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Vaginal Wall Tubularization Urethroplasty (Female)

Vaginal wall tubularization urethroplasty rolls a pedicled flap of anterior vaginal wall into a tube to create a neourethra, replacing a segment of urethra that has been lost or destroyed. This is distinct from vaginal-flap onlay or inlay techniques, which augment an existing urethral lumen; tubularization creates an entirely new urethral conduit from vaginal tissue. Blaivas described tubularized vaginal reconstruction in 10 women with total or partial urethral loss. Later reports of 49 and 74 women included broader urethral and vesical-neck pathology and varied reconstructions.[1][2][3]

For related options, see Bladder Wall Flap Urethroplasty, Staged BMG Urethroplasty (Female), and Combined Vaginal Flap + BMG.

Concept and Rationale​

Vaginal wall tubularization differs from other vaginal-flap urethroplasty techniques in the degree of urethral replacement.

  • Onlay / inlay techniques. In Blandy, Orandi-type and dorsal vaginal flap repairs, the strictured urethra is incised longitudinally and a vaginal flap is sutured to the urethral edges to widen the lumen. The native urethral wall forms part of the circumference; the flap provides the remainder. Augmentation procedure.[4][5]
  • Tubularization. The damaged or absent urethral segment is replaced entirely by rolling a vaginal flap into a complete tube (360° circumference), creating a neourethra with no native urethral wall contribution. Substitution or replacement procedure.[1]

Blaivas originally proposed this technique as "an alternative to the bladder flap neourethra," arguing that vaginal tissue is more accessible, avoids the morbidity of an abdominal approach, and provides a simpler single-stage reconstruction.[1]

Historical Development​

  • Blaivas 1989. Initial description in 10 women with total or partial urethral loss and extensive vesical-neck / trigone damage from operative complications. A neourethra was constructed by rolling a vaginal flap into a tube, covered with a Martius labial fat pad graft and vaginal flap. 9/10 had a satisfactory neourethra, but 3 required generous meatotomy and 2 temporary intermittent catheterization; 6/10 were continent after a single reconstruction with anti-incontinence surgery.[1]

  • Blaivas & Heritz 1996. Expanded series of 49 women with anatomical damage to the urethra or vesical neck. 48 underwent vaginal-flap reconstruction; 47 had a Martius flap, 41 had a concomitant fascial pubovaginal sling, 5 a modified Pereyra procedure and 1 a Kelly plication. Continence in 42/49 (the abstract labels this 87%, a numerical inconsistency) after the initial procedure; 6 of 7 failures salvaged by secondary procedures.[2]

  • Flisser & Blaivas 2003. A broader mixed reconstruction series: 74 women with urethral pathology requiring reconstruction. 72 underwent vaginal-flap repairs (56 with concomitant pubovaginal sling). Successful anatomical repair in 93% by single-procedure vaginal-flap repair. Of 62 patients with preoperative incontinence, 87% considered themselves cured or improved. Follow-up 1–15 yr (median 1.5 yr).[3]

  • Sawant 2016. Seven women with complete urethral loss underwent tubularized anterior vaginal-flap reconstruction with Martius coverage and an autologous fascial sling. At median 35 months, all were catheter-free; one had mild stress incontinence and one developed stenosis managed with serial dilation. This retrospective series reports outcomes for tubularization itself.[13]

Indications​

  • Total or near-total urethral loss. Iatrogenic injury (sling complications, mesh erosion, repeated urethral surgery), trauma, or malignancy.[1][6]
  • Extensive vesical-neck and urethral damage. When any of the bladder neck, proximal urethra and trigone are destroyed and require reconstruction.[2]
  • Obliterative urethral stricture. When no functional lumen is identifiable and augmentation is not feasible, replacement of the segment is considered.[7]
  • Failed prior urethral reconstruction. When previous repairs have failed and insufficient native urethral tissue remains for augmentation.[3]

For female stricture with usable native urethral wall, onlay or inlay augmentation using a vaginal flap, buccal mucosal graft, or labial tissue preserves that wall; vaginal-wall tubularization has been described for urethral loss.[8][1][14] For female stricture, the EAU 2026 guideline recommends initial dilation to 24–41 Fr ; at first recurrence, repeat dilation with planned weekly 16–18 Fr intermittent self-dilation or planned repeat dilation ; and after a second recurrence, urethroplasty when self-dilation is unsuitable or definitive treatment is desired .[14]

