is slit directly over the strictured segment rather than extending to the meatus, avoiding meatal widening and urinary spraying.[5]
Graft vs Flap Distinction
Two vaginal-tissue approaches exist:
- Free graft — vaginal mucosa is harvested as a free graft without a vascular pedicle and placed as a dorsal onlay.[1][3]
- Pedicled flap — vaginal tissue is mobilized on a lateral vascular pedicle (inspired by the Orandi technique), preserving its blood supply.[6][7]
Both approaches have been used successfully; the pedicled flap may offer advantages in maintaining tissue viability for longer strictures.[6]
Outcomes
The AUA 2023 Urethral Stricture Disease Guideline reports success rates of 69–95% across various female urethroplasty techniques (dorsal/ventral, oral mucosa grafts, vaginal flaps).[2]
| Series | Approach | n | Headline outcomes |
|---|---|---|---|
| Petrou 2012[1] | Dorsal vaginal graft | 11 | Qmax 7.3 → 21.8 mL/s (p=0.001); PVR 187 → 76 mL (p=0.003); no new SUI; no reoperations at mean 22.7 mo |
| Romero-Maroto 2018[7] | Lateral-based ventral vaginal flap | 9 | Qmax 6.8 → 21 mL/s; caliber 10.8 Fr → ≥20 Fr; no recurrences at mean 80.7 mo |
| Katiyar 2021[8] | Prospective RCT dorsal vs ventral | 24 | 91% overall success; comparable outcomes; dorsal technically better for distal strictures requiring meatal reconstruction |
Comparison with Buccal Mucosal Graft
A recent single-center series found dorsal onlay buccal mucosal graft urethroplasty (DOBMGU) achieved a higher success rate (87.5%) than vaginal flap urethroplasty (57.1%) — though the vaginal flap was primarily used for distal strictures while DOBMGU was applied across all segments.[9] The vaginal-graft approach avoids the donor-site morbidity associated with buccal harvest (oral pain, numbness, restricted mouth opening).[3]
Complications
Reported complications are generally low and include de novo stress urinary incontinence (rare), urinary spraying (more common with ventral approaches or when meatal reconstruction is required), and occasional need for intermittent self-catheterization.[1][6][9][10]
Dorsal vs Ventral Approach Considerations
| Feature | Dorsal (12-o'clock) | Ventral (6-o'clock) |
|---|---|---|
| Meatal reconstruction | Better suited | Easier meatus preservation |
| Bleeding | Moderate | Less |
| Operative field | Narrower | Wider |
| Sexual function preservation | Favorable (away from clitoral NVB) | Variable |
| Urinary spraying | Less common (especially meatal-sparing) | Less common |
| Success rate | ~91% | ~91% |
Sources: Petrou 2012; Wessells AUA 2023; Borchert 2022.[1][2][3]
See Also
- Female Dorsal Onlay Urethroplasty (BMG)
- Female Ventral Onlay Urethroplasty
- Lateral-Based Anterior Vaginal Wall Flap (Romero-Maroto / Simonato)
- Anterior Vaginal Wall Mucosal Inlay (Önol)
- Female DVIU & Dilation
References
1. Petrou SP, Rogers AE, Parker AS, Green KM, McRoberts JW. "Dorsal Vaginal Graft Urethroplasty for Female Urethral Stricture Disease." BJU Int. 2012;110(11 Pt C):E1090–5. doi:10.1111/j.1464-410X.2012.11233.x
2. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482
3. Borchert A, Jamil M, Perkins S, Raffee S, Atiemo H. "Vaginal Free Graft Dorsal Onlay Urethroplasty." Urology. 2022;159:256. doi:10.1016/j.urology.2021.06.004
4. Faiena I, Koprowski C, Tunuguntla H. "Female Urethral Reconstruction." J Urol. 2016;195(3):557–67. doi:10.1016/j.juro.2015.07.124
5. Mittal A, Bahuguna G, Sarin I, et al. "Meatal-Sparing Dorsal Onlay Vaginal Graft Urethroplasty: Widening the Surgical Horizons of Female Urethral Stricture." Int Urogynecol J. 2021;32(3):737–9. doi:10.1007/s00192-020-04524-w
6. Simonato A, Varca V, Esposito M, Carmignani G. "Vaginal Flap Urethroplasty for Wide Female Stricture Disease." J Urol. 2010;184(4):1381–5. doi:10.1016/j.juro.2010.06.042
7. Romero-Maroto J, Verdú-Verdú L, Gómez-Pérez L, et al. "Lateral-Based Anterior Vaginal Wall Flap in the Treatment of Female Urethral Stricture: Efficacy and Safety." Eur Urol. 2018;73(1):123–8. doi:10.1016/j.eururo.2016.09.029
8. Katiyar VK, Sood R, Sharma U, et al. "Critical Analysis of Outcome Between Ventral and Dorsal Onlay Urethroplasty in Female Urethral Stricture." Urology. 2021;157:79–84. doi:10.1016/j.urology.2021.05.021
9. Higuchi M, Horiguchi A, Ashiya M, et al. "Vaginal Flap Urethroplasty and Dorsal Onlay Buccal Mucosal Graft Urethroplasty for Female Urethral Stricture: A Single-Center Experience." Int J Urol. 2026;33(5):e70477. doi:10.1111/iju.70477
10. Hajebrahimi S, Maroufi H, Mostafaei H, Salehi-Pourmehr H. "Reconstruction of the Urethra With an Anterior Vaginal Mucosal Flap in Female Urethral Stricture." Int Urogynecol J. 2019;30(12):2055–60. doi:10.1007/s00192-019-03910-3