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Page 6 of 10 Joshi et al. Plast Aesthet Res 2022;9:22 https://dx.doi.org/10.20517/2347-9264.2021.98

mobilized based on its dartos pedicle. The preputial ring flap is opened ventrally until the penoscrotal
junction. Then, the flap is transposed to the perineum through an opening at the basis of the penis. The flap
is tubularized to bridge the long gap between the anterior and posterior urethra. The outer prepuce is
[16]
sacrificed [Figure 4]. This technique can be done using distal penile skin when patient is circumcised .

2.“Q” Flap:
Occasionally, the gap in the bulbar urethra is much longer than anticipated [Figure 5A]. The length of the
penis is usually 10-12 cm during erection. Thus, the length of a circumferential flap of prepuce or distal
penile skin can reach 10-12 cm at best. In patients with longer gaps, we harvest a “Q”-shaped flap, as
described by Morey [Figure 5B]. The length of such flap can be up to 20 cm.
[17]

BUIN in circumcised patients, or for those patients with a small penis with insufficient penile skin,
represent a challenging scenario. The options to repair the urethral gap include the following.

3. Oral mucosal flap:
An appropriately sized buccal mucosal graft is harvested and placed and quilted over the dartos of the
[18]
scrotum. A week later, a flap made from the graft and its underlying dartos can be mobilized with its pedicle
and transposed to the perineum serving as an onlay flap or tube for reconstruction [Figure 6].

4. Scrotal drop back (Turner-Warwick):
The scrotal skin is used to bridge the gap between the two ends of the urethra. A midline perineal vertical
incision is made. Dissection of the posterior urethra is done. The distal urethra is identified. The scrotal skin
is then folded on itself, and an opening is made on the lowest part which is anastomosed to the posterior
urethra. This helps the scrotal skin, which is mobile, to form a urethral plate. Six months later, the scrotal
skin is tabularized, and urethral continuity is achieved. It has been described in the literature as a surgical
procedure for primary perineal urethrostomy but is uncommonly utilized. We have used this technique in 7
patients with complex PFUI with BUIN and reported a success rate of 33.33%.

5. Entero-urethroplasty:
Since 1995, we have performed five entero-urethroplasties following the technique described by Mundy and
Andrich . Patient selection for these procedures is of paramount importance. The key is to evaluate which
[5]
patients could benefit from urethral substitution using a bowel segment. Secondly, it is very important to
find the best suited bowel segment for the reconstruction. Usually, we choose the segment of bowel based
on the mobility of its pedicle and its proximity to the prostate. Most frequently, the choice falls on the
sigmoid. An urethroplasty usually starts with a perineal incision. The healthy distal end of the anterior
urethra is identified. Crural separation and inferior pubectomy are performed according to the need to
reduce the gap between the distal end and the bowel segment. Frequently, we also approach the area with a
suprapubic incision, which allows reaching the extraperitoneal space of Retzius, excising additional wedges
of the pubic bones, and removing more scar tissue. The posterior urethra is incised on a bougie passed from
the SPC tract though the bladder and the bladder neck. Once the posterior urethra is circumferentially
mobilized, we assess the gap length between the two urethral ends. The sigmoid colon is then disconnected
from the intestine and mobilized on its mesentery. The more distal portion of the sigmoid is usually
sacrificed due to its poor blood supply, while the upper part is swung down on its pedicle. The sigmoid is
tailored on a 26-30 Fr nelaton catheter. Then, the enteric segment is transposed to the perineum, and the
two anastomoses between proximal sigmoid-end and bulbo membranous junction as well as between the
distal sigmoid-end and the anterior urethra are performed. Finally, the omentum is mobilized and wrapped
around the proximal anastomosis to offer a vascular support and to prevent from leak and fistulae