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Anterior Vaginal Wall Mucosal Inlay (Önol)

The anterior vaginal wall mucosal inlay urethroplasty is a ventral augmentation technique for female urethral stricture (FUS) that opens the urethra ventrally and inlays a pedicled strip of anterior vaginal wall mucosa into the urethrotomy to widen the lumen. The technique most closely associated with this terminology is the one described by Önol 2011, who used it in 10 of 17 women undergoing urethroplasty.[1][2][3] A simplified variant was described by Schwender / Gormley 2006.[9]

For the family of related anterior-vaginal-wall techniques, see the Blandy U-Flap and the Lateral-Based Anterior Vaginal Wall Flap (Romero-Maroto / Simonato). For graft alternatives, see Female Dorsal Onlay BMG and Ventral Onlay BMG.

Where the Önol Inlay Sits in the Family​

"Anterior vaginal wall mucosal inlay" is a family of related techniques sharing one principle: ventral urethrotomy with inlay of anterior vaginal wall tissue to augment the urethral lumen. Variants:[2][3][4]

  • Blandy U-flap — proximally based U-shaped pedicled flap (classic).
  • Lateral-based vaginal flap (Romero-Maroto / Simonato) — laterally pedicled modification.
  • Gormley / Schwender vaginal inlay flap — simplified ventral inlay approach.[9]
  • Önol anterior vaginal wall mucosal inlay — ventral pedicled flap inlay; the largest single-technique series using this specific terminology.[1]
  • Borchert vaginal free graft (dorsal onlay) — non-pedicled graft placed dorsally; same tissue source, different placement.[5]

The Önol inlay is distinguished from a dorsal-onlay graft (different urethral surface) and from a tubularized vaginal flap such as the Blaivas neourethra (rolled into a tube rather than inlaid).

Indications​

  • FUS refractory to dilation or DVIU.[1][2]
  • Mid-to-distal urethral strictures — most common location.[1][6]
  • Healthy, well-estrogenized anterior vaginal wall.[2][7]
  • Can be used as primary urethroplasty — Önol notably advocated this as a first-line option over repeated dilation, performing primary urethroplasty in 10 of 17 patients.[1]

Contraindications​

  • Lichen sclerosus / vaginal atrophy — compromised tissue; BMG preferred. Önol used dorsal BMG in 2 patients with atrophic vaginas.[1][2][7]
  • Prior synthetic midurethral sling with periurethral scarring — Önol used Martius-reinforced ventral BMG in this scenario.[1]

Önol Technique​

Dorsal lithotomy, regional or general anesthesia.[1]

  1. Preoperative assessment — pressure-flow studies confirming bladder-outlet obstruction (urethral pressure > 20 cm H₂O during voiding). Cystourethroscopy to confirm stricture location and length.
  2. Anterior vaginal wall incision — midline longitudinal incision overlying the urethra; vaginal mucosa dissected laterally off the periurethral tissue to expose the ventral urethral surface.
  3. Ventral urethrotomy — longitudinal 6 o'clock incision through the full length of the stricture into healthy mucosa proximally and distally.
  4. Vaginal mucosal flap creation — flap fashioned from anterior vaginal wall adjacent to the urethrotomy. The flap remains pedicled (attached to its submucosal vascular supply) — this is the key distinction from a free graft.
  5. Inlay — flap inlaid into the ventral urethrotomy defect and sutured to the urethral mucosa with interrupted 4-0 / 5-0 polyglactin, augmenting the lumen ventrally.
  6. Proximal urethral mucosa adjunct — in one Önol patient, the dilated proximal urethral mucosa was used as an additional tissue source, illustrating the technique's adaptability.[1]
  7. Second-layer closure — vaginal wall closed as a second layer over the repair.
  8. Catheter — postoperative urethral catheter.

Technical pearls — keep the inlay pedicled (preserves blood supply); the ventral approach preserves the dorsal urethral surface and pubourethral ligaments.[2][3][8] Schwender / Gormley specifically emphasized the technique's simplicity and learnability.[9]

Schwender / Gormley Variant (J Urol 2006)​

A closely related simplified ventral inlay:[9]

  • Ventral aspect of the stricture incised longitudinally.
  • Vaginal inlay flap advanced into the urethrotomy defect and sutured to urethral edges.
  • 8 women, 2 institutions, 1–9 yr follow-up.
  • 100% subjective symptom relief; caliber 9.25 → 16.5 Fr; PVR 130 → 15 cc; 0% de novo SUI; 1 patient required a single repeat dilation 3 weeks postop without subsequent recurrence.

