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Female Ventral Onlay Urethroplasty

Female ventral onlay urethroplasty places a tissue graft (usually buccal mucosa) or pedicled flap on the ventral (6 o'clock) surface of the urethra to augment a strictured segment. Modern series report success rates of 86–98%, with technical advantages over the dorsal approach: easier meatus preservation, wider operative field, less intraoperative bleeding, and a vaginal-sparing technique when BMG is used.[1][2][3]

For the dorsal counterpart see Female Dorsal Onlay Urethroplasty. For the inlay variant (graft placed into the urethrotomy without urethral mobilization), see Female Ventral Inlay BMG (Mandal RCT). For pedicled-flap alternatives see the Blandy U-Flap, Lateral-Based Anterior Vaginal Wall Flap, and Önol Anterior Vaginal Wall Mucosal Inlay.

Rationale and Indications​

Indications mirror those for dorsal onlay — recurrent or refractory FUS after failed dilation or DVIU. AUA 2023 endorses urethroplasty for FUS given low endoscopic durability, with success of 69–95% across techniques driven by surgeon experience.[4]

The ventral approach is particularly favored when:

  • Meatus preservation is desired (mid- or proximal strictures).[2]
  • A vaginal-sparing technique is preferred (BMG avoids vaginal-wall harvest).[5]
  • Reduced intraoperative bleeding is a priority (10 vs 20 mL vs dorsal in Savun 2026).[3]
  • The surgeon has greater familiarity with the ventral dissection plane.[12]

Graft / Flap Options​

SourceProsCons / Cautions
Buccal mucosa graft (BMG)Most commonly reported; thick epithelium, hairless, infection-resistant; periurethral fascia provides vascular bed[1][7]Oral donor-site morbidity (transient)
Vaginal wall pedicled flapOwn blood supply; useful for distal strictures; lateral-based variant preserves orthotopic meatus[8]Lower success in some series (57–73%); spraying risk with classic Blandy[10]
Vaginal wall free graftNo oral morbidityAvoid in LS / atrophy; vaginal-narrowing risk. Kumar 2025 meta — BMG 86.2% vs VWG 89.8% (not significantly different)[11]

Surgical Technique — Ventral Onlay BMG​

Dorsal lithotomy.[1][12][7][13]

  1. Setup — urethral catheter for identification.
  2. Anterior vaginal wall incision — longitudinal, over the urethra.
  3. Periurethral fascia dissection — incise the fascia and elevate two lateral fascial flaps, exposing the ventral urethral surface. These flaps are the analog of the male dartos and form the vascular bed for the graft.[1]
  4. Ventral urethrotomy — longitudinal 6 o'clock incision through the entire stricture into healthy urethra proximally and distally.
  5. BMG harvest — inner cheek; defat / remove fibromuscular tissue from the graft.
  6. Graft placement — graft sutured to the urethral mucosal margins on both sides (running or interrupted absorbable); tension-free augmentation.
  7. Fascial flap coverage — periurethral fascial flaps closed over the graft, providing the vascularized bed and mechanical support.[1]
  8. Vaginal wall closure — anterior vaginal wall closed over the repair.
  9. Catheter — urethral ± SPC for ~ 3 weeks.

Modified "AZ" technique (Ozlulerden 2020)​

BMG sutured to urethral mucosa with periurethral tissue closed in a second layer. 100% in 7 patients at mean 23 mo with mean OR time of just 64 min.[13]

Martius-Reinforced Ventral BMG Onlay​

When the periurethral tissue is compromised — typically after synthetic sling or mesh erosion, prior failed urethroplasty, or pelvic radiation — the periurethral fascial bed is unreliable as a vascular supply for the graft. In these cases, a Martius (labial fat-pad) flap is mobilized and interposed between the BMG and the vaginal-wall closure to provide a vascularized second layer. Önol et al. specifically described this Martius-reinforced ventral BMG approach in 2 of 17 women with prior synthetic midurethral slings; the broader 17-patient series achieved 100% objective cure at median 24 months.[17] The same principle underlies the high distal-cure rates (~ 97%) reported with Martius interposition during urethral diverticulum repair.[18]

Indications for Martius reinforcement:

  • Prior synthetic midurethral sling or vaginal mesh erosion.
  • Failed prior urethroplasty with scarred / poorly vascularized periurethral bed.
  • Pelvic radiotherapy.
  • Adjunctive coverage of a tenuous closure layer.

