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Page 4 of 10 Joshi et al. Plast Aesthet Res 2022;9:22 https://dx.doi.org/10.20517/2347-9264.2021.98

Table 1. Urethroplasties performed for bulbar urethral necrosis
Procedure Number Success rate
Pedicled preputial tube and Q flap 132 86.4%
Oral mucosal flap 10 58.6%
Pedicled prepuce as onlay augmentation with dorsal BMG 16 89.1%
Scrotal drop back 7 33.3%
Enterourethroplasty 5 100%
Forearm flap with microvascular anastomosis 3 100%
Pedicled anterolateral thigh flap 2 50%
Dorsal BMG with ventral BMG on gracilis muscle transposed to perineum 2 100%
Total 177 76.7%
BMG: Buccal mucosa graft.

to the primary trauma or congenital. During the preoperative work-flow of patients with PFUI, we
recommend assessing the presence of erectile dysfunction using standardized questionnaires such as IIEF
and the examination of the vascular supply with the penile doppler ultrasound [10,11] . These tests allow a
comprehensive evaluation of the genital organ and guide surgeons during the dissection of the posterior
urethra reducing the risk of iatrogenic injury of the vessels. The parameters which are assessed during the
penile doppler are the peak of systolic velocity (PSV), end diastolic velocity, and resistance index for both
cavernosal and dorsal penile arteries before and after administration of intracavernosal Prostaglandin E1.
Patients with PSV greater than 35 cm/s were considered to have a normal arterial response, while less than
25 cm/s is associated with severe arterial deficiency. In patients with severe arterial deficiency, we
recommend penile revascularization procedure, using microvascular anastomosis between inferior
epigastric artery and dorsal penile vessels prior to PFUI repair to avoid BUIN .
[12]

Diagnosis of BUIN
The best way to diagnose the BUIN is performing a retrograde and/or micturition urethrogram (RGU and
MCU, respectively) [Figure 1]. These tests would show a long stenotic segment of bulbar urethra (bulbar
[14]
[13]
urethral fibrosis) or a complete gap of bulbar urethra [Figure 2]. MRI and 3D printing models have also
proved to be useful for the diagnosis and assessment of patients with PFUI and suspected BUIN.
In established cases of bulbar urethral ischemia, there are limited options for reconstruction. These patients
require care in high volume referral centers to achieve valid functional outcomes and reduce incidence of
[15]
complications . Initial evaluation includes the identification of the type of injury, the extent of injury, prior
number and type of repairs, and preoperative assessment of antegrade and retrograde blood flow to the
urethra. All these parameters are of paramount importance.

Herein, we present our management algorithm (Figure 3 for BUIN ).
[9]

Treatment of BUIN
In patients with BUIN presenting with a long stenotic segment, urethral augmentation using a buccal graft,
or a penile skin flap is recommended. Presence of lumen and the amount of spongiofibrosis determines the
need for a vascularized flap as opposed to a buccal mucosal graft.

The following surgical approaches are available.