Skip to main content

Female Vaginal Flap Urethroplasty (Blandy U-Flap)

The Blandy U-flap vaginal flap urethroplasty is the foundational ventral-onlay vaginal-flap technique for female urethral stricture (FUS) repair. A U-shaped anterior-vaginal-wall flap is mobilized on a proximal pedicle, the strictured urethra is opened ventrally, and the flap is inlaid into the urethrotomy defect to augment the urethral lumen.[1][2][3] It is the female counterpart of the male ventral-onlay urethroplasty.

Blandy U-flap female vaginal-flap urethroplasty: a U-shaped anterior-vaginal-wall flap with a proximal pedicle is inlaid into a ventral urethrotomy over a Foley, augmenting the ventral circumference

Blandy U-flap geometry. (1) A U-shaped anterior-vaginal-wall flap with a proximal pedicle is raised over the strictured urethra and a ventral (6 o'clock) urethrotomy is planned. (2) The flap is inlaid into the opened urethra as a ventral onlay over a 16–18 Fr Foley, sutured to the native plate. The cross-section shows the result: native dorsal urethral plate above, vaginal-flap onlay ventrally. Being pedicled, the flap keeps its submucosal vascular plexus — no buccal-graft donor site. (Original WARWIKI schematic)

For the broader female-stricture treatment ladder, see Female DVIU and Urethral Dilation, Distal Urethrectomy with Advancement Meatoplasty, Lateral-Based Anterior Vaginal Wall Flap, Female Dorsal Onlay BMG, and Ventral Onlay BMG.

Eponym and Concept​

Attributed to John Blandy. The U-flap design uses anterior vaginal wall as a pedicled flap (proximal base), preserving the submucosal vascular plexus, and avoids the donor-site morbidity of buccal mucosa.[1][3]

Indications​

  • FUS refractory to dilation or DVIU.[4][5]
  • Distal and mid-urethral strictures (most common application).[6][7]
  • Healthy, well-estrogenized anterior vaginal wall (no LS, no severe atrophy).[4][8]
  • Selected longer / pan-urethral strictures in experienced hands.[9]

Contraindications / Limitations​

  • Lichen sclerosus or vaginal atrophy compromising the flap.[4][8]
  • Prior pelvic radiation.
  • Prior synthetic midurethral sling with periurethral scarring limiting flap mobilization.[7]

Technique​

Dorsal lithotomy under regional or general anesthesia.[2][10]

  1. Cystourethroscopy — confirm location, length, and proximal urethra / bladder.
  2. Foley placement — identifies the urethral lumen and serves as a guide.[2]
  3. U-shaped vaginal incision — two parallel longitudinal incisions in the anterior vaginal wall flanking the urethra, beginning at the meatus and extending proximally past the stricture, joined distally around the meatus to create a U-shaped flap with a proximal pedicle.[2][3]
  4. Flap elevation — vaginal mucosal flap dissected off the periurethral tissue and reflected cephalad to expose the ventral urethra.[2]
  5. Ventral urethrotomy — longitudinal 6 o'clock incision through the full length of the stricture, extending into healthy mucosa proximally and distally.[2][10]
  6. Flap inlay — distal tip of the vaginal flap sutured to the proximal end of the urethrotomy with interrupted 4-0 / 5-0 polyglactin; lateral edges sutured to the lateral edges of the incised urethral mucosa to augment the ventral circumference.[2][10]
  7. Tubularization of the inner portion of the flap over a 16–18 Fr Foley to ensure adequate caliber.[2]
  8. Second-layer closure — outer flap layer or native vaginal wall edges closed as a watertight second layer.[2]
  9. Catheter — 10–21 days postoperatively (varies by series).[2][10]

Technical principles — pedicled (not free graft); U-width must allow tension-free augmentation; ventral approach preserves the dorsal urethral surface and pubourethral ligaments.[4][11][12]

Important Modifications​

Lateral-based anterior vaginal wall flap (Romero-Maroto / Simonato)​

Romero-Maroto 2018 and Simonato 2010 independently described a lateral-based rather than midline U-flap, inspired by the Orandi technique. The lateral pedicle better preserves the vascular axis; Simonato's variant adds partial de-epithelialization of the flap edges to promote cicatrization at the suture line and reduce fistula risk. Romero-Maroto specifically developed the modification because the classic Blandy U-flap produced retrusive meatus and inward urinary stream — a recognized functional limitation of the proximal-pedicled design.[1][9] See Lateral-Based Anterior Vaginal Wall Flap.

