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Primary End-to-End Anastomosis (Female)

Primary end-to-end anastomosis (EPA) in females excises the strictured or obliterated urethral segment and directly re-approximates the healthy proximal and distal ends in a tension-free, spatulated, mucosa-to-mucosa fashion without interposition of graft or flap tissue. In women, this technique is most commonly used for pelvic fracture urethral injury (PFUI) rather than for typical female urethral stricture disease; the evidence base consists of case reports, small case series, and one systematic review.[1][2] It differs from the augmentation urethroplasty techniques (BMG, vaginal flap) that dominate the female stricture literature.

Concept and Rationale​

The principle of EPA is identical across sexes: excise the diseased segment, mobilize the healthy urethral ends, and create a direct, tension-free, spatulated anastomosis. This avoids the need for graft or flap tissue. Current selection distinguishes traumatic full-thickness obliteration from nontraumatic short strictures, for which nontransecting or graft options may be preferred. EPA is also the standard repair for posterior urethral distraction defects after PFUI.

In females, the rationale is most compelling in two scenarios:

  1. Acute pelvic fracture urethral injury. The urethra is avulsed or transected and the ends can be directly re-approximated before fibrosis develops.
  2. Short-segment obliterative stricture. A very short fibrotic segment can be excised with the healthy ends brought together without tension.

Indications​

  • Pelvic fracture urethral injury (PFUI). The most common indication. Patel et al.'s SR found that 80% (66/83) of immediately repaired female PFUI cases were managed with anastomotic repair.[1]
  • Very short urethral obliteration. In women without PFUI, the EAU female-stricture guideline describes two very short midurethral anastomotic cases and gives no validated length cutoff. Direct repair requires healthy ends that meet without tension while preserving continence anatomy.[23]
  • Traumatic urethral transection. Iatrogenic (during pelvic surgery) or external trauma causing clean urethral disruption.
  • Xu et al. used end-to-end anastomosis in 4 of 44 patients (9%) with female urethral stricture associated with urethrovaginal fistula. The authors based technique selection on fistula location, stricture length and vaginal anatomy.[2]

Contraindications and Limitations​

  • Defect too long for tension-free anastomosis. The female urethra is only 3–5 cm long, so even modest tissue loss creates a proportionally large gap. Unlike the bulbar urethra (which can be mobilized to bridge 2–3 cm in many male pelvic-fracture posterior urethral distraction repairs), the female urethra has limited mobility; if healthy ends cannot meet without tension, consider graft or flap substitution.[5][6][25]
  • Bladder-neck or proximal-urethra involvement. Excision here risks the continence mechanism, so plan the exposure and repair carefully rather than treating proximal involvement as an absolute contraindication. The EAU describes retropubic exploration and primary suturing for proximal female disruptions once stable.[17]
  • Extensive periurethral fibrosis. Prevents adequate mobilization.
  • Concomitant urethrovaginal fistula. May require tissue interposition rather than direct closure.
  • Lichen sclerosus. Diseased tissue margins may extend beyond the visible stricture.

Surgical Technique​

The technique in females is adapted from male EPA principles but performed via a vaginal approach (or combined vaginal-abdominal or transpubic approach for proximal injuries).

Early Anastomotic Repair for Acute PFUI​

EAU guidelines recommend early repair (within seven days) for female PFUI, in preference to delayed repair or early realignment . Early repair is preferred once the patient is haemodynamically stable, and proximal or midurethral disruptions are repaired through retropubic and transvaginal routes.[17] The EAU cites pooled complication rates from one review by female PFUI management strategy; early repair includes suturing lacerations and disrupted ends.[17]

StrategyStrictureFistulaIncontinenceVaginal stenosisPermanent diversion
Early realignment59%13%0%0%0%
Early repair (7 days or less)3%6%9%0%3%
Delayed repair (more than 7 days)3%4%31%4%7%

