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Lateral-Based Anterior Vaginal Wall Flap (Romero-Maroto / Simonato)

The lateral-based anterior vaginal wall flap urethroplasty is a modification of the classic Blandy U-flap developed specifically to address the retrusive-meatus and inward-stream problem of the proximal-pedicled design. The lateral-based variant was described independently by Romero-Maroto 2018 and Simonato 2010, and both were inspired by the male Orandi technique (1968). The EAU 2026 update classifies these repairs as lateral C flaps.[1][2][3][16]

For the broader female-stricture treatment ladder, see Female DVIU and Urethral Dilation, Distal Urethrectomy with Advancement Meatoplasty, Female Dorsal Onlay BMG, and Ventral Onlay BMG.

Rationale — Why a Lateral Pedicle​

The Blandy technique produced a retrusive meatus and an inward urinary stream in the Romero-Maroto patients, and the proximal pedicle is the presumed cause.[1] A lateral pedicle has the following aims:

  • It preserves the vascular axis of the anterior vaginal wall along the lateral pedicle.[2]
  • It keeps the meatus orthotopic, with normal anterior stream direction.[1]
  • Spraying remains unquantified for the lateral-based flap: Romero-Maroto assessed stream direction, while Higuchi reported spraying in 2/7 women with an unspecified vaginal-flap subtype.[1][8]

Indications​

  • FUS refractory to dilation or DVIU is one indication for reconstruction.[1][4] AUA 2023 statement 26 permits vaginal-flap reconstruction; its discussion advises offering urethroplasty for FUS given low endoscopic efficacy.[7] EAU 2026 recommends initial dilation and urethroplasty at second recurrence if ISD is unsuitable or definitive repair is desired .[7][16]
  • Distal, mid, or pan-urethral strictures. Romero-Maroto treated three pan-urethral strictures among nine women; Simonato treated five mid-to-distal strictures and one with proximal extension.[1][2]
  • Healthy, well-estrogenized anterior vaginal wall (no LS, no severe atrophy).[4][5]

Contraindications​

  • LS or vaginal atrophy compromising flap quality.[4][5]
  • Prior radiation involving the proposed flap tissue may limit its suitability if the vaginal mucosa is unhealthy or lacks pliability; assess local tissue quality.[5]
  • Prior sling-related periurethral scarring may limit local flap mobilization. In Önol's series, two women with prior synthetic midurethral slings received Martius-reinforced ventral BMG instead.[6]

Romero-Maroto Technique (Eur Urol 2018)​

Dorsal lithotomy, regional or general anesthesia.[1]

  1. Map the stricture and secure access. Use VCUG to define site and length; cystourethroscopy can confirm the stricture when urethral caliber exceeds 14 Fr. Before the vaginal incision, pass an 8-Fr Foley catheter or, if it will not pass, a guidewire.[1][17]
  2. Vaginal exposure and ventral urethrotomy. Make a midline anterior vaginal wall incision and mobilize the wall on the chosen side while preserving vascularity. Then incise the urethra at 6 o'clock from the meatus until the proximal stricture is fully open. When the meatus is not strictured, carry the flap only to the distal stricture limit.[1]
  3. Lateral flap design. Rectangular or trapezoidal anterior-vaginal-wall flap outlined lateral to the urethra, with the vascular pedicle based laterally (Orandi analog).
  4. Flap elevation. Select a rectangular segment of anterior vaginal wall matched to stricture length and caliber. Mobilize the outer border while preserving a wide axial vascular pedicle. Waterloos and Verla describe deep medial periurethral and superficial lateral submucosal dissection, sufficient pedicle mobilization, and careful bipolar hemostasis to preserve vascularity; Romero-Maroto's inset does not require tunneling or flap rotation.[1][17] 5.[2] Flap inlay. Suture the inner vaginal-flap edge to the ipsilateral urethrotomy margin with interrupted 3-0 polyglactin. Turn the outer edge around and suture it to the contralateral margin without rotating or tunneling the flap.[1]
  5. Donor-site closure. Primary; the lateral pedicle keeps the meatus in its orthotopic position without posterior retraction.
  6. Catheter. Postoperative urethral catheter.

