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Female Dorsal Inlay BMG Urethroplasty

Female dorsal inlay urethroplasty is a minimally invasive technique for female urethral stricture (FUS) in which a buccal mucosal graft is placed into the opened urethral lumen from the dorsal (12 o'clock) aspect via a transurethral approach, without extensive urethral mobilization or vaginal-wall dissection. Reported success is 92–100% at short- to intermediate-term follow-up, with same-day discharge, 0% complications, and 0% de-novo SUI across the published literature.[1][2][3]

For the traditional dorsal-onlay alternative, see Female Dorsal Onlay Urethroplasty. For the ventral counterpart, see Female Ventral Inlay BMG (Mandal RCT) and Female Ventral Onlay Urethroplasty. For the broader ladder, see Female DVIU and Urethral Dilation.

Inlay vs Onlay — the Defining Distinction​

FeatureDorsal InlayDorsal Onlay (traditional)
AccessTransurethral (nasal speculum) or small suprameatalSuprameatal vaginal-wall incision
Vaginal-wall incisionNone (transurethral variant)Yes
Urethral mobilizationMinimal — superficial dorsal urethrotomy onlyExtensive dorsal dissection
Graft fixationSutures (proximal / distal) + surgical glue or quiltingRunning / interrupted sutures + quilting
Operative footprintOutpatient, same-day dischargeInpatient (median 2 d)

The technique mirrors the ventral inlay (Mandal / Gaur) approach but applied dorsally — combining the dorsal periurethral tissue bed (favorable for graft take) with the minimally invasive transurethral approach.

Historical Development​

  • Tsivian-Sidi 2006 — first described, using a suprameatal incision + dorsal inlay (vaginal or buccal graft). 3 patients, all normal micturition / no recurrence at up to 27 mo.[3]
  • Petrou 2012 — refined Tsivian-Sidi suprameatal technique with autologous vaginal-epithelium inlay in 11 women: 100% success at mean 22.7 mo; Qmax 7.3 → 21.8 mL/s; PVR 187 → 76 mL; 0% de-novo SUI.[4]
  • Linder / Balzano / Warner 2022 — first fully transurethral outpatient approach using a nasal speculum + suture-passing device.[2]
  • Jefferson 2025 — largest transurethral dorsal-inlay series to date (n = 21).[1]

Indications​

  • Recurrent / refractory FUS after failed dilation or DVIU.[5]
  • Strictures of any urethral segment — Jefferson 2025 distribution: distal 33%, mid 19%, proximal 19%, multifocal / pan-urethral 19%.[1]
  • AUA 2023 endorses urethroplasty for FUS (69–95% success across techniques).[5]

Particularly advantageous when:

  • Minimally invasive, outpatient / same-day discharge is desired.
  • Minimal urethral mobilization is important (prior pelvic surgery, sphincter-disruption concern).
  • Proximal urethral strictures — the transurethral approach avoids the deep vaginal dissection required for traditional dorsal onlay.[2]

Technique — Transurethral Dorsal Inlay (Linder / Jefferson)​

Dorsal lithotomy.[1][2]

  1. Setup — urethral catheter; lithotomy.
  2. BMG harvest — inner cheek; avoid Stensen's duct; defat / trim.
  3. Transurethral access — nasal speculum placed transurethrally distal to the stricture for visualization.
  4. Dorsal urethrotomy — superficial 12 o'clock incision through the full length of the strictured segment. No urethral mobilization off surrounding tissue.
  5. Graft delivery and proximal fixation — a suture-passing device places typically 3 sutures at the bladder neck (proximal extent) and through the BMG; ties are tied transurethrally with a laparoscopic knot pusher, parachuting the graft into the proximal end.
  6. Distal fixation — distal end of the BMG secured to the meatus with interrupted sutures.
  7. Mid-graft fixation — surgical (tissue) adhesive secures the midportion of the graft to the underlying dorsal periurethral tissue.
  8. Catheter — urethral catheter for 3 weeks.
  9. Discharge — same day in the Jefferson series.[1]

Technical principles — minimal mobilization (the urethra is not dissected from surrounding tissue); graft survives on the native dorsal periurethral bed via imbibition / inosculation; suture (proximal / distal) + glue (mid) gives secure fixation without extensive intraurethral suturing.

Technique — Suprameatal Dorsal Inlay (Tsivian-Sidi / Petrou)​

Intermediate between fully transurethral and traditional dorsal onlay:[3][4]

  1. Suprameatal incision above the meatus on the anterior vaginal wall.
  2. Limited dorsal dissection of the distal urethra through this incision.
  3. Dorsal urethrotomy at 12 o'clock through the stricture.
  4. Graft harvest — vaginal-wall graft (1.5 cm wide) or BMG.
  5. Inlay placement — mucosal surface against the urethral lumen, sutured with running 5-0 polyglactin to the open urethra.
  6. Catheters — 18 Fr urethral × 2 wk; 16 Fr SPC × 3 wk.[3]

Combined Dorsal + Ventral Inlay for Obliterative Strictures​

Jefferson 2025 reported that 2 of 21 (10%) required a combined dorsal + ventral inlay through the transurethral approach for obliterative strictures — effectively a circumferential augmentation through one minimally invasive operation.[1]

Outcomes​

SeriesnApproachGraftSuccessFollow-upKey findings
Jefferson 2025[1]21Transurethral dorsal inlayBMG95% at 4 mo; 92% at 12 momedian 13.2 moSame-day discharge; OR median 60 min; 0% complications; 0% SUI
Petrou 2012[4]11Suprameatal dorsal inlayVaginal graft100%mean 22.7 moQmax 7.3 → 21.8; PVR 187 → 76; 0% SUI
Tsivian-Sidi 2006[3]3Suprameatal dorsal inlayVaginal / BMG100%up to 27 moFirst description; all normal micturition
Linder 2022[2]1Transurethral dorsal inlayBMG100%3 moFirst transurethral approach; outpatient; proximal stricture

