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Female Dorsal Onlay Urethroplasty

Female dorsal onlay urethroplasty places a tissue graft (buccal, lingual, vaginal, or labial mucosa) on the dorsal (12 o'clock) surface of the urethra to augment a strictured segment. It is the most evidence-supported definitive treatment for female urethral stricture (FUS), with success rates of ~ 87–95% — substantially higher than dilation / DVIU at 41–49%.[1][2][3]

For the broader female-stricture treatment ladder, see Female DVIU and Urethral Dilation, Distal Urethrectomy with Advancement Meatoplasty, Blandy U-Flap, Lateral-Based Anterior Vaginal Wall Flap, and Ventral Onlay BMG. For graft tissue principles, see the Buccal Mucosa Graft (foundations) article.

Epidemiology and Etiology of FUS​

FUS accounts for ~ 1% of women presenting with LUTS and is frequently underdiagnosed.[4][5] Most common etiologies:

  • Iatrogenic — repeated dilations, traumatic catheterization, transurethral procedures.[6][7]
  • Idiopathic — > 50% of cases in some series.[3]
  • Obstetric — particularly cephalopelvic disproportion.[6]
  • Lichen sclerosus / lichen planus.[6]
  • Pelvic trauma, radiation, urethral / vaginal atrophy, recurrent infection.[6][8]

Mid-urethral location is most common; mean stricture length ~ 1.5–2 cm.[10]

Diagnosis​

The AUA 2023 guideline includes urethral stricture in the differential for women with decreased stream, incomplete emptying, dysuria, recurrent UTI, or rising PVR.[6] Workup:

  • Uroflowmetry (reduced Qmax), PVR, urethral calibration (inability to pass small catheter), cystourethroscopy (failure of 16 Fr), VCUG / retrograde urethrography, video-urodynamics to differentiate anatomic stricture from functional obstruction.[6][9][5]

Indications​

  • Recurrent / refractory FUS after failed dilation or DVIU.[6]
  • Strictures of any urethral segment (distal / mid / proximal / pan-urethral).[10][11]
  • AUA 2023 recommends urethroplasty over endoscopic re-treatment given low endoscopic durability.[6]
  • Some experts advocate upfront urethroplasty rather than serial dilation.[10]

Graft Materials​

The dorsal onlay technique is donor-source agnostic: the operative principles (urethral mobilization, dorsal urethrotomy, graft fixation, quilting onto the periurethral bed) are identical regardless of the tissue source. The choice of donor is driven by tissue availability, prior harvests, and patient preference.

SourceProsCons / CautionsAnchor evidence
Buccal mucosa (most common default)Hairless, thick epithelium, infection-resistant, well-suited for wet environmentOral donor-site morbidity (transient discomfort); cheek scarringRichard 2021 (n=19, 89.5%);[2] Khawaja 2022 (n=25, > 90%);[10] Savun 2026 (n=38 dorsal arm, 92.1%);[15] Higuchi 2026 (n=8, 87.5% vs 57.1% VFU)[11]
Labial mucosaHairless, wet, elastic, easily accessible; same operative field as the urethrotomy; no oral harvest requiredCompromised by lichen sclerosus or vulvovaginal atrophy; smaller global evidence baseJena 2025 (n=204; 93.5% at 2 yr) — largest single-surgeon female urethroplasty series in print[1]
Lingual mucosaSame biology as buccal; alternative oral source when buccal sites have been previously harvestedTongue-tip dysesthesia; smaller series than buccalSimonato 2006 pilot;[18] Goel 2014 — direct comparison with labial mucosa showed equivalent outcomes[19]
Vaginal mucosa (free graft)Same operative field; no oral morbidity; reserved when a vaginal pedicled flap cannot be safely rotated (prior vaginal surgery, compromised lateral pedicle)Avoid in LS / atrophy; vaginal-narrowing risk if harvest site poorly selected; ~ 80% reported success — generally inferior to BMG / labial because of more limited donor biologyBorchert 2022 narrative review[12]

For mucosa-tissue principles see Buccal Mucosa Graft (foundations), Labial Mucosa Graft, and Lingual Mucosa Graft.