Delayed repair often needs a complex abdominal or combined abdominal-vaginal reconstruction. Associated vaginal lacerations are closed in two layers at the same time, and a distal urethral injury that spares the sphincter mechanism can be left hypospadiac.[17]

Children. Urethral injury without pelvic fracture is uncommon in girls;[20] in a U.S. trauma registry of girls younger than 16 with pelvic fractures, 81/2,639 (3%) had bladder and/or urethral injury.[24] EAU paediatric guidance weakly recommends either suprapubic diversion with delayed repair or early transurethral realignment for posterior injury, but its supporting discussion largely concerns boys.[21] The separate EAU female-PFUI guideline recommends repair within seven days once haemodynamically stable , without an adult-only qualifier.[17] In girls with gross haematuria, urinary retention, or vaginal or rectal injury, evaluate under anesthesia with cystourethroscopy and vaginoscopy; VCUG alone can miss female urethral injury.[17][20] Continence can be favorable when the bladder neck is spared.[20]

  1. Timing. Performed as soon as the patient is hemodynamically stable. Patel et al. concluded, from very-low-quality literature, that primary anastomotic repair via a vaginal approach "as soon as the patient is haemodynamically stable appears to be optimal." Dorairajan et al. performed same-day repair or realignment in 4 girls or young women with PFUI.[1][7]
  2. Assessment and positioning. Assess the urethra and vagina with cystourethroscopy and vaginoscopy ; position in lithotomy for vaginal exposure, adapting positioning if retropubic or combined access is needed for the injury level.[17]
  3. Approach. Anterior vaginal-wall incision; identification of the disrupted urethral ends.
  4. Debridement. Devitalized tissue at both urethral ends is debrided back to healthy, bleeding mucosa. Because the female urethra is short, keeping debridement to the minimum needed to reach healthy tissue has been described.[18]
  5. Mobilization. Both urethral ends are mobilized circumferentially to allow tension-free approximation. The distal end typically has more mobility than the proximal end. When a vaginal laceration accompanies the injury, mobilizing the urethra and vagina as a single unit to bridge the defect and reduce anastomotic tension has been described.[18] When proximal dissection separates the bladder from the anterior vaginal wall, ureteral stents or infant feeding tubes have been used to identify and protect the ureters; if the urethral mucosa is too fragile to hold sutures, further mobilizing the bladder away from the anterior vaginal wall is an option.[18]
  6. Spatulation. Both ends are spatulated (incised longitudinally for about 5 mm on opposite sides) to widen the anastomosis and reduce circumferential contracture risk.
  7. Anastomosis. Mucosa-to-mucosa with interrupted or running 4-0 or 5-0 absorbable sutures (polyglactin or poliglecaprone) over a 14–16 Fr urethral catheter.
  8. Reinforcement. Periurethral fascia or a Martius flap may be interposed between the anastomosis and the vaginal wall for vascular support and fistula prevention.
  9. Vaginal closure. Layered closure of the anterior vaginal wall.
  10. Catheter management. Urethral catheter (± SPC) for 2–3 weeks. A four-week urethral-and-suprapubic-catheter interval, followed by pericatheter and voiding studies before catheter removal, has also been described.[18]

Delayed Anastomosis for Established Obliterative Stricture​

Delayed reconstruction is for established defects or when early repair was not feasible.

