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Tanagho Anterior Bladder Tube

The Tanagho flap (also called the Tanagho anterior bladder tube or Tanagho bladder neck reconstruction) is a technique originally described by Emil A. Tanagho in the 1970s for the treatment of total urinary incontinence. It involves creating a tubularized flap from the anterior bladder wall to reconstruct the bladder neck and proximal urethra, providing both a conduit for voiding and a continence mechanism through the inherent smooth muscle tone of the bladder wall tube.

Historical Context and Original Description​

Tanagho's landmark 10-year experience (1981) reported on 50 patients treated with the anterior bladder tube reconstruction (plus 6 additional patients who underwent the same technique after retropubic prostatectomy).[1] This was compared to the older posterior bladder tube (Leadbetter) technique used in 25 patients. The anterior approach was developed to overcome limitations of the posterior (trigonal) tube, which risked ureteral injury and had a more complex dissection.

Indications in the original series[1]​

  • Post-prostatectomy incontinence (the major indication — 44 patients)
  • Trauma
  • Congenital anomalies (epispadias)
  • Post-urethrotomy / urethral excision

The overall success rate with the anterior repair was approximately 70%.[1]

Surgical Technique​

The Tanagho anterior bladder tube is constructed as follows:[1][2][3][4]

  1. Exposure: The bladder is exposed via a lower midline or Pfannenstiel incision. The space of Retzius is developed and the anterior bladder wall is fully mobilized.
  2. Anterior cystotomy: The bladder is opened anteriorly to expose the interior, including the bladder neck region and trigone.
  3. Flap design: A rectangular or trapezoidal strip of full-thickness anterior bladder wall is outlined. The flap is based proximally (at the bladder neck) and extends cephalad on the anterior bladder wall. Typical dimensions are approximately 5 cm at the base and 3 cm at the apex (trapezoidal), or a strip of sufficient width to create a tube of adequate caliber (typically 2–3 cm wide).[4]
  4. Tubularization: The strip of anterior bladder wall is tubularized over a catheter (typically 18–30 Fr), creating a tube of bladder wall that will serve as the neo-urethra / neo-bladder neck. The tube is closed with absorbable sutures in a running or interrupted fashion, with the mucosal surface facing inward (lumen) and the serosal/muscular surface facing outward.
  5. Positioning: The tubularized flap is directed caudally toward the urethral stump or perineum. The distal end of the tube is anastomosed to the remaining urethra (if present) or brought to the perineum.
  6. Bladder closure: The donor site defect on the anterior bladder wall is closed primarily.
  7. Catheter management: A urethral catheter is left through the neo-urethra; a suprapubic catheter is typically placed for drainage during healing.

Key principle. The continence mechanism relies on the intrinsic smooth muscle tone of the bladder wall tube. The detrusor fibers within the tube provide passive resistance to urine flow at rest, and during voiding the detrusor contracts and the tube opens. This is fundamentally different from sphincteric continence — it is a passive resistance mechanism rather than an active sphincter.[1][5]

Koraitim Modifications: Four Forms of the Anterior Bladder Tube​

Koraitim (1985) described four configurations of the anterior bladder flap tube, tailored to the specific anatomical defect:[2]

  1. Standard Tanagho procedure — used in 10 patients with the classic technique.
  2. Three variants — designed to address specific defects in the remaining 17 patients, adapting the flap orientation, length, and tubularization to the particular anatomy.

The overall success rate across all four forms was 85%, attributed to matching the correct tube configuration to the specific etiology of incontinence.[2]

Beck Modification: Anterior Bladder Tube After Radical Prostatectomy​

Beck et al. (1979) adapted the Tanagho anterior bladder tube specifically for urethrovesical anastomosis after radical retropubic prostatectomy in 5 patients where standard anastomosis was technically difficult:[3]

  • The anterior bladder tube flap was created and tubularized, then anastomosed to the transected membranous urethra.
  • This facilitated a tension-free anastomosis when the bladder neck-to-urethral gap was too large for direct suturing.
  • The technique improved transient postoperative incontinence compared to standard anastomosis.

Seaman / Benson Modification: Tubularized Bladder Neck Reconstruction After Radical Prostatectomy​

Seaman and Benson (1996) applied a similar concept to improve continence after radical retropubic prostatectomy in 29 patients:[4]

  • A trapezoidal anterior bladder flap (5 cm base × 3 cm apex) was tubularized over a 30 Fr catheter prior to urethrovesical anastomosis.
OutcomeTubularized BN (n=29)Control (n=30)
Continent at 24 hours24%3%
Continent at 3 months93%73%
Total continence rate97% (28/29)80%
BNC rate3.4% (1/29)Not reported

Continence rates were significantly higher at all follow-up time points in the tubularized group, suggesting the anterior bladder tube creates a functional continence zone that accelerates recovery of continence.[4]

Gallagher et al.: Tanagho BNR for Complex Adult Incontinence​

The most detailed outcomes study of the Tanagho technique in adults with complex incontinence (1995, n=8):[7]

  • Population: 7 women with epispadias or severe urethral damage from obstetrical/gynecological procedures; 1 additional patient.
  • 3 of 8 patients were unsuitable for AUS due to severe scarring and tissue loss.
  • Concurrent procedures in 5 patients: colposuspension (4), fistula closure (2), vaginal reconstruction (1).

