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Bladder Wall Flap Urethroplasty (Female)

Bladder wall flap urethroplasty is a reconstructive technique reserved for the most complex female urethral defects, particularly those involving complete urethral loss, obliterative strictures, and bladder-neck involvement where local genital tissue (vaginal or labial flaps) is insufficient or unavailable.[1][2] It uses a pedicled full-thickness flap from the anterior or posterior bladder wall, tubularized to create a neourethra or used as an onlay augmentation.

For related bladder-flap principles in the upper tract and outlet, see Boari Flap & Psoas Hitch and the bladder-flap foundations article.

Indications​

This technique occupies a specific niche in the reconstructive ladder for female urethral defects.

  • Complete urethral loss (post-traumatic, post-pelvic fracture).[3][4]
  • Obliterative bladder neck contracture (post-pelvic fracture).[3]
  • Complex urethral defects with bladder neck involvement (congenital or acquired).[2]
  • Vesicovaginal fistulas with urethral involvement (obstetric trauma).[5]
  • Neurogenic incontinence with low urethral resistance (myelomeningocele and exstrophy, Pippi Salle procedure).[6][7]
  • Failed prior urethral reconstruction where local tissue is depleted.[1]

Named Techniques and Variants​

1. Tanagho Anterior Bladder Tube​

The classic technique tubularizes a proximally based anterior bladder-wall flap through combined vaginal and abdominal access.[4] In their three-case technique report, Nayyar and colleagues identified anterosuperior bladder-neck shift as a possible cause of voiding difficulty, the posterior suture line as a potential vaginal fistula risk, and rotational tug as a source of suture-line tension with the Tanagho approach.[3]

2. Nayyar U-Shaped Anterior Bladder Tube​

This modification was designed to overcome Tanagho's limitations. A U-shaped flap is raised from the anterior bladder wall and tubularized, keeping the native bladder-neck fibers in their anatomical position. It avoids anterosuperior bladder-neck displacement. Tubes of 3, 3.5 and 3.5 cm were fashioned in the three reported patients.[3] Nayyar and colleagues explain the rationale as incorporating the full circumference of detrusor fibers near the bladder neck, contrasted with the Tanagho tube, which they estimate excludes about 60–70% of that circumference from contributing to continence. As a qualitative anatomical rationale, they suggest basing the flap on the posterior three-fourths of the detrusor and orienting its base toward the trigone, reasoning that neural input arrives from the posterolateral aspect.[10]

3. Pippi Salle Procedure (Anterior Bladder Wall Flap for Urethral Lengthening)​

The Pippi Salle procedure was described for neurogenic incontinence and exstrophy in children (mean age 9 years in the 1997 series).[6] A midline anterior bladder-wall flap is sutured to the posterior wall (trigonal mucosa) in an onlay fashion, creating a flap-valve mechanism that increases urethral resistance. Bladder emptying is by clean intermittent catheterization, and bladder augmentation accompanied the procedure in 13 of 17 patients. Modifications include an anterolateral flap (for exstrophy) and an extended distal mucosal flap (to avoid ureteral reimplantation).[6][7][8]

4. Flipped Anterior Bladder Wall Tube​

Described by Mitsui et al. for pediatric patients with complete urethral disruption. The anterior bladder-wall flap is tubularized and flipped caudally to reach the proximal urethral remnant, combined with a fascial sling for continence.[9] An earlier report by Ahmed (1995) described the same concept in two girls with an absent urethra and a closed bladder neck: a distally based anterior bladder-wall flap, tubularized and flipped caudally to the native meatus site, an orientation intended to keep the suture line away from the posterior vaginal wall rather than against it, as in the classic Tanagho configuration. Both patients were continent, one voiding normally and the other by clean intermittent catheterization.[11]

5. Anterior Bladder Wall Advancement (Elkins Technique)​

A transvaginal approach where the anterior bladder wall is mobilized and advanced into the vagina, then rolled into a neourethra or connected to the urethral remnant. Originally described for vesicovaginal fistulas with urethral loss secondary to obstetric trauma.[5]

6. Posterior Bladder Wall Flap​

Used when the anterior wall is unsuitable (prior surgery, scarring). Patidar et al. used posterior bladder flaps in 6 of 22 patients with complex urethral defects.[2]

