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Combined Vaginal Flap + BMG Urethroplasty (Female)

Combined vaginal epithelial flap and BMG urethroplasty would use a pedicled vaginal mucosal flap and a free buccal mucosal graft in the same repair. The AUA Urethral Stricture Disease Guideline Amendment (2023) states that surgeons may reconstruct female strictures using oral mucosal grafts, vaginal flaps or a combination of these techniques . The guideline reports success rates of 69–95% across these approaches.[1]

Concept and Rationale​

Most female urethral strictures are managed with a single tissue source, either a vaginal flap or graft or a BMG alone. Selection between a vaginal flap and BMG depends on stricture severity, local tissue quality, and anatomy.[2][3] The cited pairings use periurethral fascia or Martius fat as BMG coverage, or BMG after a prior vaginal-flap repair; none documents simultaneous vaginal epithelial flap plus BMG augmentation.[4][5][6]

  • Vaginal flap. A vaginal flap is well vascularized, is readily available in the same operative field and allows a dorsal or ventral urethroplasty. Coexisting lichen sclerosus or vaginal atrophy may compromise the tissue.[2]
  • BMG. BMG is non-hair-bearing oral donor tissue that avoids diseased genital skin, including tissue affected by lichen sclerosus or vaginal atrophy. It still requires a viable recipient bed and can fail or develop recurrent disease.[2]

Clinical Configurations​

1. Ventral BMG with Periurethral Fascial Flaps​

Ventral BMG with periurethral fascial flaps is a distinct configuration. The flaps are fascia, not vaginal epithelial flaps. In the ventral onlay BMG technique of Berdondini et al. (n = 42, single surgeon), a longitudinal incision is made through the anterior vaginal wall and the periurethral fascia is incised to create two flaps. The ventral urethrotomy runs from the meatus into healthy proximal urethra. The BMG is sutured to the urethral mucosal margins and to the fascial flaps, and the vaginal wall is closed. At a mean follow-up of 38.1 mo, 41 of 42 patients (98%) were stricture-free. The authors consider the periurethral fascia a vascular and mechanical support for the graft.[4]

2. Martius Flap–Reinforced Ventral BMG Onlay​

Önol et al. described a Martius flap–reinforced ventral BMG onlay in 2 of 17 patients with prior synthetic midurethral slings. The BMG provides the mucosal lining, and a Martius (labial fat pad) flap is interposed for a vascular bed and reinforcement.[5] See Female Ventral Onlay Urethroplasty — Martius-Reinforced Variant for the canonical operative description.

3. Sequential or Staged Vaginal Flap → BMG for Recurrent Stricture​

Blaivas et al. reported 9 women who underwent vaginal flap urethroplasty. There was no recurrence at a minimum of 1 year, but 2 strictures recurred at 5.5 and 6 years.[6] Both women received a BMG and were stricture-free 12–15 months later; separately, the authors report 100% success at 1 year and 78% at 5 years for urethroplasty in their selected series.[6]

Limits of the Combination Label​

A periurethral fascial flap, a vaginal epithelial flap and a Martius labial fat-pad flap are different tissues, so fascial coverage of a BMG or Martius interposition is not a vaginal-flap-plus-BMG augmentation. Salvage BMG after a previous vaginal repair is a sequence of operations, not a single combined procedure.

A two-surface reconstruction has been described with BMG alone. In the transurethral dorsal inlay series of Jefferson et al. (n = 21), 2 patients with obliterative strictures received combined dorsal and ventral inlay grafts.[7] The AUA guideline permits combinations of techniques but does not describe a segmental or two-surface vaginal flap plus BMG operation. No source cited here gives a step-by-step operation that combines a dorsal vaginal flap with a ventral BMG. A directly documented technique suited to the defect is the safer basis for operative planning.[1][4][5]

Outcomes​

No series cited here isolates simultaneous vaginal epithelial flap plus BMG reconstruction as a distinct cohort. The EAU 2026 guideline likewise reports vaginal-flap and oral-graft outcomes in separate categories, without a combination-specific success estimate.[12] The series below report BMG sutured to periurethral fascial flaps, Martius-reinforced BMG, or BMG salvage after a prior vaginal-flap repair; none provides an outcome estimate for a simultaneous vaginal epithelial flap plus BMG repair.

StudyConfigurationnFollow-upSuccess
Önol 2011[5]Martius-reinforced ventral BMG2 (of 17)median 24 mo17/17 objective cure across all techniques; no Martius subgroup estimate
Gul 2026[11]Martius-reinforced ventral BMG; selected analysis overlapping an earlier center cohort13 analyzed (18 evaluated)median 30 mo (IQR 12–30)No surgical failure, recurrent stricture or new incontinence reported among 13
Blaivas 2012[6]Sequential VFU → BMG salvage2 of 9 VFU recipients (17 women total)12–15 mo post-BMG2/2 stricture-free after salvage
Berdondini 2024[4]Ventral BMG + periurethral fascia flaps; complete urethral obstruction excluded42mean 38.1 mo98% (41/42)
AUA 2023[1]Oral mucosa, vaginal flap, or combination (range across studies)—variable69–95%

