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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 / inlay techniques (which augment an existing urethral lumen) — tubularization creates an entirely new urethral conduit from vaginal tissue. The technique is most closely associated with Blaivas, who published the largest cumulative experience (10 → 49 → 74 patients across three landmark publications) and represents one of the most extensively reported approaches for complete or near-complete female urethral loss.[1][2][3]

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

Concept and Rationale​

The fundamental distinction between vaginal wall tubularization and other vaginal-flap urethroplasty techniques lies in the degree of urethral replacement:

  • Onlay / inlay techniques (Blandy, Orandi-type, dorsal vaginal flap): 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 / 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; 6/10 were continent after a single procedure (with concomitant 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. Continence in 42/49 (87%) after the initial procedure; 6 of 7 failures salvaged by secondary procedures.[2]
  • Flisser & Blaivas 2003 — largest 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]

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 the bladder neck, proximal urethra, and / or trigone are destroyed and require reconstruction.[2]
  • Obliterative urethral stricture — no functional urethral lumen identifiable; the entire strictured segment must be replaced.[7]
  • Failed prior urethral reconstruction — when previous repairs have failed and insufficient native urethral tissue remains for augmentation.[3]

The technique is not indicated for standard urethral strictures where the urethral lumen is narrowed but present — these are better managed with augmentation (onlay / inlay) techniques using vaginal flap, BMG, or labial tissue.[8]

Surgical Technique (Blaivas Method)​

Based on the descriptions across the three Blaivas publications.[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 the proximal healthy urethra / bladder neck.
  3. Anterior vaginal-wall incision — inverted-U or rectangular incision over the area of urethral loss. Flap must be wide enough to be rolled into a tube of adequate caliber (typically ≥ 16–18 Fr).
  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 — vaginal flap rolled into a tube over a 14–18 Fr urethral catheter, with the epithelial (mucosal) surface facing inward. Edges sutured with running or interrupted 4-0 / 5-0 absorbable sutures (polyglactin).
  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 to wrap around the tubularized neourethra. Provides vascular support, a tissue barrier between the neourethra and the vaginal closure (preventing fistula), and mechanical reinforcement.[1][2] In the 1996 series, a Martius flap was used in 47 of 48 patients (98%); 1 patient had a gracilis flap.[2]
  9. Anti-incontinence procedure — because tubularization creates a neourethra without intrinsic sphincteric function, a concomitant anti-incontinence procedure is almost always performed:
    • 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 — urethral catheter (± SPC) for 2–3 weeks.

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 mid / distal, 1 pan-urethral) 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: normal micturition in all; 1 required CIC 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 10.8 Fr → ≥ 20 Fr; Qmax 6.8 → 21 mL/s; no recurrence and no de novo SUI.[4]

These Orandi-type techniques are technically onlay / 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 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 spontaneous resolution, 1 required TOT).[9]

Outcomes​

StudynIndicationTechniqueAnatomical SuccessContinenceFollow-up
Blaivas 1989[1]10Total / partial urethral lossTubularized vaginal flap + Martius + anti-incontinence90% (9/10)60% after 1st; 80% after salvageNot specified
Blaivas / Heritz 1996[2]49Urethral / vesical-neck damageVaginal flap + Martius + PVS87% continence (42/49)87% initial; 98% after salvage1–11 yr
Flisser / Blaivas 2003[3]74Urethral pathology requiring reconstructionVaginal flap + Martius + PVS93%87% cured / improved (of 62 with preop incontinence)1–15 yr (median 1.5)
Simonato 2010[5]6Wide mid / distal strictureOrandi-type lateral-pedicle vaginal flap83% (5/6 no additional treatment)Not specifically reported70.8 mo (mean)
Romero-Maroto 2018[4]9Urethral strictureOrandi-type lateral vaginal flap100% (0% recurrence)100% (no de novo SUI)80.7 mo (mean)
Hajebrahimi 2019[9]14Urethral strictureU-shaped vaginal flap with tubularization100% voiding improvement86% (2 SUI; 1 resolved)Not specified
Higuchi 2026[11]7 (VFU)Distal urethral strictureVaginal flap urethroplasty57.1% (4/7)86% (1 de novo incontinence)12 mo (median)
Kowalik 2014[12]5 (VFU)Mid / distal strictureVaginal flap urethroplasty60% (2/5 recurred)Not reportedNot specified

