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Female Dorsal Inlay BMG Urethroplasty

Female dorsal inlay urethroplasty places a graft into a dorsal (12 o'clock) urethrotomy through either transurethral or suprameatal access. The transurethral BMG variant avoids vaginal-wall dissection and extensive urethral mobilization.[2][3][4] Small early series report high short-term patency and outpatient feasibility.[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 incision between the meatus and clitoral region
Vaginal-wall incisionNone in the transurethral variantNot inherent to dorsal urethral access; a separate vaginal donor-site incision is needed when harvesting vaginal graft
Urethral mobilizationMinimal (superficial dorsal urethrotomy only)Extensive dorsal dissection
Graft fixationSutures (proximal / distal) + surgical glue or quiltingRunning / interrupted sutures + quilting
Operative footprintSame-day discharge reported in a small seriesDischarge varies with procedure, patient and local practice

The technique mirrors the ventral inlay (Mandal / Gaur) approach but is 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 and dorsal inlay (vaginal or buccal graft). 3 patients, all with normal micturition and no additional treatment required at 1, 8 and 27 mo of follow-up.[3]
  • Petrou 2012. Refined the Tsivian-Sidi suprameatal technique with autologous vaginal-epithelium inlay in 11 women: no repeat surgery reported at mean 22.7 mo (not equivalent to freedom from all recurrence or dilation); Qmax rose from 7.3 to 21.8 mL/s; PVR fell from 187 to 76 mL; 0% de-novo SUI.[4]
  • Berdondini 2021. A transurethral mini-dorsal BMG technique with limited urethral-edge dissection and graft quilting was reported in 13 women with distal strictures.[9]
  • Panda 2021. An operative chapter described a nasal-speculum transurethral dorsal BMG inlay with graft-edge suturing and quilting.[7]
  • Linder / Balzano / Warner 2022. One outpatient proximal-stricture case used a nasal speculum and suture-passing device.[2]
  • Jefferson 2026. Retrospective series of 21 women treated with the transurethral dorsal inlay, the largest reported at publication.[1]

Indications​

  • Recurrent or refractory FUS after failed dilation or DVIU.[5]
  • Jefferson’s 21-woman mixed-procedure cohort included distal (33%), mid (19%), proximal (19%), and multifocal or pan-urethral (19%) strictures.[1] For a short meatal stricture, the EAU recommends meatotomy/meatoplasty .[8]
  • The 2023 AUA amendment states that urethroplasty should be offered to women with urethral stricture; it reports success rates of 69–95% across oral mucosa graft and vaginal flap techniques.[5]

Selection considerations include:

  • Minimally invasive, outpatient or same-day discharge is desired.
  • Minimal urethral mobilization is a goal (prior pelvic surgery, sphincter-disruption concern).
  • Proximal urethral strictures, where the transurethral approach avoids the dorsal periurethral dissection used in traditional dorsal onlay.[2]

Technique — Transurethral Dorsal Inlay (Linder / Jefferson)​

Dorsal lithotomy.[1][2]

  1. Setup. Urethral catheter; lithotomy.
  2. BMG harvest. Before surgery, counsel about oral donor-site pain, numbness, chewing difficulty and mouth tightness; the EAU rates oral-graft morbidity counseling a Strong recommendation, and buccal-graft mouth tightness has persisted beyond six months.[10] Harvest from the inner cheek, avoid Stensen’s duct, and defat and trim the graft.
  3. Transurethral access. A nasal speculum is 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. In Linder's transurethral case, the urethral catheter was removed at 3 weeks.[2]
  9. Discharge. Same day in the Jefferson series.[1]
  10. Follow-up in that series. Cystoscopy, uroflowmetry and Global Response Assessment were scheduled at 4 and 12 months; cystoscopic absence of recurrence defined clinical success.[1]

Technical principles. The urethra is not dissected from surrounding tissue. The graft survives on the native dorsal periurethral bed by imbibition and inosculation. Proximal and distal sutures plus mid-graft glue secure the graft without extensive intraurethral suturing.

Panda variant. Arabind Panda describes making the dorsal urethrotomy from inside in short segments, placing stay sutures as the incision is extended, and repeating urethroscopy before each proximal extension, because the female urethra has no reliable landmark and an overly proximal cut can injure the bladder neck. His incision extends about 0.5–1 cm beyond the stricture while stopping short of the bladder neck. For proximal graft fixation he places five 4-0 monofilament PDS sutures with a modified ski-needle/reverse-Webster technique, rather than the three proximal sutures and glue described above. He then sutures the graft edges to the urethral sides and quilts the graft to limit displacement and hematoma.[7] In his noncomparative experience, 12 of 14 women were voiding well with Qmax >15 mL/s and no subjective voiding LUTS; six years was the maximum follow-up.[7]

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

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

  1. Suprameatal incision above the meatus between the meatus and clitoral region.
  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 2026 reported that 2 of 21 (10%) required a combined dorsal and ventral inlay through the transurethral approach for obliterative strictures. Both walls were augmented, rather than excising the stricture and replacing it with a circumferential tubularized free graft.[1]

