Lower urinary tract obstruction in females occurs in 3%-8% of cases, with urethral stricture contributing up to 13%, presenting a therapeutic challenge. Strictures can be idiopathic, iatrogenic, or caused by trauma or infection, diagnosed through urethral diameter measurements and imaging. Urethroplasty is the gold standard for refractory cases, with inner cheek buccal mucosal grafts (BMG) commonly used for reconstruction. This study explores the feasibility of using a lower lip BMG dorsal graft for female urethroplasty, hypothesizing that it offers a less invasive, effective option with improved cosmetic outcomes due to the lip's rich blood supply, promoting faster healing and evaluating the short term follow up outcomes.

Women with urethral stricture who had previously undergone urethral dilation or urethrotomy were eligible for the study. Exclusion criteria included prior anti-incontinence surgeries or neurologic bladder dysfunction. 

For the operation under general anesthesia, the patient was positioned in lithotomy, and a 4 cm by 1–1.5 cm strip of lower lip buccal mucosal graft was harvested using a surgical blade, ensuring the submucosal fatty tissue was preserved. Hemostasis was achieved with gauze soaked in diluted epinephrine, with bipolar cautery used if necessary.

A fine semilunar incision was made on the urethra from 12 to 9 o’clock, and the dorsal urethra was carefully released. The graft was then anastomosed to the bladder neck with 4-0 vicryl sutures in separate stitches from the bladder neck towards the urethral meatus, followed by sutures to reapproximate the mucosa. A 14 F silicone catheter was inserted and kept in place for 2 weeks. Patients received broad-spectrum IV antibiotics during hospitalization and oral antibiotics for 5 days post-surgery.

A total number of 29 patients were entered to the study from March 2021 until December 2022 and followed for one year afterwards. The mean age of the study group was 51.66±11.27 years (range: 33-72). Mean operation time was recorded 52.85±6.54 minutes (range: 40-65). Idiopathic etiology consisted of 56% and previous instrumentations was accountable for 33% of urethral strictures. Lower lip BMG improved urinary mean maximum urine flow (Qmax 11.2±3.5 to 24.49±4.0) ml /sec (p<0.0001) preoperatively and postoperatively respectively. This finding was also supported by AUA questionnaire score and PVR reduction postoperatively.

The operation was uneventful in all cases. There were no major complications according to Clavien-Dindo classification. Only one patient required a urethral dilation 3 weeks after Silicone urethral catheter removal due to delayed absorption of suture material in the urethral lumen. Two patients of the study group experienced “scattered voiding” instead of the normal voiding stream but without any other urinary symptoms.

This study demonstrates the feasibility and success of using lower lip buccal mucosal grafts (BMG) for urethroplasty in females with urethral strictures with a 96% success rate (28 out of 29 patients) in our study, suggest that the lower lip BMG approach is an effective and low-risk alternative to traditional graft sites like the inner cheek. The lower lip’s high vascularity, ease of access, and minimal post-operative complications (no permanent lip deviation or pain) support its potential as an optimal donor site for BMG in female urethroplasty. The use of the dorsal approach, which minimizes damage to critical sphincter structures, further enhances the procedure's safety and efficacy, leading to favorable short-term functional results and reduced complications.

The female augmented urethroplasty from lower lip BMG with dorsal approach is a safe and highly successful approach with favorable results, minimal risk of fistula formation, donor site complications at short term follow up. A longer follow-up and larger, multicenter studies would be valuable to confirm the long-term durability and utility of this approach.