Innovative Approaches for Complex Penile Urethral Strictures

Jordan Siegel; Timothy J. Tausch; Jay Simhan; Allen F. Morey


Transl Androl Urol. 2014;3(2):179-185. 

In This Article

Dorsal Graft With Ventral Penile Skin Flap

The combination of dorsal buccal graft with ventral penile skin flap has been suggested for patients with long anterior urethral strictures including a severely narrowed or obliterated urethral plate. Morey initially described a one-stage approach consisting of urethral plate salvage using a dorsal buccal graft combined with a ventral penile skin flap in patients with severe pendulous urethral strictures.[39] In the early utilization of this novel technique (mean follow-up 2.1 years), all four patients meeting study inclusion criteria voided without difficulty and required no additional instrumentation.

Likewise, Erickson and colleagues described a one-stage repair of anterior urethral strictures in 14 men using a combined dorsal onlay buccal graft with a ventral fasciocutaneous flap.[40] The average stricture length in this group was 9.75 cm with 12 (12/14, 85%) structures located in the penile/bulbar location. At a median follow up of 2.5 years, the study investigators reported an overall success rate of 78% (11/14 patients), although two of these patients (14%) required an additional endoscopic procedure to achieve urethral patency. Patients with longer strictures appeared to be at higher risk of stricture recurrence (12.8 vs. 8.7 cm).

Gelman and associates described a similar experience treating distal obliterative strictures with a combined dorsal buccal graft and a ventral penile skin flap (n=12).[41] Though the authors did not mention stricture length, various size buccal grafts were utilized (range, 2–6.5 cm) with all strictures located in the pendulous urethra. All patients (n=12) were noted to have urethral patency on follow-up cystoscopy at three months postoperatively with normal voiding demonstrated at a mean 39 months follow-up.

Djordjevic and colleagues have also applied this technique in a pediatric hypospadias population.[42] A group of 17 patients, all less than 24 months old, underwent a one-stage repair for severe hypospadias (13 penoscrotal and 4 scrotal). The similar technique involved a dorsal buccal graft combined with a ventrally applied dorsal island penile skin flap. At a mean follow up of 25 months, 14 patients (82%) achieved success while complications of urethral fistula and distal urethral stricture were observed in the remaining three patients (18%).

The overall success of a combined dorsal buccal graft with ventral penile skin flap is likely due to the optimized blood supply utilized by both components of the repair. Previous failures using tubularized grafts or flaps were thought to be due to insufficient blood supply at the edges of the graft.[40] In the case of this combined technique, however, both graft and flap components have an independent, reliable blood supply. The dorsal buccal graft has been shown previously to have excellent success rates.[27–33] This is largely due to its robust and evenly distributed microvascular structure which promotes inosculation and imbibition when fixed to the tunical recipient bed.[27] At the same time, a fasciocutaneous flap relies on its own established blood supply originating from Buck's fascia that is preserved during its harvest.

Nevertheless, there are limitations in the use of penile skin flaps for urethral reconstruction. Manipulation of penile skin for urethral reconstruction must be avoided in patients with lichen sclerosis and is often discouraged in patients with hypospadias. As a significant number of patients with long anterior urethral strictures have a history of such conditions, these interesting techniques often cannot be performed and utilization of buccal mucosa grafting only is paramount.