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Page 2 of 12 Dávila et al. Plast Aesthet Res 2022;9:31 https://dx.doi.org/10.20517/2347-9264.2021.133

thereby only preserving a limited urethral plate and a hostile ground for a comfortable and straightforward
urethroplasty.

The vast majority of urethral strictures can be managed with a single surgical procedure using grafts, flaps,
[2]
or excision and primary anastomosis . In the presence of an extensive and fully circumferential injury of
the urethral plate segment, these resources may be insufficient, and a standard staged urethroplasty is the
option of choice. A staged urethroplasty creates a hypospadic meatus for a least six months and will require
at least one additional intervention to complete the urethral reconstruction. Staged urethroplasty is usually
performed with skin flaps or buccal mucosa graft to correct complex hypospadias.

The combination of graft and a flap is an alternative way to reconstruct these complex obliterative urethral
lesions. This option is less commonly used, but it must be part of the reconstructive urologist’s
armamentarium. The literature is lacking in regards to the combined use of grafts and flaps. Of those
published, all are related to hypospadias cripple or some form of obliterative penile pathology . We present
[3]
a review of this complex reconstruction with indications and techniques.

PRINCIPLES OF TISSUE TRANSFER TECHNIQUES
When performing a graft, flap, or combination technique, important principles must be kept in mind for
the selection of the surgical procedure. The tissue must be hairless, have the ability to adapt to a new
[4-5]
environment, and preferentially present a good aesthetic result .
Vascular anatomy of the penis and urethra
A thorough understanding of the anatomy and vascularization of the penis and urethra is essential to
choose the best surgical procedure with a decrease in complications or unwanted results. Additionally,
penile cutaneous flaps utilized in urethroplasty are “axial” (based on a specific feeding vessel) and “island”
(completely separated from the skin from which it is lifted); they are only attached by and dependent on the
pedicle, which carries the blood supply to the skin island.

The urethra has two principal sources of arterial blood supply, allowing for extensive dissection,
mobilization, and division without generating ischemic injury. Arterial blood supply to the urethra and
corpus spongiosum follows both antegrade and retrograde patterns. It originates from the bulbar and dorsal
arteries, which derive from the common penile arteries. The common penile arteries, in turn, arise from the
internal pudendal artery. The common penile artery then divides into the bulbar, urethral, and dorsal
arteries. Together, the bulbar arteries supply antegrade flow to the urethra and corpus spongiosum, while
the dorsal arteries vascularize the glans.

A venous plexus exists in the glans, the most distal segment of the corpus spongiosum. This plexus merges
with three main venous branches. The periurethral vein courses within the corpus spongiosum and
arborizes with the deep dorsal vein through numerous circumflex veins that circle both corpora cavernosa.
As these veins progress further proximally, they merge at Santorini’s plexus just proximal to the symphysis
[6]
pubis, alongside the prostate on each side .

Graft and flap materials and their characteristics
Types of grafts and graft techniques
Many grafts have been used in urethral reconstruction, including oral mucosa, lingual mucosa, penile skin,
tunica vaginalis, bladder mucosa, colonic mucosa, and acellular grafts including porcine small intestinal
submucosa and tissue-engineered material . An oral mucosal graft (OMG) urethroplasty is currently the
[7,8]