Surgical Technique — General Principles​

  1. Exposure. Combined abdominal and vaginal approach (Tanagho, Nayyar) or transvaginal alone (Elkins); transpubic approach may be needed for pelvic-fracture cases.
  2. Flap design. A rectangular or U-shaped full-thickness bladder-wall flap is outlined, typically from the anterior wall, with its base at the bladder neck.
  3. Flap harvest. Raised preserving its vascular pedicle (based on superior vesical artery branches).
  4. Tubularization. Roll and suture the flap into a tube of adequate caliber. In Zhu et al.’s mixed-sex series, the flap was sutured over a 12–14 Fr catheter, which was then replaced with a 10–12 Fr catheter.[12]
  5. Anastomosis and fixation. Connect the neourethra to a distal urethral remnant or bring it to the perineum or vaginal vestibule. In Radwan’s Tanagho repair, fixation sutures secured the neourethra to the base of the pubic periosteum.[4]
  6. Interposition for associated fistula. Nayyar used omentum when repairing a concomitant urogenital fistula.[3] A Martius flap may be considered when urethral involvement, tissue loss or poor vascularity makes layered fistula closure difficult.[13]
  7. Bladder closure and reservoir assessment. Close the donor defect in layers. Assess capacity before bladder-wall tube harvest; Radwan and colleagues selected labial tubes when small capacity or adhesions precluded a Tanagho tube. Augmentation accompanied the separate pediatric Pippi Salle procedure in 13/17 patients.[4][6]
  8. Catheter drainage. Duration varies by repair: Nayyar removed the urethral catheter at 3 weeks in three cases, while Radwan maintained it for 2 weeks, then obtained a voiding cystourethrogram through the suprapubic catheter and removed that catheter after satisfactory voiding without extravasation.[3][4]

Outcomes​

StudyTechniquenFollow-upReported repair / dryness outcomeContinence
Patidar 2021[2]Anterior + posterior bladder flaps22Not specified18/22 (82%) socially dry15/22 (68%) complete
Radwan 2013[4]Tanagho anterior bladder tube6Mean 42 mo across 15 followed patients in both groups; Tanagho-specific follow-up not reported6/6 (100%) anatomical repair4/6 (66.6%) total continence
Nayyar 2020[3]U-shaped anterior bladder tube33–15 mo3/3 (100%)3/3 (100%)
Elkins 1992[5]Anterior bladder wall advancement20Not specified18/20 (90%) fistulas closedVariable (4 required SUI surgery)
Salle 1997[6]Pippi Salle urethral lengthening for pediatric neurogenic incontinence/exstrophy (mixed sexes)17mean 25.6 moNot a urethral-loss repair endpoint12/17 (70%) >4 hours dry between catheterizations
Mitsui 2010[9]Flipped anterior bladder-wall tube + fascial sling + Mitrofanoff channel1 pediatric patient8 mo after catheter removalVoided normally without intermittent catheterization (1/1)Continent after combined repair (1/1)

Complications​

  • Urethrovesical / urethrovaginal fistula. Fistula occurred in 2/17 patients in the 1997 Pippi Salle series and 1/6 in the 1994 series.[6][7]
  • Stress urinary incontinence. Four of 20 Elkins patients required additional anti-incontinence surgery. In Patidar, 3 of 18 socially dry patients had minimal stress incontinence managed conservatively.[2][5]
  • Voiding difficulty / need for self-catheterization. 2/22 Patidar patients required self-calibration.[2]
  • Catheterization difficulty. 3/17 Pippi Salle patients had problems with catheterization.[6]
  • Urethral stenosis. Two of 20 Elkins patients required dilation, and 2 had small bladder capacity with detrusor instability.[5]
  • Bladder capacity. Concurrent augmentation was performed in 13 of 17 and 14 of 18 patients in the two Pippi Salle series, which were pediatric neurogenic and exstrophy cohorts.[6][8]

Advantages and Limitations​

Advantages

  • Provides tissue for complete urethral replacement; tubes of 3–3.5 cm were reported in three patients.[3]
  • Urothelium-lined lumen is physiologically compatible.
  • Well-vascularized pedicled tissue.
  • Applicable when all local genital tissue options are exhausted.[1]

Limitations

  • Requires an abdominal approach in the Tanagho and Nayyar techniques, which is more invasive than transvaginal techniques.
  • Flap harvest may reduce bladder capacity. In a retrospective series of 16 female patients aged 4–73 years, 10 had good voiding and urinary control, 4 had stress incontinence, and 2 had urination difficulties during follow-up (mean 46.6 months; range 16–108).[12] One underwent resection of bladder-neck mucosal prolapse; the other required vulvar-flap meatoplasty for meatal stenosis.[12] That center considered capacity <200 mL or significant bladder inflammation unsuitable for its procedure.[12] Augmentation accompanied the distinct pediatric Pippi Salle procedure in 13/17 patients.[6]
  • Reported fistulas lack a comparative rate against vaginal or labial flaps in these small, heterogeneous series.
  • Continence after urethral-loss reconstruction and patency after standard stricture augmentation are different endpoints.
  • Limited evidence base; small case series only.[2][3][4]