  1. Timing. For female PFUI, use delayed reconstruction when early repair was not feasible.[8][17] Plan reconstruction after major injuries stabilize and safe positioning is possible; the AUA's usual 3–6-month interval describes delayed PFUI reconstruction predominantly in men.[8][17]
  2. Preoperative assessment. VCUG, cystoscopy (antegrade via SP tract and retrograde), and MRI to define gap length and relationship to the bladder neck.
  3. Approach. A vaginal approach is described for accessible defects; proximal disruptions may require retropubic or combined exposure. Transpubic access has been reported for complex PFUI strictures reconstructed with tubularized labial flaps, not as a routine EPA approach for long defects.[1][9][17]
  4. Scar excision. Excise the fibrotic obliterated segment completely to healthy urethral mucosa at both ends. If a false passage obscures the true proximal lumen, antegrade cystoscopy has been described in one female case to identify that lumen and guide stay-suture placement before anastomosis.[22]
  5. Mobilization and anastomosis. As above.
  6. Adjunctive maneuvers when the gap exceeds tension-free vaginal anastomosis:
    • Inferior pubectomy (male-derived maneuver). Partial resection of the inferior pubic symphysis can shorten the inter-end distance in male bulboprostatic anastomosis; benefit as a female EPA adjunct has not been established.[8][10]
    • Transpubic approach. Wider exposure for proximal urethral mobilization.[9]
    • If tension-free anastomosis remains impossible, convert to substitution urethroplasty (vaginal flap, labial flap, BMG, or bladder flap).[2]

For a bladder-neck-level avulsion repaired transabdominally, identifying the bladder neck through the suprapubic tract under endoscopic guidance (a 12-Fr mini-nephroscope has been described) before placing the posterior anastomotic sutures, then passing a 14-Fr silicone catheter across the repair to guide placement of the anterior sutures, with omental interposition over the anastomosis, has been described for selected proximal injuries.[19]

Outcomes​

StudyContextn (primary repair)TimingSuccessContinenceFollow-up
Patel 2017 SR[1]Female PFUI66 (primary anastomosis)ImmediateUrethral integrity similar to delayed repairLess incontinence than delayed repairVariable
Dorairajan 2004[7]Female PFUI (girls and one adult)4 (repair or realignment)Same-dayAll voided satisfactorily; 2 needed dilation or urethrotomy4/4 continent at follow-up; 1 had transient SUI33 mo (mean)
Xu 2013[2]FUS + UVF4 (of 44 total)Delayed93.2% anatomical success (41/44, all techniques); EPA not separately reportedNot reported separately42.3 mo (mean, all techniques)
Waterloos 2021[12]Iatrogenic injury and stricture; mixed techniques4 early primary repairs; 4 delayed primary closures after sling erosion (not isolated EPA outcomes)Early or delayed100% patency in the 14-patient mixed-technique series; no EPA-specific estimate3/14 had postoperative incontinence, including 2 after sling removalMedian 30 mo (early injury group); 13 mo (delayed stricture group)
Black 2006[11]Pelvic-fracture urethral/bladder-neck injury in girls and women; avulsions and lacerations21/25 had primary repair (EPA-specific outcomes unavailable)Immediate5/25 required secondary procedures (4 fistula repairs, 1 continent diversion)9/21 assessed had moderate or severe LUTS; treatment groups not separated7.3 yr (mean)

Key Findings — Patel 2017 Systematic Review​

A systematic review of female PFUI management covering 158 female patients across 51 articles; the authors rated the literature as very low quality.[1]

  • 83 (53%) managed with immediate repair: 17 via primary alignment, 66 via anastomotic repair.[1]
  • 75 (47%) managed with delayed repair.[1]
  • Urethral stenosis and fistula rates were highest after primary alignment (not anastomotic repair).
  • Urethral integrity was similar between primary anastomosis and delayed repair.
  • Incontinence and vaginal stenosis were significantly more common after delayed repair, which favors early anastomotic repair when feasible.
  • Delayed repair patients more often required more extensive reconstructive surgery (substitution urethroplasty rather than simple anastomosis).
  • Conclusion: "Primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal."

