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Staged BMG Urethroplasty (Female)

Staged BMG urethroplasty in females is a rarely reported, extrapolated technique adapted from the well-established male two-stage (Johanson-type) BMG urethroplasty, reserved for the most complex female urethral strictures — particularly obliterative disease, lichen sclerosus involvement, failed prior urethroplasty, or severely scarred periurethral tissue where a single-stage repair is deemed unreliable. There are no dedicated female-specific series reporting staged BMG urethroplasty as a distinct technique; the concept is derived from male reconstructive principles and applied case-by-case in women.

For the male template, see Johanson Two-Stage Urethroplasty. For single-stage female alternatives, see Female Dorsal Onlay Urethroplasty, Female Ventral Onlay Urethroplasty, and Combined Vaginal Flap + BMG.

Concept and Rationale​

In single-stage BMG urethroplasty, the graft is harvested, placed as an onlay or inlay, and the urethra is closed over it in a single operation. The graft relies on the surrounding vascular bed (periurethral fascia, vaginal wall, or Martius flap) for imbibition and inosculation.[1][2] In a staged approach, reconstruction is intentionally divided into two operations separated by a maturation interval:

  • Stage 1 — the strictured urethra is opened (or excised) and a BMG is sutured into the defect as an open plate (not tubularized). The graft matures and vascularizes in situ over 4–6 months.
  • Stage 2 — after graft maturation, the now-vascularized BMG plate is tubularized (rolled and closed) to recreate the urethral lumen.

This two-stage principle is well established in male urethroplasty, where it is the procedure of choice for complex penile strictures associated with lichen sclerosus or failed hypospadias repair.[3][4] Allowing the graft to mature on a vascular bed before tubularization theoretically improves graft survival and reduces contracture risk vs primary tubularization of a free graft.

Male Staged BMG: The Template​

The male experience provides the technical and outcomes framework from which the female staged approach is derived.

  • Palminteri 2002 — 2-stage technique in 24 men with complex bulbar strictures: BMG sutured to the left urethral mucosal-plate margin at stage 1, perineostomy closed at stage 2. 92.8% success at median 18 mo; mean Qmax 22 mL/s.[5]
  • Kozinn / Buckley / Zinman 2013 — multistage series (n = 91), the largest male staged BMG cohort. Complex anterior strictures (45% hypospadias; 32% LS). Urethrectomy with BMG replacement in staged fashion: 51/91 (56%) underwent tubularization (stage 2); 17/91 (18.7%) required revision of stage 1 (4 with ≥ 2 revisions); 7/51 (13.7%) required revision of stage 2; 90% overall success despite extreme complexity; Qmax 6.7 → 21.5 mL/s.[6]
  • Patel 2016 — three approaches for LS strictures in 79 men: single-stage BMG (75% success), 2-stage BMG (with 24% requiring stage-1 revision due to recurrent LS in the graft), and perineal urethrostomy (93%). LS can recur in the BMG itself, complicating staged reconstruction.[7]
  • Warner 2015 — multi-institutional 466 men with long-segment strictures (≥ 8 cm): second-stage Johanson recurrence 35.7% vs single-stage BMG 17.5% (p < 0.05), suggesting staging does not inherently improve outcomes and may introduce additional failure points.[8]

Indications for Staged Approach in Females​

Based on extrapolation from male principles and the limited female literature.[6][9][10][14]

  1. Obliterative urethral stricture — no urethral lumen identifiable; the entire strictured segment must be excised, leaving no native wall for single-stage graft support.[9][10]
  2. Lichen sclerosus — when LS involves periurethral / vaginal tissue, compromising the vascular bed for single-stage graft take. AUA 2023 notes LS-related strictures are best reconstructed with oral mucosa grafts and that genital skin should be avoided. Whether staging improves outcomes over single-stage BMG in female LS remains unknown. In males, a meta-analysis found one-stage BMG had a pooled recurrence rate of 10% overall (18% at ≥ 24 mo) in LS — not significantly different from non-LS overall but higher in long-term studies (OR 1.83, p = 0.05).[11][12][13]
  3. Failed prior urethroplasty with extensive periurethral scarring — when periurethral tissue is too scarred / devascularized to support a free graft in a single stage.[6]
  4. Severely compromised local tissue — vaginal atrophy, prior radiation, or extensive prior surgery depleting all local tissue options.[14]
  5. Very long or pan-urethral stricture — where reconstruction length exceeds what can be reliably supported by available vascular tissue in a single stage.

