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Circular (Circumferential) BMG Urethroplasty (Female)

Circular (circumferential) BMG urethroplasty is a specialized technique for severe distal female urethral strictures in which the strictured segment is excised and replaced with a tubularized buccal mucosal graft that reconstructs the full circumference of the urethra. It is among the least commonly reported female urethroplasty techniques; the primary description comes from Önol et al. (2011), who used it in 2 of 17 patients.[1] The evidence base is extremely limited (case reports and small case series), and the technique is not addressed in current guidelines as a distinct entity.

Concept and Rationale​

Most BMG urethroplasty techniques in women use the graft as a single-surface augmentation — dorsal onlay, ventral onlay, or ventral inlay — where the graft replaces only one wall of the urethra and the remaining native wall provides structural support and a vascular bed for graft take.[2][3] In contrast, the circular / circumferential approach involves complete excision of the diseased urethral segment and replacement with a BMG that is tubularized to form the entire urethral circumference. This is conceptually analogous to tubularized graft reconstruction in male urethroplasty, which is generally discouraged due to high failure rates from poor graft take in the absence of a native vascular bed.

Indications​

Reserved for a narrow subset of cases:

  • Severe distal urethral stricture with near-complete or complete luminal obliteration where the urethral mucosa is too damaged for augmentation alone.[1]
  • Circumferential spongiofibrosis where no viable native urethral wall remains to serve as a graft bed.
  • Failed prior augmentation urethroplasty with circumferential scarring.
  • Situations where local tissue (vaginal, labial) is unavailable (atrophy, lichen sclerosus, prior surgery) and the stricture is too short to justify a bladder-flap reconstruction.[4][5]

Surgical Technique (Önol)​

  1. Patient positioning — lithotomy; vaginal approach.
  2. Exposure — anterior vaginal-wall incision; circumferential dissection of the strictured distal urethral segment.
  3. Excision — the fibrotic / strictured segment is excised completely, leaving healthy proximal and distal urethral margins.
  4. Graft harvest — buccal mucosa from the inner cheek, sized to match the excised length and wide enough to create a tube of adequate caliber (~ 2–2.5 cm width for an ~ 18 Fr tube).
  5. Tubularization — the BMG is tubularized over a catheter (mucosal surface inward) using continuous or interrupted absorbable sutures.
  6. Anastomosis — end-to-end to the proximal healthy urethra and distally to the meatal remnant or vestibular mucosa.
  7. Vascular support — a Martius flap or periurethral tissue is wrapped around the tubularized graft to provide a vascular bed for take and mechanical reinforcement.[1][4]
  8. Closure — layered vaginal-wall closure over the reconstruction.
  9. Catheter management — urethral catheter (± SPC) for ~ 3 weeks.

Relationship to Other Techniques​

TechniqueGraft ConfigurationNative UrethraVascular Bed
Dorsal onlay BMGSingle-surface dorsal augmentationPreserved (ventral wall intact)Periurethral / pubic tissue
Ventral onlay BMGSingle-surface ventral augmentationPreserved (dorsal wall intact)Periurethral fascia
Ventral inlay (vaginal-sparing) BMGSingle-surface ventral inlayPreserved (dorsal wall intact)Periurethral fascia
Dorsal inlay BMGSingle-surface dorsal inlayPreserved (ventral wall intact)Periurethral tissue
Combined dorsal + ventral inlayTwo-surface augmentationPreserved (lateral walls intact)Periurethral tissue
Circular (circumferential) BMGFull-circumference tubularized graftExcisedMartius flap or periurethral wrap

Aybek-Zumrutbas (AZ) Technique​

A distinct technique that should not be confused with circular BMG. Gülpınar et al. described the AZ technique as a novel BMG approach that achieved 100% success in 14 patients at 24.6-month median follow-up, outperforming both ventral onlay (83.3%) and vaginal-sparing inlay (87.5%) in their series.[9] Technical details in the available literature suggest a combined or modified graft-placement strategy rather than full circumferential replacement.

Combined Dorsal + Ventral Inlay​

Jefferson et al. described a transurethral approach where 2 of 21 patients with obliterative strictures required a combined dorsal and ventral inlay, augmenting both surfaces of the urethra without full circumferential excision; 92% success at 12 months across the entire cohort.[8]

Outcomes​

The evidence for circular BMG urethroplasty specifically is extremely limited:

  • Önol 2011 — 2 patients with severe distal strictures underwent circular BMG reconstruction within a 17-patient series. Overall series achieved 100% objective cure and 88% subjective cure at median 24-month follow-up (range 6–78 mo). Mean Qmax 10.8 → 28.9 mL/s. Individual outcomes for the 2 circular-BMG patients were not reported separately.[1]

No other published series has reported outcomes for circumferential BMG urethroplasty in women as a distinct cohort.

