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Labia Minora Pedicled Flap (Female Urethroplasty)

The labia minora pedicled flap is a 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. Reports have concentrated on complex strictures, obliterative disease and urethral strictures with associated urethrovaginal fistulas.[1][2]

For a different genital flap and its anatomy, see Labia Majora Fasciocutaneous Flap. Oral-lip mucosal grafts are a separate donor category.

Tissue Properties​

Labia minora tissue is considered a suitable 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.[3] The EAU 2026 review includes 12 labia-minora and 17 vestibular flap repairs. At mean/median follow-up of 6–15 months across the two series, 12/12 labia-minora flap patients and 15/17 vestibular flap patients were stricture-free; neither small series reported adverse effects.[8]

A tunneled transfer route for this configuration has been described: the urethra is exposed through an anterior vaginal-wall incision, a rectangular island is marked on the inner aspect of the labium minus, and an ipsilateral urethrotomy is extended from the meatus into healthy, nonfibrotic tissue. Stay sutures at the flap's upper edge draw the island through a tunnel beneath the vaginal wall to the urethrotomy, where its epithelial surface is sutured inward to the urethral edges before the labial donor site is closed. The vascular basis of this pedicle is not well defined, and the describing authors report flap necrosis in a small subset of their own cases.[10]

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. Transpubic access gives wider exposure for complex obliterative strictures secondary to pelvic fracture.[1][2]

Key Steps (Tubularized Technique)​

  1. Assess bladder-neck integrity and continence needs, then design the flap on the inner aspect of the labium minus while preserving its lateral vascular pedicle. In Radwan's total-loss series, nine of ten women received a concurrent transobturator sling; the woman with an intact bladder neck did not.[4]
  2. Careful dissection maintaining the subdermal vascular plexus.
  3. Tubularization of the flap over a catheter / stent.
  4. Anastomosis of the neourethra to the remaining healthy proximal urethra when present, or to the bladder when the urethra is absent.[1][4]
  5. In a tubularized labial repair such as Radwan's,[4] a separate Martius labial fat-pad flap may be interposed between the neourethra and vaginal closure when scarred tissue or fistula repair needs vascularized coverage.[11]
  6. Layered vaginal-wall closure.
  7. Postoperative drainage and leak assessment: Radwan used urethral and suprapubic catheters, removed the urethral catheter after two weeks, and obtained a voiding cystourethrogram through the suprapubic tube. The suprapubic tube was removed after satisfactory voiding without extravasation.[4]

Indications​

The EAU 2026 guideline recommends urethroplasty for women with a second recurrence of female urethral stricture who cannot perform intermittent self-dilatation or wish definitive treatment .[8] Technique selection depends on surgeon experience, graft or flap availability and quality, and the quality of the ventral versus dorsal urethra.[8] Xu et al. reported 44 women with urethral stricture associated with urethrovaginal fistula. Labial pedicle flap urethroplasty was the most frequently used technique (24 of 44 patients). The authors conclude that procedure selection should be based on fistula location, stricture length and vaginal anatomy, that a transvaginal approach may be optimal when the vagina is wide and easily dilated, and that the pedicle labial flap is a reliable technique for complex strictures.[2]

IndicationConfiguration Described
Selected distal non-obliterative urethral stricture with adequate labial widthOnlay augmentation flap described in a two-patient labia-minora series; a long tunneled flap may compromise tip perfusion.[9][10]
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][5]