Pedicled Inlay vs Vaginal Free Graft​

FeaturePedicled Vaginal Inlay (Önol / Gormley)Vaginal Free Graft (Borchert)
Blood supplyMaintains own pedicleRelies on recipient bed (imbibition → inosculation)
Tissue viabilityHigher — independent supplyRecipient-bed dependent
PlacementVentralDorsal (Borchert technique)
Tissue handlingLess manipulation; stays attachedHarvest, prepare, transplant
Vaginal narrowing riskMinimal (in situ)Possible if graft large
Behavior in scarred bedsBetter — own blood supplyMay fail in poorly vascularized beds
Donor-site morbidityNoneMinimal (vaginal harvest site)

Borchert 2022 described the free-graft variant: the vaginal mucosa is harvested separately, the underlying fibromuscular tissue is removed, and the thin mucosal graft is placed dorsally after dorsal urethrotomy. Key tenets are adequate dorsal dissection, full-length stricture incision, and tension-free anastomosis. Harvest-site selection is critical to avoid vaginal narrowing.[5]

Outcomes​

SeriesnTechniqueSuccessFollow-upCaliber / QmaxPVRDe-novo SUI
Önol 2011[1]10 (of 17)Anterior vaginal wall mucosa inlay100% objective24 mo (median; range 6–78)Qmax 10.8 → 28.9 mL/s120 → 30 mLnot reported
Schwender / Gormley 2006[9]8Vaginal inlay flap100% subjective1–9 yrcaliber 9.25 → 16.5 Fr130 → 15 mL0%
Hajebrahimi 2019[10]14U-shaped vaginal flap (Blandy)100% (voiding improved)—Qmax → 15.8 mL/s→ 27.4 mL14%
Romero-Maroto 2018[11]9Lateral-based vaginal flap100%80.7 moQmax 6.8 → 21 mL/s—0%
Lane 2020 SUFU[12]local-flap subsetLocal-tissue flap (mixed)83% at 12 mo14.6 mo (median)———

Pooled local-flap urethroplasty success in systematic reviews is ~ 92%, vs 87–90% for grafts and 41–49% for dilation.[4][13]

Inlay vs Other Urethroplasty Tissue Sources​

TechniqueTissue / approachReported successKey advantageKey limitation
Anterior vaginal wall mucosal inlay (pedicled)Anterior vaginal wall, ventral92–100%[1][9][10]Own blood supply; no donor-site morbidity; simpleTissue-quality dependent; spraying risk
Vaginal free graft (dorsal onlay)Anterior vaginal wall, dorsalvariable[5]Avoids BMG harvest; dorsal placementRecipient-bed dependent; vaginal narrowing risk
Dorsal onlay BMGBuccal mucosa, dorsal87–94%[14]Versatile; any location; LS-resistantOral donor-site morbidity
Ventral onlay BMGBuccal mucosa, ventral89–98%[8][15]Preserves sphincter; spongiosal supportOral donor-site morbidity
Dorsal onlay labial mucosaLabia minora, dorsal93.5% at 2 yr (Jena n = 200+)[16]Largest single-surgeon series; minimal donor morbidityLimited data outside that center

Kumar 2025 SR / meta of 18 BMG-vs-VWG studies found no significant difference in success (BMG 86.2% vs VWG 89.8%), Qmax, or PVR.[17] AUA 2023 frames urethroplasty success in women as 69–95% across techniques, with selection driven by surgeon experience.[18]

Advantages​

  1. No donor-site morbidity — same operative field; no oral wound, no cheek / lip numbness, no trismus.[1][2]
  2. Pedicled blood supply — better than free graft in compromised beds.[2][3]
  3. Technical simplicity — Schwender / Gormley specifically emphasized this as an advantage given the rarity of FUS and limited surgical experience.[9]
  4. Single operative field — no second team or harvest site.[1]
  5. Tissue compatibility — vaginal mucosa is wet, hairless, elastic, histologically similar to urethral mucosa.[2]
  6. Primary-urethroplasty option — Önol used it as a first-line operation in patients without prior instrumentation.[1]

Limitations and Concerns​

  • Tissue-quality dependence — contraindicated in LS, vaginal atrophy, prior radiation; BMG preferred.[2][7]
  • Urinary spraying — 29% (2 / 7) in Higuchi 2026 VFU vs 0% in DOBMGU (ventral-approach concern).[6]
  • Retrusive meatus — classic Blandy variant carries this risk; the lateral-based modification eliminates it.[11]
  • Lower success in some VFU series — Higuchi 2026: 57.1% (VFU) vs 87.5% (DOBMGU); Kowalik 2014: 60% (VFU) vs 100% (dorsal BMG). These pooled mixed VFU techniques (not exclusively Önol-style ventral inlay).[6][19]
  • Limited applicability for proximal / pan-urethral — most ventral-inlay series focus on distal-to-mid; BMG is more versatile.[6][14]
  • Small evidence base — all series are small (6–17 patients), retrospective, single-center.[1][9][20]