Key technical tenets:

  • Urethrotomy must extend through the entire stricture length into healthy tissue.
  • Periurethral fascial flaps provide the vascular bed essential for graft take (analog of dartos in male urethroplasty).[1]
  • The ventral approach preserves the dorsal urethral sphincter mechanism, potentially reducing incontinence risk.[1]

Surgical Technique — Ventral Vaginal Flap​

A pedicled anterior vaginal wall flap rather than a free graft:[8][14]

  1. Two parallel incisions on the anterior vaginal wall around the meatus.
  2. Raise a U-shaped (Blandy) or lateral-based vaginal flap with vascular pedicle intact.
  3. Ventral urethrotomy through the stricture.
  4. Rotate and suture the flap to the urethral edges.
  5. Close the remaining vaginal wall.

The lateral-based anterior vaginal wall flap (Romero-Maroto) achieved 100% success in n = 9 at mean 80.7 mo with no recurrence, no de-novo SUI, and orthotopic meatus.[8]

Outcomes​

SeriesnTechniqueSuccessFollow-upKey findings
Berdondini 2024[1]42Ventral BMG98%mean 38.1 moQmax 7.7 → 25.9 mL/s; 0% incontinence
Mukhtar / Greenwell 2017[7]22Ventral BMG95.5%median 21.5 moQmax 7 → 18 mL/s; 1 mild SUI (resolved)
Savun 2026 (multicenter)[3]27 (ventral arm)Ventral BMG92.6%variableComparable patency to dorsal (92.1%); less bleeding
Coguplugil 2021[15]8Ventral BMG100%mean 16.4 moNo SUI; 1 dyspareunia
Ozlulerden 2020 ("AZ")[13]7Modified ventral BMG100%mean 23 moQmax 5.1 → 31.8 mL/s
Romero-Maroto 2018[8]9Ventral vaginal flap (lateral-based)100%mean 80.7 moOrthotopic meatus; 0% recurrence / SUI
Waterloos / Lumen EAU 2025[9]115 VOGU / 17 VOFUVentral graft / flap86% / 73% at 2 yrmedian 29 moPrior radiotherapy = independent predictor of recurrence (p = 0.015)
Katiyar 2021 RCT[2]12 (ventral arm)Ventral BMG91%—Comparable to dorsal; less bleeding, wider field

Functional improvements consistent across series — Qmax 7.7 → 25.9 mL/s; PVR 100 → 15 mL.[1][7]

Meta-Analytic Evidence — Ventral vs Dorsal​

Three recent high-level analyses converge on equivalence:

  • Li 2026 — 5 studies, n = 319: no significant difference in success (RR 1.00; 95% CI 0.91–1.10; p = 0.95), Qmax, PVR, or AUA score.[6]
  • Ortac 2025 — 25 studies: pooled success 92.1% (dorsal) vs 95.5% (ventral), OR 0.84, p = 0.74. SUI 4 ventral vs 2 dorsal cases.[16]
  • Savun 2026 — largest individual comparative cohort (n = 65): patency 92.1% dorsal vs 92.6% ventral (p = 1.0); no FSFI / PGIC / SUI difference; significantly less blood loss with ventral (10 vs 20 mL, p = 0.001).[3]

Advantages​

  • Easier meatus preservation — ventral incision naturally avoids the meatus.[2]
  • Wider operative field.[2]
  • Less intraoperative bleeding (10 vs 20 mL, Savun).[3]
  • Vaginal-sparing when BMG is used.[5]
  • Sphincter preservation — dorsal sphincter complex untouched.[1]
  • Familiar plane for female pelvic reconstructive surgeons.[12]

Limitations​

  • Less suited to distal strictures requiring meatal reconstruction — dorsal approach is preferred there.[2]
  • Urinary spraying — more common with ventral / VFU than with BMG techniques.[10]
  • Graft support depends on periurethral fascial flaps — may be less robust than the dorsal periurethral bed in some patients.[1]
  • Vaginal compromise risk if a vaginal flap (not BMG) is used.