Outcomes​

SeriesnApproachGraftSuccessFollow-upKey findings
Jefferson 2026[1]21 (19 dorsal only; 2 combined dorsal and ventral)Transurethral inlayBMGMixed-procedure cohort: 95% at 4 mo; 92% at 12 mo (no recurrence on cystourethroscopy)median 13.2 mo (IQR 5.1–23.5)Same-day discharge; OR median 60 min; no observed complications or de novo SUI; 1 retreatment
Petrou 2012[4]11Suprameatal dorsal inlayVaginal graftNo repeat surgery reportedmean 22.7 moQmax 7.3 → 21.8; PVR 187 → 76; 0% de novo SUI
Tsivian-Sidi 2006[3]3Suprameatal dorsal inlayVaginal / BMGNo additional treatment1, 8 and 27 moFirst description; all normal micturition
Linder 2022[2]1Transurethral dorsal inlayBMGImproved urinary stream in one patient3 moOutpatient case report; no stress incontinence; proximal stricture

In the Jefferson series of 21 women (19 dorsal inlay and two combined dorsal and ventral inlay), median Qmax rose from 7.0 to 13.0 mL/s at 4 months and 13.3 mL/s at 12 months (p = 0.20 and 0.50), and 90% reported improvement on the Global Response Assessment.[1] In the Petrou series, Qmax rose from 7.3 to 21.8 mL/s and PVR fell from 187 to 76 mL.[4] No de novo SUI was observed in the Jefferson (21 women) or Petrou (11 women) series; Linder's single patient had no stress incontinence at 3 months. Tsivian-Sidi did not report a separate SUI outcome.[1][2][3][4]

Continence Interpretation​

No de novo SUI was observed in the 21-patient Jefferson series.[1]

Advantages​

  • Minimal urethral mobilization is the rationale for preserving periurethral blood supply and sphincter integrity.[1]
  • All Jefferson 2026 patients were discharged the same day.[1]
  • Median operative time was 60 min (IQR 56–86).[1]
  • The transurethral variant needs no vaginal-wall incision.[1]
  • No complications occurred in the 21-patient series.[1]
  • No de novo SUI was reported across the series.[1][3][4]
  • The technique has been applied to distal, mid, proximal and pan-urethral disease.[1]
  • Dorsal inlay was described in Tsivian-Sidi’s three-patient series; Panda describes the vascular dorsal periurethral tissue as the rationale for graft take.[3][7]

Limitations​

  • Very limited evidence base. Largest series 21 patients; median follow-up 13.2 mo.[1]
  • Short follow-up. The 92% cystourethroscopic clinical success at 12 mo[1] may evolve with longer follow-up; late recurrences are known with urethroplasty generally.
  • Limited visualization. The 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. A small female trial compared ventral inlay versus dorsal onlay (Mandal 2025).[6]
  • Single-center experience. The Linder and Jefferson reports come from one institution, and no multicenter series has been reported.
  • Obliterative strictures. 10% required combined dorsal and ventral inlay.[1]

Comparison With Other Graft Approaches​

Transurethral dorsal inlay reduces external dissection, while traditional dorsal onlay offers direct access to the dorsal recipient bed. Ventral inlay preserves the vagina through a different urethral access plane. Differences in anatomy, tissue source and follow-up across published cohorts preclude ranking operating time, catheter duration, patency or continence.[1][5][6]

Patient-Selection Pearls​

Factors to assess when considering dorsal inlay include:

  • Patients prioritizing a minimally invasive, outpatient procedure.
  • Proximal urethral strictures, where transurethral access avoids deep vaginal dissection.[2]
  • Patients in whom minimizing dissection is a goal, with explicit counseling that a continence advantage has not been proven.
  • Multifocal or pan-urethral strictures, which were treated in the Jefferson series.[1]
  • After prior pelvic surgery or with altered vaginal anatomy, assess the quality of the dorsal and ventral urethral tissue before choosing an approach.[8]

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

Guideline Position​

The 2023 AUA amendment states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination. It reports success rates of 69–95%, and technique is chosen by surgeon experience.[5] Dorsal inlay is not named separately in the 2023 AUA statement or the 2026 EAU female-stricture guideline.[5][8] Its evidence base is small.[5][8] For women with a second recurrence who cannot perform intermittent self-dilation or want definitive treatment, the EAU strongly recommends urethroplasty and bases technique selection on surgeon experience, graft or flap availability and quality, and ventral versus dorsal urethral quality.[8]

Summary​

Female dorsal inlay BMG urethroplasty places the graft transurethrally with minimal urethral mobilization. Early reports document feasibility. Small cohorts and short follow-up limit conclusions about safety and durability.[1][2][3][4]

Videos​

Transurethral Dorsal BMG Urethroplasty for Female Urethral Stricture
SUFU Surgical Video Library. Operative video of the transurethral dorsal-inlay BMG technique (Linder / Jefferson) in a female urethral stricture. Hosted on the SUFU Vimeo channel; embed restricted to sufuorg.com, so opens externally.
sufuorg.com · Surgical Video Library

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. 2026;45(1):155-161. 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.

7. Panda A. Dorsal (Anterior) Inlay Technique for Buccal Mucosal Graft for Female Urethroplasty. In: Khattar N, Nayyar R, Panda A, eds. Female Bladder Outlet Obstruction and Urethral Reconstruction. Springer; 2021:175-181. doi:10.1007/978-981-15-8521-0_16

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

9. Berdondini E, Tosco L, Margara A, et al. "Minimally invasive buccal mucosa dorsal graft for female distal urethroplasty." Eur Urol Open Sci. 2021;24:34-38. doi:10.1016/j.euros.2020.12.001

10. European Association of Urology. "EAU Guidelines on Urethral Strictures: Tissue Transfer." 2026. Guideline