Surgical Technique (Female Adaptation)​

No standardized female-specific staged BMG technique has been formally described, but the adaptation from male principles would proceed as follows.

Stage 1​

  1. Patient positioning — lithotomy; vaginal approach.
  2. Suprapubic catheter placement — preoperatively or at stage 1 to provide urinary diversion during the maturation period.
  3. Exposure — anterior vaginal-wall incision; circumferential dissection of the strictured urethral segment.
  4. Stricture management — strictured / obliterated segment is opened ventrally along its full length (marsupialized) or completely excised if obliterative.
  5. BMG harvest — inner cheek; sized to defect length + 1 cm margins; defatted.
  6. Graft placement — BMG sutured to the edges of the opened urethral plate (or the periurethral tissue bed if the urethra was excised) as a flat open plate; not tubularized at this stage.
  7. Graft fixation — quilting sutures secure the graft to the underlying vascular bed (periurethral fascia, vaginal wall, or pubic periosteum dorsally).
  8. Wound management — graft left exposed to the vaginal / vestibular surface or covered with a light bolster; vaginal wall partially closed around graft edges.
  9. Maturation period — 4–6 months for vascularization, epithelialization, and tissue softening. Patient voids via SPC or through the open plate.

Stage 2​

  1. Assessment — matured graft inspected for vascularization, pliability, absence of contracture or LS recurrence. Unhealthy graft → stage-1 revision before proceeding.[6]
  2. Tubularization — matured BMG plate rolled over a 16–18 Fr catheter and closed with running or interrupted absorbable sutures.
  3. Reinforcement — periurethral fascia, vaginal wall, or Martius flap closed over the tubularized neourethra as a second layer.
  4. Vaginal closure — layered closure of the anterior vaginal wall.
  5. Catheter management — urethral catheter (± SPC) for 3 weeks post-tubularization.

Outcomes​

There are no published female-specific series reporting outcomes of staged BMG urethroplasty as a distinct technique.

StudyPopulationTechniquenSuccessFollow-up
Kozinn 2013[6]Male, complexMultistage BMG9190%15 mo
Palminteri 2002[5]Male, complex bulbar2-stage BMG2492.8%18 mo
Patel 2016[7]Male, LS2-stage BMG3776% (24% stage-1 revision)32 mo
Warner 2015[8]Male, long-segment2nd-stage Johanson5664.3%20 mo
Warner 2015[8]Male, long-segment1-stage BMG22382.5%20 mo
Female single-stage BMG (pooled)[1][9][15][16]FemaleVarious 1-stage BMGVariable86–98%12–38 mo

Comparison — Staged BMG vs Alternatives for Complex Female Strictures​

ApproachAdvantagesDisadvantagesBest For
Staged BMGAllows graft maturation; applicable when all local tissue compromisedTwo operations; prolonged SPC; no female-specific data; ~ 19% stage-1 revision (male data)Obliterative stricture with no viable local tissue
Combined dorsal + ventral BMG (single-stage)Single operation; augments both surfacesRequires some native urethral wall laterallyNear-obliterative stricture with residual lumen
Combined vaginal flap + BMGSingle operation; vascularized tissue supports graftRequires adequate vaginal tissueStricture with partial periurethral scarring
Bladder wall flapPedicled, well-vascularized; bridges long defectsAbdominal approach; reduces bladder capacityComplete urethral loss, bladder-neck involvement
Labia minora pedicled flap (tubularization)Maintains blood supply; single stageLimited length; requires healthy labiaModerate-length stricture with healthy labia

Advantages and Limitations​

Advantages

  • Allows graft maturation on a vascular bed before tubularization, theoretically improving survival.
  • Applicable when periurethral tissue is too scarred for single-stage graft take.
  • Avoids circumferential graft contracture seen with primary tubularized grafts.
  • Allows assessment of graft health before committing to tubularization.

Limitations

  • No female-specific evidence — entirely extrapolated from male data.
  • Two operations, with prolonged SPC dependence (4–6 mo between stages).
  • Stage-1 revision may be needed in ~ 19% of cases (male data), adding a third operation.[6]
  • LS can recur in the BMG — Patel found 24% of staged LS patients had recurrent LS in the first-stage graft.[7]
  • Single-stage BMG may be superior — Warner showed single-stage BMG outperformed staged Johanson in males even for long-segment strictures.[8]
  • Female anatomy differs — shorter urethra, proximity to the vaginal wall (a readily available vascular bed), and absence of corpus spongiosum mean the conditions necessitating staging in males (long penile strictures, LS-affected genital skin) are less commonly encountered.
  • Alternative tissue sources unique to female anatomy — vaginal and labial pedicled flaps reduce the need for staged free-graft approaches.