Complications​

  • De-novo SUI — 0–4.5% across ventral BMG series; usually mild, conservatively managed.[1][7][16]
  • Stricture recurrence — 2–14% across techniques and follow-up windows.[1][9]
  • Dyspareunia — ~ 12.5% in one small series.[15]
  • Spraying — primarily VFU rather than BMG.[10]
  • Donor-site morbidity — minimal; transient oral discomfort.

Prognostic Factor​

The Waterloos / Lumen EAU multicenter study (n = 165) identified prior pelvic radiotherapy as the only independent predictor of stricture recurrence after female urethroplasty (p = 0.015). Stricture etiology, location, and length were not significant predictors.[9]

Summary​

Female ventral onlay urethroplasty achieves 86–98% success across modern series, equivalent to dorsal onlay (Li 2026 / Ortac 2025 / Savun 2026 metas) with the practical advantages of meatus preservation, less bleeding, vaginal sparing (BMG), and dorsal sphincter preservation. Berdondini 2024 (n = 42, 98%, Qmax 7.7 → 25.9 mL/s) is the strongest contemporary single-center series; the Mandal 2025 RCT (covered on the Ventral Inlay BMG page) established non-inferiority of the inlay variant. Prior pelvic radiotherapy is the strongest negative prognostic factor.[1][3][6][9]

References​

1. Berdondini E, Eissa A, Margara A, et al. Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture: medium-term results in a single surgeon experience. Urology. 2024;193:194-200. doi:10.1016/j.urology.2024.06.045.

2. 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.

3. 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.

4. 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.

5. 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.

6. Li X, Zhao X, Li Z, et al. Dorsal versus ventral onlay buccal mucosal graft urethroplasty in female urethral stricture: a meta-analysis. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06516-8.

7. Mukhtar BMB, Spilotros M, Malde S, Greenwell TJ. Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women. BJU Int. 2017;120(5):710-716. doi:10.1111/bju.13970.

8. 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):123-128. doi:10.1016/j.eururo.2016.09.029.

9. Waterloos M, Lumen N, Ockrim JL, et al. Diagnostics, reconstructive approaches, and outcomes in female urethroplasty patients. BJU Int. 2025;135(6):1025-1030. doi:10.1111/bju.16701.

10. 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.

11. Kumar L, Thakur A, Agarwal S, et al. Buccal versus vaginal graft urethroplasty in female urethral stricture: a systematic review and meta-analysis. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06171-5.

12. Petrikovets A, Sun HH, Kiechle J, et al. Ventral-onlay buccal mucosal graft urethroplasty for the treatment of female urethral stricture: a step-by-step video for female pelvic reconstructive surgeons. Int Urogynecol J. 2019;30(12):2191-2193. doi:10.1007/s00192-019-03987-w.

13. Ozlulerden Y, Celen S, Zumrutbas AE, Aybek Z. Female buccal mucosa graft urethroplasty: a new modified ventral onlay "AZ" technique. Int Urogynecol J. 2020;31(12):2543-2550. doi:10.1007/s00192-020-04354-w.

14. 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):2055-2060. doi:10.1007/s00192-019-03910-3.

15. Coguplugil AE, Ebiloglu T, Sarikaya S, et al. Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture. Int J Urol. 2021;28(5):538-543. doi:10.1111/iju.14504.

16. Ortac M, Ozervarli MF, Ergul RB, et al. Comparing ventral and dorsal oral mucosal graft urethroplasty in female urethral stricture: a systematic review and meta-analysis. World J Urol. 2025;43(1):397. doi:10.1007/s00345-025-05773-4.

17. Önol FF, Antar B, Köse O, Erdem MR, Önol ŞY. Techniques and results of urethroplasty for female urethral strictures: our experience with 17 patients. Urology. 2011;77(6):1318-1324. doi:10.1016/j.urology.2011.01.017.

18. Malde S, Sihra N, Naaseri S, et al. Female urethral diverticulum: current diagnostic and management aspects. Ther Adv Urol. 2017;9(11):261-272. doi:10.1177/1756287217714174.