Introduction and Hypothesis <p>The objective was to compare the outcomes of dorsal and ventral onlay urethroplasties using buccal mucosal grafts for the treatment of urethral strictures in women, focusing on patency, complications, de novo incontinence, and impact on sexual function.</p> Methods <p>A retrospective analysis was conducted on 65 patients who underwent dorsal (<i>n</i> = 38) and ventral (<i>n</i> = 27) onlay female urethroplasty using a buccal mucosal graft between July 2017 and January 2024 across three centers. Patency was determined by the successful passage of a 16-French cystoscope or by a maximum flow rate exceeding 15&#xa0;ml/s.</p> Results <p>Median age, etiology, and stenosis characteristics of the two groups were comparable. At the final follow-up, the patency rates for dorsal and ventral onlay female urethroplasty were 92.1% and 92.6% respectively (<i>p</i> = 1.0). There was no significant difference in postoperative maximum flow rates, postvoid residual urine, Female Sexual Function Index scores, Patient Global Impressions of Change scores, and de novo incontinence rates between the groups. The median blood loss was significantly lower in the ventral onlay group than in the dorsal onlay group (10 vs 20&#xa0;ml, <i>p</i> = 0.001).</p> Conclusions <p>Dorsal and ventral onlay urethroplasties with buccal mucosal graft are safe and effective techniques for managing female urethral stricture, with similar patency, complications, de novo incontinence rates, and improvements in sexual function. Ventral onlay female urethroplasty has been associated with reduced intraoperative bleeding. To the best of our knowledge, this study represents the largest individual comparative cohort in the literature that directly evaluates dorsal and ventral onlay female urethroplasty.</p>