Female urethral stricture is a rare, often underdiagnosed condition that can be difficult to manage [1]. Although urethral dilation is first line therapy, recurrence rates reach 50–60% [2]. Urethroplasty offers higher success rates (80–94%) and is typically reserved for patients who fail dilation.  Surgical planning involves choosing a dorsal or ventral approach, selecting a graft, and deciding between an inlay or onlay technique.  Buccal mucosa is most commonly used, though vaginal grafts or flaps, labial flaps, or combinations are alternatives. Because most urethroplasties are performed in men, the use of vaginal epithelium for FUS remains underexplored.  For FUS specifically, vaginal epithelium offers advantages due to its estrogen sensitivity and shared embryologic origin with the urethra. Compared to traditional pedicled vaginal flaps placed dorsally, we propose use of a vaginal free graft techniques that incises fibromuscular tissue of the urethral stricture and relies upon neovascularization and integration of the vaginal graft. This approach reduces morbidity associated with buccal grafts while providing technical flexibility [3].

A 56-year-old female presented with incomplete bladder emptying and slow urinary stream. A post-void residual volume was 175 mL and uroflowmetry revealed valsalva assisted voiding.  A voiding cystourethrogram was performed to reveal a stricture at the midurethra. Prior attempts at resolution with urethral dilation procedures failed to manage her symptoms. A ventral approach to urethroplasty was performed to prevent disruption of dorsal urethral support and continence mechanism.  Ventral dissection of the female urethra was performed just proximal to the symphysis pubis followed by full thickness incision of the urethra to release the stricture. Next, a vaginal graft was harvested from the posterior vaginal wall and used as inlay graft. Interposition of posterior vaginal wall graft inlay was attached to the released edges of the urethra and secured with suture. The external urethral meatus was reconstructed. Large bore Foley catheterization was used as urethral stent for 4 weeks.

The surgery was successfully completed without perioperative complication. Operative time was one hour, forty-five minutes with estimated blood loss of 75 ml.  Postoperatively she had resolution of voiding dysfunction, normal flow rate and PVR, and excellent urethral meatal cosmesis.

Female urethral stricture disease may be successfully managed with vaginal interposition graft as a biologically superior graft without associated risks of harvesting buccal mucosa. This video demonstrates necessary components of preoperative evaluation and a reproducible step-wise technique that leads to high rates of resolution without additional morbidity.

Singh M, Kapoor R, Kapoor D, Kapoor R, Srivastav A, Chipde S (2013) Dorsal onlay vaginal graft urethroplasty for female urethral stricture. Indian J Urol. 29(2):124-128. doi:10.4103/0970-1591.114034
man NI, Mangera A, Chapple CR (2013) A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol. 64(6):965-973. doi:10.1016/j.eururo.2013.07.038
Borchert A, Jamil M, Perkins S, Raffee S, Atiemo H (2022) Vaginal Free Graft Dorsal Onlay Urethroplasty. Urology. 10.1016/j.urology.2021.06.004