Surgical Technique​

Dorsal lithotomy.[12][2][14][4]

  1. Setup — urethral catheter for identification; ± SPC.
  2. Vaginal incision — suprameatal inverted-U or semi-lunar incision over the urethra.
  3. Urethral mobilization — dissect the urethra dorsally off the underlying vaginal tissue, exposing the dorsal surface.
  4. Dorsal urethrotomy — longitudinal 12 o'clock incision through the entire stricture length.
  5. Graft harvest — buccal / lingual / vaginal / labial; defat / remove fibromuscular tissue from the graft.
  6. Graft placement — onlay sutured to both urethrotomy edges with running or interrupted absorbable sutures; tension-free anastomosis.
  7. Graft fixation — quilting sutures to the periurethral tissue / pubic periosteum to prevent contracture and provide vascular contact.
  8. Catheter — urethral catheter (± SPC) for ~ 3 weeks.[14]

Meatal-sparing modification (Mittal 2021) — for mid- or proximal strictures, the urethrotomy is centered over the strictured segment, sparing the meatus. Avoids meatal widening and stream spraying.[13]

Key technical tenets — adequate dorsal dissection and mobilization; full-stricture-length incision; defat the graft; tension-free anastomosis.[12] Some experts advocate extensive grafting of the entire urethra given the difficulty of precisely delineating stricture extent intraoperatively.[10][4]

Outcomes​

SeriesnGraftApproachSuccessFollow-up
Jena 2025[1]204Labial mucosaDorsal onlay93.5% at 2 yrmedian 29 mo
Richard 2021[2]19Oral (buccal / lingual)Dorsal onlay89.5% overall; 90.9% at 1 yrmedian 12 mo
Higuchi 2026[11]8Buccal mucosaDorsal onlay87.5% (vs 57.1% VFU same series)median 12 mo
Khawaja 2022[10]25Buccal mucosaDorsal onlay> 90%—
Savun 2026[15]38 (dorsal arm)Buccal mucosaDorsal onlay92.1% patencyvariable
Gomez 2020[4]pooled reviewBuccal mucosaDorsal onlay~ 86%mean 21 mo

Functional improvements consistent across series: Qmax 7.4 → 15.2 mL/s; PVR 161 → 72 mL (Richard).[2] Mean OR time ~ 98 min; median LOS ~ 2 d.[1]

Complications​

  • De novo SUI — 9–16% at 1–3 mo, decreasing to ~ 9% at 1 yr; most resolve with PFPT.[2][3]
  • Stricture recurrence — 5–7% at 1–2 yr; salvage with repeat urethroplasty.[1][2]
  • Perioperative complications — Clavien-Dindo II–III in ~ 3%.[1]
  • Urinary spraying — more common with ventral / VFU approaches; rare with dorsal onlay.[11]
  • Donor-site morbidity — minimal; transient oral discomfort with BMG; vaginal-narrowing risk if free-graft harvest site is poorly selected.[12][8]

Dorsal vs Ventral Onlay​

Comparable success rates (~ 89–92%) across approaches.[15][16][17] Practical distinctions:

  • Dorsal — preserves ventro-lateral urethral support important for continence; better suited for distal strictures requiring meatal reconstruction.[16][4]
  • Ventral — easier meatus preservation, wider operative field, lower intraoperative bleeding (10 vs 20 mL), vaginal-sparing.[15][16][17]
  • No significant difference in de-novo SUI, sexual function (FSFI), or PROs between approaches.[15]

Guideline Position​

The AUA 2023 Urethral Stricture Disease Guideline Amendment recommends offering urethroplasty to female patients given the low efficacy of endoscopic treatment, with success rates of 69–95% across techniques driven by surgeon experience.[6]