Results:[7]

  • 5/8 (63%) completely continent and satisfied.
  • 2 underwent ileal conduit diversion (1 for incontinence, 1 refused CIC).
  • 1 incontinent awaiting further treatment.
  • Best results in patients with healthy bladder and periurethral tissues.
  • Among patients potentially suitable for AUS: 80% (4/5) satisfied.
  • Among patients unsuitable for AUS: 33% (1/3) satisfied.

The authors concluded the Tanagho BNR is a useful alternative to AUS in carefully selected patients, particularly women with epispadias who wish to avoid the long-term complications of an artificial sphincter.[7]

Radwan et al.: Tanagho vs. Labial Flap for Female Urethral Reconstruction​

A 12-year comparative experience (2013, n=16) in women with post-traumatic total urethral loss:[8]

ParameterTanagho Anterior Bladder Tube (n=6)Labial Fat Pad Flap + TOT Sling (n=10)
ApproachCombined vaginal + abdominalPerineal
Mean follow-up42 months42 months
Total continence66.6% (4/6)66.6% (6/9)
Partial continence (1–2 pads/d)13.3% (combined)13.3% (combined)
Failure12
ComplicationsNoneMeatal stenosis (1), urinary retention (2)
Anatomical success100%100%

Both techniques achieved equivalent continence rates (66.6%), but the Tanagho approach required a combined vaginal and abdominal approach, making it more invasive than the perineal labial flap technique.[8]

Limitations of the Classic Tanagho Repair​

Nayyar et al. (2020) identified the following limitations of the classic Tanagho repair that prompted development of their novel U-shaped anterior bladder tube modification:[9]

  1. Bladder neck shifted anterosuperiorly — the tubularized flap pulls the bladder neck upward and forward, potentially causing voiding difficulties.
  2. Posteriorly directed suture line — risks fistula formation with the vagina (particularly in female patients).
  3. Rotational tug on the bladder — the flap creates tension at the suture line as the bladder fills and empties, potentially compromising healing.
  4. Limited tube length — the standard anterior flap may not provide sufficient length for long urethral defects.

Nayyar's U-shaped modification (2020)[9]​

To overcome these limitations, a U-shaped anterior bladder wall flap was designed that:

  • Keeps the native bladder neck fibers in their anatomical position (not shifted anterosuperiorly).
  • Allows creation of tubes up to 3.5 cm in length without tension.
  • Avoids the posteriorly directed suture line.
  • Resulted in 3/3 patients with normal voiding and continence at follow-up (3–15 months).

The Pippi Salle procedure (1994) is a conceptually related but distinct pediatric technique that uses an anterior bladder wall flap for urethral lengthening rather than tubularization:[10][11]

  • Instead of fully tubularizing the flap, the anterior bladder wall strip is sutured to the posterior wall in an onlay fashion, creating a flap valve mechanism.
  • This increases functional urethral length and leak point pressure without creating a full tube.
  • Originally developed for neurogenic incontinence and exstrophy in children.
  • Continence rates: 70% (12/17 patients dry >4 hours) in the expanded series.[11]
  • Complications: vesicourethral fistula in 2 patients, catheterization difficulties in 3.

The Pippi Salle procedure differs from the Tanagho tube in that it creates a valve mechanism (onlay) rather than a tube mechanism (circumferential tubularization), and is primarily used in the pediatric population.[10][11]

Tubularized Bladder Flap as Continent Catheterizable Channel​

The anterior bladder wall tube concept has also been applied to create continent catheterizable channels (CCCs) — an alternative to appendicovesicostomy (Mitrofanoff) or Monti channels. Long-term data from Polm et al. (2024) compared three CCC types over a median follow-up of >12 years:[12]

  • Tubularized bladder flaps (TBF) had comparable revision-free survival to appendicovesicostomy (AVS) and Monti channels.
  • Approximately 50% of all CCCs required at least one surgical revision during follow-up.
  • Mean revision-free survival exceeded 13 years for all three techniques.
  • Monti channels had significantly higher overall revision rates, but time-to-first-revision did not differ significantly between techniques.