Primary vs Delayed Repair​

ParameterPrimary AnastomosisDelayed Repair
TimingWithin seven days once hemodynamically stable[17]More than seven days after injury, once reconstructive surgery is safe[17][8]
Urethral integritySimilarSimilar
IncontinenceLowerHigher
Vaginal stenosisLowerHigher
Complexity of surgerySimpler (direct anastomosis)More complex (often requires substitution)
Tissue qualityFresh edges, less fibrosisFibrotic; may require extensive excision
Patient selectionHemodynamically stable, identifiable endsSelected patients when early repair is not feasible

Source: Patel 2017 SR.[1]

Comparison with Male EPA​

Koraitim reported success in 90% of perineal and 98% of perineo-abdominal repairs in 155 patients over 27 years.[4]

In males, the SIU/ICUD consultation reported 93.8% overall success for EPA of bulbar strictures across 1,234 patients (17 articles).[3]

FeatureMale EPAFemale EPA
Primary indicationShort bulbar stricture (≤ 2 cm) or PFUIPFUI primarily; rarely for short stricture
Urethral length~ 18–20 cm for the whole male urethra, not just the anterior segment3–5 cm
Mobilization potentialExtensive (bulbar urethra mobilizable several cm)Limited
Adjunctive maneuversCrural separation, inferior pubectomy, urethral reroutingRetropubic exposure for proximal injury; transpubic access described for complex flap substitution, not established for EPA; benefit of inferior pubectomy for female EPA unestablished[9][10][17]
Success rateDepends on site, etiology and endpointLimited female-specific data; no valid cross-sex equivalence comparison
Continence riskLow (external sphincter preserved)Higher concern (shorter urethra, less sphincteric redundancy)
Non-transecting optionDescribed (vessel-sparing EPA)Two-case uncontrolled series described[18]

Non-Transecting EPA: Male Rationale and Limited Female Experience​

In males, non-transecting, vessel-sparing EPA preserves the bulbar arteries and periurethral vasculature by excising only the fibrotic mucosa or submucosa without transecting the full thickness of the corpus spongiosum. The Scandinavian Urethroplasty RCT (n = 151) showed that transecting EPA was followed by more patient-reported penile complications than BMG (reduced glans filling, p = 0.03; penile shortening, p = 0.001), with no difference in IIEF-5 scores and recurrence requiring further treatment at 12 months in 12.9% overall; the trial was not designed to detect a recurrence difference.[14] The penile complications questionnaire was not validated.[14] AUA notes that non-transecting substitution urethroplasty results in fewer penile complications than transecting urethroplasty for short bulbar strictures.[8][13]

Viswaroop and Gopalakrishnan describe performing non-transecting anastomotic urethroplasty in two women with obliterative or near-obliterative strictures under 1 cm, an approach they extrapolated from male experience. The scarred segment is opened longitudinally, the fibrotic mucosa is excised, and the posterior mucosa is approximated over a catheter without full urethral transection. Both women voided per urethra: one at 18 months of follow-up, and the other required cystoscopy with or without dilation every three months and was later reclassified as primary voiding dysfunction rather than a true stricture recurrence.[18] The female urethra lacks a corpus spongiosum.

Advantages and Limitations​

Advantages

  • No graft or flap harvest is required, which avoids donor-site morbidity.
  • Technically simpler when feasible (short defect, identifiable healthy ends).
  • No concerns about graft take or flap viability.
  • Lower incontinence and vaginal stenosis rates compared to delayed repair (for PFUI).[1]
  • Single-stage procedure.
  • No foreign tissue; healing is native urethra to urethra.

Limitations

  • Narrow applicability. The short female urethra (3–5 cm) limits the length of stricture that can be excised while still achieving tension-free anastomosis.
  • Continence risk. Excision of any urethral segment shortens functional length and may compromise the continence mechanism, particularly if the mid-urethral high-pressure zone is involved.[11]
  • No female-specific large series. Outcomes data derived from small case reports and a SR of heterogeneous PFUI literature.[1]
  • Not applicable to most female urethral strictures. The majority are idiopathic, mid-urethral, and best managed with augmentation (BMG or vaginal flap) rather than excision.[15]
  • Risk of tension. Even modest gaps may preclude tension-free repair, necessitating conversion to substitution urethroplasty.
  • Long-term LUTS. In Black et al.’s pelvic-fracture cohort of 25 girls and women (21 repaired primarily; four treated nonoperatively), 9/21 assessed patients (43%) had moderate or severe LUTS at a mean of 7.3 years. Sexual dysfunction was also reported among respondents.[11]

Position in the Female Reconstructive Algorithm​

EPA occupies a specific niche distinct from the augmentation techniques used for typical stricture disease.

