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Combined Vaginal Flap + BMG Urethroplasty (Female)

Combined vaginal flap + BMG urethroplasty refers to a reconstructive strategy in which both a vaginal flap (pedicled, vascularized tissue) and a buccal mucosal graft (free graft) are used together in the same procedure to address complex female urethral strictures that cannot be adequately managed with either tissue source alone. The AUA Urethral Stricture Disease Guideline Amendment (2023) explicitly recognizes "a combination of these techniques" alongside oral mucosa grafts and vaginal flaps, with success rates of 69–95%.[1] The combined approach is not a single standardized technique — it encompasses several distinct configurations.

Concept and Rationale​

Most female urethral strictures can be managed with a single tissue source — either a vaginal flap / graft or a BMG alone. The combined approach is reserved for situations where one tissue source is insufficient due to stricture complexity, tissue quality, or anatomical constraints. The rationale is to leverage the complementary advantages of each tissue.[2][3]

  • Vaginal flap — well-vascularized pedicled tissue that maintains its own blood supply, is readily available in the same operative field, and can serve as both a urethral augmentation and a vascular bed / reinforcement layer for an overlying graft.
  • BMG — robust, non-hair-bearing mucosa resistant to contracture and unaffected by local conditions (lichen sclerosus, vaginal atrophy) that may compromise vaginal tissue quality.

Clinical Configurations​

1. BMG Urethroplasty with Vaginal Flap as Vascular Reinforcement​

The most commonly described combined approach uses the vaginal flap not as the primary urethral augmentation but as a vascular pedicle wrap to support BMG graft take. In Berdondini et al.'s ventral onlay BMG technique (n = 42), the anterior vaginal wall is incised and the periurethral fascia is raised as bilateral flaps that are then closed over the BMG, providing both vascular and mechanical support. The vaginal wall is closed as a separate layer; 98% stricture-free at 38.1 mo.[4] Although the vaginal tissue is not the primary urethral lining, it plays a critical structural role in graft survival.

2. Martius Flap–Reinforced Ventral BMG Onlay​

Önol et al. specifically described a Martius flap–reinforced ventral BMG onlay in 2 of 17 patients with prior synthetic midurethral slings, where periurethral tissue was scarred and devascularized. The BMG provides the mucosal lining; a Martius (labial fat pad) flap is interposed for the 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. described a sequential approach: 9 women initially underwent vaginal flap urethroplasty with 100% success at 1 year but only 78% at 5 years. The 2 patients who recurred at 5.5 and 6 years were salvaged with BMG urethroplasty and were stricture-free at 12–15 months.[6] A combined approach across procedures rather than within a single operation, demonstrating the complementary roles of the two tissue sources in the reconstructive algorithm.

4. Vaginal Flap for One Urethral Segment + BMG for Another​

In long or pan-urethral strictures, different segments may be addressed with different tissues — for example, a distal segment reconstructed with a vaginal flap while a more proximal segment (where vaginal mobilization is harder) is augmented with BMG. Referenced in the AUA 2023 guideline as "a combination of these techniques."[1]

5. Vaginal Flap Ventral + BMG Dorsal (Two-Surface Reconstruction)​

Conceptually analogous to the combined dorsal + ventral inlay approach described by Jefferson et al. for obliterative strictures, a combined approach can use a vaginal flap ventrally and a BMG dorsally — effectively reconstructing both surfaces of the urethra with different tissue sources. Most relevant for near-obliterative or circumferential strictures where neither single-surface augmentation alone nor the circumferential BMG salvage is preferred.[7]

General Surgical Principles​

The specific technique varies by configuration, but the general principles include:[4][5]

  1. Patient positioning — lithotomy; vaginal approach.
  2. Anterior vaginal-wall incision — inverted-U or midline over the urethra.
  3. Urethral dissection — circumferential or partial mobilization of the strictured segment.
  4. Urethrotomy — ventral or dorsal (depending on configuration) through the strictured segment into healthy urethra proximally and distally.
  5. BMG harvest — inner cheek; sized to stricture length + 1 cm margin; defatted.
  6. Graft placement — BMG sutured to the urethral mucosal edges as a dorsal or ventral onlay / inlay.
  7. Vaginal flap mobilization — pedicled vaginal-wall flap raised on its lateral vascular pedicle, used to (a) cover and reinforce the BMG (vascular bed), (b) augment a separate urethral segment, or (c) provide a second tissue layer between graft and vaginal closure.
  8. Layered closure — periurethral fascia over the graft, then vaginal-wall closure.
  9. Catheter management — urethral catheter (± SPC) for 2–3 weeks.

