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Staged BMG Urethroplasty (Female)

Staged BMG urethroplasty in females is a rarely reported, extrapolated technique adapted from the 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 an interval that lasts several months in male series.
  • Stage 2. After graft maturation, the now-vascularized BMG plate is tubularized (rolled and closed) to recreate the urethral lumen.

The two-stage principle is used in male urethroplasty, where it is one option for adverse local tissue, severe scarring or failed reconstruction.[3][4] Allowing the graft to mature on a vascular bed before tubularization theoretically improves graft survival and reduces contracture risk versus 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. Two-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. Success was 23/24 (95.8%) at median 18 mo; mean Qmax was 22 mL/s.[5]
  • Kozinn et al. 2013 (multistage series, n = 91). A large male staged BMG cohort of complex anterior strictures (45% hypospadias; 32% LS; 55% panurethral). Urethrectomy with BMG replacement in staged fashion: 51/91 (56%) underwent tubularization (stage 2), 17 were pending closure and 23 had stage 1 only with no plan for completion. Stage 1 required revision in 17/91 (18.7%; 4 with ≥ 2 revisions) and stage 2 in 7/51 (13.7%). At a mean follow-up of 15 months, 82/91 men (90%) did not require scheduled balloon dilation or a chronic catheter; this whole-cohort endpoint includes men who had not undergone stage-2 tubularization. Mean Qmax rose from 6.7 to 21.5 mL/s.[6]
  • Patel 2016. Three approaches for LS strictures in 79 men: single-stage BMG (75% success), 2-stage BMG (9/37, 24%, had stricture recurrence or recurrent LS in the first-stage graft), and perineal urethrostomy (93%). LS can recur in the BMG itself, complicating staged reconstruction.[7]
  • Warner 2015. In 466 men with nonobliterated long-segment strictures (≥ 8 cm), recurrence was 20/56 (35.7%) after second-stage Johanson repair versus 39/223 (17.5%) after single-stage BMG (p < 0.01). The Johanson subgroup included 46 BMG repairs (13/46, 28.3% recurrence), nine skin-graft repairs, and one without a graft. Second-stage Johanson urethroplasty had higher adjusted odds of recurrence than single-stage BMG (OR 2.82, 95% CI 1.41–5.86) in this retrospective male comparison.[8]

Indications for Staged Approach in Females​

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

  1. Obliterative or near-obliterative urethral stricture. Reconstruction depends on the residual urethral tissue and available vascularized graft bed.[10] Jefferson et al. treated two women with obliterative strictures in one stage using combined dorsal and ventral BMG inlays.[9]
  2. Lichen sclerosus. Vulvar LS can compromise labial skin but does not involve vaginal mucosa.[17] AUA 2023 recommends against genital skin for reconstruction of LS-proven urethral stricture and notes that LS-related meatal and fossa navicularis strictures are more likely to be reconstructed successfully with oral mucosal grafts.[11] 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% among studies with follow-up ≥ 24 mo) in LS, which was 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. The staged-repair rationale here is extrapolated from male salvage experience.[6] In a selected nine-woman series after failed ventral repair, one-stage redo dorsal BMG met the study's success definition in 7/9 at median 18 months.[21]
  4. Severely compromised local tissue. Vaginal atrophy can limit vaginal tissue options, while radiation or prior surgery may impair the recipient bed. Assess vascularity directly: staging cannot rescue an avascular free-graft bed, and vascularized tissue may be needed. One-stage dorsal BMG has been reported in three irradiated women at 12 months.[14][18][19] 5.[15] Very long or pan-urethral stricture. A one-stage dorsal BMG series included 4/25 women with panurethral disease.[15]

Operative Planning Boundary​

The male template, as described by Palminteri and by Kozinn and colleagues, gives the general sequence.[5][6] At stage 1 the strictured segment is opened or excised and a buccal graft is sutured as an open plate onto a vascular bed, with urine diverted by a suprapubic catheter or through the open plate. Before stage 2 the graft is assessed for take, pliability, contracture and LS recurrence, and stage 1 is revised if the graft is unhealthy. At stage 2 the plate is tubularized over a catheter and covered with a second layer of vascularized tissue. For a woman, a vaginal approach with periurethral fascia, vaginal wall or a Martius flap as the graft bed is the logical adaptation, but no series describes it. A complex female defect requires individualized assessment of residual urethra, continence mechanism, vascularized tissue, fistula and drainage options by a reconstructive team.