Illustrated steps of the lateral vaginal wall flap urethroplasty

Lateral vaginal wall flap ("Orandi flap") urethroplasty: (a) longitudinal midline incision of the anterior vaginal wall; (b) ventral stricturotomy; (c) mobilization of the lateral vaginal wall flap; (d) suturing the medial surface of the flap to the ipsilateral side of the urethra; (e) turning the mucosal surface of the flap toward the urethral lumen and suturing its lateral side to the contralateral side of the urethra; (f) completed closure. From Waterloos M, Verla W. Biomed Res Int. 2019;2019:6715257, Figure 7 (CC BY 4.0).[17]

Simonato Technique (J Urol 2010) — De-Epithelialization Refinement​

Simonato also used a lateral vascular pedicle, but inverted the flap apex onto itself and partially de-epithelialized the suture-bearing area; Romero-Maroto inset the flap without this inversion.[1][2]

  • Partial de-epithelialization of the flap edges where sutures are placed. The exposed submucosal connective tissue promotes scar (cicatrix) formation at the suture line, which Simonato designed to avoid fistula formation.
  • Allows reconstruction of long segments including pan-urethral strictures.

Lateral-Based Flap vs Classic Blandy U-Flap​

FeatureClassic Blandy U-FlapLateral-Based Flap (Romero-Maroto / Simonato)
Pedicle orientationProximalLateral
Vascular axisProximal pediclePreserved along lateral pedicle
Meatal positionRisk of retrusiveOrthotopic
Urinary streamInward / posterior reportedNormal anterior preserved
Fistula-related designStandard suture lineSimonato de-epithelialized the flap near the sutures to favor cicatrix formation; prevention was not compared[2]
Stricture lengthDistal / midDistal / mid / pan-urethral
Urinary sprayingNo classic U-flap estimate from the cited studies; Higuchi did not specify VFU subtype[8]No distinct spraying endpoint in Romero-Maroto; not reported in Simonato's abstract[1][2]

Outcomes​

Romero-Maroto 2018 — Eur Urol[1]​

  • Nine women underwent repair; eight returned for a later medical review, and one died after an earlier review. The cross-sectional study included chart review. Mean age was 56 years (range 41–78), and mean reported follow-up was 80.7 months (range 12–198).[1]
  • 100% symptom relief; urethral caliber rose from 10.8 to ≥ 20 Fr; Qmax rose from 6.8 to 21 mL/s (3-fold).[1]
  • No recurrence, de novo SUI, or fistula was reported in nine women; all neomeatuses remained orthotopic without a reported change in stream direction. Spraying was not measured separately.[1]

Simonato 2010 — J Urol[2]​

  • n = 6 with extensive strictures (5 involving the middle and distal urethra, 1 also involving the proximal urethra with bilateral hydronephrosis).[2]
  • Mean follow-up 70.8 mo.
  • Normal micturition in all after catheter removal; 5/6 (83%) required no further treatment; 1/6 (17%) required CIC for significant residual urine.[2]

Comparative context​

SeriesTechniquenSuccessMean follow-upDe-novo SUISpraying
Romero-Maroto 2018[1]Lateral-based flap9No recurrence reported80.7 mo0/9Not separately reported
Simonato 2010[2]Lateral-pedicle + de-epithelialization65/6 (83%) needed no further treatment; 6/6 voided normally after catheter removal70.8 mo——
Hajebrahimi 2019[9]Tubularized anterior vaginal U-flap with dorsal urethrotomy1414/14 voiding LUTS improved or cured—14% (2/14) postoperative SUI; new onset not specifiednot reported
Higuchi 2026[8]VFU74/7 (57.1%) cystoscopic absence of re-stricture without secondary intervention12 mo (median, whole 15-patient series; VFU-only follow-up not reported)1 in whole series (group not stated)29% (2/7)
Kowalik 2014[10]VFU vs dorsal BMG102 VFU recurrences; none after BMG—not reportednot reported
Önol 2011[6]Anterior vaginal wall inlay (10 of 17) and other techniques17100% objective (all 17)24 mo (median)not reportednot reported

Advantages​

  1. Orthotopic meatus. This is the main reported gain over the Blandy flap.[1]
  2. Preserved vascular axis along the lateral pedicle.[2]
  3. Versatility. Simonato extended the technique to long or pan-urethral disease.[2]
  4. Stream direction. Romero-Maroto reported an orthotopic meatus and unchanged stream direction in nine women; spraying was not assessed separately.[1] 5.[2] De-epithelialization (Simonato). The author partially de-epithelialized the flap at the suture line to encourage cicatrix formation and avoid fistula.[2]
  5. No oral donor-site morbidity. The vaginal donor site still has wound and scarring risks.[4]