Complications​

  • Stricture recurrence — 0–43% across series and follow-up windows.[19]
  • De novo SUI — 0–14% across vaginal-flap series; mostly mild and PFPT-responsive.[10][21]
  • Urinary spraying — ventral-approach-specific.[6]
  • De novo urgency — reported even with technically successful repairs.[10]
  • Urethrovaginal fistula — rare; reduced by multi-layer closure ± Martius interposition.[2]

When to Choose the Önol Inlay​

  • Stricture is distal or mid-urethral.[1][2]
  • Anterior vaginal wall is healthy and well-estrogenized (no LS).[2][7]
  • Surgeon prefers to avoid BMG donor-site morbidity.[1][2]
  • A pedicled flap with own blood supply is preferred over a free graft.[2][3]
  • No prior synthetic MUS (periurethral scarring limits flap mobilization).[1]
  • Primary urethroplasty is being considered as a definitive first-line treatment.[1]

Postoperative Management​

  • Urethral catheter 10–21 days.[1][9]
  • Voiding trial with uroflowmetry and PVR.
  • Cystoscopy at 3–6 mo.
  • Topical estrogen in postmenopausal women.[7]
  • Long-term surveillance — late recurrences documented.[12]

Summary​

The Önol anterior vaginal wall mucosal inlay is a technically straightforward ventral augmentation urethroplasty that uses a pedicled strip of anterior vaginal wall mucosa to widen the lumen, with 100% objective cure at 24-month median follow-up in the index series and pooled local-flap success of ~ 92%. Its strengths are technical simplicity, no donor-site morbidity, and a pedicled blood supply. Its limitations are dependence on healthy vaginal tissue, the ventral-approach spraying risk, and lower comparative success in some small head-to-head series against dorsal BMG. Patient selection is critical; BMG urethroplasty remains the preferred alternative when vaginal tissue quality is compromised.[1][6][17][21]

References​

1. 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.

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

3. Faiena I, Koprowski C, Tunuguntla H. Female urethral reconstruction. J Urol. 2016;195(3):557-567. doi:10.1016/j.juro.2015.07.124.

4. Chakraborty JN, Chawla A, Vyas N. Surgical interventions in female urethral strictures: a comprehensive literature review. Int Urogynecol J. 2022;33(3):459-485. doi:10.1007/s00192-021-04906-8.

5. 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.

6. 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.

7. West C, Lawrence A. Female urethroplasty: contemporary thinking. World J Urol. 2019;37(4):619-629. doi:10.1007/s00345-018-2564-4.

8. 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.

9. Schwender CE, Ng L, McGuire E, Gormley EA. Technique and results of urethroplasty for female stricture disease. J Urol. 2006;175(3 Pt 1):976-980; discussion 980. doi:10.1016/S0022-5347(05)00336-8.

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

11. 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.

12. Lane GI, Smith AL, Stambakio H, et al. Treatment of urethral stricture disease in women: a multi-institutional collaborative project from the SUFU research network. Neurourol Urodyn. 2020;39(8):2433-2441. doi:10.1002/nau.24507.

13. Sarin I, Narain TA, Panwar VK, et al. Deciphering the enigma of female urethral strictures: a systematic review and meta-analysis of management modalities. Neurourol Urodyn. 2021;40(1):65-79. doi:10.1002/nau.24584.

14. Khawaja AR, Dar YA, Bashir F, et al. Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (FUSD): our institutional experience. Int Urogynecol J. 2022;33(3):697-702. doi:10.1007/s00192-021-04840-9.

15. 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.

16. Jena AK, Jena R, Madhavan M, Madhavan K. Dorsal onlay labial mucosal graft urethroplasty in female urethral stricture: outcomes of over 200 cases from a single surgeon. Urology. 2025. doi:10.1016/j.urology.2025.05.040.

17. 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.

18. 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.

19. Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. Intermediate outcomes after female urethral reconstruction: graft vs flap. Urology. 2014;83(5):1181-1185. doi:10.1016/j.urology.2013.12.052.

20. Turchi B, Lumen N, Verla W, Waterloos M. Female urethral stricture disease: a narrative review on diagnosis, surgical techniques and outcomes. Int J Impot Res. 2026;38(4):286-295. doi:10.1038/s41443-025-01079-6.

21. Chakraborty JN, Enganti B, Nayak P. Female urethroplasty: a critical review of indications, techniques and concerns. Int Urogynecol J. 2026;37(4):823-833. doi:10.1007/s00192-025-06415-4.