Dorsal vaginal graft urethroplasty for female urethral stricture disease


Steven Petrou, Department of Urology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA. e-mail:


Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

Female urethral stricture disease has been described for almost 200 years. The symptoms of female stricture disease may range from clinically insignificant to severe and debilitating with the exact aetiology being unclear. No strict criteria for diagnosis have been established with the diagnosis often relying on a combination of presenting symptoms and objective findings. Initial therapy for female urethral stricture disease has often rested on urethral dilatations and self-intermittent catheterisation with surgery reserved for patients that failed conservative measures. Female urethroplasty currently is a topic of increasing attention with multiple surgical approaches described including use of both grafts (vaginal wall, buccal mucosal membrane, lingual mucosa, and labia minus) and flaps (vaginal vestibule, anterior vagina, and lateral vagina).

We describe our approach to female urethroplasty using a suprameatal (dorsal) approach (described by Tsivian and Sidi) with an autologous vaginal epithelium inlay graft. The technique and modern approaches to female urethroplasty are contrasted and discussed. The success of the approach including continence rates and lack of need for long-term self-intermittent catheterisation is noted.


  • • To review the technique and outcomes of using a dorsal vaginal graft to perform urethroplasty for the treatment of urethral strictures in women.


  • • This is a retrospective chart review of 11 women who were treated with a dorsal vaginal graft urethroplasty by one surgeon.
  • • All women underwent preoperative evaluation that included history, physical examination, fluoro-urodynamics and urethral calibration.
  • • After surgery interviews, physical examinations, and urinary flow and postvoid residual urine volumes (PVRs) were obtained.


  • • In all, 11 women who had undergone dorsal vaginal graft urethroplasty were identified for review. The mean (range) age was 60.6 (39–75) years. The mean (range) follow-up was 22.7 (6–46) months.
  • • There were no cases of new onset stress urinary incontinence. The mean PVRs before and after surgery were 187.1 mL and 75.8 mL, respectively (P= 0.003). The mean urinary flows before and after surgery were 7.3 mL/s and 21.8 mL/s, respectively (P= 0.001).
  • • No patient has required repeat surgery.
  • • Self-reporting satisfaction scores using the Patient Global Impression of Improvement showed that four patients scored 1 (very much better), three scored 2 (much better), two patients scored 3 (a little better), and one scored 4 (no change). Only one patient scored a 5 (worse).


  • • Dorsal graft urethroplasty with vaginal mucosa may be considered as a first-line option for definitive management of female urethral stricture disease. No consensus exists for the surgical treatment of female urethral stricture disease.

postvoid residual urine volume


stress urinary incontinence


Patient Global Impression of Improvement


While the technique itself was first described almost 200 years ago, the performance of female urethroplasty to treat urethral stricture disease (i.e. stricture and urethral stenosis) has recently gained increased attention. Motivating this renewed interest may in part be due to the fact that, although female urethral stricture disease is relatively rare, the symptoms and therapies associated with this disease represent a significant level of expenditure to the healthcare system [1]. This notion was recently substantiated by Wu and Stone [2] in their review of the impact of and treatment options for urethral stricture disease in women. In addition to underscoring the considerable costs associated with urethral stricture disease in women, Wu and Stone [2] also highlighted the underlying variation in aetiology, the overuse of urethral dilatation as both primary and chronic therapy, and the absence of a definitive surgical option for these women. They reviewed several surgical techniques for female urethroplasty to treat urethral stricture disease in women. The obvious value of these studies notwithstanding, most of these reports are descriptive in nature and generally do not provide meaningful indications of the success (subjective or objective) of the particular surgical intervention. Motivated by this, in the present study, we describe our results in a series of women surgically treated for female urethral stricture disease using a transvaginal suprameatal approach with a vaginal epithelium inlay graft as originally described by Tsivian and Sidi [3]. Specifically, we assessed improvements in objective measures, e.g. urinary flow and postvoid residual urine volume (PVR), as well as standardised clinical evaluations.


