Blandy Perineal Urethrostomy
The Blandy perineal urethrostomy (PU) is one of the classical techniques for creating a permanent perineal stoma, originally described by John P. Blandy in 1968.[1] It is characterized by an inverted U-shaped, posteriorly based perineal skin flap that is advanced and sutured to the opened (marsupialized) bulbar urethra — distinct from the simple skin-edge marsupialization of the Johanson technique and from the laterally based 7-flap (urethra transected and amputated) of the modern algorithmic midline approach.
For the modern midline algorithmic approach, see Midline Perineal Urethrostomy (loop / 7-flap). The inverted-U incision described here can also carry a dorsal buccal-mucosa onlay to widen the stoma — see Augmented Perineal Urethrostomy. For dorsal-plate-preservation PU, see Myers / McAninch principles. For salvage of a failed PU when local perineal tissue is depleted, see Propeller Flap PU Revision.
Historical Background and Concept
Blandy's 1968 paper introduced a broad, posteriorly based inverted U-shaped perineal skin flap raised from the perineum and advanced anteriorly to be sutured to the spatulated bulbar urethra, creating a widely patent stoma.[1][2] This was a deliberate departure from the earlier Johanson technique (1953), which relied on simple marsupialization of the opened urethra to perineal skin edges without a formal flap.[2][3]
Indications
The Blandy technique shares the general indications for definitive PU:
- Complex, long-segment, or panurethral strictures — 62.6% of patients in the largest dedicated Blandy series had panurethral disease.[4]
- Recurrent strictures after failed urethroplasty or endoscopic management.
- Lichen sclerosus (30.4% of cases in Ponce de León).[4]
- Iatrogenic (27%) and idiopathic (25.7%) strictures.[4]
- Older or comorbid patients poor candidates for complex multi-stage reconstruction — definitive PU is preferentially performed in older patients with worse cardiovascular comorbidity and longer strictures.[5]
- Post-urethrectomy / post-penectomy as the definitive voiding outlet after oncologic resection.[2]
- Patient preference — nearly half of patients undergoing Stage 1 of an intended multi-stage urethroplasty refuse closure and elect to remain with PU, supporting offering PU as a primary option from the outset.[5]
The AUA 2023 urethral stricture guideline amendment endorses PU as a long-term option, either as an alternative to urethroplasty (Conditional Recommendation) or for patients at high risk for reconstruction failure (Expert Opinion).[6]
Surgical Technique
Positioning and preparation
- Dorsal lithotomy with stirrups; perineum, genitalia, and inner thighs prepped and draped.
- Plan drainage using the existing suprapubic catheter where appropriate. Its association with failure in one retrospective cohort may reflect disease severity; it does not establish that the catheter causes failure.[4]
Step 1 — Inverted U-shaped perineal incision
- The defining feature of the Blandy technique.
- The rounded apex of the U is directed anteriorly (toward the scrotum); the open base/pedicle is directed posteriorly (toward the anus) — i.e., the flap is posteriorly based.
- The two limbs of the U run roughly parallel on either side of the midline raphe, originating from the posterior base and joined anteriorly by the curved apex near the scrotal junction.
- Tailor flap length and base to the measured urethra-to-skin distance, preserving a broad vascular base and tension-free reach; fixed dimensions are not appropriate for every perineum.
Step 2 — Flap elevation
- Elevate the inverted U as a full-thickness skin flap with subcutaneous tissue intact, developed off the underlying bulbocavernosus muscle (the flap contracts substantially once released).
- The flap is posteriorly based — blood supply enters from the posterior perineal vasculature at the base (the open end of the U, toward the anus).
- Reflect the flap to expose the bulbospongiosus and corpus spongiosum.
Step 3 — Urethral exposure and ventral urethrotomy
- Divide the bulbospongiosus to expose the corpus spongiosum and bulbar urethra.
- Open the urethra ventrally along the strictured segment — the urethra is laid open (marsupialized) rather than transected. This is the central technical distinction from the 7-flap.
- Extend the urethrotomy proximally until healthy, well-vascularized mucosa is encountered.
- Spatulate widely to a broad fish-mouth opening.