Position in the Reconstructive Algorithm​

Bladder wall flap urethroplasty is generally a salvage or last-resort technique when vaginal, labial, and buccal tissue sources are unavailable or have failed. Radwan et al. compared the Tanagho bladder tube with a labia minora pedicled tube (with a concomitant TOT sling) in 15 patients with post-traumatic urethral loss. Among the 15 patients followed for a mean of 42 months, total continence was 4/6 (66.6%) after Tanagho bladder tube and 6/9 (66.6%) after labial-tube repair.[4] Equivalence was not established. The labial approach avoids the abdominal incision.[4] The technique is used mainly for obliterative bladder-neck pathology and total urethral loss when other tissue sources cannot bridge the defect.[1][3]

See Also​

Videos​

Robotic Bladder Flap Urethroplasty
Lee C. Zhao, MD (2023)

References​

1. Faiena I, Koprowski C, Tunuguntla H. "Female Urethral Reconstruction." J Urol. 2016;195(3):557–67. doi:10.1016/j.juro.2015.07.124

2. Patidar V, Dias S, Prakash S, et al. "Results of Bladder Neck Reconstruction Using Bladder Flaps in Complex Female Urethral Defects." Int Urogynecol J. 2021;32(3):665–71. doi:10.1007/s00192-020-04538-4

3. Nayyar R, Jain S, Sharma K, Pethe S, Kumar P. "A Novel Anterior Bladder Tube for Traumatic Bladder Neck Contracture in Females: Initial Results." Urology. 2020;139:201–6. doi:10.1016/j.urology.2019.12.037

4. Radwan MH, Abou Farha MO, Soliman MG, et al. "Outcome of Female Urethral Reconstruction: A 12-Year Experience." World J Urol. 2013;31(4):991–5. doi:10.1007/s00345-013-1087-2

5. Elkins TE, Ghosh TS, Tagoe GA, Stocker R. "Transvaginal Mobilization and Utilization of the Anterior Bladder Wall to Repair Vesicovaginal Fistulas Involving the Urethra." Obstet Gynecol. 1992;79(3):455–60. doi:10.1097/00006250-199203000-00026

6. Salle JL, McLorie GA, Bägli DJ, Khoury AE. "Urethral Lengthening With Anterior Bladder Wall Flap (Pippi Salle Procedure): Modifications and Extended Indications of the Technique." J Urol. 1997;158(2):585–90. doi:10.1016/S0022-5347(01)64560-9

7. Salle JL, de Fraga JC, Amarante A, et al. "Urethral Lengthening With Anterior Bladder Wall Flap for Urinary Incontinence: A New Approach." J Urol. 1994;152(2 Pt 2):803–6. doi:10.1016/s0022-5347(17)32715-5

8. Salle JL, McLorie GA, Bägli DJ, Khoury AE. "Modifications of and Extended Indications for the Pippi Salle Procedure." World J Urol. 1998;16(4):279–84. doi:10.1007/s003450050067

9. Mitsui T, Tanaka H, Moriya K, et al. "Construction of Neourethra Using Flipped Anterior Bladder Wall Tube in a Prepubertal Girl With Complete Disruption of Urethra." Urology. 2010;76(1):112–4. doi:10.1016/j.urology.2009.08.046

10. Nayyar R, Bansal D, Uppal Nayyar B. Female pelvic fracture associated urethral injury and stricture: principles of management. In: Khattar N, Nayyar R, Panda A, eds. Female Bladder Outlet Obstruction and Urethral Reconstruction. Springer; 2021:207-208.

11. Ahmed S. Construction of female neourethra using a flipped anterior bladder wall tube. J Pediatr Surg. 1995;30(12):1728-1731. doi:10.1016/0022-3468(95)90466-2

12. Zhu WD, Guo H, Xie H, Song LJ, Xu YM. "Neourethra reconstruction using an anterior bladder wall flap for the treatment of complex urethral obliteration and absence." Transl Androl Urol. 2025;14(2):432-440. doi:10.21037/tau-24-443

13. Kapriniotis K, Loufopoulos I, Gresty HCM, Greenwell TJ, Ockrim JL. "The utility of Martius fat pad in the repair of urogenital fistulae: review of current evidence." BJU Int. 2024;134(3):365-374. doi:10.1111/bju.16350