Selecting Tissue and Coverage​

The urethral lining and the vascularized coverage are chosen separately. Adequate oral mucosa may reconstruct a long stricture without a second lining tissue. Scarred or deficient periurethral tissue may call for additional vascularized coverage, and unhealthy vaginal tissue can limit a vaginal flap. Extent of disease, recipient viability, prior surgery and continence goals guide the plan. No validated hierarchy assigns a named combination to each scenario.[1][2]

Comparative Evidence — BMG vs Vaginal Tissue (Single-Tissue)​

A 2025 meta-analysis (Kumar et al., 18 studies) compared BMG with vaginal-wall free graft, not vaginal-flap-plus-BMG repair. It found no significant differences in reported success (86.2% versus 89.8%), Qmax (23.3 versus 24.9 mL/s), or PVR (14.7 versus 23.0 mL); its success definition combined Qmax >15 mL/s at 3 months, PVR <30 mL, and improvement in AUA symptom score.[8] Heterogeneity was I² = 0% for Qmax and success rate and high (I² > 50%) for PVR. The included studies were retrospective, prospective and comparative cohorts.[8] The authors conclude that graft choice should rest on graft availability, patient characteristics and surgeon preference and expertise.[8]

When vaginal flap (pedicled) is compared directly to dorsal BMG (free graft), Higuchi et al. (retrospective, 15 women) reported success of 87.5% (7/8) for dorsal onlay BMG versus 57.1% (4/7) for vaginal flap at median 12 mo.[9] The vaginal flap was mainly used for distal strictures, whereas BMG was used in any segment, including pan-urethral disease. Urinary spraying was reported in 2/7 vaginal-flap recipients and 0/8 dorsal-BMG recipients at a median follow-up of 12 months for the whole cohort.[9] Kowalik et al. retrospectively reviewed 10 women, nine with stricture and one with a traumatic urethral laceration. Recurrent stricture requiring dilation occurred in 2/6 vaginal-flap recipients and 0/4 dorsal-BMG recipients.[10][12]

Advantages and Limitations​

Advantages

  • Allows oral mucosa to supply urethral lining while periurethral fascia or a Martius flap provides separate vascularized coverage in the documented configurations.[4][5]
  • Provides vascular support for free-graft take.
  • When vaginal mucosa is compromised, oral mucosa can provide the lining; a vaginal epithelial flap may be unsuitable even if separate vascularized fascial or Martius coverage is available.[2]
  • In selected obliterative strictures, two-surface reconstruction has been reported with BMG on both surfaces (2 of 21 women).[7]
  • Salvage option when single-tissue repair fails.

Limitations

  • Greater surgical complexity and operative time.
  • Additional dissection depends on the configuration: periurethral fascia beneath the vaginal wall or a labial Martius fat pad, alongside oral BMG harvest.[4][5]
  • Urethrovaginal fistula. A technical review identifies sparse ventral muscular tissue and overlapping urethral and vaginal suture lines as fistula concerns after ventral reconstruction. Its authors advise a low threshold for Martius interposition when ventral local tissue is poor; this is expert guidance, without a quantified risk reduction.[13]
  • Limited evidence base as a distinct technique.
  • Potential donor-site morbidity at both sites.
  • Vaginal narrowing if excessive tissue harvested.
  • No standardized technique description.
  • New-onset urinary incontinence was reported in 15/161 vaginal-flap recipients (series mean/median follow-up 10–80.7 mo), and new-onset stress urinary incontinence in 8/247 ventral oral-graft recipients (series mean/median follow-up 6–38.1 mo).[12]

Summary​

The combined vaginal flap and BMG approach is a reconstructive principle and has no single standardized technique. The reported variants address different operative problems: periurethral fascia supports ventral BMG, a Martius flap reinforces BMG in selected women with prior sling surgery, and BMG has been used after recurrence following vaginal-flap repair.[4][5][6] The AUA 2023 guideline allows combinations alongside single-tissue approaches, and the AUA's 69–95% range across studies does not give a distinct success rate for each combination.[1] The cited reinforcement configurations are BMG augmentation with periurethral fascia or a Martius labial fat pad (Berdondini ventral onlay, 41/42; Önol Martius-reinforced ventral BMG, 2 of 17 patients; objective cure was 17/17 across the full cohort).[4][5]

See Also​

References​

1. 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

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

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

4. 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

5. 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):1318–24. doi:10.1016/j.urology.2011.01.017

6. Blaivas JG, Santos JA, Tsui JF, et al. "Management of Urethral Stricture in Women." J Urol. 2012;188(5):1778–82. doi:10.1016/j.juro.2012.07.042

7. 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

8. 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

9. 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

10. Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. "Intermediate Outcomes After Female Urethral Reconstruction: Graft vs Flap." Urology. 2014;83(5):1181–5. doi:10.1016/j.urology.2013.12.052

11. Gul D, Uysal B, Atik YT, et al. "Ventral onlay buccal mucosa graft urethroplasty for female urethral stricture improves female sexual functions." Int J Impot Res. 2026;38(4):296–301. doi:10.1038/s41443-023-00743-z

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

13. 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