Female Ventral Inlay BMG Urethroplasty
Ventral inlay buccal mucosal graft urethroplasty is a vaginal-sparing option for female urethral stricture. The stricture is opened through the meatus/transurethrally and augmented with oral mucosa while preserving the anterior vaginal wall. Small female studies report encouraging patency; they do not establish a universally best approach or a zero risk of incontinence.[1][2][3]
For the related techniques, see Female Ventral Onlay, Female Dorsal Onlay and the Female Dilation / Reconstruction Pathway.
Access and Patient Selection
| Feature | Ventral inlay | Ventral onlay |
|---|---|---|
| Access | Meatal/transurethral | Through an anterior vaginal incision |
| Vaginal wall | Preserved in the vaginal-sparing variant | Opened and closed separately |
| Graft fixation | Secured to urethral margins and recipient bed | Secured to urethral margins with periurethral tissue coverage |
| Selection | Requires adequate exposure and viable recipient tissue | Provides wider open exposure; local tissue quality matters |
Confirm an anatomical stricture and define its length, location and proximity to the continence mechanism before selecting reconstruction. Recurrent disease, patient preference for definitive treatment, donor/recipient tissue quality and surgeon experience guide the choice. AUA and EAU guidance support female urethroplasty but do not designate ventral inlay as the default for every woman.[5][6]
Vaginal sparing may be helpful after prior vaginal surgery or when further vaginal dissection is undesirable. It does not remove the need to assess periurethral scarring, support, baseline continence and graft-bed viability.
Operative Principles
The cited female techniques use a ventral urethrotomy through meatal/transurethral access, extending the stricture opening into healthy urethral mucosa. Oral mucosa is harvested and prepared to fit the defect, then secured proximally, along the urethral margins and to the recipient bed. Maintain a tension-free inset, mucosa facing the lumen, and preserve the vaginal wall and periurethral support.[1][2][3]
Catheter size and duration, suture choice and fixation method vary among reports and should follow the actual female technique and intraoperative findings. The Sterling/Nikolavsky transurethral fossa-navicularis technique is a male operation; its 44-patient results, externally tied sutures, fixed 24-Fr target and one-week catheter protocol are not female outcome or protocol evidence. See the separate male transmeatal technique.
Female Outcome Evidence
| Study | Population / design | Reported outcome | Interpretation |
|---|---|---|---|
| Gaur 2024[1] | Female comparative cohort; 46 ventral-inlay patients | 89.1% success, median follow-up 27.5 months; dorsal-onlay group 88.9% | Similar observed proportions do not establish equivalence |
| Mandal 2025[2] | Single-center randomized trial: 47 randomized, 40 analyzed (20 per arm) | One failure per arm at one year; 95% success in each; median follow-up 21 months | Small study with exclusions after randomization; not proof of equal long-term durability |
| Kumaraswamy 2022[3] | Retrospective analysis of prospectively maintained data, 21 women | 90.5% overall success; life-table estimate 85% at 2–5 years; median follow-up 42 months | Later estimates are based on fewer patients at risk |
| Gülpınar 2021[4] | Small observational comparison; eight vaginal-sparing inlay patients | 87.5% success at median 24.6 months | Insufficient to rank three techniques |
The Kumaraswamy series reported improved symptoms, flow and residual urine, with no observed urinary incontinence. Zero events in 21 patients does not establish zero risk. Recurrence, incontinence, donor-site symptoms, urinary spraying, infection and fistula remain relevant outcomes to monitor.
What the 2025 Randomized Trial Adds
In the 40 analyzed participants, ventral inlay had shorter median operating time (30 versus 44.5 minutes), lower median blood loss (10 versus 15 mL), and less early pain than dorsal onlay. Success was 95% in each arm. The report describes similar outcomes; without a verified prespecified noninferiority margin and adequate analysis, identical success percentages should not be described as proof of noninferiority.[2]
These results inform counseling and operative planning but do not establish the lowest morbidity among all female urethroplasty techniques. Other small randomized female comparisons also exist; this is not the only female urethroplasty RCT.
Follow-up and Remaining Uncertainty
Assess voiding symptoms, uroflowmetry, residual urine, continence and sexual function after repair, using cystoscopy or other anatomical evaluation when indicated. Long-term follow-up matters because late recurrence can occur. The current evidence supports ventral inlay as one reconstructive option in experienced hands; it does not justify extrapolating male distal-urethral protocols to female surgery.[3][5][6]
Videos
References
1. 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.
2. 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.
3. Kumaraswamy S, Mandal S, Das MK, Nayak P. Long-term follow-up and success rate of ventral inlay buccal mucosal graft urethroplasty for female urethral stricture disease. Urology. 2022;166:146-151. doi:10.1016/j.urology.2022.05.002.
4. Gülpınar Ö, Zumrutbas AE, Sancı A, et al. The outcomes of three buccal mucosal graft urethroplasty techniques in women with urethral stricture disease. Neurourol Urodyn. 2021;40(8):1921-1928. doi:10.1002/nau.24764.
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. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Females. 2026. Guideline.