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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. Small early series report high short-term patency and outpatient feasibility. They do not establish zero complication risk or superiority over open graft techniques.[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 onlyExtensive 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 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: no repeat surgery reported at mean 22.7 mo (not equivalent to freedom from all recurrence or dilation); 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 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 — 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 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 2025 reported that 2 of 21 (10%) required a combined dorsal + ventral inlay through the transurethral approach for obliterative strictures — augmentation of both walls, rather than excision and circumferential tubularized free-graft replacement.[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 graftNo repeat surgery reported; not a complete recurrence-free endpointmean 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]

Continence Interpretation​

No de novo SUI was observed in the 21-patient Jefferson series. This small uncontrolled experience cannot show that dorsal inlay is safer for continence than dorsal onlay, and pooled complication percentages from different operations should not be compared as though randomized. Minimal mobilization is a technical rationale, not proof of protection from SUI.[1][5]

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. A small female trial compared ventral inlay vs dorsal onlay (Mandal 2025); it is not a comparison of dorsal inlay with dorsal onlay.[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 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. Published cohorts differ in anatomy, tissue source and follow-up; their operating times, catheter durations, patency and continence rates cannot establish a reliable ranking.[1][5][6]

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 in whom minimizing dissection is a goal, with explicit counseling that a continence advantage has not been proven.
  • 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 feature is transurethral graft placement with minimal urethral mobilization. Early reports document feasibility; small cohorts and incomplete long-term follow-up limit safety and durability conclusions. Larger multicenter studies and direct comparisons with dorsal onlay are needed before it can be considered standard.[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. 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.