Summary​

Female dorsal onlay urethroplasty — most commonly with buccal mucosa, with growing evidence for labial mucosa (Jena 2025, n = 204, 93.5%) — is the most evidence-supported definitive treatment for FUS. Success is ~ 87–95% across modern series with low de-novo SUI (resolving to ~ 9% by 1 yr), 5–7% recurrence at 1–2 yr, and very low rates of urinary spraying compared with ventral / vaginal-flap techniques. AUA 2023 endorses offering urethroplasty over repeated endoscopic management for FUS.[1][2][6][15]

Videos​

Female Urethroplasty: Dorsal Onlay
Dmitriy Nikolavsky
Female Urethroplasty: Anterior Onlay
Pankaj Joshi

References​

1. Jena AK, Jena R, Madhavan M, Madhavan K. Dorsal onlay labial mucosal graft urethroplasty in female urethral stricture: outcomes of over 200 cases from a single surgeon. Urology. 2025. doi:10.1016/j.urology.2025.05.040.

2. Richard C, Peyronnet B, Drain A, et al. Dorsal onlay oral mucosa graft urethroplasty for female urethral stricture. Urology. 2021;158:215-221. doi:10.1016/j.urology.2021.09.001.

3. Chakraborty JN, Chawla A, Vyas N. Surgical interventions in female urethral strictures: a comprehensive literature review. Int Urogynecol J. 2022;33(3):459-485. doi:10.1007/s00192-021-04906-8.

4. Gomez RG, Segura FJ, Saavedra A, Campos RA. Female urethral reconstruction: dorsal buccal mucosa graft onlay. World J Urol. 2020;38(12):3047-3054. doi:10.1007/s00345-019-02958-6.

5. Turchi B, Lumen N, Verla W, Waterloos M. Female urethral stricture disease: a narrative review on diagnosis, surgical techniques and outcomes. Int J Impot Res. 2026;38(4):286-295. doi:10.1038/s41443-025-01079-6.

6. 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.

7. West C, Lawrence A. Female urethroplasty: contemporary thinking. World J Urol. 2019;37(4):619-629. doi:10.1007/s00345-018-2564-4.

8. Bouchard B, Campeau L. Surgery for female urethral stricture. Neurourol Urodyn. 2025;44(1):51-62. doi:10.1002/nau.25358.

9. Waterloos M, Verla W. Female urethroplasty: a practical guide emphasizing diagnosis and surgical treatment of female urethral stricture disease. Biomed Res Int. 2019;2019:6715257. doi:10.1155/2019/6715257.

10. Khawaja AR, Dar YA, Bashir F, et al. Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (FUSD): our institutional experience. Int Urogynecol J. 2022;33(3):697-702. doi:10.1007/s00192-021-04840-9.

11. 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.

12. 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.

13. 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):737-739. doi:10.1007/s00192-020-04524-w.

14. Kuo T, Uçar M, Venugopal S, et al. Female urethroplasty with a buccal mucosa graft using a supraurethral approach. Int Urogynecol J. 2024;35(5):1093-1095. doi:10.1007/s00192-024-05737-z.

15. Savun M, Cubuk A, Colakoglu Y, Aksakal YN, Simsek A. Comparative analysis of dorsal and ventral onlay urethroplasty with buccal mucosal graft in female urethral strictures: a multi-center study. Int Urogynecol J. 2026;37(2):511-516. doi:10.1007/s00192-025-06479-2.

16. 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.

17. Gaur AS, Tarigopula V, Mandal S, et al. Comparison of ventral inlay and dorsal onlay urethroplasty for female urethral stricture. Urology. 2024;193:46-50. doi:10.1016/j.urology.2024.06.046.

18. Simonato A, Gregori A, Lissiani A, et al. The tongue as an alternative donor site for graft urethroplasty: a pilot study. J Urol. 2006;175(2):589-592. doi:10.1016/S0022-5347(05)00166-7.

19. Goel A, Paul S, Dalela D, et al. Lingual mucosal graft and labial mucosal graft urethroplasty in female urethral strictures: a comparative study. Urol Ann. 2014;6(2):117-120. doi:10.4103/0974-7796.130549.