Surgical Technique (Reported Tubularization Methods)​

The tubularized technique was described in the initial 10-patient report. Subsequent publications describe broader vaginal reconstruction without a shared tubularization protocol.[1][2][3]

  1. Patient positioning. Dorsal lithotomy.
  2. Assessment. Cystoscopy (if possible) and vaginal exam to define the extent of urethral loss and identify any healthy proximal urethra and the bladder neck. Assess vaginal-tissue pliability and exclude coexisting vesicovaginal or ureterovaginal fistula before flap design. In Sawant's seven-patient complete-loss series, suprapubic drainage was used until definitive management; upper-tract imaging was performed 8–12 weeks after injury, followed by preoperative panendoscopy and pelvic examination.[13]
  3. Anterior vaginal-wall incision. Inverted-U or rectangular incision over the area of urethral loss; flap width must permit tubularization without tension. In Sawant's seven-patient series, two parallel anterior vaginal incisions outlined a 4–5 cm by 1.8–2 cm flap that was tubularized over a 14 Fr Foley.[13]
  4. Flap elevation. Vaginal-wall flap raised with its vascular pedicle intact (typically based laterally or proximally). Includes the full thickness of the vaginal epithelium and underlying connective tissue.
  5. Tubularization. Roll the vaginal flap into a tube with its epithelial surface facing inward. In Sawant's seven-patient series, the flap was tubularized over a 14 Fr Foley catheter using absorbable 4-0 polyglactin sutures.[13]
  6. Proximal anastomosis. The proximal end of the tubularized neourethra is anastomosed to the healthy proximal urethra or bladder neck with interrupted absorbable sutures (watertight, mucosa-to-mucosa).
  7. Distal anastomosis. The distal end is brought to the vestibular surface to create a new meatus, or anastomosed to the remaining distal urethral stump.
  8. Martius flap interposition. A Martius labial fat pad flap is harvested from the labium majus and tunneled beneath the vaginal wall. Blaivas described coverage of the neourethral anastomosis; Sawant described Martius coverage of the neourethra as a separate layer.[1][13] Provides vascular support, a tissue barrier between the neourethra and the vaginal closure (intended to reduce fistula risk), and mechanical reinforcement.[1][2] In the 1996 series, 47/49 women received a Martius flap and one received a gracilis flap; one underwent anterior bladder-tube reconstruction instead of vaginal-flap repair.[2]
  9. Continence planning. Assess the amount of native outlet preserved, preoperative continence and obstruction risk. Many reported patients received concurrent continence surgery, but this is not mandatory for every reconstruction:
    • Fascial pubovaginal sling. Used in 41/49 patients (1996) and 56/72 patients (2003); placed over the Martius flap without tension.[2][3]
    • Modified Pereyra procedure: used in a minority; associated with higher failure rates (3/5 had postop SUI in the 1996 series).[2]
    • Kelly plication: used rarely.[2]
  10. Vaginal closure. Remaining vaginal wall closed over the Martius flap as a separate layer.
  11. Catheter management. The EAU 2026 perioperative-care chapter notes that an indwelling catheter is commonly left for 2–3 weeks after urethroplasty.[16] In Sawant's seven-patient series of complete urethral loss, the urethral catheter was removed after three weeks and the suprapubic catheter after a successful voiding trial.[13]

Orandi-Type Vaginal Flap Variant (Onlay, Not Tubularization)​

Two groups have described a vaginal-flap technique inspired by the Orandi technique, adapted for women.