Step 4 — Flap advancement and anastomosis
- Advance the apex anteriorly and deep into the wound.
- Parachute the apex of the flap (the rounded anterior tip) to the proximal edge of the spatulated urethra using pre-placed apical sutures of 4-0 or 5-0 absorbable suture (polyglactin or polyglycolic acid).
- Suture the lateral edges of the flap to the lateral urethral mucosal edges along the length of the urethrotomy.
- Suture the remaining perineal and scrotal skin edges to the distal urethral opening to complete the stoma.
- The flap fills the ventral urethrotomy, with its apex at the proximal opening and its sides sutured to mucosa. Select skin that will not introduce hair into the outlet; perineal skin is not inherently hairless.[2]
Step 5 — Catheter and closure
- 16–18 Fr Foley through the urethrostomy into the bladder.
- Layered wound closure.
- Catheter duration depends on the reconstruction. EAU guidance permits removal after 3–5 days following an uncomplicated perineostomy; graft augmentation, leakage or wound problems require an individualized plan.[13]
How Blandy Differs From Other PU Techniques
| Technique | Skin flap | Urethral handling |
|---|---|---|
| Blandy (1968) | Inverted U-shaped, posteriorly based, advanced to opened urethra | Laid open (marsupialized) |
| Johanson (1953) | None — simple marsupialization to skin edges | Laid open (marsupialized) |
| 7-Flap (Morey 2011) | Laterally based 7-shaped flap, advanced to amputated stump | Transected and amputated |
| Myers / McAninch (2011) | None — midline; dorsal urethral plate preserved | Opened ventrally; dorsal plate intact |
Anatomic Cost of the Inverted-U Incision
Cadaveric studies by Lin show the inverted-U incision damages 1.6–2.0× more vessels and nerves than a vertical midline incision while providing equivalent operative exposure.[7] In a matched retrospective bulbar/posterior urethroplasty cohort (not a direct comparison of PU techniques), the authors also reported:
| Endpoint | Inverted U | Midline vertical |
|---|---|---|
| Surgical site infection | 16.4–18.6% | 1.9–3.1% (p < 0.05) |
| Hospital stay | 15.8 ± 9.0 days | 12.7 ± 3.8 days (p < 0.05) |
Applying these incision findings to PU is an extrapolation; they do not establish that Blandy PU has the same infection rates or inferior patency to a midline PU.[7][14]
Outcomes
| Series | n | Technique | Success | Follow-up | Notable |
|---|---|---|---|---|---|
| Ponce de León 2023[4] | 115 | Blandy (inverted U) | 51.3% overall; 75% in last 8 yr | 71 mo | Age, BMI, SPC, era predicted failure; 88.7% voiding satisfaction |
| Lumen 2015[2] | 16 (Blandy) / 35 (Johanson) | Blandy vs Johanson | 87.5% (Blandy) / 74.3% (Johanson) | Mean 11.1 / 47.9 mo | No significant difference (p = 0.248); Qmax improved in both |
| Myers / McAninch 2011[8] | 40 followed of 45 enrolled | Dorsal-plate preservation (midline) | 83% primary / 93% secondary | 31 mo | Radiation OR 11.2 (95% CI 1.4–87.2) |
| Joshi / Morey 2024[9] | 103 | Midline (7-flap / loop) | 95.1% | Median 61 mo at survey in 49 respondents | 42/49 satisfied; 6/103 complications |
| Fuchs / Morey 2018[10] | 77 | Midline PU | 94.8% | 50.7 mo | Nonrandomized comparisons with different reconstruction groups |
The most important Blandy-specific finding: success rates have improved markedly over time — from 51.3% across the full Ponce de León cohort to 75% in the most recent 8-year era — likely reflecting refinements in patient selection, technique, and postoperative management.[4]
Prognostic Factors for Failure
Ponce de León's multivariate analysis (n = 115, 71 mo follow-up) identified four independent predictors:[4]
- Age (p = 0.01) — older patients had higher failure.
- BMI (p = 0.01) — higher BMI predicted failure (urethra-to-skin distance + wound-healing burden).
