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Dorsal Vaginal Graft Urethroplasty (Female)

Dorsal vaginal graft 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. Petrou et al. proposed dorsal vaginal graft urethroplasty as a first-line definitive option in a retrospective series of 11 women.[1] The 2023 AUA guideline favors urethroplasty over endoscopic treatment for female stricture, but its Moderate Recommendation names oral mucosal grafts and vaginal flaps, not vaginal free grafts.[2] The 2026 EAU guideline weakly recommends initial dilation for uncomplicated female stricture.[11]

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] Petrou's retrospective series reported preoperative history, physical examination, fluorourodynamics, and urethral calibration.[1] The 2026 EAU guideline strongly recommends flow rate, PVR, and VCUG or videourodynamics for all women with refractory lower urinary tract symptoms; cystourethroscopy can identify the distal stricture and exclude functional obstruction.[11] Flexible cystoscopy and VCUG can also help plan repair, as discussed by Faiena et al.[4] Confirm sufficient vaginal mucosa before graft harvest; atrophy or lichen sclerosus may limit donor-tissue suitability, and the harvest site should avoid excessive vaginal narrowing.[3][13] For women with a second recurrence who cannot perform intermittent self-dilation or want definitive treatment, the 2026 EAU guideline strongly recommends urethroplasty and bases technique selection on surgeon experience, graft or flap availability and quality, and ventral versus dorsal urethral quality.[11]

Surgical Technique​

Tsivian and Sidi reported a suprameatal dorsal free-graft repair in three women (two vaginal grafts and one buccal graft); the steps below also include later dorsal vaginal onlay variants.[18][1][3]

  1. Dorsal urethral dissection and mobilization. Dissect dorsally away from the clitoral neurovascular bundle; this plane was described in a single-case video as a means of preserving sexual function.[5]

  2. Stricturotomy. The urethra is incised dorsally through the entire length of the stricture.

  3. Graft harvest. A free vaginal mucosal graft is harvested from the anterior vaginal wall, with careful site selection to avoid excessive vaginal narrowing.[3]

  4. Graft preparation. Underlying fibromuscular tissue is removed from the graft.[3]

  5. Dorsal graft placement. In Petrou's suprameatal inlay, suture the free vaginal graft to the opened urethra with its mucosa facing the lumen.[1] For a dorsal vaginal onlay, suture the graft edges to the urethrotomy, quilt the graft to the dorsal bed, and close the vaginal harvest defect, as described by Kore and Martins.[3][14]

  6. Drainage and imaging. In Singh et al.'s dorsal vaginal-onlay series, an 18 Fr catheter was left across the graft; patients returned for voiding cystourethrography and catheter removal at 14 days.[12]

A meatal-sparing modification has been described for mid- and proximal urethral strictures. In Mittal et al.'s single-case video, the urethrotomy was limited to the strictured segment instead of extending to the meatus, with the aim of avoiding meatal widening and urinary spraying.[5]

Graft vs Flap Distinction​

Two vaginal-tissue approaches exist:

  • Free graft. Vaginal mucosa is harvested without a vascular pedicle. Petrou describes a suprameatal dorsal inlay; dorsal onlay variants also place a free vaginal graft along a stricturotomy.[1][3][5]
  • Pedicled flap. Vaginal tissue is mobilized on a lateral vascular pedicle (inspired by the Orandi technique), preserving its blood supply.[6][7]

The cited pedicled lateral vaginal flaps use a ventral approach and are separate operations.[6]

Outcomes​

The 2023 AUA Urethral Stricture Disease Guideline amendment states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination .[2] The AUA’s 69–95% range refers to oral mucosal grafts and vaginal flaps, not vaginal free grafts.[2] For dorsal vaginal free grafts, the 2026 EAU review reports no recurrent stricture in 64/75 women (85.3%) across five studies at mean or median follow-up of 8.5–24.65 months, with no new urinary incontinence reported.[11]

SeriesApproachnHeadline outcomes
Petrou 2012[1]Suprameatal dorsal vaginal inlay11Qmax 7.3 → 21.8 mL/s (p=0.001); PVR 187 → 76 mL (p=0.003); no new SUI or repeat surgery at mean 22.7 mo (range 6–46); PGI-I unchanged or worse in 2/11
Singh 2013[12]Dorsal vaginal onlay; mid-urethral strictures16Qmax 6.2 → 27.6 mL/s; PVR 160 → 20 mL; one proximal soft stricture required dilation and self-calibration; mean follow-up 24.5 mo; routine early self-calibration was advised
Romero-Maroto 2018[7]Lateral-based ventral vaginal flap9Qmax 6.8 → 21 mL/s; caliber 10.8 Fr → ≥20 Fr; no recurrences at mean 80.7 mo
Katiyar 2021[8]Prospective RCT, dorsal versus ventral buccal mucosal graft (indirect for vaginal free graft)[11]2491% overall success (22/24), one recurrence per arm after at least 6 months; comparable outcomes; authors favored dorsal access for distal strictures needing meatal reconstruction