  • Simonato 2010. 6 women with wide stricture disease (5 with stricture of the entire middle and distal urethra, 1 with proximal involvement and bilateral hydronephrosis) using a vaginal flap with a lateral vascular pedicle. The flap was partially de-epithelialized at the suture margins to promote cicatrix formation and prevent fistula. At mean 70.8 mo, all had normal micturition after catheter removal; 1 required intermittent self-catheterization for significant PVR.[5]
  • Romero-Maroto 2018. 9 women with a lateral-based anterior vaginal-wall flap, developed as an alternative to the Blandy technique (which caused retrusive meatus and inward urinary stream). At mean 80.7 mo (range 12–198): all had symptom relief; caliber increased from 10.8 Fr to ≥ 20 Fr; Qmax from 6.8 to 21 mL/s; there was no recurrence and no de novo SUI.[4]

These Orandi-type techniques are technically onlay or inlay rather than full tubularization; the vaginal flap replaces one wall of the urethra while the remaining native urethral wall is preserved.

Hajebrahimi U-Shaped Hybrid Tubularization​

Hajebrahimi 2019 described a hybrid technique, in a retrospective series of 14 women, that incorporates elements of both onlay and tubularization. Two parallel anterior vaginal-wall incisions around the meatus, vaginal flaps flipped up, dorsal urethra incised vertically through the stricture, distal flap end sutured to the proximal urethra, and the inner part of the flap is tubularized over a large Foley. The second layer of folded vaginal flap is sutured to native vagina. All patients improved in voiding LUTS; mean Qmax 15.82 mL/s, PVR 27.35 mL. 2 patients (14%) developed SUI (1 improved by 6 months, 1 required TOT at 12 months), and new-onset urgency and worsening urge incontinence were also reported.[9]

Outcomes​

StudynIndicationTechniqueAnatomical SuccessContinenceFollow-up
Blaivas 1989[1]10Total / partial urethral lossTubularized vaginal flap + Martius + anti-incontinence9/10 satisfactory neourethra; includes 3 requiring meatotomy60% after 1st; 80% after salvageNot specified
Blaivas / Heritz 1996[2]49Mixed urethral / vesical-neck damage48 vaginal-flap reconstructions; varied continence proceduresNot a tubularization-specific endpoint42/49 initially continent; 6/7 initial failures successfully treated secondarily1–11 yr
Flisser / Blaivas 2003[3]74 procedures; 72 vaginal-flap repairsUrethral pathology requiring reconstructionVaginal flap repair (56/72 with PVS)67/72 (93%) anatomical repair after one procedure54/62 (87%) with preoperative incontinence self-reported cure or improvement1–15 yr (median 1.5)
Simonato 2010[5]6Wide mid / distal strictureOrandi-type lateral-pedicle vaginal flapAnatomical success not reported; 5/6 required no additional treatmentNot specifically reported70.8 mo (mean)
Romero-Maroto 2018[4]9Urethral strictureOrandi-type lateral vaginal flap100% (0% recurrence)0/9 developed de novo SUI80.7 mo (mean)
Hajebrahimi 2019[9]14Urethral strictureU-shaped vaginal flap with tubularizationAnatomical success not reported; 14/14 had voiding LUTS improvement2/14 developed SUI; one improved by 6 mo, and one received transobturator tape at 12 moNot specified
Higuchi 2026[11]7 (VFU)Mainly distal urethral strictureVaginal flap urethroplasty4/7 (57.1%) without cystoscopic re-stricture or secondary interventionOne de novo incontinence event in the entire 15-patient series; arm not specified12 mo (overall median)
Kowalik 2014[12]10 (VFU or dorsal BMG)Mid / distal strictureVaginal flap urethroplasty vs dorsal BMG2 VFU recurrences; none after dorsal BMGNot reportedNot specified
Sawant 2016[13]7Complete urethral lossTubularized anterior vaginal-wall flap + Martius + autologous fascial slingAnatomical success not separately defined; 1/7 developed stenosis managed with serial dilation; all 7 were catheter-free (distinct functional endpoint)6/7 continent; 1/7 mild SUI35 mo (median follow-up)

Key Technical Considerations​

Flap design and vascularity. The determinant of success is maintaining the vascular pedicle. Configurations described:

  • Lateral pedicle (Orandi-type). Preserves the lateral vascular axis; Simonato and Romero-Maroto.[4][5]
  • Proximal pedicle. Base of the flap toward the bladder neck; Blaivas technique.[1]
  • U-shaped bilateral pedicle. Hajebrahimi, with bilateral vaginal-wall flaps maintaining lateral blood supply.[9]