Full Institutional Review Board review and approval was obtained before the initiation of the study. There was no funding for this research and its publication. The charts of all women who had undergone a dorsal graft urethroplasty for the diagnosis of urethral stricture were identified and retrospectively reviewed. Demographic data points were identified in addition to pertinent clinical and urodynamic parameters including pre- and postoperative urinary flow and PVR; history of UTIs before or after the procedure; and any pertinent upper tract imaging was reviewed. Clinical follow-up included a series of standardised questions including if they needed repeat urethral dilatation or therapy for urethral stricture disease in the postoperative period and if they had symptoms of stress urinary incontinence (SUI) or urinary urgency. During follow-up, each woman's personal assessment of surgical success was obtained using the Patient Global Impression of Improvement (PGI-I) questionnaire with scores of 1–5: 1 (very much better), 2 (much better), 3 (a little better), 4 (no change), 5 (worse) [4].

For descriptive purposes, we calculated means and percentages for all of our study variables. A primary focus of our investigation was the comparison of pre- and postoperative PVRs and urinary flow values for the women in our cohort. Given the few patients and paired nature of our data, we performed nonparametric, paired statistical tests to analyse these data. Specifically, we compared pre- and postoperative mean values for PVR and urinary flow using the Wilcoxon matched-pairs signed-rank test and report the associated P-values.


The patient is prepared in the modified dorsal lithotomy position under either general or regional anaesthesia. The vagina is prepared in the manner for traditional transvaginal surgery. A female sound is passed through the female urethra to identify the position and calibre of the stricture. A 12 or 14 F urethral catheter is then passed into the urethra and anchored in the bladder. The anterior vaginal wall is examined and a free graft of vaginal epithelium is harvested (Fig. 1). The optimal graft will be about 1.5–2 cm wide and 3.5 cm long. With the use of a no. 15 blade the graft is dissected from the vaginal tissue. We do not routinely inject normal saline or an epinephrine mixture before dissection.

Figure 1.

Harvesting the vaginal graft.

The harvest site is examined; haemostasis optimised and closed with interrupted 2-0 absorbable sutures. A running suture may also be used according to surgeon's preference and vaginal packing is placed. The vaginal graft is kept in a normal saline-soaked gauze sponge for use later in the case. A semi-lunar incision is made and a plane is developed through the vestibular membrane dorsal to the urethral meatus mirroring the dissection used for a suprameatal transvaginal urethrolysis (Fig. 2). Dissection is carried proximal towards the pubic bone. The ideal plane of dissection is dorsal to the urethra without violation of the urethra proper. Lateral dissection should not be overly explorative in view of potential bleeding and the lack of requirement for lateral dissection. With the use of digital palpation, the pubic bone may be identified to help identify the appropriate proximal dissection point.

Figure 2.

Suprameatal approach.

Dissection should be carried through and proximal to the point of urethral stricture. With diffuse urethral stenosis or stricturing, the entire urethra will have to be dissected to the bladder neck. The incision site is now identified in the urethra. The incision is made at the 12 o'clock position with either a sharp scalpel blade or with sharp dissecting scissors (Fig. 3). This should be carried through the stricture and into proximal normal tissues. The urethral catheter is removed and the proximal urethra calibrated with a 30 F bougie-à-boule to assure adequate patency. The graft is sutured in place. The mucosal surface of the graft is sutured facing the urethral lumen with two 2-0 poliglecaprone 25 (Monocryl) sutures. Each suture is first placed at the apex of the graft with one suture to be run on the right and one suture to be run on the left (Fig. 4). In addition, one or two 3-0 poliglecaprone 25 quilting sutures are placed in the centre of the graft to minimise sliding. This is especially important during the first 2 postoperative days when the graft is nourished by inosculation, a process of plasma absorption, followed by capillary ingrowth generally within 36 h. These central graft sutures not only prevent graft migration but mitigate against accumulation of undue plasma under the graft, which can prevent revascularisation. The graft should be approximated to the urethral mucosa to minimise the risk of a new stricture. Also, there should be slight redundancy in the graft to compensate for inevitable postoperative shrinkage. Excess redundant graft is now trimmed and a 30 F female sound is passed into the bladder to assure the desired calibre. An 18 F silastic catheter is anchored in the bladder to gravity drain. The vaginal incision lines are closed with running and interrupted 2-0 polyglactin 910 (Vicryl) sutures. An overnight vaginal pack is put in place. The catheter is left in place for ≈2 weeks, at which time the patient returns for catheter removal and urethral calibration and clinical examination.

