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Combined Dorsal BMG + Ventral Fasciocutaneous Flap (Erickson)

The combined dorsal buccal mucosal graft (BMG) with ventral fasciocutaneous flap is a single-stage tissue-transfer technique for complex, long-segment, or obliterative anterior urethral strictures where neither a graft nor a flap alone provides sufficient tissue for circumferential urethral reconstruction. It was described by Erickson, Breyer, and McAninch in 2012.[1][2] The AUA 2023 urethral stricture guideline amendment endorses this combination approach as a Moderate Recommendation (Grade C) for long, multi-segment strictures.[3]

For graft material principles, see Buccal Mucosa Graft. For the ventral pedicled-flap principles, see Penile / Preputial Flap. For the dual-BMG (Palminteri / Gelman) alternative, see Dorsal Onlay BMG and Ventral Onlay BMG. The Karapanos plate-and-spongiosum-preserving modification with the Orandi flap is described in the technique section below.

Concept and Rationale​

The technique leverages the complementary strengths of two tissue types:

  • BMG (dorsal) — a free graft that requires a well-vascularized recipient bed. Quilted directly onto the tunica albuginea of the corpora cavernosa, which provides excellent imbibition / inosculation.[2][4]
  • Fasciocutaneous flap (ventral) — a pedicled penile-skin flap that carries its own dartos-fascia blood supply. Placed ventrally, it does not depend on the recipient bed for survival, making it ideal where ventral spongiofibrosis has compromised local vascularity.[1][5]

Together they form a circumferential neourethra — dorsal BMG roof + ventral flap floor — enabling complete segmental urethral replacement in a single stage.[1]

Indications and Patient Selection​

  • Long-segment anterior urethral strictures (mean ~ 9.75 cm in the Erickson / McAninch series).[1]
  • Obliterative or near-obliterative strictures not amenable to EPA or simple onlay augmentation.[1][2]
  • Panurethral or multi-segment strictures involving both penile and bulbar urethra.[1]
  • Failed prior urethroplasty with damaged urethral plates.[5]
  • Prerequisite: healthy, non-hair-bearing penile skin available for the fasciocutaneous flap.[1][3]

A 2024 GURS survey found that ~ 90% of contemporary reconstructive urologists prefer multiple BMGs (dual dorsal + ventral) over combined graft / flap for panurethral strictures — but the combined Erickson technique remains an important option when single-stage repair is desired and the urethral plate is severely compromised.[6]

Patients with lichen sclerosus are not candidates — genital skin should not be used.[1][3]

Surgical Technique​

The key steps as described by Erickson, Breyer, and McAninch and refined by Kojovic / Djordjevic:[1][2]

StepDetail
1. ExposurePerineal approach; identify the strictured segment; open the urethra ventrally through the stricture
2. Dorsal BMG placementMobilize corpus spongiosum off the corpora cavernosa dorsally; harvest BMG from inner cheek(s); quilt the graft to the tunica albuginea with interrupted sutures, forming the dorsal wall of the neourethra
3. Ventral fasciocutaneous flapRaise a longitudinal pedicled penile-skin flap on a dartos fascia pedicle; transpose ventrally into the perineum; suture flap edges to the lateral edges of the dorsal BMG, completing the ventral wall
4. Neourethral closureApproximate dorsal graft and ventral flap to form a tubular neourethra; when preserved, the corpus spongiosum is wrapped around the repair for additional support[7]
5. Catheter and closureUrethral catheter; layered wound closure

Karapanos modification​

Karapanos 2024 preserves the native urethral plate and corpus spongiosum, uses a narrower Orandi-type ventral pedicled penile-skin flap, and wraps the preserved spongiosum ventrally around the flap for reinforcement — yielding a triangular-cross-section neourethra and 91.7% success at 38 mo for narrow penile strictures, with transient fistulas in 25% (3 / 12) all healing with prolonged catheterization.[7]

Outcomes​

SeriesnMean stricturePrimary successOverall successMean FU
Erickson 2012[1]149.75 cm64% (9 / 14)79% (11 / 14)2.5 yr
Kojovic / Djordjevic 2019[2]465.2 cm84.8%78.3% (incl. fistula)49 mo
Karapanos 2024 (modification)[7]125 cm91.7%91.7%38 mo
Anadani 2025 (case report)[5]15 cmSuccess—3 mo