Outcomes​

  • Xu 2009 transpubic tubularized labial flaps (minora or majora; n = 8): Mean follow-up was 48.25 months (range 10–118). One woman required urethral dilation at three months (Qmax 13 mL/s); the others voided normally after catheter removal. Transient dysuria in two and SUI in one resolved spontaneously; no other postoperative complications were reported.[1]
  • Xu 2013 multi-technique cohort (n = 44; labial pedicle flap in 24): Across all five procedures, anatomical success was 41/44 (93.2%) and functional success was 40/44 (90.9%) at mean 42.3 months. Two fistulas recurred in association with infection, one stricture developed, and one woman developed de novo SUI.[2]
  • Radwan 2013 labia minora pedicled tube (n = 10; post-traumatic total urethral loss): Nine women received a concomitant TOT sling; the woman with an intact bladder neck did not and was lost to follow-up. The authors reported anatomical repair in all ten. Of the nine women followed, six were totally continent, one partly continent (one or two pads/day), and two had continence failure. One meatal stenosis required meatotomy, and two women required temporary intermittent catheterization for postoperative retention. Mean follow-up was 42 months among all 15 women followed in both repair groups.[4]
  • Jiang 2017 labia minora skin flap (n = 4 girls; urethrovaginal fistula after pelvic fracture): Mean follow-up 27 mo. All voided well with normal urinary control, and 1 had a recurrent fistula.[5]
  • Tanello 2002 pedicled labia-minora island-flap onlay (n = 2; posttraumatic and postinflammatory stricture): Both women voided normally after repair, and cystourethrography at 24 months showed a normal urethral silhouette without residual urine.[9]
  • Osman 2013 systematic review (all retrospective case series): Vaginal or labial flap augmentation had a mean success rate of 91% at 32.1 mo (58 patients). Vaginal or labial graft augmentation had 80% (25 patients, 22 mo), oral mucosal augmentation 94% (32 patients, 15 mo) and urethral dilation 47% (107 patients, 43 mo).[6]
  • Free labial grafts (Rehder dorsal, Tahra ventral; 30 women): At 24 months, 6/8 in Rehder's series had no stricture recurrence; at median 37 months, 20/22 in Tahra's series met its cure criterion (Qmax >15 mL/s and no further intervention).[8][12][13] The latter series reported transient urgency urinary incontinence in 8/22, resolving within six months.[8][12]

Pedicled Flap vs Free Graft from Labia Minora​

The pedicled flap differs from the free labial mucosal graft:

  • The pedicled flap retains its own vascular supply, which is the rationale for using it in a poorly vascularized bed. Comparative data are lacking.[3][7]
  • A free graft loses its native pedicle and depends on revascularization from a healthy recipient bed.[3]
  • When an adequate pedicled flap cannot be mobilized, a free labial or vaginal graft may be considered if local donor tissue is healthy. Lichen sclerosus or vaginal atrophy can limit genital-tissue use; buccal mucosa grafting may be needed for more severe stricture.[3]

Advantages and Limitations​

Advantages

  • Same operative field, no second incision site.
  • Preserved blood supply, which may help in a poorly vascularized bed.
  • Hairless, elastic, mucosa-like tissue.
  • Can be tubularized for complete urethral replacement.
  • Used in young girls with post-traumatic urethrovaginal fistula.[5]

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​

Videos​

Modified Martius Flap Urethroplasty: Inner Labial Skin Island
Rust and Twiss, AUA video session

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. 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

6. 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

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. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Females (limited update 2026), section 7.3.2. Guideline

9. Tanello M, Frego E, Simeone C, et al. "Use of Pedicle Flap From the Labia Minora for the Repair of Female Urethral Strictures." Urol Int. 2002;69(2):95-98. doi:10.1159/000065554

10. Dalela D, Lohani R. Labial and Vaginal Flaps for Female Urethroplasty. In: Khattar N, Nayyar R, Panda A, eds. Female Bladder Outlet Obstruction and Urethral Reconstruction. Springer; 2021:189-200. doi:10.1007/978-981-15-8521-0_18

11. Wilson A, Pillay S, Greenwell T. "How and Why to Take a Martius Labial Interposition Flap in Female Urology." Transl Androl Urol. 2017;6(Suppl 2):S81–S87. doi:10.21037/tau.2017.04.38

12. Tahra A, Sobay R, Küçük EV. "Quality of Life Is Improved After Urethroplasty in Women With Urethral Stricture." Int Urogynecol J. 2022;33(3):597–603. doi:10.1007/s00192-021-05026-z

13. Rehder P, Glodny B, Pichler R, Exeli L, Kerschbaumer A, Mitterberger MJ. "Dorsal urethroplasty with labia minora skin graft for female urethral strictures." BJU Int. 2010;106(8):1211–1214. doi:10.1111/j.1464-410X.2010.09240.x