Limitations and Caveats​

  • Small evidence base. The two primary series total 15 patients (Level 4). The EAU 2026 update lists 47 women treated with a lateral C flap across two studies, and its pooled vaginal flap data (161 women) show 81.4% patency (range 67–100%) and new-onset urinary incontinence in 9.3%.[1][2][16]
  • Tissue-quality dependence. Like all VFU techniques, requires healthy vaginal tissue.[4][5]
  • Vaginal graft versus flap distinction. Kumar 2025 SR / meta of 18 studies found no significant difference in success between BMG (86.2%) and vaginal-wall graft (89.8%), Qmax, or PVR.[11] Separately, Kowalik 2014 (10 women) reported two recurrences after VFU and none after dorsal BMG, and Higuchi 2026 reported 87.5% (DOBMGU) versus 57.1% (VFU).[10][8] In a 2025 multicenter cohort of 165 women, 2-year stricture-free survival was 73% after ventral onlay flap (17 women), 86% after ventral onlay graft (115), and 80% after dorsal onlay graft (33), without a significant between-group difference; median follow-up was 29 months.[19] Flap subtype was not specified, and prior radiotherapy predicted recurrence in the full cohort.[19]
  • Residual urine. One of 6 women in Simonato's series required CIC for significant residual urine.[2]

Martius Adjunct​

The Martius labial fat-pad flap can interpose vascularized tissue between the urethral repair and the vaginal closure, particularly when tissue quality is suspect or fistula risk is elevated.[12][13][14]

  • Malde 2017 reviewed Martius use in female urology (12 women in the urethroplasty subset).[12]
  • Blaivas-Heritz 1996 used Martius in 47 of 49 women with urethral or vesical neck damage, with a pubovaginal sling in 41. Continence was achieved in 87% at 1 to 11 years.[13]
  • Flisser-Blaivas 2003 reported 93% anatomic success by a single vaginal flap procedure in 72 women (56 with a concomitant pubovaginal sling), median follow-up 1.5 years.[14]
  • Önol 2011 used Martius-reinforced ventral BMG specifically when prior synthetic midurethral sling created periurethral scarring.[6]

When to Choose This Technique​

ScenarioReconstructive optionRationale
Distal / mid stricture, healthy vaginal tissueLateral-based flapOrthotopic meatus and no oral donor site; mean follow-up 6–7 yr in two small series[1][2]
Pan-urethral / long-segmentLateral-based flap or dorsal BMGRomero-Maroto treated three panurethral strictures with a lateral-based flap; Simonato treated one stricture with proximal extension, and Higuchi treated three panurethral strictures with dorsal BMG.[1][2][8]
LS / atrophyDorsal onlay BMGVaginal tissue unsuitable[4][5]
Prior MUS with periurethral scarringMartius-reinforced ventral BMGScarring limits flap mobilization[6]
Concern for meatal retractionLateral-based flapOrthotopic meatus in 9/9 Romero-Maroto patients; spraying was not measured separately[1]

The AUA 2023 amendment states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination . It cites success of 69–95% across techniques and selection by surgeon experience.[7]

Postoperative Management​

  • Catheter and leak check. Romero-Maroto kept a urethral catheter for 3 weeks (4 weeks in one patient), and Simonato reported normal voiding after catheter removal. Waterloos and Verla describe urethrography before removal, with removal when no contrast extravasation is seen.[1][2][17]
  • Voiding trial with uroflowmetry and PVR.
  • Cystoscopy at 3–6 months.
  • Preoperative vaginal-tissue preparation (Romero-Maroto series). Two postmenopausal women received intravaginal estrogen for 3 months before surgery; flap selection depends on tissue quality.[1][5]
  • Long-term surveillance — late recurrences ≥ 5 yr have been reported with VFU generally.[15]