Outcomes​

No large series has specifically isolated the combined vaginal flap + BMG approach as a distinct cohort. Available evidence comes from series that include combined cases within larger mixed-technique cohorts.

StudyConfigurationnFollow-upSuccess
Önol 2011[5]Martius-reinforced ventral BMG2 (of 17)median 24 mo100% objective cure (entire cohort)
Blaivas 2012[6]Sequential VFU → BMG salvage2 (of 17)12–15 mo post-BMG100% (both salvage)
Berdondini 2024[4]Ventral BMG + periurethral fascia flap4238.1 mo98%
Mukhopadhyay 2019[8]Combined dorsal vaginal flap + ventral BMGsmall series—favorable
AUA 2023[1]Oral mucosa, vaginal flap, or combination (pooled)—variable69–95%

Decision — Combined vs Single-Tissue Approach​

Clinical ScenarioPreferred ApproachRationale
Standard mid / distal stricture, healthy vaginal tissueVaginal flap OR BMG aloneSingle tissue source sufficient; equivalent outcomes
Stricture with prior midurethral slingBMG + Martius / vaginal-flap reinforcementPeriurethral scarring compromises vaginal flap; BMG needs vascular support
Lichen sclerosus or vaginal atrophyBMG alone (dorsal or ventral)Vaginal tissue compromised
Pan-urethral / very long strictureCombined vaginal flap + BMG (segmental)Single tissue source insufficient in length
Recurrent stricture after vaginal flap failureBMG salvageDifferent tissue source for revision
Near-obliterative strictureCombined dorsal BMG + ventral vaginal flapBoth surfaces need augmentation

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

A 2025 meta-analysis (Kumar et al., 18 studies) found no significant differences between BMG and vaginal-wall graft urethroplasty in success rate (86.2% vs 89.8%), Qmax (23.3 vs 24.9 mL/s), or PVR (14.7 vs 23.0 mL), with no heterogeneity (I² = 0%).[9] This supports the AUA position that graft choice should be based on tissue availability, patient characteristics, and surgeon expertise rather than inherent superiority.[1]

When vaginal flap (pedicled) is compared directly to dorsal BMG (free graft), Higuchi 2026 found dorsal-BMG 87.5% vs vaginal flap 57.1% at 12 mo — though the vaginal-flap arm had distal-only strictures while BMG included pan-urethral disease.[10] Kowalik et al. similarly found 2/5 vaginal-flap recurrences vs 0/5 dorsal BMG in a small cohort.[11]

Advantages and Limitations​

Advantages

  • Maximizes tissue availability for complex / long strictures.
  • Provides vascular support for free-graft take.
  • Allows BMG when vaginal tissue is compromised.
  • Enables reconstruction of multiple urethral surfaces.
  • Salvage option when single-tissue repair fails.

Limitations

  • Greater surgical complexity and operative time.
  • Two tissue harvest sites (oral + vaginal).
  • Limited evidence base as a distinct technique.
  • Potential donor-site morbidity at both sites.
  • Vaginal narrowing if excessive tissue harvested.
  • No standardized technique description.

Summary​

The combined vaginal flap + BMG approach is best understood as a reconstructive principle rather than a single standardized technique. It is most valuable when a single tissue source is insufficient — whether due to stricture length, tissue quality, prior surgery, or obliterative disease. The AUA 2023 guideline endorses the combination alongside single-tissue approaches with comparable success rates.[1] The most commonly described configuration is BMG augmentation with vaginal / periurethral tissue providing vascular reinforcement (Berdondini ventral onlay, 98%; Önol Martius-reinforced ventral BMG, 100% in the broader 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. 2025. doi:10.1002/nau.70161

8. Mukhopadhyay S, Naskar D, Mete UK, et al. "Combined Dorsal Anterior Vaginal Wall Flap and Ventral Buccal Mucosa Graft Urethroplasty for Complex Female Urethral Stricture." Indian J Urol. 2019;35(4):298–302. doi:10.4103/iju.iju_138_19

9. 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. doi:10.1007/s00192-025-06171-5

10. 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

11. 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