Genital flaps for anterior urethral reconstruction

Abstract

Genital flaps can provide versatile options for complex penile, genital, and urethral reconstruction. Pedicled muscle flaps can be used in combination with grafting for urethral reconstruction, and genital skin flaps can also be utilized as urethral augmentation or replacement. Penile skin flaps, in particular, offer versatile options for the management of anterior urethral stricture disease. The choice of urethral reconstruction depends on surgeon expertise and patient disease. Given its surgical complexity, flap reconstruction is equally dependent on an appropriate understanding of patient disease and surgeon experience. It is crucial to understand the patients’ comorbid diseases (e.g., smoking status or lichen sclerosis), potential flap tissue quality (i.e., penile/preputial skin quality), and stricture anatomy (length, caliber, location). Of particular importance is any prior intervention that may alter the normal vascular supply to the proposed flap. The ideal skin flap will be (1) hairless; (2) accustomed to the aqueous environment; (3) adaptable; and (4) cosmetic. This review will cover the operative approaches and peri-operative outcomes of genital flaps to manage urethral reconstruction. Particular attention will be paid to penile skin flap urethroplasty.

Keywords

Urethral stricture / genital flap / penile flap / reconstructive urology

References

[1] Faris SF,Voelzke BB.Trauma and Urologic Reconstruction Network of Surgeons (TURNS)Assessment of the male urethral reconstruction learning curve.Urology2016;89:137-42 PMCID:PMC4792781

[2] Wisenbaugh ES.The use of flaps and grafts in the treatment of urethral stricture disease.Adv Urol2015;2015:979868 PMCID:PMC4668293

[3] Andrich DE.What is the best technique for urethroplasty?.Eur Urol2008;54:1031-41

[4] Whitson JM,Elliott SP.Long-term efficacy of distal penile circular fasciocutaneous flaps for single stage reconstruction of complex anterior urethral stricture disease.J Urol2008;179:2259-64

[5] Venn SN.Urethroplasty for balanitis xerotica obliterans.Br J Urol1998;81:735-7

[6] Depasquale I,Bracka A.The treatment of balanitis xerotica obliterans.BJU Int2000;86:459-65

[7] Belsante MJ,Peterson AC.The contemporary management of urethral strictures in men resulting from lichen sclerosus.Transl Androl Urol2015;4:22-8 PMCID:PMC4708274

[8] Lumen N,Hoebeke P.Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis.Urol Int2012;89:387-94

[9] Gallegos MA.Advances in urethral stricture management.F1000Res2016;5:2913 PMCID:PMC5225410

[10] Wessells H.Use of free grafts in urethral stricture reconstruction.J Urol1996;155:1912-5

[11] Bhargava S.Buccal mucosal urethroplasty: is it the new gold standard?.BJU Int2004;93:1191-3

[12] Alsikafi NF,Mcaninch JW.317: Long-term outcomes of penile skin graft versus buccal mucosal graft for substitution urethroplasty of the anterior urethra.J Urol2005;173:87-8

[13] Breyer BN,Whitson JM.Multivariate analysis of risk factors for long-term urethroplasty outcome.J Urol2010;183:613-7

[14] Dubey D,Kapoor R.Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial.J Urol2007;178:2466-9

[15] Chapman DW,Johnsen NV.Nontransecting techniques reduce sexual dysfunction after anastomotic bulbar urethroplasty: results of a multi-institutional comparative analysis.J Urol2019;201:364-70

[16] Blaschko SD,Cinman NM,Breyer BN.De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis.BJU Int2013;112:655-63 PMCID:PMC3740455

[17] Elliott SP. Penile skin flaps for urethral reconstruction. In: Brandes SB, editor. Urethral reconstructive surgery. Totowa: Humana Press; 2008. p. 153-64.

[18] Gil-Vernet J,Gil-Vernet A,Gelabert-Mas A.A new biaxial epilated scrotal flap for reconstructive urethral surgery.J Urol1997;158:412-20

[19] Carrera A,Forcada P,Llusa M.Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps.BJU Int2009;103:820-4

[20] Gil-Vernet A,Gil-Vernet JJ,Gil-Vernet J.Scrotal flap epilation in urethroplasty: concepts and technique.J Urol1995;154:1723-6

[21] Provet JA,Grunberger I,Brown J.Scrotal island flap urethroplasty in the management of bulbar urethral strictures.J Urol1989;142:1455-7

[22] Yachia D.A New, One-Stage Pedicled scrotal skin graft urethroplasty.J Urol1986;136:589-92

[23] Blandy J.Two stage scrotal flap urethroplasty.Ann Urol (Paris)1993;27:213-8; discussion 219

[24] Blandy JP,Notley RG.The results and complications of scrotal-flap urethroplasty for stricture.Br J Urol1971;43:52-7

[25] Zinman L.Muscular, myocutaneous, and fasciocutaneous flaps in complex urethral reconstruction.Urol Clin North Am2002;29:443-66

[26] Nikolavsky D.Prelaminated gracilis flap with buccal mucosal graft for salvage of devastated urethra.Case Rep Urol2015;2015:490518 PMCID:PMC4519531

[27] Goel A,Singh M.Orandi flap for penile urethral stricture: polishing the gold standard.Can Urol Assoc J2015;9:E160-3 PMCID:PMC4455633

[28] Orandi A.One-stage urethroplasty: 4-year followup.J Urol1972;107:977-80

[29] Heo JW,Kim YH,Kim J.Urethroplasty of extensive penile urethral strictures with a longitudinal ventral tubed flap of penile skin (modified Orandi urethroplasty): 20 years of follow-up of two cases.Arch Plast Surg2020;47:613-8 PMCID:PMC7700859

[30] Turner-Warwick R.Principles of urethral reconstruction.Reconstr Urol1993;2:609-42.

[31] Jordan GH.Reconstruction of the fossa navicularis.J Urol1987;138:102-4

[32] Mcaninch JW.Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap.J Urol1993;149:488-91

[33] Andrich DE,Mundy AR.The problems of penile urethroplasty with particular reference to 2-stage reconstructions.J Urol2003;170:87-9

[34] McAninch JW.Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures.J Urol1998;159:1209-13

[35] Wessells H,Elliott S.Male urethral stricture: American Urological Association guideline.J Urol2017;197:182-90

[36] Kim KR,Paick JS.Surgical outcome of urethroplasty using penile circular fasciocutaneous flap for anterior urethral stricture.World J Mens Health2014;32:87-92 PMCID:PMC4166375

[37] Hmida W,Bako A,Mosbah F.Penile skin flap: a versatile substitute for anterior urethral stricture.Int Braz J Urol2019;45:1057-63 PMCID:PMC6844360

[38] Ali AI,Abdel-Rassoul MA.Buccal mucosal graft versus penile skin flap urethroplasty for long segment penile urethral stricture: a prospective randomized study.Cent European J Urol2019;72:191-7 PMCID:PMC6715090

[39] El-kassaby AW,Reyad AM.Management of men with ultra-short penile urethral stricture using augmented anastomotic penile skin flap urethroplasty; a retrospective analysis.Afr J Urol2021;27:33

[40] Virasoro R,Jordan GH.Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique.BJU Int2007;100:1143-5