Figure 3.

Incision of the urethra at the 12 o'clock position.

Figure 4.

Tying the graft in place.


We identified 11 women who underwent dorsal vaginal graft urethroplasty for female urethral stricture disease between 2007 and 2011. Preoperative patient characteristics were collected (Table 1). The mean (range) age for our cohort was 60.6 (39–75) years and the mean follow-up was 22.7 (6–46) months. Eight of the 11 women had ≥12-month follow-up. All women underwent full clinical evaluation including fluoro-urodynamics and urethral calibration preoperatively. Six of the 11 women had preoperative urethral calibration of 14 Fr while three calibrated at 16 Fr. One woman calibrated to 17 Fr while the remaining woman calibrated at 18 Fr preoperatively. Four of the 11 women had preoperative symptoms of SUI. After the procedure, postoperative characteristics were noted (Table 2). One of these four women continued with SUI postoperatively while the other women's symptoms abated. Evaluation postoperatively revealed a Valsalva leak-point pressure of 109 cmH2O. There were no cases of new onset SUI after the procedure. Seven of the 11 patients had preoperative urinary urgency. Of these seven, three had their symptoms resolve while four continued to experience urinary urgency symptoms. There was one woman with new onset symptoms of urgency after the procedure. Pre- and postoperative urodynamics were measured and compared (Table 3). Using urodynamic pressure flow analysis we recorded a mean (range) maximum detrusor voiding pressure of 43.7 (12–94.7) cmH2O. The mean (range) preoperative PVR for the cohort was 187.1 (14–400) mL, while the mean postoperative PVR decreased to 75.8 (0–245) mL (P= 0.003). Similarly, the mean (range) preoperative urinary flow was 7.3 (2.5–12.3) mL/s; however, the postoperative mean urinary flow value increased to 21.8 (13.1–41.3) mL/s (P= 0.001). One women failed to obtain a postoperative urinary flow rate. Finally, one woman reported the continued practice of self-catheterisation postoperatively for personal satisfaction. Two patients reported the need for a dilatation by their local urologists during the postoperative period but no further urological intervention.

Table 1. Preoperative patient characteristics
Pt noAgeUrethral calibration (Fr)Incontinence (type)
27018Y (Stress)
34614Y (Urge)
47016Y (Stress)
57316Y (Urge)
67114Y (Urge)
87516Y (Urge)
95214Y (Urge)
106214Y (Stress/Urge)
115414Y (Stress/Urge)
Table 2. Postoperative patient characteristics
Pt noFollow up (months)Urethral calibration (Fr)Incontinence (type)PGI-I scorePost op dilations
  1. CIC, clean intermittent catherisation.

1626Y (Urge)2N
51924N3Y + CIC
82720Y (Urge)1N
93320Y (Urge)2N
104624Y (Stress/Urge)5N
114622Y (Urge)1N
Table 3. Urodynamics
Patient NoPreop VLPPpDetmaxPreop PVRPostop PVRPreop uroflowPostop uroflow
  1. VLPP, Valsalva leak-point pressure; pDetmax, Maximum Detrusor Pressure.


Any available preoperative upper tract imaging was reviewed. Five of the 11 women had prior imaging (CT or retrograde pyelography). Overall, genitourinary findings were unremarkable with no findings of obstruction or upper tract dilatation. A distended bladder was noted on one woman's CT scan. Her PVR was 366 mL on preoperative evaluation and diminished to 100 mL on postoperative measurement. Based on these initial findings, none of the women required postoperative imaging beyond cystography before Foley catheter removal in the initial postoperative period.

