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Blandy Flap

The Blandy flap is an eponymous urethral reconstructive technique attributed to Sir John Blandy (1927–2011), Professor of Urology at The London Hospital and a pioneering British urologist. The eponym refers to two distinct but related techniques:

1.[15] Female Blandy ventral vaginal flap urethroplasty or meatoplasty is an inverted U-shaped anterior vaginal wall advancement flap for selected female urethral strictures. Current technique selection depends on stricture location, tissue quality and surgeon experience.[1][2][3][15] 2. Male Blandy perineal urethrostomy is a permanent perineal stoma made with a posteriorly based inverted-U perineal skin flap sutured to an opened bulbar urethra. It is distinct from a laterally based scrotal 7-flap.[16]

Sir John Blandy's contributions to urethral surgery, stone disease and oncology are memorialized in the textbook Blandy's Urology (now in its 3rd edition).[4] The "Blandy technique" for female urethral stricture was described by Romero-Maroto and colleagues as "the most common technique used" for this condition.[1]

Female Blandy Ventral Vaginal Flap Urethroplasty​

Technique​

A ventral meatoplasty / urethroplasty using the anterior vaginal wall as a local advancement flap to augment the strictured distal female urethra:

1.[15] Position and lumen access. Place the patient in dorsal lithotomy. Pass a guidewire into the bladder before opening the stricture when feasible to reduce false-passage risk; use a Foley catheter for lumen identification when it traverses the narrowing.[17] 2. Incision. Make an inverted U-shaped incision in the anterior vaginal wall just below the ventral meatus. Mobilize the flap from the ventral urethra while preserving its submucosal vascular layer; Waterloos and Verla describe approximately 3 cm of mobilization.[17] The curved free tip of the U will be inset into the proximal urethrotomy. 3. Urethrotomy. Incise the ventral (posterior) urethral wall longitudinally through the meatus and the full stricture length until healthy proximal mucosa is reached. In the technique described by Waterloos and Verla, the opened urethra admits a 20 Fr catheter and bilateral stay sutures expose its edges.[17] 4. Flap inset. Turn the free tip of the U-shaped vaginal flap toward the proximal end of the ventral urethrotomy and suture it there; then suture the flap edges to the urethral edges toward the meatus to augment the lumen.[17] 5. Closure. Suture the flap to the urethral edges with absorbable suture and close the vaginal-wall donor site primarily. For an anterior vaginal-wall flap, Waterloos and Verla describe a 16–20 Fr catheter for 7–10 days, removed after urethrography excludes contrast extravasation.[17] Adjust catheter duration to the actual reconstruction and healing plan; no single duration applies to every flap repair.

Like the male Orandi penile-skin onlay flap, this is tissue-augmented reconstruction after a longitudinal urethrotomy and is not a simple transverse Heineke-Mikulicz closure. Simonato's series describes a lateral vaginal flap, distinct from the inverted-U Blandy flap.[1][5]

Primary indication — female urethral stricture​

Female urethral stricture is rare. Management options:

  • Urethral dilation. The EAU guideline accepts dilation as an initial option for uncomplicated stricture; dilation-only patency was 40.1% across its summarized studies (range 7.5–51%).[15] The 6% first-dilation figure came from one selected 17-patient series.[6]
  • Distal urethrectomy with advancement meatoplasty
  • Blandy ventral vaginal flap meatoplasty / urethroplasty
  • Lateral-based vaginal wall flap (Orandi-inspired modification)
  • Dorsal or ventral buccal mucosal graft (BMG) urethroplasty

The 2023 AUA guideline amendment states that surgeons may reconstruct female strictures using oral mucosal grafts, vaginal flaps or a combination and cites success rates of 69–95% across these techniques.[7] The EAU 2026 guideline weakly recommends initial dilation to 24–41 Fr and, at first recurrence, planned repeat dilation or repeat dilation with weekly 16–18 Fr intermittent self-dilation.[15] It strongly recommends urethroplasty at second recurrence when intermittent self-dilation is unsuitable or the woman wants definitive treatment.[15] It recommends meatotomy or meatoplasty for meatal strictures .[7][15]