Gormley vaginal inlay flap​

Simplified ventral-incision-and-inlay variant. Gormley 2010: 12 patients, follow-up 3 mo–9 yr, 100% subjective symptom relief, all able to catheterize 14 Fr, 0% de novo SUI.[10]

Blaivas vaginal flap reconstruction (urethral loss / neourethra)​

For urethral loss rather than stricture: vaginal flap rolled into a tube to create a neourethra, covered with a Martius labial fat-pad flap, combined with pubovaginal sling. Blaivas-Heritz 1996: 49 women, continence in 87%.[13][14]

Outcomes​

SeriesnTechniqueSuccessMean follow-upDe-novo SUI
Hajebrahimi 2019[2]14U-shaped vaginal flap100% (voiding improved)—14% (2/14)
Gormley 2010[10]12Vaginal inlay flap100% (symptom relief)3 mo–9 yr0%
Romero-Maroto 2018[1]9Lateral-based vaginal flap100% (no recurrence)80.7 mo0%
Simonato 2010[9]6Lateral-pedicle vaginal flap83% (5/6)70.8 mo0%
Önol 2011[7]10 (of 17)Anterior vaginal wall inlay100% objective24 mo (median)not reported
Higuchi 2026[6]7VFU (various)57.1% (4/7)12 mo (median)0%
Blaivas 2012[15]9Vaginal flap100% at 1 yr; 78% at 5 yr1–11 yrconcurrent sling
Flisser-Blaivas 2003[16]72Vaginal flap ± sling93% anatomic1.5 yr (median)concurrent sling

Pooled vaginal-flap urethroplasty success in systematic reviews is 91–93% at 32–42 months mean follow-up.[5]

The Retrusive-Meatus / Spraying Problem​

The defining functional limitation of the classic Blandy design is the proximal pedicle pulling the neomeatus posteriorly, resulting in:

  • A retrusive (posteriorly displaced) neomeatus.
  • An inward urinary stream that sprays the perineum or vagina rather than directing anteriorly.
  • Urinary spraying reported in 2 / 7 (29%) of VFU patients in Higuchi 2026; not reported with BMG urethroplasty in the same series.[6]

This is the rationale for the lateral-based flap modification, which keeps the neomeatus orthotopic and preserves normal stream direction.[1]

Complications​

  • Stricture recurrence — 0–43% across series; late recurrences at ≥ 5 yr documented.[15][17]
  • De novo SUI — 0–14%; mostly mild and PFPT-responsive; persistent SUI may require TOT or PVS.[2][5]
  • Retrusive meatus / inward stream — specific to the classic U-flap.[1]
  • Urinary spraying — VFU-specific; not reported with BMG urethroplasty.[6]
  • De novo urgency / urge incontinence — reported even with technically successful repairs.[2][10]
  • Urethrovaginal fistula — rare; risk reduced by multi-layer closure and Martius interposition.[9][13]
  • Need for CIC — occasional (1 / 6 in Simonato).[9]

Comparison with Alternatives​

FeatureBlandy U-FlapLateral-Based FlapDorsal Onlay BMGVentral Onlay BMG
Tissue sourceAnterior vaginal wallAnterior vaginal wallBuccal mucosaBuccal mucosa
Blood supplyPedicled (proximal base)Pedicled (lateral base)Free graftFree graft
Meatal positionRisk of retrusiveOrthotopicOrthotopicOrthotopic
Urinary sprayingReportedNot reportedNot reportedNot reported
Stricture locationDistal / midDistal / mid / panAnyAny
Reported success57–100%83–100%87–92%89–98%
Donor-site morbidityNone (same field)NoneOralOral
Vaginal-tissue health requiredYesYesNoNo

A 2026 meta-analysis (n = 319) found no significant difference between dorsal and ventral onlay BMG in success rate (RR 1.00; 95% CI 0.91–1.10), Qmax, PVR, or AUA score.[20] AUA 2023 frames urethroplasty success in women as 69–95% depending on technique, with technique selection driven by surgeon experience.[21]

When to Choose the Blandy U-Flap​

  • Stricture is distal or mid-urethral.[4][6]
  • Anterior vaginal wall is healthy and well-estrogenized (no LS).[4][8]
  • Surgeon prefers to avoid BMG donor-site morbidity.[19]
  • A pedicled (vs free-graft) reconstruction is preferred.

