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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, both adapting the male Orandi 1968 dartos-pedicled penile flap to the anterior vaginal wall.[1][2][3]

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 U-flap pulls the neomeatus posteriorly because its pedicle is proximal; this produces a retrusive meatus and an inward urinary stream.[1] A lateral pedicle:

  • Preserves the natural vascular axis of the anterior vaginal wall along the lateral pedicle.[2]
  • Keeps the meatus orthotopic with normal anterior stream direction.[1]
  • Eliminates urinary spraying reported with classic VFU (up to 29% in Higuchi 2026).[1][8]

Indications​

  • FUS refractory to dilation or DVIU.[1][4]
  • Distal, mid, or pan-urethral strictures — Simonato extended the technique to long-segment disease.[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 pelvic radiation.
  • Prior synthetic midurethral sling with periurethral scarring (Önol used Martius-reinforced ventral BMG instead in this scenario).[6]

Romero-Maroto Technique (Eur Urol 2018)​

Dorsal lithotomy, regional or general anesthesia.[1]

  1. Cystourethroscopy — confirm stricture location and length.
  2. Ventral urethrotomy — longitudinal 6 o'clock incision through the full stricture into healthy mucosa proximally and distally.
  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 — flap raised off the periurethral tissue, lateral pedicle preserved, then mobilized medially.
  5. Flap inlay — flap rotated medially into the ventral urethrotomy defect; medial and opposite edges sutured to the urethral mucosa with interrupted 4-0 / 5-0 polyglactin.
  6. Donor-site closure — primary; the lateral pedicle keeps the meatus in its orthotopic position without posterior retraction.
  7. Catheter — postoperative urethral catheter.

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

Same lateral-pedicled design, with one key technical addition:[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 and reduces fistula risk by avoiding epithelium-to-epithelium apposition.
  • 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 axisMay be compromised by midline dissectionPreserved along lateral pedicle
Meatal positionRisk of retrusiveOrthotopic
Urinary streamInward / posterior reportedNormal anterior preserved
Fistula preventionStandard suture lineDe-epithelialization of suture edges (Simonato)
Stricture lengthDistal / midDistal / mid / pan-urethral
Urinary sprayingReportedNot reported

Outcomes​

Romero-Maroto 2018 — Eur Urol[1]​

  • n = 9, mean age 56 yr (range 41–78); mean follow-up 80.7 mo (range 12–198 mo).
  • 100% symptom relief; urethral caliber 10.8 → ≥ 20 Fr; Qmax 6.8 → 21 mL/s (3-fold).
  • 0% recurrence, 0% de novo SUI, 0% fistula, 0% spraying; all neomeatuses orthotopic.

Simonato 2010 — J Urol[2]​

  • n = 6 with extensive strictures (5 mid-to-distal, 1 pan-urethral with bilateral hydronephrosis).
  • 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 elevated PVR (impaired detrusor function rather than recurrence).
  • 0% reoperation for recurrence, 0% de novo SUI, 0% fistula (attributed to de-epithelialization).

Comparative context​

SeriesTechniquenSuccessMean follow-upDe-novo SUISpraying
Romero-Maroto 2018[1]Lateral-based flap9100%80.7 mo0%0%
Simonato 2010[2]Lateral-pedicle + de-epithelialization683%70.8 mo0%0%
Hajebrahimi 2019[9]Classic U-flap (Blandy)14100% (voiding)—14%not reported
Higuchi 2026[8]VFU (various)757.1%12 mo0%29% (2/7)
Kowalik 2014[10]VFU vs dorsal BMG10VFU 60%; BMG 100%22 monot reportednot reported
Önol 2011[6]Anterior vaginal wall inlay10100% objective24 monot reportednot reported

Advantages​

  1. Orthotopic meatus — the most clinically significant gain over Blandy.[1]
  2. Preserved vascular axis along the lateral pedicle.[2]
  3. Versatility — Simonato extended the technique to long / pan-urethral disease.[2]
  4. No spraying in either reported series.[1][8]
  5. De-epithelialization (Simonato) — fistula prevention without donor-site morbidity.[2]
  6. No donor-site morbidity — same operative field.[4]

Limitations and Caveats​

  • Tiny evidence base — the two primary series total 15 patients (Level 4).[1][2]
  • Tissue-quality dependence — like all VFU techniques, requires healthy vaginal tissue.[4][5]
  • VFU vs BMG — 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] Counterpoints: Kowalik 2014 reported 0% recurrence with dorsal BMG vs 40% with VFU; Higuchi 2026 reported 87.5% (DOBMGU) vs 57.1% (VFU). These studies pooled mixed VFU techniques (not exclusively the lateral-based modification).[8][10]
  • Detrusor function — 17% (1/6 in Simonato) required CIC for elevated PVR despite a patent urethra.[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 47/49 vaginal flap reconstructions, achieving 87% continence.[13]
  • Flisser-Blaivas 2003 reported 93% anatomic success with single-stage VFU + Martius + pubovaginal sling.[14]
  • Önol 2011 used Martius-reinforced ventral BMG specifically when prior synthetic midurethral sling created periurethral scarring.[6]

When to Choose This Technique​

ScenarioRecommendedRationale
Distal / mid stricture, healthy vaginal tissueLateral-based flapOrthotopic meatus, no donor-site morbidity, durable in long-FU series[1][2]
Pan-urethral / long-segmentLateral-based (Simonato) or dorsal BMGBoth can cover length; BMG is more versatile[2][8]
LS / atrophyDorsal onlay BMGVaginal tissue unsuitable[4][5]
Prior MUS with periurethral scarringMartius-reinforced ventral BMGScarring limits flap mobilization[6]
Concern for retraction / sprayingLateral-based flapSpecifically designed to prevent both[1]

AUA 2023 frames urethroplasty success in women as 69–95% across techniques, with selection driven by surgeon experience.[7]

Postoperative Management​

  • Urethral catheter 10–21 days.[1][2]
  • Voiding trial with uroflowmetry and PVR.
  • Cystoscopy at 3–6 months.
  • Topical estrogen in postmenopausal women.[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 refined Blandy modification that specifically corrects the retrusive-meatus and inward-stream problems of the classic U-flap. With 100% success at ~ 6.7 yr (Romero-Maroto, n = 9) and 83% success at ~ 5.9 yr (Simonato, n = 6, with the de-epithelialization fistula-prevention refinement), durability appears excellent. Sample sizes remain small (n = 15 combined across both series), but the technique is a compelling option for women with healthy vaginal tissue who prefer single-stage repair without oral-mucosa donor-site morbidity.[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. PMID: 4880395.

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. 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.

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.