De-epithelialization. Simonato specifically described partial de-epithelialization of the flap at the suture margins to promote tissue cicatrix and prevent fistula.[5]

Martius flap reinforcement. The Blaivas group used a Martius flap in nearly all cases (47/49 in the 1996 cohort), placing the pubovaginal sling over it without tension.[2] The Blaivas reports describe a neourethra covered with a Martius flap and, in many patients, a pubovaginal sling; 41/49 women in the 1996 mixed-reconstruction cohort received a fascial sling.[1][2]

Continence planning. Extensive outlet loss often requires a continence procedure, but the residual sphincter, bladder function and risk of obstruction or catheter dependence must guide selection. The Blaivas group favored the fascial pubovaginal sling over the modified Pereyra procedure (3/5 Pereyra patients had postop SUI; all subsequently cured by sling).[2]

Tubularization vs Onlay / Inlay Vaginal Flap​

FeatureTubularizationOnlay / Inlay
Urethral replacementComplete (360°)Partial (one wall)
Primary indicationTotal urethral lossStricture with preserved lumen
Native urethral wallNot requiredRequired
Anti-incontinence procedureFrequently needed with major outlet loss; individualizedBased on preoperative and postoperative continence
Martius flapUsed in nearly all Blaivas casesOptional
Continence outcomesDirect tubularization series: 6/10 continent after the initial reconstruction with anti-incontinence repair (Blaivas 1989); 6/7 reported continent after tubularization, Martius coverage and autologous sling (Sawant 2016; median follow-up 35 months)[1][13]Vary with baseline continence, technique and outcome definition
Anatomical successInitial 10-patient report: 9 satisfactory neourethras, with secondary meatotomy in 3Small heterogeneous cohorts
ComplexityHigher (tubularization + Martius + sling)Lower (single-layer augmentation)
Urinary sprayingNo comparative estimate establishedReported in some small vaginal-flap cohorts

Tubularization vs Bladder Wall Flap Neourethra​

Blaivas originally proposed vaginal-wall tubularization specifically as an alternative to the Tanagho bladder-flap neourethra.[1]

FeatureVaginal Wall TubularizationBladder Wall Flap (Tanagho)
ApproachVaginalAbdominal
Tissue sourceAnterior vaginal wallAnterior bladder wall
VascularityPedicled (vaginal blood supply)Pedicled (vesical blood supply)
Access-related considerationsAvoids an abdominal incision but adds vaginal and possible labial donor-site morbidityRequires bladder harvest and often abdominal access; no direct comparative morbidity estimate
Bladder capacityNo bladder-wall harvestBladder-wall harvest makes capacity a selection concern; Zhu et al.'s 27-patient mixed-sex retrospective series considered baseline capacity <200 mL or significant inflammation unsuitable[15]
ComplexityModerateHigher
Best forSelected urethral loss with adequate vaginal tissue, including vesical-neck damage[1]Urethral loss when local vaginal tissue is inadequate or unavailable[13]

Advantages and Limitations​

Advantages

  • Vaginal tissue is readily available, well vascularized and in the operative field. A concomitant Martius flap or autologous fascial sling adds a labial or fascial donor site, respectively.[7][13]
  • The procedure is single-stage.[1][2]
  • Avoids abdominal approach (unlike bladder flap).[1]
  • Preserves bladder capacity.[1]
  • The Blaivas group’s 74-woman mixed reconstruction series included 72 vaginal-flap repairs and reported 93% anatomical repair by a single vaginal-flap procedure.[3] In 62 women with preoperative incontinence, 54 (87%) considered themselves cured or improved.[3]
  • Vaginal tissue is hairless and suited to urethral lining.[7]