Tanagho Flap in the Context of Modern BNC/VUAS Reconstruction​

The Tanagho anterior bladder tube was developed primarily for total urinary incontinence (post-prostatectomy, epispadias, trauma) rather than for bladder neck contracture or VUAS per se. However, its principles have directly influenced modern reconstruction techniques:

TechniqueRelationship to TanaghoKey Difference
Y-V plastyUses anterior bladder wall flap (single)Flap advanced into contracture, not tubularized
T-plastyUses anterior bladder wall flaps (bilateral)Two flaps advanced, not tubularized
Beck / Seaman tubularized BNDirect application of Tanagho tubeUsed at time of prostatectomy, not for BNC
Nayyar U-shaped tubeModified Tanagho for female BNCOvercomes positional limitations of classic Tanagho
Pippi SalleAnterior bladder wall flap onlayValve mechanism, not tube; pediatric population

References: [1][3][4][9][10][11][17]

In modern practice, the Tanagho tube is rarely used for male BNC/VUAS — Y-V plasty, T-plasty, and BMG urethroplasty have largely supplanted it for this indication. The Tanagho technique remains relevant for:[1][7][8][9]

  • Female urethral reconstruction after trauma with total urethral loss.
  • Complex incontinence in patients unsuitable for AUS (severe scarring, tissue loss).
  • Epispadias in women.
  • Continent catheterizable channels (as an alternative to Mitrofanoff/Monti).

Summary of Published Outcomes​

StudyYearNPopulationContinenceFollow-Up
Tanagho[1]198150Mixed (mostly post-prostatectomy)70%10 yr
Koraitim (4 forms)[2]198527Mixed etiology85%Variable
Gallagher[7]19958Complex female incontinence63%10 yr
Seaman / Benson[4]199629Post-radical prostatectomy97%6 mo
Radwan[8]20136Female post-traumatic urethral loss66.6%42 mo
Nayyar (modified)[9]20203Female traumatic BNC obliteration100%3–15 mo

References​

1. Tanagho EA. "Bladder Neck Reconstruction for Total Urinary Incontinence: 10 Years Experience." The Journal of Urology. 1981;125(3):321-6. doi:10.1016/s0022-5347(17)55024-7

2. Koraitim M. "Anterior Bladder Tube: 4 Forms for Incontinence of Different Etiology." The Journal of Urology. 1985;134(2):269-73. doi:10.1016/s0022-5347(17)47120-5

3. Beck PH, McAninch JW, Stutzman RE. "Anterior Bladder Tube Flap Reconstruction of the Urethrovesical Neck After Radical Retropubic Prostatectomy." The Journal of Urology. 1979;121(3):379-81. doi:10.1016/s0022-5347(17)56795-6

4. Seaman EK, Benson MC. "Improved Continence With Tubularized Bladder Neck Reconstruction Following Radical Retropubic Prostatectomy." Urology. 1996;47(4):532-5. doi:10.1016/S0090-4295(99)80490-7

5. Thüroff JW, Hutschenreiter G, Rumpelt HJ, Hohenfellner R. "Neourethra: A New Two-Stage Procedure for Reconstruction of the Functional Urethra." The Journal of Urology. 1983;130(6):1228-33. doi:10.1016/s0022-5347(17)51766-8

6. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." The Journal of Urology. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482

7. Gallagher PV, Mellon JK, Ramsden PD, Neal DE. "Tanagho Bladder Neck Reconstruction in the Treatment of Adult Incontinence." The Journal of Urology. 1995;153(5):1451-4.

8. Radwan MH, Abou Farha MO, Soliman MG, et al. "Outcome of Female Urethral Reconstruction: A 12-Year Experience." World Journal of Urology. 2013;31(4):991-5. doi:10.1007/s00345-013-1087-2

9. Nayyar R, Jain S, Sharma K, Pethe S, Kumar P. "A Novel Anterior Bladder Tube for Traumatic Bladder Neck Contracture in Females: Initial Results." Urology. 2020;139:201-206. doi:10.1016/j.urology.2019.12.037

10. Salle JL, de Fraga JC, Amarante A, et al. "Urethral Lengthening With Anterior Bladder Wall Flap for Urinary Incontinence: A New Approach." The Journal of Urology. 1994;152(2 Pt 2):803-6. doi:10.1016/s0022-5347(17)32715-5

11. Salle JL, McLorie GA, Bägli DJ, Khoury AE. "Urethral Lengthening With Anterior Bladder Wall Flap (Pippi Salle Procedure): Modifications and Extended Indications of the Technique." The Journal of Urology. 1997;158(2):585-90. doi:10.1097/00005392-199708000-00092

12. Polm PD, Christiaans CHH, Dik P, Wyndaele MIA, de Kort LMO. "Continent Catheterizable Urinary Channels: Lessons for Lifelong Urological Care From a Comparative Analysis of Very Long-Term Complications and Revision-Free Survival of Three Different Types." Neurourology and Urodynamics. 2024;43(5):1083-1089. doi:10.1002/nau.25350

17. Reiss CP, Rosenbaum CM, Becker A, et al. "The T-Plasty: A Modified YV-Plasty for Highly Recurrent Bladder Neck Contracture After Transurethral Surgery for Benign Hyperplasia of the Prostate: Clinical Outcome and Patient Satisfaction." World Journal of Urology. 2016;34(10):1437-42. doi:10.1007/s00345-016-1779-5