Female urethral stricture (FUS) is a rare condition, accounting for 4% to 13% of cases of bladder outlet obstruction. However, both its diagnosis and treatment remain subjects of debate in urology. There is no universally accepted standard for diagnosing and treating this condition, and differentiating between functional and anatomical urethral obstructions remains challenging. Female urethroplasty is often regarded with apprehension by urologists due to the belief that it carries a high morbidity rate and complications, including de novo urinary incontinence and urethral fistulas. This study aimed to confirm the safety and efficacy of female urethroplasty using oral mucosal graft, emphasizing the low complication rates— including de novo urinary incontinence and urethral fistulas— based on the largest Brazilian case series published, involving patients operated on a single center.

This retrospective study reviewed patients' medical records who underwent surgery at a single center in Brazil, between 2018 and 2024. The surgical technique employed was dorsal onlay urethroplasty with oral mucosal graft (Figure 1). The dorsal urethra was accessed via an arched incision over the urethral meatus, followed by dissection along the plane between the urethra and the corpora cavernosa. The oral mucosal graft was interposed between the urethral edges and anchored along its entire length to the corpora cavernosa using a 5-0 monofilament suture. Urodynamic parameters, including maximum flow rate (Qmax) and detrusor pressure at maximum flow (PdetQmax), were assessed. Clinical symptoms were evaluated using the International Prostate Symptom Score (IPSS), and urinary incontinence was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) before surgery and three months postoperatively. Statistical analysis was performed using SPSS version 22.0. A significance level of 5% (p = 0.05) was adopted for statistical analyses.

A total of 22 urethroplasties were performed on women with a mean age of 52 years, all of whom exhibited bladder outlet obstruction based on urodynamic parameters. Preoperatively, the mean Qmax was 8.45 mL/s, and the mean PdetQmax was 69.05 cmH₂O. The mean preoperative IPSS score was 26.11, while the mean international urinary incontinence score was 1.73. Postoperative analysis demonstrated a significant improvement in Qmax, which increased to a mean of 23.3 mL/s (p=0.002). Quality of life improved, as indicated by a decrease in the IPSS Quality of Life (QoL) score from 5.84 to 1.53 (p=0.001), along with a decline in IPSS from 23.46 to 9.08 (p=0.006) (Table 1). Urinary incontinence scores remained stable at 1.73, confirming that the surgery did not result in de novo urinary incontinence.

Comparing pre- and post-treatment urodynamic parameters revealed a clear improvement in voiding dysfunction, with an increase in maximum flow rate reaching normal values for age. The median Qmax improved significantly, from 8.45 to 23.3 mL/s (p = 0.002). A maximum flow rate exceeding 20 mL/s is generally sufficient to rule out voiding dysfunction.
Postoperative IPSS analysis demonstrated a significant reduction in the median score from 23.46 to 9.08 (points (p = 0.006), indicating an improvement of over 50% in symptoms—an expected outcome for voiding dysfunction treatments. Additionally, quality of life significantly improved, with the score decreasing from 5.84 to 1.53 (p = 0.001).
Regarding urinary continence, as assessed by the ICIQ-SF before and after surgery, no significant changes were observed. Patients who reported urinary incontinence postoperatively were the same individuals who had preoperative complaints, indicating no new cases of de novo incontinence.

Urethroplasty with oral mucosa graft is a safe and highly effective surgical option. This study demonstrated significant improvements in urinary flow and symptoms without the feared complication of incontinence.