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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 is fundamentally different from the augmentation urethroplasty techniques (BMG, vaginal flap) that dominate the female stricture literature.

Concept and Rationale​

The principle of EPA is identical in both 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. In males, EPA is the gold standard for short (≤ 2 cm) bulbar strictures with a pooled success rate of 93.8% across 1,234 patients in the SIU/ICUD consultation;[3] it is also the standard for posterior urethral distraction defects after PFUI, with 90–98% success in Koraitim's 27-year experience.[4]

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]
  • Short-segment urethral obliteration — typically ≤ 1–1.5 cm, where healthy ends can be mobilized and approximated tension-free.
  • 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, reserving it for cases with a short stricture and permissive vaginal anatomy.[2]

Contraindications and Limitations​

  • Stricture length > 1–1.5 cm — 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), the female urethra has limited mobility, making tension-free anastomosis difficult beyond very short defects.[5][6]
  • Bladder neck or proximal-urethra involvement — excision in this area risks damage to the continence mechanism.
  • 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 / transpubic approach for proximal injuries).

Primary (Immediate) Anastomosis for Acute PFUI​

  1. Timing — performed as soon as the patient is hemodynamically stable. Patel et al. concluded 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 in 4 girls / young women with PFUI.[1][7]
  2. Patient positioning — lithotomy.
  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.
  5. Mobilization — both urethral ends are mobilized circumferentially to allow tension-free approximation. The distal end typically has more mobility than the proximal end.
  6. Spatulation — both ends are spatulated (incised longitudinally for ~ 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 / 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.

Delayed Anastomosis for Short Obliterative Stricture​

  1. Timing — 3–6 months after the initial injury, once inflammation has resolved and fibrosis stabilized.[8]
  2. Preoperative assessment — VCUG, cystoscopy (antegrade via SP tract + retrograde), and MRI to define gap length and relationship to the bladder neck.
  3. Approach — vaginal for most cases; transpubic for proximal / long defects.[8][9]
  4. Scar excision — fibrotic obliterated segment is excised completely until healthy urethral mucosa is identified at both ends.
  5. Mobilization and anastomosis — as above.
  6. Adjunctive maneuvers when the gap exceeds tension-free vaginal anastomosis:
    • Inferior pubectomy — partial resection of the inferior pubic symphysis to shorten the inter-end distance (analogous to the male technique).[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]

Outcomes​

StudyContextn (EPA)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)4Same-day100% voiding; 2 needed secondary procedures3/4 fully continent; 1 transient SUI33 mo (mean)
Xu 2013[2]FUS + UVF4 (of 44 total)Delayed93.2% overall (all techniques); EPA not separately reportedNot reported separately42.3 mo
Waterloos 2021[12]Mixed (injury + stricture)Included in "primary repair" groupVariable100% patency3/14 total had incontinence13–30 mo
Black 2006[11]Female PFUI21 (primary repair)Immediate5/21 required secondary procedures (24%)43% moderate-severe LUTS at 7.3 yr7.3 yr

Key Findings — Patel 2017 Systematic Review​

The most comprehensive analysis of female PFUI management, reviewing 158 female patients across 51 articles.[1]

  • 83 (53%) managed with immediate repair: 17 via primary alignment, 66 via anastomotic repair.
  • 75 (47%) managed with delayed repair.
  • 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 — a critical finding favoring 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
TimingAs soon as hemodynamically stable3–6 mo post-injury
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 endsAll patients after stabilization

Source: Patel 2017 SR.[1]

Comparison with Male EPA​

FeatureMale EPAFemale EPA
Primary indicationShort bulbar stricture (≤ 2 cm) or PFUIPFUI primarily; rarely for short stricture
Urethral length~ 20 cm (anterior urethra)3–5 cm
Mobilization potentialExtensive (bulbar urethra mobilizable several cm)Limited
Adjunctive maneuversCrural separation, inferior pubectomy, urethral reroutingInferior pubectomy, transpubic approach
Success rate90–97%Limited data; appears comparable when feasible
Continence riskLow (external sphincter preserved)Higher concern (shorter urethra, less sphincteric redundancy)
Non-transecting optionWell-established (vessel-sparing EPA)Not described

Non-Transecting (Vessel-Sparing) EPA — Male Concept, Not Applicable in Females​

In males, non-transecting / vessel-sparing EPA preserves the bulbar arteries and periurethral vasculature by excising only the fibrotic mucosa / submucosa without transecting the full thickness of the corpus spongiosum. The Scandinavian Urethroplasty RCT (n = 151) showed transecting EPA caused more penile complications (reduced glans filling, penile shortening) than BMG, with similar recurrence (12.9% in both arms).[14] AUA notes that non-transecting substitution urethroplasty results in fewer penile complications than transecting urethroplasty for short bulbar strictures.[8][13]

This concept has not been described or applied in females — the female urethra lacks a corpus spongiosum, the vascular anatomy differs fundamentally, and the concerns about glans filling and penile shortening are obviously not applicable.

Advantages and Limitations​

Advantages

  • No graft or flap harvest required — 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 — native urethra-to-urethra healing.

Limitations

  • Very narrow applicability — the short female urethra (3–5 cm) severely 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 — Black et al. found 43% of women had moderate-severe LUTS at 7.3 yr after primary repair of PFUI, and 38% had sexual dysfunction.[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 the preferred technique when urethral ends can be identified and approximated tension-free. The ACS Best Practices 2025 guideline recommends urologic and gynecologic consultation, with management options including urethral catheterization vs immediate primary repair (vaginally, transabdominally, or combined). Patel 2017 supports primary anastomotic repair via a vaginal approach as optimal.[1][16]
  2. For delayed PFUI reconstruction — AUA recommends delayed urethroplasty over delayed endoscopic procedures, with anastomotic reconstruction via perineal approach (males) using mobilization and crural separation for tension-free repair. 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. AUA recommends urethroplasty using oral mucosa grafts, vaginal flaps, or a combination (69–95% success). Augmentation preserves urethral length and the continence mechanism, making them preferable for the vast majority of female strictures.[8]
  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 + UVF, reserving it for the simplest cases.[2]

Summary​

Primary end-to-end anastomosis in females is a well-established technique for pelvic fracture urethral injury but is rarely applicable to typical female urethral stricture disease. The strongest evidence comes from Patel 2017, which found that primary anastomotic repair via a vaginal approach as soon as the patient is hemodynamically stable is optimal for female PFUI, with lower rates of incontinence and vaginal stenosis vs delayed repair.[1] For non-traumatic female strictures, the short urethral length (3–5 cm) severely limits applicability, and augmentation techniques (BMG, vaginal flap) are preferred. When EPA is feasible, the key 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.