Summary​

The lateral-based anterior vaginal wall flap is a modification of the Blandy U-flap intended to avoid the retrusive meatus and inward stream of the classic design. Romero-Maroto reported symptom relief in all nine women at a mean of 6.7 yr, while Simonato reported that five of six women required no further treatment at a mean of 5.9 yr (with partial flap de-epithelialization).[1][2] The two original series included 15 women. A 2026 three-center retrospective series reported composite functional success in 23/24 women, with follow-up reported as 9.5 years (range 2–21.8); 4/24 had Clavien-Dindo grade I complications, with no long-term complications or de novo incontinence reported.[18] Its patients may overlap the Romero-Maroto cohort.[18] The technique is an option for women with healthy vaginal tissue who want single-stage repair without an oral-mucosa donor site.[1][2]

References​

1. Romero-Maroto J, Verdú-Verdú L, Gómez-Pérez L, et al. Lateral-based anterior vaginal wall flap in the treatment of female urethral stricture: efficacy and safety. Eur Urol. 2018;73(1):123-128. doi:10.1016/j.eururo.2016.09.029.

2. Simonato A, Varca V, Esposito M, Carmignani G. Vaginal flap urethroplasty for wide female stricture disease. J Urol. 2010;184(4):1381-1385. doi:10.1016/j.juro.2010.06.042.

3. Orandi A. One-stage urethroplasty. Br J Urol. 1968;40(6):717-719. doi:10.1111/j.1464-410x.1968.tb11872.x. PMID: 4883846.

4. Bouchard B, Campeau L. Surgery for female urethral stricture. Neurourol Urodyn. 2025;44(1):51-62. doi:10.1002/nau.25358.

5. West C, Lawrence A. Female urethroplasty: contemporary thinking. World J Urol. 2019;37(4):619-629. doi:10.1007/s00345-018-2564-4.

6. 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):1318-1324. doi:10.1016/j.urology.2011.01.017.

7. 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.

8. Higuchi M, Horiguchi A, Ashiya M, et al. Vaginal flap urethroplasty and dorsal onlay buccal mucosal graft urethroplasty for female urethral stricture: a single-center experience. Int J Urol. 2026;33(5):e70477. doi:10.1111/iju.70477.

9. Hajebrahimi S, Maroufi H, Mostafaei H, Salehi-Pourmehr H. Reconstruction of the urethra with an anterior vaginal mucosal flap in female urethral stricture. Int Urogynecol J. 2019;30(12):2055-2060. doi:10.1007/s00192-019-03910-3.

10. Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. Intermediate outcomes after female urethral reconstruction: graft vs flap. Urology. 2014;83(5):1181-1185. doi:10.1016/j.urology.2013.12.052.

11. Kumar L, Thakur A, Agarwal S, et al. Buccal versus vaginal graft urethroplasty in female urethral stricture: a systematic review and meta-analysis. Int Urogynecol J. 2025;36(11):2121-2132. doi:10.1007/s00192-025-06171-5.

12. Malde S, Spilotros M, Wilson A, et al. The uses and outcomes of the Martius fat pad in female urology. World J Urol. 2017;35(3):473-478. doi:10.1007/s00345-016-1887-2.

13. Blaivas JG, Heritz DM. Vaginal flap reconstruction of the urethra and vesical neck in women: a report of 49 cases. J Urol. 1996;155(3):1014-1017. doi:10.1016/s0022-5347(01)66372-9. PMID: 8583550.

14. Flisser AJ, Blaivas JG. Outcome of urethral reconstructive surgery in a series of 74 women. J Urol. 2003;169(6):2246-2249. doi:10.1097/01.ju.0000061763.88247.16.

15. Blaivas JG, Santos JA, Tsui JF, et al. Management of urethral stricture in women. J Urol. 2012;188(5):1778-1782. doi:10.1016/j.juro.2012.07.042.

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

17. Waterloos M, Verla W. Female urethroplasty: a practical guide emphasizing diagnosis and surgical treatment of female urethral stricture disease. Biomed Res Int. 2019;2019:6715257. doi:10.1155/2019/6715257.

18. Sarrio-Sanz P, Gómez-Perez L, López López AI, et al. "Multicentric evaluation of a lateral-based anterior vaginal wall flap for female urethral stricture repair." Minerva Urol Nephrol. 2026 Mar 16. doi:10.23736/S2724-6051.25.06533-4

19. Waterloos M, Lumen N, Ockrim JL, et al. "Diagnostics, reconstructive approaches, and outcomes in female urethroplasty patients." BJU Int. 2025;135(6):1025-1030. doi:10.1111/bju.16701