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Page 2 of 11 Shaw et al. Plast Aesthet Res 2021;8:52 https://dx.doi.org/10.20517/2347-9264.2021.53

flaps, and combined tissue transfer provide durable options for single or two-stage repairs. However, there
is no consensus on a single best reconstructive technique as the efficacy of each technique in restoring
[2,3]
urethral patency varies with both patient disease and surgeon expertise .

Anterior and posterior urethral strictures are considered separate disease processes, and flaps do not
currently play a role in posterior urethral reconstruction. Therefore, this review will focus on the use of
genital skin flaps, particularly those derived from penile skin, in anterior urethral reconstruction. Special
consideration should be taken for cases of urethral reconstruction in patients with a neophallus. Urethral
reconstruction in these patients is inherently complicated as the vascular supply of the neophallus is derived
from a non-anatomic pedicled flap. The description of penile skin flaps is therefore not applicable in the
reconstruction of the urethra in the neophallus as penile skin flaps depend on native penile vasculature. For
the purposes of this review, the focus will be on male anterior urethral stricture disease with native penile
tissue. Patient selection, flap characteristics, focused genital anatomy, and types of flaps will be discussed.
Operative approaches and recommendations on the use of each flap will be provided in addition to an
overview of published success rates.

PATIENT SELECTION
Appropriate understanding of patient comorbid diseases is essential in the choice of urethral reconstruction.
The approach to genital flaps, in particular, can be surgically challenging, and appropriate patient selection
is crucial. Patient comorbid diseases, particularly conditions that can compromise blood flow, are important
to understand as they can affect flap failure and wound healing. For example, patients with a history of
smoking, peripheral vascular disease, or radiation are at a higher rate of flap failure . Physical examination
[4]
to assess penile/genital skin integrity and concomitant wounds, fistulae, or abscesses is also important to
select appropriate flap locations and counsel patients on post-operative expectations. The presence of lichen
sclerosis (LS) bears particular mention. While there are reports of using flaps from uninvolved genital skin
in patients with LS, the success rates are lower, and often a two-stage approach has been preferred in this
population . Therefore, skin involved with LS should not be used for urethral reconstruction.
[5-7]

Stricture location and length often indicate the surgical technique best suited for repair. Genital flaps with
or without combined tissue transfer can play a role in bulbar urethroplasty, but generally, anastomotic or
buccal mucosal grafting (BMG) is preferred in the bulbar urethra. The tunneling of penile skin into the
perineum adds additional technical challenges - which makes this technique less favorable given the durable
success rates of BMG [8-12] . In general, flaps have fallen out of favor as a mainstream reconstructive option in
favor of BMG due to the risk of flap loss, increased technical demands, and patient satisfaction [13,14] . In the
appropriately selected patient, however, flaps still offer excellent success. Obliterative strictures can be
particularly challenging to manage as these have the insufficient dorsal urethral plate to perform onlay
techniques. For short obliterative strictures (< 2 cm), particularly in the bulbar urethra, anastomotic
urethroplasty with excision of the obliterated urethra is preferred due to the high published success rate. For
longer obliterative strictures, the dorsal urethral plate requires reconstruction. Combined tissue transfer
with dorsal graft (e.g., BMG) and ventral skin flap can be used in these cases. Two-stage repair, where the
first stage reconstructs the dorsal plate, can also be considered. Tubularized repairs are not preferred and
should be avoided if possible.

Patient age and goals are also important for patient counseling and choosing the appropriate reconstructive
technique. For older men with significant comorbidities, operations with less time in lithotomy position or
highest single-stage success may be preferred to the durability of repair. Paramount to this discussion is an
understanding of patients’ sexual function. There is emerging evidence that non-transecting techniques may