Functional improvements consistent: Qmax 7.0 → 13.0–13.3 mL/s (Jefferson); 7.3 → 21.8 mL/s (Petrou); PVR 187 → 76 mL; 90% improved on Global Response Assessment; 0% de-novo SUI across all series.[1][3][4]

Why the SUI Rate May Be Lower Than Dorsal Onlay​

The 0% de-novo SUI signal across all dorsal-inlay series is notable vs the 9–16% early SUI with dorsal onlay. The most plausible explanation is the minimal urethral mobilization of the inlay technique — the urethra is not dissected from periurethral support, preserving the extrinsic sphincter mechanism and periurethral structures, whereas dorsal onlay requires full dorsal mobilization that may temporarily or permanently disrupt them.[1][4]

Advantages​

  • Minimal urethral mobilization — defining advantage; preserves periurethral blood supply and sphincter integrity.[1]
  • Same-day discharge in all Jefferson 2025 patients.[1]
  • Short OR time — median 60 min (IQR 56–86).[1]
  • No vaginal-wall incision with the transurethral variant.[1]
  • 0% complications in the largest series.[1]
  • 0% de-novo SUI across all reported series.[1][3][4]
  • Versatile location — applied to distal / mid / proximal / pan-urethral disease.[1]
  • Robust dorsal graft bed — same biology that supports dorsal onlay success.[3]

Limitations​

  • Very limited evidence base — largest series 21 patients; median follow-up 13.2 mo.[1]
  • Short follow-up — 92% at 12 mo may evolve with longer follow-up; late recurrences are known with urethroplasty generally.
  • Limited visualization — nasal-speculum field is narrow.
  • Glue-based mid-graft fixation — long-term durability of tissue adhesive in this role is uncertain.
  • No comparative data — no study compares dorsal inlay to dorsal onlay in women. The only female-urethroplasty RCT compared ventral inlay vs dorsal onlay (Mandal 2025).[6]
  • Single-center experience — primarily Mayo Clinic (Linder / Jefferson); multicenter validation pending.
  • Obliterative strictures — 10% required combined dorsal + ventral inlay, suggesting dorsal alone may be insufficient for the most severe disease.[1]

Comparison — Dorsal Inlay vs Dorsal Onlay vs Ventral Inlay​

FeatureDorsal Inlay (transurethral)Dorsal Onlay (traditional)Ventral Inlay
AccessTransurethral (nasal speculum)Suprameatal vaginal incisionTransurethral / meatal
Vaginal incisionNoYesNo
Urethral mobilizationMinimalExtensive dorsal dissectionMinimal
Graft fixationSutures + surgical glueSutures + quiltingSutures + quilting
OR time~ 60 min44.5–98 min~ 30 min
Same-day dischargeYesNoYes (transurethral)
Catheter3 wk~ 3 wk1–3 wk
Reported success92–100%87–95%85–95%
De-novo SUI0%9–16% early, ~ 9% at 1 yr0%
Largest series21204 (Jena labial)46 (Gaur)
Evidence levelLevel 4 (case series)Level 2–4Level 2 (1 RCT)

Patient-Selection Pearls​

The dorsal inlay approach may be particularly well-suited for:

  • Patients prioritizing a minimally invasive, outpatient procedure.
  • Proximal urethral strictures where transurethral access avoids deep vaginal dissection.[2]
  • Patients at elevated SUI risk, where minimal mobilization may be protective.
  • Multifocal / pan-urethral strictures — successfully applied in the Jefferson series.[1]
  • Patients with prior pelvic surgery or altered vaginal anatomy.

For obliterative strictures, plan for possible combined dorsal + ventral inlay.[1]

Guideline Position​

AUA 2023 recommends urethroplasty for FUS with success rates of 69–95% across techniques driven by surgeon experience.[5] The dorsal-inlay technique is not specifically named but falls within the umbrella of dorsal oral-mucosa-graft approaches. Given novelty and small evidence base, it is not yet a standard technique but represents a promising evolution of the dorsal approach.

Summary​

Female dorsal inlay BMG urethroplasty is the newest and least studied of the four major female urethroplasty approaches. Its key innovation — transurethral graft placement with minimal urethral mobilization — yields short OR times, same-day discharge, 0% complications, and 0% de-novo SUI in early series, with 92–100% success at short-to-intermediate follow-up. Larger multicenter studies and direct comparisons with dorsal onlay are needed before it can be considered standard.[1][2][3][4]

References​

1. Jefferson FA, Lee YS, Rafetto AN, et al. Short-term outcomes following transurethral dorsal buccal graft urethroplasty for female urethral strictures. Neurourol Urodyn. 2025. doi:10.1002/nau.70161.

2. Linder BJ, Balzano FL, Warner JN. Transurethral dorsal buccal graft urethroplasty for proximal female urethral strictures. Int Urogynecol J. 2022;33(8):2317-2319. doi:10.1007/s00192-022-05262-x.

3. Tsivian A, Sidi AA. Dorsal graft urethroplasty for female urethral stricture. J Urol. 2006;176(2):611-613; discussion 613. doi:10.1016/j.juro.2006.03.055.

4. 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-E1095. doi:10.1111/j.1464-410X.2012.11233.x.

5. 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.

6. Mandal S, Gaur AS, Singh K, et al. Comparative efficacy of dorsal-onlay and ventral-inlay buccal mucosal graft urethroplasty in female urethral stricture: a randomized clinical trial. Urology. 2025;200:52-58. doi:10.1016/j.urology.2025.01.064.