Theoretical Concerns and Limitations​

  • Graft take — a free graft requires imbibition and inosculation from a vascular bed. When the graft forms the entire circumference, there is no native urethral wall to provide blood supply — the graft depends entirely on the surrounding wrap (Martius flap or periurethral tissue). This is the same concern that limits tubularized graft use in male urethroplasty, where failure rates are significantly higher than for onlay techniques.[4][5]
  • Contracture risk — circumferential grafts are prone to cicatricial contracture during healing, with potential restricture.
  • Continence risk — excision of the distal urethral segment may compromise the intrinsic sphincteric mechanism, though the distal female urethra contributes less to continence than the mid-urethral high-pressure zone.
  • Limited tissue — buccal harvest is constrained (typically ~ 6–7 cm from one cheek), limiting the length of tubularized reconstruction possible.

Position in the Reconstructive Algorithm​

Circular BMG urethroplasty occupies a very narrow niche. The current evidence strongly favors single-surface augmentation techniques (dorsal or ventral onlay / inlay) for the vast majority of female urethral strictures, with meta-analyses showing equivalent success rates of ~ 92–95% for both dorsal and ventral approaches.[10][11] The AUA 2023 guideline recommends urethroplasty using oral mucosa grafts, vaginal flaps, or a combination, without specifically endorsing circumferential reconstruction.[12]

When circumferential disease precludes augmentation, preferred alternatives in approximate order:

  1. Combined dorsal + ventral graft — augments both surfaces while preserving lateral urethral walls.[8]
  2. Pedicled labial or vaginal flap tubularization — maintains vascular supply, unlike a free graft.[1]
  3. Circular BMG with Martius flap wrap — when no local flap tissue is available.[1]
  4. Bladder wall flap urethroplasty — for longer defects or bladder-neck involvement.[13]

Summary​

Circular BMG urethroplasty is a rarely used salvage technique for severe circumferential female urethral strictures where augmentation alone is insufficient and local pedicled tissue is unavailable. The evidence base is limited to 2 patients in a single series.[1] The technique requires meticulous vascular support (typically a Martius flap) to overcome the inherent disadvantage of a free graft lacking a native urethral vascular bed. For most female urethral strictures, single-surface or combined dorsal-ventral augmentation techniques provide superior outcomes with less risk.

See Also​

References​

1. 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):1318–24. doi:10.1016/j.urology.2011.01.017

2. Berdondini E, Eissa A, Margara A, et al. "Ventral Onlay Buccal Mucosa Graft Urethroplasty for Female Urethral Stricture: Medium-Term Results in a Single Surgeon Experience." Urology. 2024;193:194–200. doi:10.1016/j.urology.2024.06.045

3. Gaur AS, Tarigopula V, Mandal S, et al. "Comparison of Ventral Inlay and Dorsal Onlay Urethroplasty for Female Urethral Stricture." Urology. 2024;193:46–50. doi:10.1016/j.urology.2024.06.046

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

5. West C, Lawrence A. "Female Urethroplasty: Contemporary Thinking." World J Urol. 2019;37(4):619–29. doi:10.1007/s00345-018-2564-4

6. Khawaja AR, Dar YA, Bashir F, et al. "Outcome of Dorsal Buccal Graft Urethroplasty in Female Urethral Stricture Disease (FUSD): Our Institutional Experience." Int Urogynecol J. 2022;33(3):697–702. doi:10.1007/s00192-021-04840-9

7. Higuchi M, Horiguchi A, Ashiya M, et al. "Vaginal Flap Urethroplasty and Dorsal Onlay Buccal Mucosal Graft Urethroplasty for Female Urethral Stricture: A Single-Center Experience." Int J Urol. 2026;33(5):e70477. doi:10.1111/iju.70477

8. Jefferson FA, Lee YS, Rafetto AN, et al. "Short-Term Outcomes Following Transurethral Dorsal Buccal Graft Urethroplasty for Female Urethral Strictures." Neurourol Urodyn. 2025. doi:10.1002/nau.70161

9. Gülpınar Ö, Zumrutbas AE, Sancı A, et al. "The Outcomes of Three Buccal Mucosal Graft Urethroplasty Techniques in Women With Urethral Stricture Disease." Neurourol Urodyn. 2021;40(8):1921–8. doi:10.1002/nau.24764

10. Li X, Zhao X, Li Z, et al. "Dorsal Versus Ventral Onlay Buccal Mucosal Graft Urethroplasty in Female Urethral Stricture: A Meta-Analysis." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06516-8

11. Ortac M, Ozervarli MF, Ergul RB, et al. "Comparing Ventral and Dorsal Oral Mucosal Graft Urethroplasty in Female Urethral Stricture: A Systematic Review and Meta-Analysis." World J Urol. 2025;43(1):397. doi:10.1007/s00345-025-05773-4

12. 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

13. 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