Outcomes​

StudyTechniquenSuccessFollow-upNotes
Önol 2011[10]Anterior vaginal wall inlay (10), other repairs (7)17 total17/17 objective, 15/17 subjective cure in the mixed cohortMedian 24 mo—
Hajebrahimi 2019[11]Anterior U-shaped vaginal flap; dorsal urethral incision reported1414/14 reported voiding improvementVariableQmax 15.8 mL/s postop; 2 developed SUI; not the classic ventral stricturotomy
Blaivas 2012[6]Nine vaginal flaps and one BMG among 17 women17 totalSelected reconstructed patients: 100% at 1 yr; 78% at 5 yrTwo late recurrences at 5.5 and 6 yr1/17 had lasting response to initial dilation in this series
Flisser & Blaivas 2003[12]Vaginal flap repairs (72); concomitant PVS in 5674 women with varied urethral pathology93% single-procedure anatomic success among followed patientsMedian 1.5 yr54/62 with preoperative incontinence cured or improved
Kowalik 2014[13]Vaginal flap vs dorsal BMG10 totalTwo flap patients required dilation; no graft patient didIntermediate, variableSmall nonrandomized comparison; no technique superiority established
Spilotros 2017[14]BMG (14), vaginal flap (2)16 reconstructed (of 26 overall)13/14 BMG and 2/2 flap patients stricture-freeVariableTiny flap subgroup; avoid a comparative ranking

Other female applications​

Meatal reconstruction after vulvectomy​

An anatomically related vaginal-wall V-Y advancement has been used for urethral meatus reconstruction after oncologic vulvectomy, which is a different indication from female stricture repair. In 42 reconstructions in 41 women, the authors reported three major complications: one neomeatal stenosis, one partial vaginal-flap necrosis and one circumferential neomeatal dehiscence and occlusion. The V-Y design was intended to avoid a circumferential suture line.[8]

Distal urethral stricture in transwomen​

The inverted U-flap concept has been applied to neo-vaginal advancement flap urethroplasty in transwomen with distal urethral strictures. In five patients (three inverted-U, including one with an additional buccal graft for lichen sclerosus, and two seven-flap), no recurrences were observed at median 37-month follow-up.[9]

Limitations and known drawbacks​

  • Retrusive meatus. Romero-Maroto's group reported a retrusive meatus and inward-directed stream after the Blandy technique in their own patients. This motivated their lateral-based vaginal-wall flap modification in a nine-patient single-arm series (mean follow-up 80.7 months).[1]
  • Limited reach for proximal strictures. - Limited reach for proximal strictures. Waterloos and Verla describe the anterior vaginal-wall flap for meatal and short (<2 cm) distal strictures and suggest grafts or a lateral vaginal flap for longer or proximal disease.[17] Dorsal BMG or combined approaches may also be considered where anatomy and tissue quality warrant them; comparative superiority is not established.[2][3][7][17]
  • Vaginal-tissue quality. Coexisting lichen sclerosus or vaginal atrophy may affect the results of vaginal or labial tissue and favor buccal mucosa.[2] In a multicenter cohort of 165 women treated with flap or graft urethroplasty, prior radiotherapy was independently associated with stricture recurrence (P = 0.015; median follow-up 29 months).[20]
  • New urinary incontinence. The EAU compilation reports 15/161 (9.3%) new UI across vaginal-flap variants.[15] Hajebrahimi reported two SUI cases among 14 women (one improved by 6 months; one had a TOT at 12 months) and new-onset urgency or worsening urge incontinence during follow-up. Counsel according to baseline continence and planned reconstruction.[11][15]

Comparison with alternative female-urethral-stricture techniques​

The EAU estimates combine series with differing patient selection and follow-up.[1][15]