For UTIs, nine of the 11 women had UTIs before the procedure and after the surgery, eight of them continued to have recurrent UTIs. One woman who had no UTIs before the procedure now reports UTIs that are managed with antibiotics on an as-needed basis.

Self-reporting satisfaction scores using the PGI-I showed that four patients scored 1 (very much better), three scored 2 (much better), two scored 3 (a little better). One patient scored a 1 (no change) and only one scored a 5 (a little worse).


The history of female urethral stricture disease has been well described by Brannan [5] in his treatise on the subject with his attributing the initial discussion of female stricture disease to Liz Frank in 1824 and the first case report to the Earl of London in 1828. Stevens [6] felt that female urethral stricture disease is more common than thought. Its actual incidence as opposed to the rate of female urethral dilatation has been contrasted by Santucci et al. [1]. They noted that although urethral dilatation is practiced rather frequently in the clinic, it is of no therapeutic value with patients plagued with strictly irritative voiding symptoms in the absence of confirmed urethral stricture disease. The exact incidence of female urethral stricture disease is unknown with <100 cases having been reported in the contemporary literature [7]. Nevertheless, the diagnosis resulted in 1.2 million office visits from 1992 to 2000 in the USA [1]. This incongruence suggests that clinical thought may have not progressed significantly since the 1930s when Folsom and Alexander [8] stated: ‘Any pain within 2 feet of the urethra which does not seem to be adequately accounted for by some definite pathology should be suspected of being due to the urethra’. Although the exact aetiology at this time is unclear many have felt that urethral stricture may be related to infection, chronic irritation, prior dilatation, difficult catheterisation, urethral surgery and trauma [9,10,11]. The trauma has been described as either obstetrical, blunt pelvic trauma, as well as repeated vigorous coitus [5]. In addition, radiation for gynaecological malignancies may lead to urethral stricture disease [12]. It is estimated that 3–8% of women with BOO have a urethral stricture [13]. The symptoms of female stricture disease may cover a wide spectrum from clinically insignificant to severe and debilitating. No strict criteria for diagnosis have been established, but a combination of presenting symptoms and objective findings tend to lead to findings of a urethral stricture. Successful cure for female urethral stricture disease has been described with minimally invasive corrective therapy, e.g. urethral dilatation and self-intermittent catheterisation, with surgery being advocated for patients who have failed these tactics [9,11,14]. Many women not undergoing surgery but treated with chronic interval urethral dilatations and internal urethrotomies will have high recurrences and may result in increased scarring and fibrosis [7,15].

We describe our approach to female urethroplasty using a suprameatal (dorsal) approach and using a vaginal autologous graft in a retrospective series with ≥6 months of follow-up. This was originally described by Tsivian and Sidi [3]. The present patients who underwent urethroplasty were women who presented with the combination of a history of repeat urethral dilatations with short-lived but temporally successful clinical response, continued voiding symptomatology, and a desire for permanent therapy for their condition.

Currently, it seems that female urethroplasty is a topic of increasing attention with multiple approaches described including both grafts and flaps. Reported grafts include: vaginal wall, buccal mucosal membrane, lingual mucosa, and labia minus [3,15–19]. Pedicle flaps have also been created from the vaginal vestibule, anterior vagina, and lateral vagina [7,9,11,20–22]. We chose to use the suprameatal approach because of the ease of incision for urethrolysis and to make access for future anti-incontinence procedure(s) less problematic [23]. This potential advantage of a dorsal approach has been noted by other authors [15,18]. In addition, Migliari et al. [15] argue that the dorsal approach minimises graft sacculations, leads to a urethral meatus that is directed upwards and allows for future mid-urethral anti-incontinence procedures. Another benefit includes minimal risk of urethral hypospadias or urethro-vaginal fistula.