Limitations

  • Requires adequate vaginal tissue. Atrophy (postmenopausal, hypoestrogenic), prior vaginal surgery, or lichen sclerosus may compromise tissue quality and availability.[7]
  • Concurrent continence surgery may be needed, adding obstruction and catheter-dependence risks that must be discussed.[2]
  • Martius flap harvest. Used in 47/49 women in Blaivas and Heritz's mixed-reconstruction series; it adds an operative step and a labial donor site.[2]
  • Urinary spraying. Higuchi noted urinary spraying only in the VFU group (2/7), not the BMG group.[11]
  • Vaginal narrowing. Harvesting a large vaginal flap may narrow the vaginal canal.
  • Long-term recurrence. Blaivas 2012 (vaginal flap urethroplasty for stricture, n = 9) found no recurrence at a minimum of 1 yr, but 2 of 9 patients (22%) recurred at 5.5 and 6 yr, so long-term surveillance is needed.[10]
  • Small augmentation comparisons. Higuchi reported 4/7 vaginal-flap repairs and 7/8 dorsal BMG repairs free of cystoscopic re-stricture or secondary intervention at a cohort median of 12 months; flap patients mainly had distal strictures, whereas BMG patients had distal through panurethral disease. Kowalik reported two flap recurrences and none after dorsal BMG among 10 women. Neither study estimates a comparative outcome for tubularized urethral replacement.[11][12]

Position in the Female Reconstructive Algorithm​

Vaginal wall tubularization occupies a specific niche for cases of complete or near-complete urethral loss where the native urethral lumen cannot be preserved or augmented. The AUA 2023 guideline amendment states that surgeons may reconstruct female strictures with oral mucosal grafts, vaginal flaps or a combination , citing success rates of 69–95%. It does not distinguish onlay from tubularization configurations.[8] For standard urethral strictures with a preserved lumen, augmentation techniques (dorsal or ventral BMG onlay, vaginal flap onlay) are preferred over tubularization because they preserve native urethral tissue and sphincteric function. Tubularization is used when no native urethra remains to augment.

Summary​

Vaginal wall tubularization is an option for extensive female urethral loss when viable vaginal tissue is available. The initial report contained 10 women. The later 74-woman series involved mixed reconstructions, and its 87% cured-or-improved result is not complete continence after tubularization.[3] A pedicled anterior vaginal-wall flap is rolled into a tube to create a neourethra, reinforced with a Martius labial fat pad flap and, in most reported patients, combined with a fascial pubovaginal sling. The technique is indicated for total or near-total urethral loss. For female stricture with a preserved urethral wall, the EAU 2026 guideline recommends initial dilation and urethroplasty after a second recurrence when intermittent self-dilation is unsuitable or definitive treatment is desired ; onlay or inlay augmentation can preserve the native wall when urethroplasty is selected.[14] The Orandi-type lateral-pedicle variants (Simonato, Romero-Maroto) are onlay or inlay repairs, not tubularization. In Romero-Maroto's 9 women, none had recurrence at mean 80.7 mo.[4]

See Also​

References​

1. Blaivas JG. "Vaginal Flap Urethral Reconstruction: An Alternative to the Bladder Flap Neourethra." J Urol. 1989;141(3):542–5. doi:10.1016/s0022-5347(17)40887-1

2. 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):1014–7. doi:10.1016/s0022-5347(01)66372-9. PMID: 8583550

3. Flisser AJ, Blaivas JG. "Outcome of Urethral Reconstructive Surgery in a Series of 74 Women." J Urol. 2003;169(6):2246–9. doi:10.1097/01.ju.0000061763.88247.16

4. 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):123–8. doi:10.1016/j.eururo.2016.09.029

5. Simonato A, Varca V, Esposito M, Carmignani G. "Vaginal Flap Urethroplasty for Wide Female Stricture Disease." J Urol. 2010;184(4):1381–5. doi:10.1016/j.juro.2010.06.042

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

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

8. 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

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):2055–60. doi:10.1007/s00192-019-03910-3

10. 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

11. 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

12. 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

13. Sawant A, Kasat GV, Kumar V, et al. "Reconstruction of Female Urethra with Tubularized Anterior Vaginal Flap." J Clin Diagn Res. 2016;10(7):PC01–PC03. doi:10.7860/JCDR/2016/19502.8088

14. Lumen N, Campos-Juanatey F, Dimitropoulos K, et al. "EAU Guidelines on Urethral Strictures: Limited Update 2026." EAU Guidelines Office, Arnhem, Netherlands; 2026:§7.3. Full guideline

15. Zhu WD, Guo H, Xie H, Song LJ, Xu YM. "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

16. EAU Guidelines Office. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery." EAU Guidelines. 2026, §10.3. Official chapter