Given the retrusive-meatus / spraying signal, many contemporary surgeons prefer the lateral-based flap modification or BMG urethroplasty when the stricture extends beyond the distal urethra.[1][6][18]

Postoperative Management​

  • Urethral catheter 10–21 days (surgeon preference).[2][10]
  • Voiding trial after catheter removal.
  • Uroflowmetry, PVR, and cystoscopy at 3–6 mo.
  • Topical estrogen in postmenopausal women.[8]
  • Long-term surveillance is essential — late recurrences ≥ 5 yr documented.[15]

Summary​

The Blandy U-flap is the foundational ventral-onlay vaginal-flap urethroplasty for FUS — pedicled, donor-site-free, distal / mid-urethral, with reported success of 57–100% across small series. Its defining limitation is retrusive meatus and inward urinary stream from the proximal-pedicled design, which has driven adoption of the lateral-based Romero-Maroto / Simonato modification and the increasing preference for BMG urethroplasty when the stricture extends beyond the distal urethra or when local tissue is unhealthy.[1][4][5][6]

Videos​

Female Urethroplasty: Blandy Flap
ICS Television

References​

1. 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):123-128. doi:10.1016/j.eururo.2016.09.029.

2. 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):2055-2060. doi:10.1007/s00192-019-03910-3.

3. 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.

4. Bouchard B, Campeau L. Surgery for female urethral stricture. Neurourol Urodyn. 2025;44(1):51-62. doi:10.1002/nau.25358.

5. Chakraborty JN, Chawla A, Vyas N. Surgical interventions in female urethral strictures: a comprehensive literature review. Int Urogynecol J. 2022;33(3):459-485. doi:10.1007/s00192-021-04906-8.

6. 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.

7. 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):1318-1324. doi:10.1016/j.urology.2011.01.017.

8. West C, Lawrence A. Female urethroplasty: contemporary thinking. World J Urol. 2019;37(4):619-629. doi:10.1007/s00345-018-2564-4.

9. Simonato A, Varca V, Esposito M, Carmignani G. Vaginal flap urethroplasty for wide female stricture disease. J Urol. 2010;184(4):1381-1385. doi:10.1016/j.juro.2010.06.042.

10. Gormley EA. Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn. 2010;29 Suppl 1:S42-S45. doi:10.1002/nau.20814.

11. Faiena I, Koprowski C, Tunuguntla H. Female urethral reconstruction. J Urol. 2016;195(3):557-567. doi:10.1016/j.juro.2015.07.124.

12. Katiyar VK, Sood R, Sharma U, et al. Critical analysis of outcome between ventral and dorsal onlay urethroplasty in female urethral stricture. Urology. 2021;157:79-84. doi:10.1016/j.urology.2021.05.021.

13. 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):1014-1017.

14. Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol. 1989;141(3):542-545. doi:10.1016/s0022-5347(17)40887-1.

15. Blaivas JG, Santos JA, Tsui JF, et al. Management of urethral stricture in women. J Urol. 2012;188(5):1778-1782. doi:10.1016/j.juro.2012.07.042.

16. Flisser AJ, Blaivas JG. Outcome of urethral reconstructive surgery in a series of 74 women. J Urol. 2003;169(6):2246-2249. doi:10.1097/01.ju.0000061763.88247.16.

17. Kowalik C, Stoffel JT, Zinman L, Vanni AJ, Buckley JC. Intermediate outcomes after female urethral reconstruction: graft vs flap. Urology. 2014;83(5):1181-1185. doi:10.1016/j.urology.2013.12.052.

18. Savun M, Cubuk A, Colakoglu Y, Aksakal YN, Simsek A. Comparative analysis of dorsal and ventral onlay urethroplasty with buccal mucosal graft in female urethral strictures: a multi-center study. Int Urogynecol J. 2026;37(2):511-516. doi:10.1007/s00192-025-06479-2.

19. Borchert A, Jamil M, Perkins S, Raffee S, Atiemo H. Vaginal free graft dorsal onlay urethroplasty. Urology. 2022;159:256. doi:10.1016/j.urology.2021.06.004.

20. Li X, Zhao X, Li Z, et al. Dorsal versus ventral onlay buccal mucosal graft urethroplasty in female urethral stricture: a meta-analysis. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06516-8.

21. 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.