  1. For acute PFUI. EPA is used when the urethral ends can be identified and approximated tension-free. EAU guidelines recommend early repair within seven days .[17] The ACS Best Practices 2025 guideline recommends urologic and gynecologic consultation, with management options including urethral catheterization versus immediate primary repair (vaginally, transabdominally, or combined).[16] Patel 2017 favored primary anastomotic repair via a vaginal approach.[1]
  2. For delayed PFUI reconstruction. The AUA recommends delayed urethroplasty instead of delayed endoscopic procedures for obstruction or obliteration after PFUI ; its accompanying perineal/bulbar anastomotic technique discussion concerns male anatomy.[8] For female PFUI, the EAU recommends early repair within seven days when feasible .[17] In females the vaginal approach is used; transpubic access for proximal defects.[8][9]
  3. For typical female urethral stricture (idiopathic, iatrogenic). EPA is rarely indicated. The AUA states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination , with reported success of 69–95%.[8] Augmentation preserves urethral length, whereas EPA is limited by the short female urethra.
  4. For short-segment obliterative stricture without PFUI. EPA may be considered if the obliterated segment is very short (≤ 1 cm) and surrounding tissue is healthy, but this scenario is uncommon. Xu used EPA in only 4 of 44 patients (9%) with FUS and UVF.[2]

Summary​

Primary end-to-end anastomosis in females has been described mainly for pelvic fracture urethral injury and is rarely applicable to typical female urethral stricture disease. The main evidence is Patel 2017, a systematic review of very-low-quality literature, which concluded that primary anastomotic repair via a vaginal approach as soon as the patient is haemodynamically stable appears optimal for female PFUI, with less incontinence and vaginal stenosis than delayed repair. EAU guidelines recommend early repair within seven days .[1][17] For non-traumatic female strictures, the short urethral length (3–5 cm) limits applicability, and augmentation techniques (BMG, vaginal flap) are used instead. When EPA is feasible, the technical principles (complete scar excision, adequate mobilization, spatulation and tension-free mucosa-to-mucosa anastomosis) mirror those established in the extensive male literature.[3][4]

See Also​

References​

1. Patel DN, Fok CS, Webster GD, Anger JT. "Female Urethral Injuries Associated With Pelvic Fracture: A Systematic Review of the Literature." BJU Int. 2017;120(6):766–73. doi:10.1111/bju.13989

2. Xu YM, Sa YL, Fu Q, et al. "A Rationale for Procedure Selection to Repair Female Urethral Stricture Associated With Urethrovaginal Fistulas." J Urol. 2013;189(1):176–81. doi:10.1016/j.juro.2012.09.005

3. Morey AF, Watkin N, Shenfeld O, Eltahawy E, Giudice C. "SIU/ICUD Consultation on Urethral Strictures: Anterior Urethra — Primary Anastomosis." Urology. 2014;83(3 Suppl):S23–6. doi:10.1016/j.urology.2013.11.007

4. Koraitim MM. "On the Art of Anastomotic Posterior Urethroplasty: A 27-Year Experience." J Urol. 2005;173(1):135–9. doi:10.1097/01.ju.0000146683.31101.ff

5. Faiena I, Koprowski C, Tunuguntla H. "Female Urethral Reconstruction." J Urol. 2016;195(3):557–67. doi:10.1016/j.juro.2015.07.124

6. West C, Lawrence A. "Female Urethroplasty: Contemporary Thinking." World J Urol. 2019;37(4):619–29. doi:10.1007/s00345-018-2564-4

