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cutaneous island flap is based and lifted on a broad pedicle of dartos fascia and is designed transversally on
the ventral skin of the penis. In this technique, a well-vascularized fasciocutaneous distal transverse ventral
skin flap is prepared and sutured to the ventral urethra [Figure 1]. Glans wings are raised and
reapproximated over the flap. Only minimal advancement of the flap is needed, making the final cosmetic
appearance highly gratifying. Long-term stricture free rates after this technique were 83% with a mean
[22]
follow-up of 10.3 years . In 1998, Armenakas and McAninch reported a modification of the previous
technique to mitigate potential complications of glans dehiscence that utilized a similar ventral transverse
[24]
skin flap but with preservation of the glans and elevation of the glans off the urethra [Figure 2] . The
authors reported a stricture-free rate of 94% at a mean follow-up of 43 months. Globally, patients were very
[25]
pleased with the cosmetic outcome. McAninch and Morey also adapted this concept to complex, long
urethral strictures extending from the FN to the proximal penile urethra. Based on a modification of the
original technique, they utilized a circumferential penile fasciocutaneous flap for long anterior urethral
strictures spanning up to 15 cm. They initially reported 79% successful results. Asserting that the total
length of FN stricture disease is a predictor for restricture, Virasoro et al. stratified FN strictures into two
[22]
groups, those < 2.5 cm and those > 2.5 cm, finding a statistical difference in terms of restricture in the longer
stricture cohort The use of local genital cutaneous flaps was strongly discouraged in the presence of LS,
which was associated with a 50% higher risk of restricture at the flap location in their series.

Grafts
Grafting procedures for distal penile strictures are deemed more flexible than flap procedures. Grafts can be
employed in inflammatory strictures, especially LS that discourages the use of penoscrotal cutaneous flaps.
Venn and Mundy compared the results between a single-stage penile skin flap urethroplasty and a
[26]
traditional staged graft (posterior auricular skin or oral mucosa) urethroplasty in patients with LS. Patients
treated with skin flap urethroplasty had a 100% recurrence rate at a mean follow-up of five years compared
to 8.3% recurrence of those who had a graft. These findings led them to infer that genital skin that is affected
by LS must be avoided in urethral reconstruction. Depasquale et al. also published a 90% long-term
[21]
restricture rate in LS patients who underwent staged urethral reconstruction with genital skin grafting as
[27]
opposed to 0% recurrence in those who received an OMG. In 1998, Naudé initiated the concept of
endoscopic graft urethroplasty. A few modifications were published later [28-29] . Unfortunately, these
procedures did not gain popularity due to intrinsic technical complexity and problems with surgical
reconstruction of distal penile strictures. The main advantage of this concept of intraurethral urethroplasty
over open procedures is to avoid skin incisions and glans elevation with spatulation. Open procedures are
intrinsically associated with cosmetic and functional complications, including infection, dehiscence, and
fistula. In 2008, Seth et al. reported a hybrid technique of intraurethral approach to distal urethral
[29]
stricture combining a transurethral graft placement with a ventral subcoronal incision to promote better
scar removal and proximal graft anastomosis. At a mean follow-up of 38 months, an 84% success rate was
[30]
reported. In 2016, Nikolavsky et al. published a new transurethral surgical technique for the
reconstruction of distal penile strictures employing OMG with promising outcomes [Figures 3 and 4]. They
developed this innovative and elegant reconstructive concept to avoid the drawbacks, technical
complexities, and weaknesses of the previous procedures used in this urethral segment. Other advantages
include avoidance of an external skin incision, preservation of the glans penis, and use of oral mucosa for
grafting, thus providing both very good functional and cosmetic outcomes. This surgical technique is
mainly advised for men with distal strictures due to LS, where only OMGs are recommended. At an initial
follow-up of 12 months, a 93% stricture free rate was reported.

Combined graft and flap urethroplasty
In 2011, Gelman and Sohn published a surgical technique characterized by the combined use of a dorsal