Staging may be considered when definitive repair cannot safely be completed in one operation, but it still requires a viable graft bed. The number and timing of stages depend on tissue healing rather than a fixed four-to-six-month schedule.[2][11][14]

Outcomes​

There are no published female-specific series reporting outcomes of staged BMG urethroplasty as a distinct technique. Follow-up should assess recurrent obstruction, continence, fistula, and patient-reported voiding; Jefferson et al. assessed cystoscopic recurrence and patient-reported response at 4 and 12 months after single-stage repair.[9]

StudyPopulationTechniquenReported outcomeFollow-up
Kozinn 2013[6]Male, complexMultistage BMG91 enrolled; 51 tubularized82/91 (90%) avoided scheduled dilation or chronic catheterMean 15 mo (whole cohort)
Palminteri 2002[5]Male, complex bulbar2-stage BMG2423/24 (95.8%) without recurrent strictureMedian 18 mo
Patel 2016[7]Male, LS2-stage BMG379/37 (24%) recurrent stricture or LS in first-stage graft32 mo (mean, whole cohort)
Warner 2015[8]Male, nonobliterative long-segment2nd-stage Johanson: 46 BMG, 9 skin graft, 1 no graft5636/56 (64.3%) without recurrence overall; BMG subgroup 33/46 (71.7%)Mean 20 mo (whole 466-patient cohort)
Warner 2015[8]Male, long-segment1-stage BMG (203 dorsal; 20 ventral or double-face)22382.5% without recurrenceMean 20 mo (whole 466-patient cohort)
Female single-stage BMG (individual series)[1][9][15][16]FemaleVarious 1-stage BMGVariableReported success 83–100% across techniques; definitions differ12-mo outcome to mean 38.1-mo follow-up; durations differ by series

Comparison — Staged BMG vs Alternatives for Complex Female Strictures​

ApproachAdvantagesDisadvantagesBest For
Staged BMGAllows graft maturation and assessment of an open plate when a viable bed is availableTwo planned operations; no female-specific outcome series; stage-1 revision in 17/91 men (18.7%)[6]Selected complex defects with a viable graft bed when single-stage repair is unsuitable
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.
  • Allows interval assessment of graft maturation before tubularization when the first-stage graft has a viable vascularized bed.[5][6] A poorly vascularized bed instead favors a vascularized flap .[25]
  • Theoretically avoids the circumferential 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 planned operations, with drainage between stages determined by the reconstruction.[5][6]
  • Stage-1 revision was needed in about 19% of one male series, adding a further operation.[6]
  • Oral donor-site morbidity. Counsel about oral-graft complications; AUA 2023 reports more swelling, oral numbness, and difficulty opening the mouth after buccal than lingual harvest.[11][24]
  • LS can recur in the BMG. Patel found stricture recurrence or recurrent LS in the first-stage graft in 24% of patients planned for two-stage repair.[7]
  • Selection confounding. The Warner male cohorts had different disease complexity and treatment selection.[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. Vaginal and labial pedicled flaps, unique to female anatomy, reduce the need for staged free-graft approaches.

Position in the Female Reconstructive Algorithm​

Reasons to seek individualized reconstructive planning:

  1. Single-stage BMG (dorsal or ventral) has failed or is not feasible.
  2. Assess vaginal and labial tissue separately: vulvar LS may compromise labial tissue but usually spares vaginal mucosa; atrophy, surgery, and radiation may affect local tissue quality.[17][14]
  3. Bladder wall flap is unsuitable after assessment of defect anatomy and the donor bladder; Zhu et al. considered capacity <200 mL or significant inflammation unsuitable for their procedure.[22]
  4. Confirm a viable vascularized recipient bed before proposing a staged free BMG; if the bed is poorly vascularized, assess a vascularized flap.[20]

Published female series use single-stage techniques, with reported success of 83–100% across techniques in mostly short strictures; definitions and follow-up differ among series.[1][9][15][16] The AUA 2023 amendment states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination , reports success rates of 69–95%.[11] The 2026 EAU guideline recommends urethroplasty at a second recurrence when a woman cannot perform self-dilatation or wishes definitive treatment , with technique selected by surgeon experience and tissue quality.[23]

Summary​

Staged BMG urethroplasty in females is a conceptual adaptation from male reconstructive urology, and no female-specific technique has been established. Male series report variable success and revision burden.[6][8] A female single-stage BMG series reported success of 83.3–100% across three techniques at a median follow-up of 24.6 months[16]; vaginal, labial and bladder flaps are other described tissue options for female urethral reconstruction.[2]

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. doi:10.1016/s0022-5347(05)65397-9. 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. 2026;45(1):155-161. 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

17. Edwards SK, Lewis F, Fernando I, et al. "2024 British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions." Int J STD AIDS. 2025;36(5):346–371. doi:10.1177/09564624241311629.

18. European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer. 2026. Guideline.

19. Gupta P, Kalra S, Dorairajan LN, et al. "Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Post Radiation Female Urethral Stricture - A Technical Appraisal With Outcomes." Urology. 2021;156:321. doi:10.1016/j.urology.2021.06.006.

20. European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer. 2026. Guideline.

21. Karaburun MC, Akpınar Ç, İbiş MA, et al. "Outcomes of Redo Dorsal Onlay Buccal Mucosal Graft Urethroplasty After Failed Ventral Urethroplasty in Women." Int Urogynecol J. 2026;37(8):2629–2635. doi:10.1007/s00192-026-06630-7.

22. Zhu WD, Guo H, Xie H, et al. "Neourethra reconstruction using an anterior bladder wall flap for the treatment of complex urethral obliteration and absence." Transl Androl Urol. 2025;14(2):432–440. doi:10.21037/tau-24-443.

23. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Females. 2026. Guideline.

24. European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer. 2026. Guideline.

25. European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer. 2026. Guideline.