In the Erickson series, patients who recurred had significantly longer strictures (12.8 vs 8.7 cm, p = 0.04); mean time to recurrence was ~ 340 days — stricture length is a key predictor of failure.[1]

Complications​

  • Stricture recurrence — the primary concern, 15–36% depending on stricture length and complexity.[1][2]
  • Urethrocutaneous fistula — ~ 6.5% in Kojovic; transient fistulas in 25% (3 / 12) in Karapanos, all healing with prolonged catheterization.[2][7]
  • Post-void dribbling — common (41.7% in some series), likely from a compliant neourethra lacking normal spongiosal support.[7]
  • Erectile dysfunction — transient ~ 2–6%; permanent ED is rare.[8][9]
  • Donor-site morbidity — oral complications from BMG harvest (numbness, tightness) typically mild and transient.[4]

Fasciocutaneous flap procedures carry a higher overall complication rate than graft-only techniques. Warner 2015 (multi-institutional, long-segment strictures): FC-flap procedures had a 32% complication rate vs 14% without flaps (p = 0.02), though success rates were similar.[10]

Comparison With Alternative Approaches​

  • Dual BMG (Palminteri dorsal + ventral; Gelman / Siegel) — most contemporary GURS surgeons (~ 90%) now prefer dual BMGs over combined graft / flap for panurethral strictures. Gelman / Siegel 2014: 94% success with circumferential dorsal + ventral BMG for obliterative strictures.[6][11]
  • Two-stage repair (Bracka, Johanson) — gold standard for complex penile strictures, especially with LS or failed hypospadias. The combined graft / flap technique offers comparable success while avoiding a second operation.[1][12]
  • BMG alone (dorsal or ventral onlay) — excellent for non-obliterative strictures. Hassan 2025 meta found no difference in success between dorsal and ventral onlay BMG (RR 1.00, 95% CI 0.94–1.06), though ventral onlay may reduce transient ED.[8]

Key Considerations​

  • Requires healthy, hairless penile skin — contraindicated in lichen sclerosus involving penile skin, after circumcision (limited available skin), or where the available skin is hair-bearing.[1][3]
  • Hair-bearing skin must not be used for substitution urethroplasty due to risks of urethral calculi, recurrent UTI, and obstruction.[3]
  • Best suited for experienced reconstructive urologists with proficiency in both graft and flap techniques.[5][12]

References​

1. Erickson BA, Breyer BN, McAninch JW. Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long-segment strictures. BJU Int. 2012;109(9):1392-1396. doi:10.1111/j.1464-410X.2011.10483.x.

2. Kojovic V, Djordjevic ML, Vuksanovic A. Single-stage repair of obliterated anterior urethral strictures using buccal mucosa graft and dorsal penile skin flap. Int J Urol. 2019;26(1):90-95. doi:10.1111/iju.13816.

3. 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.

4. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493-503. doi:10.1111/iju.13356.

5. Anadani A, Obaidin A, Badawi B, Lutfi MY. One-stage urethroplasty using a combination of buccal mucosa graft and Q penile skin flap for a complicated urethral stricture: a challenging case report. Medicine. 2025;104(12):e41888. doi:10.1097/MD.0000000000041888.

6. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139-143. doi:10.1016/j.urology.2024.06.019.

7. Karapanos L, Halbe L, Storz E, et al. Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures. Int J Urol. 2024;31(10):1095-1101. doi:10.1111/iju.15521.

8. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.

9. Shalkamy O, Elatreisy A, Salih E, et al. Erectile and voiding function outcomes after buccal mucosa graft urethroplasty for long-segment bulbar urethral stricture: ventral versus dorsal onlay technique. World J Urol. 2023;41(1):205-210. doi:10.1007/s00345-022-04220-y.

10. Warner JN, Malkawi I, Dhradkeh M, et al. A multi-institutional evaluation of the management and outcomes of long-segment urethral strictures. Urology. 2015;85(6):1483-1487. doi:10.1016/j.urology.2015.01.041.

11. Gelman J, Siegel JA. Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures. Urology. 2014;83(6):1418-1422. doi:10.1016/j.urology.2014.01.024.

12. Patterson JM, Chapple CR. Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol. 2008;53(6):1162-1171. doi:10.1016/j.eururo.2007.10.011.