Key Technical Considerations​

Flap design and vascularity — the critical 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 consistently used a Martius flap in nearly all cases (47/48 in 1996), considering it essential for vascular support, fistula prevention, and as a bed for the pubovaginal sling.[2] The three-layer construct (neourethra → Martius flap → pubovaginal sling) is a hallmark of the Blaivas technique.

Anti-incontinence procedure — because a tubularized neourethra lacks intrinsic sphincteric function, a concomitant anti-incontinence procedure is almost always necessary. The Blaivas group strongly 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 procedureAlmost always requiredUsually not required
Martius flapStrongly recommendedOptional
Continence outcomes87% (with concomitant sling)Variable; de-novo SUI 0–14%
Anatomical success90–93%57–100%
ComplexityHigher (tubularization + Martius + sling)Lower (single-layer augmentation)
Urinary sprayingLess common (complete tube)More common (VFU group in Higuchi)

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)
MorbidityLower (no laparotomy)Higher (cystotomy, abdominal incision)
Bladder capacityPreservedReduced
ComplexityModerateHigher
Best forUrethral loss with intact bladderUrethral loss + bladder-neck involvement

Advantages and Limitations​

Advantages

  • Vaginal tissue is readily available, well-vascularized, and in the same operative field — no separate donor site (apart from Martius flap from labium).[7]
  • Single-stage procedure.[1][2]
  • Avoids abdominal approach (unlike bladder flap).[1]
  • Preserves bladder capacity.[1]
  • Largest published experience of any female urethral reconstruction technique (74 patients, Flisser & Blaivas).[3]
  • High anatomical success (93%) and continence (87%) in the largest series.[3]
  • Vaginal tissue is wet, elastic, hairless, and well-suited for urethral lining.[7]

Limitations

  • Requires adequate vaginal tissue — atrophy (postmenopausal, hypoestrogenic), prior vaginal surgery, or lichen sclerosus may compromise tissue quality and availability.[7]
  • Concomitant anti-incontinence procedure almost always needed — adds complexity and morbidity.[2]
  • Martius flap harvest required in nearly all cases — adds operative time and labial donor-site morbidity.[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 found 100% success at 1 yr but 2/9 patients (22%) recurred at 5.5 and 6 yr, indicating the need for long-term surveillance.[10]
  • Lower success vs dorsal BMG in some comparative studies — Higuchi VFU 57.1% vs DOBMGU 87.5% at 12 mo; Kowalik 2/5 VFU recurrences vs 0/5 BMG. These series used onlay / inlay rather than full tubularization.[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 endorses urethroplasty using vaginal flaps, oral mucosa grafts, or a combination, with success rates of 69–95%, without distinguishing between onlay and tubularization configurations.[8] For standard urethral strictures with a preserved lumen, augmentation techniques (dorsal / ventral BMG onlay, vaginal flap onlay) are preferred over tubularization because they preserve native urethral tissue and sphincteric function. Tubularization is reserved for the reconstructive scenario where no native urethra remains to augment.

Summary​

Vaginal wall tubularization urethroplasty, pioneered by Blaivas, is the most extensively reported technique for complete female urethral reconstruction — 93% anatomical success and 87% continence in the largest series of 74 women.[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 combined with a fascial pubovaginal sling for continence. Specifically indicated for total or near-total urethral loss rather than for standard stricture disease, where augmentation techniques are preferred. The Orandi-type lateral-pedicle variants (Simonato, Romero-Maroto) function as onlay / inlay rather than full tubularization, with excellent long-term results (100% at 80.7 mo in Romero-Maroto).[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. PMID: 8583554

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