The choice of vaginal epithelium for the inlay graft was influenced by the original description of this vaginal flap inlay technique by Tsivian and Sidi [3] in their series of three patients (two had a vaginal wall graft), and also the relative ease of harvesting the vaginal mucosal graft with its familiar dissection combined with a hairless elastic mucosal surface. However, the use of a free vaginal wall graft in this type of reconstruction is relatively infrequent [3,22].

As with all surgery, postoperative success has its foundation in the correct preoperative diagnosis. Urethral calibration was one of the metrics that was used to diagnosis urethral stricture. This was used in the past as well Powell and Powell [10] reporting a 20 F calibre threshold for diagnosis in 1949. This somewhat generous calibre for diagnosis has been further reduced with Gormley [11] reporting ≈12 F and Weinberg et al. [24] using a 16 F value for diagnosis. We consequently used a value of ≤18 F. The ultimate diagnosis was made on criteria similar to those reported by Keegan et al. [25], being a combination of symptoms, urethral meatal appearance, a history of difficult instrumentation with supportive urodynamic testing. The urodynamic studies seemed to support the clinical impression and were very similar to those stated by Nitti et al[26]. being a combination of voiding pressures, urinary flow rates, and fluoroscopic imaging.

Most of the present patients presented with irritative symptoms. This is not surprising as historical reports note that 10–35% of women with irritative symptoms may have variable degrees of urethral stricture disease [5]. That the presence of pre- and postoperative urinary urgency had minimal impact on the perceived success is in direct contrast to that found by others when examining symptom impact on success rates in patients after their anti-incontinence operations [27]. The presence of urinary urgency will not inhibit the consideration of using this operation. We only had one case of postoperative SUI and this patient was noted to have this condition preoperatively. We chose not to perform a concomitant pubovaginal sling secondary to the evolving state of female urethroplasty in our practice. The three other patients who had SUI preoperatively had no complaints of SUI postoperatively. That finding combined with the ≈50% success rate for concomitant pubovaginal sling placement reported by Gormley [11] will continue to engender discussion on whether to perform a suburethral sling at the time of urethroplasty in the patient with combined urethral stricture disease and SUI. We did not note consistently robust urinary flow rates postoperatively even among our most successful cases. This may be reflective of the long-term effect of BOO on this female population vs the urinary flow test itself. As the experience with this surgery increases, future researchers will be able to better comment on the expectations of urinary flow rates in the successful postoperative patient.

The success of this exploratory series is very competitive to other approaches, although our data is short term. In all, 10 of the women we treated did not need to perform routine postoperative daily clean intermittent catheterisation as part of their treatment plan as described in other series [11]. The one patient who has continued on self-intermittent catheterisation (although her PVRs were not markedly elevated), still felt that the operation did have a measure of success but desired to continuing this practice three times a week for peace of mind. The patients with the lower self-reported satisfaction scores seem to be the ones with a longer history of the symptoms attributed to their disease. This observation may assist us in setting expectations for the patient with a far reaching history.

Choosing to perform such a definitive surgery requires clear communication between the surgeon and patient. We considered patients for surgery when they expressed a firm desire to avoid continued intermittent urethral dilatations and/or catheterisations. The nature of our referral practice preselected a population who expressed the chief complaint of female urethral obstruction with a history of temporal but short-lived response to dilatation combined with the expressed desire for definitive therapy. Essentially, the patient dictated at what point they wanted to proceed with a surgical treatment and if our evaluation supported the historical diagnosis we offered surgical intervention.

We acknowledge that this description involves a relatively small, retrospective series with a follow-up of ≥6 months. Because this is relatively short-term data, an academic argument could be made that a follow-up of 22.7 months might not capture the deterioration of the graft and re-stricture rate of the urethra, but at this point, we are encouraged by outcomes and patient satisfaction in a unique population undergoing a relatively new surgical correction.

In conclusion, no consensus exists for the surgical treatment of female urethral stricture disease. The present experience showcases the success of a procedure for a difficult to manage problem. Dorsal graft urethroplasty with vaginal mucosa may be considered one of the options for definitive management of female urethral stricture disease.


The authors have no conflicts of interest in regards to this manuscript.