In a prospective 13-woman dorsal vaginal-onlay series, sexually active participants’ FSFI scores improved by a mean 6.42 points at three months, and three failures were reported at a mean follow-up of 8.5 months; these are early, small-series results.[15]

Comparison with Buccal Mucosal Graft​

In one retrospective 15-patient series, cystoscopic freedom from re-stricture without secondary intervention at median 12 months was 7/8 after dorsal onlay BMG and 4/7 after vaginal flap.[9] Flaps were used mainly for distal strictures, whereas grafts were used across segments.[9] A retrospective dorsal-onlay cohort (16 vaginal wall grafts, 17 BMG) reported overall patency of 31/33 (93.9%) at mean 16 months, with no statistically significant between-group difference; a 2025 meta-analysis of 18 studies also found no significant difference in reported success, Qmax or PVR.[16][17] Vaginal grafts avoid oral donor-site morbidity (pain, numbness, restricted mouth opening).[3]

Complications​

In dorsal vaginal-graft series, Petrou reported no new stress urinary incontinence (SUI) in 11 women at mean 22.7 months, and Singh reported no incontinence in 16 women at mean 24.5 months; one woman in Singh's series needed dilation and continued self-calibration for recurrent narrowing.[1][12] Separate vaginal-flap series reported no de novo SUI in Romero-Maroto's nine patients, postoperative SUI in 2/14 after Hajebrahimi's repair (new onset not established), urinary spraying in 2/7 in Higuchi's flap group, and intermittent self-catheterization for elevated residual urine in 1/6 in Simonato's series.[7][10][9][6]

Dorsal vs Ventral Approach Considerations​

FeatureDorsal (12-o'clock)Ventral (6-o'clock)
Meatal reconstructionBetter suitedEasier meatus preservation
BleedingModerateLess
Operative fieldNarrowerWider
Sexual anatomyDissection near clitoral bodies requires care; no proven sexual-function superiorityAvoids dorsal clitoral dissection; careful support preservation remains necessary
Urinary sprayingMeatal-sparing modification is intended to limit meatal widening and spraying; comparative effect unmeasured[5]No general approach-specific rate established
Success rateNo universal approach-specific rate; definitions and follow-up varyNo universal approach-specific rate; definitions and follow-up vary

Sources: Petrou 2012; Wessells AUA 2023; Borchert 2022.[1][2][3] Katiyar's small buccal-graft trial supplied the exposure observations; its results are indirect for vaginal free grafts.[8][11] The 2026 EAU review identified dorsal vaginal-graft series only.[11]

See Also​

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

11. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Females." 2026. Guideline

12. Singh M, Kapoor R, Kapoor D, Kapoor R, Srivastav A, Chipde S. "Dorsal onlay vaginal graft urethroplasty for female urethral stricture." Indian J Urol. 2013;29(2):124–128. doi:10.4103/0970-1591.114034

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

14. Kore RN, Martins FE. "Dorsal onlay urethroplasty using buccal mucosal graft and vaginal wall graft for female urethral stricture – Outcome of two-institution study." Indian J Urol. 2022;38(2):140–145. doi:10.4103/iju.iju_329_21

15. Manasa T, Khattar N, Tripathi M, Varshney A, Goel H, Sood R "Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft." Indian J Urol. 2019;35(4):267–272. doi:10.4103/iju.IJU_134_19

16. Kudunthail JR, Navriya SC, Choudhary GR, et al. "Comparative Analysis of Dorsal Onlay Buccal Mucosal Graft and Vaginal Wall Graft Urethroplasty for Female Urethral Stricture at a Tertiary Care Centre." Urology. 2025;195:28–33. doi:10.1016/j.urology.2024.08.069

17. Kumar L, Thakur A, Agarwal S, Khairnar M, Trivedi S, Shankhwar SN. "Buccal versus Vaginal Graft Urethroplasty in Female Urethral Stricture: A Systematic Review and Meta-Analysis." Int Urogynecol J. 2025;36(11):2121–2132. doi:10.1007/s00192-025-06171-5

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