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Labia Minora Pedicled Flap (Female Urethroplasty)

The labia minora pedicled flap is a versatile technique for female urethral reconstruction that uses tissue from the inner aspect of the labia minora, mobilized on its native vascular pedicle, to augment or replace the strictured urethral segment. It is particularly well-suited for complex strictures, obliterative disease, and urethral loss associated with urethrovaginal fistulas.[1][2]

For foundational labial-tissue anatomy and broader applications across reconstructive urology and urogynecology, see Labia Majora Fasciocutaneous Flap and Labial Mucosa Graft.

Tissue Properties​

Labia minora tissue is considered an excellent donor source because it is hairless, wet, elastic, and well-vascularized — properties that closely mimic urethral mucosa.[3] The tissue is easily accessible within the same operative field, avoiding the need for a separate donor site (as with buccal mucosa). The main limitations are co-existing lichen sclerosus or vulvovaginal atrophy, which compromise tissue quality and future outcomes.[3]

Surgical Technique​

Two principal configurations have been described.

1. Onlay Augmentation Flap​

The pedicled labia minora flap is harvested with its vascular pedicle intact and used as a ventral or dorsal onlay to augment the strictured urethral segment — the more common application for standard stricture disease.[2][3]

2. Tubularized Neourethra​

For obliterative strictures or complete urethral loss, a flap of approximately 3 × 3.5 × 3 cm from the labia minora (or majora) is tubularized over an 18–22 Fr fenestrated silicone stent to create a neourethra. Bilateral labial flaps may be harvested and pieced together to achieve adequate length. This approach has been described via both transvaginal and transpubic access routes — the latter providing wider exposure for complex obliterative strictures secondary to pelvic fracture.[1]

Key Steps (Tubularized Technique)​

  1. Flap design on the inner aspect of the labium minus, preserving the lateral vascular pedicle.
  2. Careful dissection maintaining the subdermal vascular plexus.
  3. Tubularization of the flap over a catheter / stent.
  4. Anastomosis of the neourethra to the proximal healthy urethra and bladder neck.
  5. Interposition of a labial fat pad (Martius flap) between the neourethra and vaginal wall for additional vascular support and tissue reinforcement when needed.[4]
  6. Layered vaginal-wall closure.

Indications​

The largest comparative series (n = 44) from Xu et al. used labial pedicle flap urethroplasty in 24/44 patients with urethral stricture associated with urethrovaginal fistula — the most frequently selected technique in that cohort. Procedure selection should be based on fistula location, stricture length, and vaginal anatomy, with pedicled labial flap as the preferred technique for complex strictures.[2]

IndicationPreferred Configuration
Standard urethral stricture (non-obliterative)Onlay augmentation flap
Obliterative stricture / complete urethral lossTubularized neourethra
Urethral stricture + urethrovaginal fistulaTubularized or onlay + fistula repair
Pediatric urethrovaginal fistula (pelvic fracture)Pedicled labia minora flap

Sources: Xu 2009; Xu 2013; Bouchard 2025; Radwan 2013; Jiang 2017.[1][2][3][4][6]

Outcomes​

  • Xu 2009 transpubic tubularized technique (n = 8): Mean follow-up 48.25 mo. No postoperative complications. One patient required a single urethral dilation at 3 mo (Qmax 13 mL/s); all others voided normally after catheter removal. Transient dysuria (2) and stress incontinence (1) resolved spontaneously.[1]
  • Xu 2013 multi-technique comparison (n = 44; labial pedicle flap in 24): Anatomical success 93.2% (41/44) and functional success 90.9% (40/44) at mean 42.3 mo. Fistula recurrence in 2 (infection-driven), stricture recurrence in 1, de novo SUI in 1.[2]
  • Radwan 2013 labia minora pedicled tube + TOT sling (n = 10): Successful anatomical repair in all. Total continence in 66.6% (6/9 with follow-up). Complications: meatal stenosis (1) and transient urinary retention (2). Mean follow-up 42 mo.[4]
  • Osman SR (n = 58 pooled): Vaginal or labial flap augmentation success 91% at mean 32.1 mo, vs 80% for free grafts and 47% for dilation alone.[5]

Pedicled Flap vs Free Graft from Labia Minora​

It is important to distinguish the pedicled flap from the free labial mucosal graft:

  • The pedicled flap retains its vascular supply, an advantage for longer strictures, irradiated fields, or cases with poor surrounding tissue vascularity.[3][7]
  • The free graft (e.g., dorsal onlay labial mucosal graft) relies on imbibition and inosculation from the graft bed. The largest series (n = 204, Jena 2025) reports 93.5% success at 2 years, demonstrating excellent outcomes even without a pedicle.[8]
  • When adequate flap mobilization is not possible (prior surgery, tissue loss, atrophy), a free graft may be substituted.[3]

Advantages and Limitations​

Advantages

  • Same operative field — no second incision site.
  • Preserved blood supply — tolerates poor graft beds.
  • Hairless, elastic, mucosa-like tissue.
  • Can be tubularized for complete urethral replacement.
  • Applicable to pediatric patients.[6]

Limitations

  • Tissue quality compromised by lichen sclerosus or vulvovaginal atrophy.
  • Limited tissue volume in some patients.
  • Potential for donor-site cosmetic changes.
  • Smaller evidence base than buccal mucosal graft.[3][7]

See Also​

References​

1. Xu YM, Sa YL, Fu Q, et al. "Transpubic Access Using Pedicle Tubularized Labial Urethroplasty for the Treatment of Female Urethral Strictures Associated With Urethrovaginal Fistulas Secondary to Pelvic Fracture." Eur Urol. 2009;56(1):193–200. doi:10.1016/j.eururo.2008.04.046

2. Xu YM, Sa YL, Fu Q, et al. "A Rationale for Procedure Selection to Repair Female Urethral Stricture Associated With Urethrovaginal Fistulas." J Urol. 2013;189(1):176–81. doi:10.1016/j.juro.2012.09.005

3. Bouchard B, Campeau L. "Surgery for Female Urethral Stricture." Neurourol Urodyn. 2025;44(1):51–62. doi:10.1002/nau.25358

4. Radwan MH, Abou Farha MO, Soliman MG, et al. "Outcome of Female Urethral Reconstruction: A 12-Year Experience." World J Urol. 2013;31(4):991–5. doi:10.1007/s00345-013-1087-2

5. Osman NI, Mangera A, Chapple CR. "A Systematic Review of Surgical Techniques Used in the Treatment of Female Urethral Stricture." Eur Urol. 2013;64(6):965–73. doi:10.1016/j.eururo.2013.07.038

6. Jiang D, Chen Z, He L, et al. "Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls." Urology. 2017;103:227–9. doi:10.1016/j.urology.2017.01.002

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

8. Jena AK, Jena R, Madhavan M, Madhavan K. "Dorsal Onlay Labial Mucosal Graft Urethroplasty in Female Urethral Stricture: Outcomes of Over 200 Cases From a Single Surgeon." Urology. 2025;S0090-4295(25)00499-6. doi:10.1016/j.urology.2025.05.040