TechniqueReported settingPractical featureTradeoffReported outcome
Blandy (ventral vaginal flap)Selected female strictures with suitable vaginal tissueLocal vascularized tissue; no oral graft harvestPossible retrusive meatus; tissue quality/reach matterAll vaginal-flap variants: 81.4% patency in 161 women (EAU)[15]
Lateral vaginal-wall flapSelected female stricturesAttempts to preserve meatal positionPedicle dissection; no direct Blandy comparisonRomero-Maroto reported 9/9 without recurrence; a later three-center series from overlapping investigators reported 23/24 meeting a composite success definition at reported 9.5-year follow-up.[1][18]
Dorsal oral mucosal graftSelected patients needing a separate tissue sourceAvoids diseased vaginal donor tissueOral donor-site morbidity83% across 319 dorsal oral-graft cases (EAU)[15]
Ventral oral mucosal graftSelected anatomy favoring ventral accessGraft option with or without interpositionDonor site and repair-dependent support90.7% stricture-free across 247 ventral oral-graft cases at mean/median follow-up of 6–38.1 months (EAU)[15]
MeatoplastyShort isolated meatal strictureLocal repair without long-segment reconstructionDoes not address proximal diseaseEAU reports 48/50 girls with resolved recurrent UTIs and improved voiding symptoms at 12 months[15]
Vaginal-wall advancement after vulvectomyPost-oncologic meatal reconstruction (17 limited, 25 extended)Avoids a circular insetDistinct disease and reconstructive settingThree major meatal complications in 42 repairs (one stenosis, one partial vaginal-flap necrosis, one dehiscence/occlusion); self-reported postoperative UI after 6/42 repairs (1/17 limited, 5/25 extended; one extended UI value missing) and urinary spraying after 2/25 extended repairs[8]

Male Blandy Perineal Urethrostomy​

The male Blandy perineal urethrostomy uses a posteriorly based inverted-U perineal skin flap advanced to a ventrally opened bulbar urethra, which is laid open and not transected, to form a permanent perineal stoma. It is an option for selected complex anterior strictures. In Lumen's comparison, 2/16 Blandy and 9/35 Johanson urethrostomies failed at mean follow-up of 11.1 versus 47.9 months, respectively.[16] In a later retrospective series of 115 nononcologic Blandy perineal urethrostomies, 51.3% required no postoperative instrumentation at median 71 months; success was 75% among procedures in the final eight years of that series.[19] The dedicated page contains the operative sequence and source-specific outcomes. The laterally based scrotal-skin 7-flap is a different operation.[16]

Perineal skin is not inherently hairless. Prior perineal surgery, altered tissue or radiation may complicate stoma construction.[16]

Key Takeaways​

  1. The female Blandy is an established ventral vaginal-tissue flap for selected female urethral strictures; the EAU's 81.4% patency combines 161 women across several vaginal-flap variants.[15]
  2. A retrusive meatus or altered stream is a recognized concern. The lateral alternative has small uncontrolled data (9 patients, no recurrence) and no proven superiority.[1]
  3. Initial dilation is an option, but recurrent stricture may warrant urethroplasty; technique choice depends on anatomy, tissue quality, patient preference and surgical expertise.[7][15]
  4. A short isolated meatal stricture may be treated by meatoplasty; no single flap or graft is the universal first choice.[15]
  5. The male Blandy perineal urethrostomy advances posteriorly based perineal skin to an opened bulbar urethra, unlike the laterally based scrotal 7-flap.[16]

See Also​

Videos​

Female Urethroplasty: Blandy Flap
ICS Television (#23321)

References​

1. Romero-Maroto J, Verdú-Verdú L, Gómez-Pérez L, et al. "Lateral-Based Anterior Vaginal Wall Flap in the Treatment of Female Urethral Stricture: Efficacy and Safety." Eur Urol. 2018;73(1):123–128. doi:10.1016/j.eururo.2016.09.029

2. Bouchard B, Campeau L. "Surgery for Female Urethral Stricture." Neurourol Urodyn. 2025;44(1):51–62. doi:10.1002/nau.25358

