Female urethral stricture (FUS) disease is rare, affecting between 4% and 13% of women presenting with bladder outlet obstruction, which is estimated to affect 3%’8% of women.^1–3 There is often a delay in diagnosis due to lack of consensus on definition, variability in normal female voiding parameters and heterogeneity of presenting symptoms.² One of the more concise definitions of FUS is “a symptomatic anatomical narrowing of the female urethra based on direct visualization and/or radiological evidence and/or urethral calibration with the exclusion of other competing etiologies.”³

Once the diagnosis is made, dilations are usually the initial treatment, despite poor long-term efficacy.¹ Conversely, in male urethral stricture disease, the urologist is more inclined to recommend urethroplasty due to well-recognized, durable success. Urethroplasty adoption in women has been slow due to a lack of consensus on surgical approach and graft material as well as concerns for complications such as de novo incontinence and fistula. Multiple urethroplasty techniques have been described utilizing flaps or grafts. Most of the literature consists of small case series or descriptive studies.

Figure 1. Retubularizing urethra after tacking BMG to dorsal tissues.

Using our expertise with male urethroplasty, we extrapolated our preferred dorsal onlay buccal mucosa grafting (BMG) technique to female urethroplasty. We performed a retrospective review of patients undergoing female urethroplasty with BMG at the University of Colorado and Denver Health hospitals between March 2015 and December 2021 by surgeons (BJF and JLO). Surgical technique was similar for both surgeons using a BMG placed via a dorsal curvilinear incision from 10 to 2 o’clock (Fig. 1). A total of 23 patients underwent dorsal onlay BMG urethroplasty and were included in our data analysis. The median age was 50 years. Etiology was primarily idiopathic (19/23). Preoperative stricture workup included cystoscopy (23 patients), uroflowmetry (8), voiding cystourethrogram (3) and/or urodynamics (7) (Figs. 2 and 3). The most common presenting symptoms included irritative voiding symptoms in 15 patients (65%), obstructive symptoms in 12 (52%) and recurrent urinary tract infections in 10 (44%). The median duration of lower urinary tract symptoms prior to urethroplasty was 16 years. Twenty patients (87%) had undergone previous dilations, with a median of 3 operative dilations (range 1–20).

Figure 2. Cystoscopic evaluation of midurethral stricture.

Figure 3. Preoperative voiding cystourethrogram of mid-to-distal urethral stricture.

At a median followup of 7.2 months (range 1–81), 4 patients required a secondary procedure for obstruction (urethral dilation or direct visual internal urethrotomy), with an overall success rate of 83% for patency. Of the patients who developed recurrences, all had had previous dilations, 1 patient had had previous vaginal flap urethroplasty and another had concomitant urethrovaginal fistula repair. Two patients developed de novo incontinence postoperatively; 1 responded well to an autologous fascia pubovaginal sling and the other responded well to sacral nerve modulation. Two patients had acute graft donor-site complaints that resolved. One patient had buccal contracture that was being managed conservatively. No patients developed a de novo fistula. The median postoperative maximal flow on uroflowmetry was 15.9 ml/second (range 6.6–26) compared to 10.8 ml/second (2–18.2) preoperatively.

There have been multiple case series describing repair techniques and outcomes. Our recurrence rate (diagnosed by cystoscopy) of 17% and de novo incontinence rate (8.7%) are consistent with the literature.^2,4 This series adds to the growing body of data on patients with FUS. Dorsal BMG urethroplasty is successful in treating FUS with a low complication rate. It also highlights a known gap in success rates of female BMG urethroplasty compared to male urethroplasty. Research is needed to help understand this gap.