7. Dorairajan LN, Gupta H, Kumar S. "Pelvic Fracture–Associated Urethral Injuries in Girls: Experience With Primary Repair." BJU Int. 2004;94(1):134–6. doi:10.1111/j.1464-4096.2004.04874.x

8. 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

9. Xu YM, Sa YL, Fu Q, et al. "Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated With Urethrovaginal Fistulas Secondary to Pelvic Fracture." Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046

10. Fu Q, Zhang J, Sa YL, Jin SB, Xu YM. "Transperineal Bulboprostatic Anastomosis in Patients With Simple Traumatic Posterior Urethral Strictures: A Retrospective Study From a Referral Urethral Center." Urology. 2009;74(5):1132–6. doi:10.1016/j.urology.2009.05.078

11. Black PC, Miller EA, Porter JR, Wessells H. "Urethral and Bladder Neck Injury Associated With Pelvic Fracture in 25 Female Patients." J Urol. 2006;175(6):2140–4. doi:10.1016/S0022-5347(06)00309-0

12. Waterloos M, Verla W, Wirtz M, et al. "Female Urethroplasty: Outcomes of Different Techniques in a Single Center." J Clin Med. 2021;10(17):3950. doi:10.3390/jcm10173950

13. Virasoro R, DeLong JM. "Non-Transecting Bulbar Urethroplasty Is Favored Over Transecting Techniques." World J Urol. 2020;38(12):3013–8. doi:10.1007/s00345-019-02867-8

14. Nilsen OJ, Holm HV, Ekerhult TO, et al. "To Transect or Not Transect: Results From the Scandinavian Urethroplasty Study, a Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting." Eur Urol. 2022;81(4):375–82. doi:10.1016/j.eururo.2021.12.017

15. Chakraborty JN, Chawla A, Vyas N. "Surgical Interventions in Female Urethral Strictures: A Comprehensive Literature Review." Int Urogynecol J. 2022;33(3):459–85. doi:10.1007/s00192-021-04906-8

16. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025.

17. European Association of Urology. EAU Guidelines on Urological Trauma, section 4.4.4 and Table 4.4.1 (female urethral injuries; limited update March 2026). Guideline.

18. Viswaroop SB, Gopalakrishnan G. Female Anastomotic Urethroplasty. In: Khattar N, Nayyar R, Panda A, eds. Female Bladder Outlet Obstruction and Urethral Reconstruction. Springer; 2021:211-220. doi:10.1007/978-981-15-8521-0_20.

19. Joshi PM, Kulkarni SB, Viswaroop B, Gopalakrishnan G. Surgical Reconstruction of Pelvic Fracture Urethral Injuries in Females. In: Martins FE, Holm HV, Sandhu JS, McCammon KA, eds. Female Genitourinary and Pelvic Floor Reconstruction. Springer; 2023:841-855. doi:10.1007/978-3-031-19598-3_49

20. Lockwood GM, Edwards AB. Urologic Evaluation of the Child. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:658-671.

21. European Association of Urology. EAU Guidelines on Paediatric Urology, section 24.4 (paediatric urethral injuries; 2026). Guideline.

22. Patil S, Dalela D, Dalela D, Goel A, Sankhwar P, Sankhwar SN. "Anastomotic urethroplasty in female urethral stricture guided by cystoscopy—a point of technique." J Surg Tech Case Rep. 2013;5(2):113–115. doi:10.4103/2006-8808.128758

23. European Association of Urology. EAU Guidelines on Urethral Strictures, section 7.3.2.f (female anastomotic urethroplasty; limited update 2026). Guideline.

24. Delaney KM, Reddy SH, Dayama A, Stone ME Jr, Meltzer JA. "Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank." J Trauma Acute Care Surg. 2016;80(3):472-476. doi:10.1097/TA.0000000000000947

25. Manikandan R, Dorairajan LN, Kumar S. "Current concepts in the management of pelvic fracture urethral distraction defects." Indian J Urol. 2011;27(3):385–391. doi:10.4103/0970-1591.85444