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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 permits grafts, flaps, or combinations for long, multi-segment strictures (Moderate Recommendation, Grade C); this is not a technique-specific endorsement of the Erickson operation.[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 respondents preferred multiple BMGs over combined graft / flap for panurethral strictures; this does not specifically mean dorsal-plus-ventral grafting. There were 134 respondents among 350 invited surgeons — 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 flapThe original Erickson operation uses a distal circumferential penile fasciocutaneous flap, opened into a strip. Kojovic uses a longitudinal dorsal penile-skin flap transposed ventrally. Preserve the vascular pedicle and join flap margins to graft/native urethral margins as appropriate
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​

SeriesEvaluated nStricture lengthReported outcomeFollow-up
Erickson 2012[1]14Mean 9.75 cm; mean circumferential replacement 5.4 cm9/14 without further intervention; 11/14 after allowing one endoscopic treatmentMedian 2.5 yr
Kojovic / Djordjevic 2019[2]46 of 51 operatedMean 5.2 cm39/46 patent (84.8%); 36/46 successful voiding (78.3%) when three fistulas also countedMean 49 mo
Karapanos 2024 (modification)[7]12Median 5 cm11/12 successful (91.7%); three transient fistulasMedian 38 mo
Anadani 2025 (case report)[5]15 cmEarly reported success; insufficient for a durability estimate3 mo

These are small, uncontrolled series with different operations and endpoints; they do not establish equivalence to staged reconstruction. Erickson reported longer strictures among the five initial failures (12.8 vs 8.7 cm, p = 0.04), an exploratory association in a 14-patient cohort.[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]
  • Sexual outcomes — reliable technique-specific ED estimates are unavailable from these small series. Rates from isolated dorsal/ventral BMG onlay studies should not be transferred to circumferential graft-plus-flap reconstruction.
  • Donor-site morbidity — oral complications from BMG harvest (numbness, tightness) typically mild and transient.[4]

In Warner 2015, a retrospective multicenter cohort of 466 strictures at least 8 cm long, flap procedures were associated with 32% complications vs 14% without flaps (p = 0.02). Differences in case complexity and procedure selection limit causal comparisons.[9]

Comparison With Alternative Approaches​

  • Dual BMG (Palminteri dorsal + ventral; Gelman / Siegel) — Gelman / Siegel reported 94% initial success in 18 patients, with one additional patient successfully treated by DVIU. This technique requires preserved spongiosum to support the ventral graft; these results do not establish superiority over a vascularized flap.[10]
  • Two-stage repair (Bracka, Johanson) — an option when the plate or local tissues cannot support a single-stage repair. Choice depends on tissue quality, previous repairs, and patient preferences; comparable success of the combined operation has not been established in a controlled trial. Genital skin flaps should not be used for LS-related reconstruction.[1][11]
  • 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 — avoid genital skin for LS-related strictures or if available skin is diseased/hair-bearing. Circumcision alone is not an absolute contraindication; assess the remaining skin and its vascularity.[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][11]

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. 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.

10. 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.

11. 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.