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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. Guidelines do not recommend the technique as a distinct entity, and the EAU 2026 review found only these two circumferential BMG cases within a larger series.[12]

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.

Reported Use and Limitations​

The AUA 2023 amendment advises against single-stage tubularized graft urethroplasty in its anterior-urethral reconstruction section because of restenosis risk ; applying its male-anatomy guidance to female circular BMG is an extrapolation.[10] It excepts a tubularized graft supported in its entirety by a suitable graft bed. A vascularized wrap has not been shown to give comparable outcomes.[10] Published or proposed applications include:

  • 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.
  • Poor local tissue quality may favor oral mucosa. Önol used dorsal onlay BMG in two patients with atrophic vaginas and reserved circular BMG for two severe distal strictures.[1][4][5]

Surgical Technique (Önol)​

The steps below combine the description in the Önol series with standard tubularized-graft principles. Dimensions are approximate.

  1. Patient positioning. Lithotomy; vaginal approach.
  2. Exposure. Make a circummeatal incision and mobilize the meatus and distal urethra from periurethral tissue.[13]
  3. Excision. Amputate the fibrotic distal urethra at healthy proximal urethral mucosa, retaining the circummeatal incision for distal graft attachment.[13]
  4. Graft harvest. Harvest buccal mucosa sized to the excised distal segment. In the Önol repair reproduced by Chua et al., a 4 × 1.5 cm graft was rotated around a 22–24 Fr Foley catheter.[13]
  5. Initial graft fixation. Incise healthy proximal urethral mucosa at 6 o’clock. Suture one graft corner to the apex and its short edge to one side of this incision before rotating it around the catheter.[13]
  6. Tubularization and proximal anastomosis. Rotate the graft counterclockwise around a 22–24 Fr Foley catheter with its mucosa inward, then suture the graft's long edge to the healthy proximal urethral mucosa.[13]
  7. Vascular support. A tubularized free graft needs a suitable graft bed around its full circumference.[4] Önol et al. described Martius flap reinforcement in two ventral onlay cases after sling surgery, separate from their circular repairs.[1][10]
  8. Distal closure. Fold the distal graft mucosa outward and suture it circumferentially to the original circummeatal incision to complete the neomeatus.[13]
  9. Catheter management. Urethral catheter (± SPC) for approximately 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 graftDistal segment excisedSuitable circumferential tissue bed; specific wrap unreported

Aybek-Zumrutbas (AZ) Technique​

Gülpınar et al. described the AZ technique as a novel BMG approach with 100% success in its 14 patients; median postoperative follow-up was 24.6 months for the full 34-patient cohort. Success rates were 83.3% for ventral onlay and 87.5% for vaginal-sparing inlay in small nonrandomized groups; superiority was not established.[7]

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; the study reported 92% clinical success (no recurrence on cystourethroscopy) at 12 months for the mixed-procedure series.[6]

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 to 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. The EAU 2026 review lists both circumferential patients as stricture-free at a mean of 21 months and notes that flow-rate and residual-volume changes are not reported for this technique.[12]

Theoretical Concerns and Limitations​

  • Graft take. A free graft requires imbibition and inosculation from a vascular bed. A full-circumference graft lacks a preserved native urethral wall, so surrounding tissue must provide a suitable graft bed along its length.[4][5][10]
  • Contracture risk. Healing contracture and restricture are theoretical concerns for a circumferential free graft without a suitable vascular bed.[10][12]
  • Continence risk. Distal urethral excision may affect stress continence: distal urethral pressure rises during exertion even though maximal resting closure pressure is in the mid-urethra.[14][15][12]
  • Limited tissue. Available cheek-graft dimensions vary.[13][16] Circumferential reconstruction uses one dimension around the tube and the other for axial length; Önol's reported repair used a 4 × 1.5 cm graft around a 22–24 Fr catheter.[13][16]

Position in the Reconstructive Algorithm​

Circular BMG urethroplasty occupies a very narrow niche. Most reported series use single-surface augmentation techniques (dorsal or ventral onlay or inlay) for female urethral strictures, with pooled studies showing high reported success for dorsal and ventral augmentation (92.1% and 95.5% in a 25-study meta-analysis, 21 of which were Level 4 evidence).[9] Meta-analyses found no significant difference between dorsal and ventral onlay.[8][9] The AUA 2023 guideline says surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or both .[10]

For an isolated short meatal stricture, the EAU recommends meatoplasty .[12] When circumferential disease precludes straightforward augmentation, several reconstructive options exist; Önol’s two circular cases involved severe distal strictures that nearly obliterated the meatus.[13] Reported options include:

  1. Combined dorsal and ventral graft. Augments both surfaces while preserving lateral urethral walls.[6]
  2. Pedicled labial or vaginal flap tubularization. A pedicled flap maintains its own vascular supply, unlike a free graft.
  3. Circular BMG. Önol reported this in two severe distal strictures; the Martius flap in that series reinforced separate ventral onlay repairs and was not described as a wrap for the circular cases.[1] A suitable circumferential graft bed remains necessary.[10]
  4. Bladder wall flap urethroplasty. For longer defects or bladder-neck involvement.[11]

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 free graft requires a suitable vascular bed around its full circumference.[1][10] Established augmentation techniques have a much broader evidence base for most female urethral strictures; the two circular-graft cases provide no comparative safety or efficacy data.

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. Jefferson FA, Lee YS, Rafetto AN, et al. "Short-Term Outcomes Following Transurethral Dorsal Buccal Graft Urethroplasty for Female Urethral Strictures." Neurourol Urodyn. 2026;45(1):155–61. doi:10.1002/nau.70161

7. 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

8. 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;37(8):2303–11. doi:10.1007/s00192-026-06516-8

9. 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

10. 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

11. 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

12. European Association of Urology. Urethral Strictures: Disease Management in Females. 2026. Official guideline.

13. Chua KJ, Mikhail M, Patel HV, et al. "Treatment of urethral stricture disease in women: Nonsystematic review of surgical techniques and intraoperative considerations." Res Rep Urol. 2021;13:381–406. doi:10.2147/RRU.S282651

14. Venema PL, Kramer G, van Koeveringe GA, Heesakkers JPFA. "The Maximal Urethral Pressure at Rest and during Normal Bladder Filling Is Only Determined by the Activity of the Urethral Smooth Musculature in the Female." J Clin Med. 2023;12(7):2575. doi:10.3390/jcm12072575

15. Constantinou CE, Govan DE. "Urodynamic analysis of urethral, vesical and perivesical pressure distribution in the healthy female." Urol Int. 1980;35(1):63–72. doi:10.1159/000280306

16. Kulkarni SB, Barbagli G, Sansalone S, Joshi PM. "Harvesting oral mucosa for one-stage anterior urethroplasty." Indian J Urol. 2014;30(1):117–121. doi:10.4103/0970-1591.124222