Position in the Female Reconstructive Algorithm​

Staged BMG urethroplasty occupies the most distal position on the female reconstructive ladder, reserved for cases where:

  1. Single-stage BMG (dorsal or ventral) has failed or is not feasible.
  2. Vaginal and labial tissue is unavailable or compromised (LS, atrophy, prior surgery, radiation).
  3. Bladder wall flap is not appropriate (no bladder-neck involvement, adequate bladder capacity must be preserved).
  4. The periurethral tissue is too scarred to support a free graft in a single stage.

In practice, the vast majority of female urethral strictures — including complex and pan-urethral disease — are managed with single-stage techniques achieving 86–98% success.[1][9][11][15] The AUA 2023 guideline recommends urethroplasty using oral mucosa grafts, vaginal flaps, or a combination, with success rates of 69–95%, without specifically addressing staged reconstruction in women.[11] The staged approach remains a theoretical option for the rare case that cannot be addressed by any single-stage technique.

Summary​

Staged BMG urethroplasty in females is a conceptual adaptation from male reconstructive urology rather than an established female-specific technique. The male literature shows ~ 90% success with staged BMG in complex cases but also that single-stage BMG often outperforms staged approaches and that ~ 19% of patients require stage-1 revision.[6][8] Given the high success rates of single-stage female BMG urethroplasty (86–98%) and the availability of alternative tissue sources (vaginal flaps, labial flaps, bladder flaps) unique to female anatomy, the need for staged BMG in women is exceedingly rare. When considered, it should be reserved for truly salvage scenarios where all single-stage options have been exhausted or are contraindicated.

See Also​

References​

1. Berdondini E, Eissa A, Margara A, et al. "Ventral Onlay Buccal Mucosa Graft Urethroplasty for Female Urethral Stricture: Medium-Term Results in a Single Surgeon Experience." Urology. 2024;193:194–200. doi:10.1016/j.urology.2024.06.045

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

3. 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

4. Patterson JM, Chapple CR. "Surgical Techniques in Substitution Urethroplasty Using Buccal Mucosa for the Treatment of Anterior Urethral Strictures." Eur Urol. 2008;53(6):1162–71. doi:10.1016/j.eururo.2007.10.011

5. Palminteri E, Lazzeri M, Guazzoni G, Turini D, Barbagli G. "New 2-Stage Buccal Mucosal Graft Urethroplasty." J Urol. 2002;167(1):130–2. PMID: 11743290

6. Kozinn SI, Harty NJ, Zinman L, Buckley JC. "Management of Complex Anterior Urethral Strictures With Multistage Buccal Mucosa Graft Reconstruction." Urology. 2013;82(3):718–22. doi:10.1016/j.urology.2013.03.081

7. Patel CK, Buckley JC, Zinman LN, Vanni AJ. "Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques." Urology. 2016;91:215–21. doi:10.1016/j.urology.2015.11.057

8. 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):1483–7. doi:10.1016/j.urology.2015.01.041

9. Jefferson FA, Lee YS, Rafetto AN, et al. "Short-Term Outcomes Following Transurethral Dorsal Buccal Graft Urethroplasty for Female Urethral Strictures." Neurourol Urodyn. 2025. doi:10.1002/nau.70161

10. Chakraborty JN, Chawla A, Vyas N. "Surgical Interventions in Female Urethral Strictures: A Comprehensive Literature Review." Int Urogynecol J. 2022;33(3):459–85. doi:10.1007/s00192-021-04906-8

11. 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

12. Chung ASJ, Suarez OA. "Current Treatment of Lichen Sclerosus and Stricture." World J Urol. 2020;38(12):3061–7. doi:10.1007/s00345-019-03030-z

13. Kurtzman JT, Blum R, Brandes SB. "One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis." J Urol. 2021;206(4):840–53. doi:10.1097/JU.0000000000001870

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

15. Khawaja AR, Dar YA, Bashir F, et al. "Outcome of Dorsal Buccal Graft Urethroplasty in Female Urethral Stricture Disease (FUSD): Our Institutional Experience." Int Urogynecol J. 2022;33(3):697–702. doi:10.1007/s00192-021-04840-9

16. Gülpınar Ö, Zumrutbas AE, Sancı A, et al. "The Outcomes of Three Buccal Mucosal Graft Urethroplasty Techniques in Women With Urethral Stricture Disease." Neurourol Urodyn. 2021;40(8):1921–8. doi:10.1002/nau.24764