- Date of surgery (p = 0.01) — more recent operations had better outcomes.
- Suprapubic catheter (p = 0.003) — a marker of more severe disease or prior failed interventions.
Diabetes, stricture etiology, stricture type, and prior surgeries were not significant in this analysis.[4]
In the Myers / McAninch dorsal-plate-preservation series, prior radiation was associated with stomal stenosis (OR 11.2; 95% CI 1.4–87.2), with considerable uncertainty in a small cohort.[8]
Complications
The Blandy technique is a low-morbidity procedure overall:[4]
| Clavien grade | Rate |
|---|---|
| None | 73% |
| I (minor deviations from usual recovery) | 25.2% |
| II (pharmacologic) | 0.9% |
| IVa (life-threatening / ICU) | 0.9% |
Primary failure mode is stomal stenosis. The incision study above did not measure Blandy-specific PU infection risk, and cross-study patency differences cannot establish that one PU technique is superior.[7][14]
Functional Outcomes and Quality of Life
- Voiding satisfaction — 88.7% in Ponce de León.[4]
- Qmax — significant improvement in both Blandy and Johanson cohorts.[2]
- QoL — comparable between Blandy and Johanson by IPSS.[2]
- Across PU techniques, patients generally maintain continence (median ICIQ-UI 0), high treatment satisfaction, and the majority (76%) are unbothered by sitting to urinate.[9][11]
Choosing the PU Technique
Blandy, dorsal-plate-preserving, loop and 7-flap reconstructions remain options. Flap reach, proximal disease, body habitus, prior operations and surgeon experience determine selection. A midline incision permits an intraoperative loop-versus-flap decision, while a 7-flap can bridge a deeper outlet in selected obese patients. Current EAU guidance does not establish a universally best PU technique.[12][14]
Videos
References
1. Blandy JP, Singh M, Notley RG, Tresidder GC. Urethroplasty by scrotal flap for long urethral strictures. Br J Urol. 1968;40(6):690-698. doi:10.1111/j.1464-410X.1968.tb09886.x.
2. 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.
3. Al-Ali M, Al-Hajaj R. Johanson's staged urethroplasty revisited in the salvage treatment of 68 complex urethral stricture patients: presentation of total urethroplasty. Eur Urol. 2001;39(3):268-271. doi:10.1159/000052451.
4. 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.
5. Verla W, Oosterlinck W, Waterloos M, Spinoit AF, Lumen N. Perineal urethrostomy for complicated anterior urethral strictures: indications and patient's choice. An analysis at a single institution. Urology. 2020;138:160-165. doi:10.1016/j.urology.2019.11.064.
6. 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.
7. Lin Y, Luo D, Liao B, et al. Perineal midline vertical incision versus inverted-U incision in urethroplasty: which is better? World J Urol. 2018;36(8):1267-1274. doi:10.1007/s00345-018-2267-x.
8. Myers JB, Porten SP, McAninch JW. The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply. Urology. 2011;77(5):1223-1227. doi:10.1016/j.urology.2010.10.041.
9. Joshi EG, VanDyke ME, Langford BT, Franzen BP, Morey AF. Algorithmic midline approach to perineal urethrostomy is associated with long-term success and high patient satisfaction. Urology. 2024;190:133-139. doi:10.1016/j.urology.2024.03.016.
10. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169-173. doi:10.1016/j.urology.2018.08.009.
11. Klemm J, Dahlem R, Schulz RJ, et al. Perineal urethrostomy for complex urethral strictures: long-term patient-reported outcomes from a reconstructive referral center and a scoping literature review. J Urol. 2024;212(5):738-748. doi:10.1097/JU.0000000000004169.
12. McKibben MJ, Rozanski AT, Fuchs JS, Sundaram V, Morey AF. Versatile algorithmic midline approach to perineal urethrostomy for complex urethral strictures. World J Urol. 2019;37(7):1403-1408. doi:10.1007/s00345-018-2522-1.
13. EAU Guidelines on Urethral Strictures: perioperative care. https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery. Accessed September 12, 2026.
14. EAU Guidelines on Urethral Strictures: perineal urethrostomy. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.