3. West C, Lawrence A. "Female Urethroplasty: Contemporary Thinking." World J Urol. 2019;37(4):619–629. doi:10.1007/s00345-018-2564-4

4. Watkin N, Kaul A. "Penis and Urethra Inflammation." Chapter 32, Blandy's Urology.

5. Simonato A, Varca V, Esposito M, Carmignani G. "Vaginal Flap Urethroplasty for Wide Female Stricture Disease." J Urol. 2010;184(4):1381–1385. doi:10.1016/j.juro.2010.06.042

6. Blaivas JG, Santos JA, Tsui JF, et al. "Management of Urethral Stricture in Women." J Urol. 2012;188(5):1778–1782. doi:10.1016/j.juro.2012.07.042

7. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

8. Lange M, Hage JJ, Hartveld L, Zijlmans HJMAA, van Beurden M. "Reconstruction of the Meatus Urethrae After Oncologic Vulvectomy: Outcome of 42 Vaginal Flap Advancements in 41 Women." Ann Plast Surg. 2022;88(5):538–543. doi:10.1097/SAP.0000000000003048

9. Waterloos M, Hollebosch S, Verla W, et al. "Neo-Vaginal Advancement Flaps in the Treatment of Urethral Strictures in Transwomen." Urology. 2019;129:217–222. doi:10.1016/j.urology.2019.02.003

10. Önol FF, Antar B, Köse O, Erdem MR, Önol ŞY. "Techniques and Results of Urethroplasty for Female Urethral Strictures: Our Experience With 17 Patients." Urology. 2011;77(6):1318–1324. doi:10.1016/j.urology.2011.01.017

11. Hajebrahimi S, Maroufi H, Mostafaei H, Salehi-Pourmehr H. "Reconstruction of the Urethra With an Anterior Vaginal Mucosal Flap in Female Urethral Stricture." Int Urogynecol J. 2019;30(12):2055–2060. doi:10.1007/s00192-019-03910-3

12. Flisser AJ, Blaivas JG. "Outcome of Urethral Reconstructive Surgery in a Series of 74 Women." J Urol. 2003;169(6):2246–2249. doi:10.1097/01.ju.0000061763.88247.16

13. Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. "Intermediate Outcomes After Female Urethral Reconstruction: Graft vs Flap." Urology. 2014;83(5):1181–1185. doi:10.1016/j.urology.2013.12.052

14. Spilotros M, Malde S, Solomon E, et al. "Female Urethral Stricture: A Contemporary Series." World J Urol. 2017;35(6):991–995. doi:10.1007/s00345-016-1947-7

15. European Association of Urology. Guidelines on Urethral Strictures, Disease Management in Females. 2026; sections 7.3.1–7.3.2 and Table 7.1.

16. Lumen N, Beysens M, Van Praet C, et al. "Perineal Urethrostomy: Surgical and Functional Evaluation of Two Techniques." Biomed Res Int. 2015;2015:365715. doi:10.1155/2015/365715. See also dedicated Blandy perineal urethrostomy operative review.

17. Waterloos M, Verla W. "Female Urethroplasty: A Practical Guide Emphasizing Diagnosis and Surgical Treatment of Female Urethral Stricture Disease." Biomed Res Int. 2019;2019:6715257. doi:10.1155/2019/6715257

18. Sarrio-Sanz P, Gómez-Perez L, López López AI, et al. "Multicentric evaluation of a lateral-based anterior vaginal wall flap for female urethral stricture repair." Minerva Urol Nephrol. 2026;published online March 16. doi:10.23736/S2724-6051.25.06533-4

19. Ponce de León J, Salas D, Calderón J, Montlleó M, Palou J. "Analysis of prognostic factors of failure in perineal urethrostomy." World J Urol. 2023;41(4):1109–1115. doi:10.1007/s00345-023-04343-w

20. Waterloos M, Lumen N, Ockrim JL, et al. "Diagnostics, reconstructive approaches, and outcomes in female urethroplasty patients." BJU Int. 2025;135(6):1025–1030. doi:10.1111/bju.16701