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Guerra et al. Plast Aesthet Res 2022;9:42 https://dx.doi.org/10.20517/2347-9264.2021.136 Page 5 of 7

[25]
can be omitted . In a personal communication from 2015, Barbagli and Kulkarni suggested ventral onlay
as an ideal technique for bulbomembranous and proximal bulbar urethra strictures. Ahyai et al. described a
[23]
retrospective study of their patients who had undergone ventral onlay urethroplasty . After a median
follow-up of 26.5 months, their success rate was 71.1% (range, 1.0-50.0) with a median time to stricture
recurrence of 17.0 months (range, 3.0-44.0) .
[23]
After the bulbar urethra is exposed and the stricture identified, the urethra is approached dorsally or
ventrally with a vertical incision . The stricture should be incised and surpassed proximally and distally to
[21]
the defect. The bulbar urethra is mobilized if a dorsal onlay will be performed, exposing the urethra and
moving it away from the corpora cavernosa. The BMG is sutured into the urethrotomy field and quilted
into the corpora cavernosa as the graft bed. After three weeks, the Foley catheter is removed .
[20]

The success rate of urethroplasty with BMG is between 79% and 96%, with a recent systematic review
demonstrating an overall 15.6% failure rate for substitution urethroplasty . However, a viable graft bed for
[24]
urethral reconstruction is vital. In these special cases with radiation-related strictures, previous
reconstructions are unique in that local flaps or graft places on these tissues are likely to be compromised by
fibrotic and ischemic surfaces. Accordingly, Meeks et al. reported stricture recurrence in one out of eight
patients who had undergone a substitution graft . Compared to EPA, the sparing of the cavernous nerves
[26]
located dorsally to the posterior urethra during dissection in BMG might advantageously result in the
preservation of erectile function after surgery or at least have less of a negative impact .
[26]

Flaps and pedicle grafts
The quest for a long-term, safe, stricture-free, hairless urethral lumen in patients with complex anterior and
posterior strictures and compromised genital skin remains one of the continuing challenges of
reconstructive urologic surgery . In severe cases in which prior RT or additional successive failed
[24]
reconstructive techniques have resulted in extreme scar tissue with inadequate vascularization, flaps or
[21]
pedicle grafts can be considered as an alternative .
Palmer et al. (2015) described the use of a ventral mucosal graft and gracilis muscle flap . They studied the
[27]
harvesting and mobilization of the gracilis muscle above the perineum and suturing to the flap making a
ventral buccal graft onlay . This research studied 20 cases with severe urethral narrowing, with a mean
[27]
stricture length of 8.2 cm. Strictures were located in the posterior urethra with or without bulbar urethral
involvement in 50% of cases (10), bulbomembranous urethra in 35% (7), bulbar urethra in 10% (2), and
proximal pendulous urethra in 5% (1). The etiologies included RT in 45% (9 of 20), idiopathic in 20% (4),
trauma in 15% (3), prostatectomy in 10% (2 of 20), and hypospadias failure and transurethral surgery in 10%
(2). Urethroplasty was described as successful in a follow-up of 40 months in 16 patients (80%), with
reoccurrence taking place within 10 months after surgery. However, this research has limited significance as
it is a retrospective study with a small sample size .
[27]
Rourke et al. published a series of 35 cases describing penile skin flaps in five patients with long post-
radiation urethral strictures , finding no significant differences compared to other techniques. However,
[22]
the limited number of patients restricts the comparison between techniques in this study. Some authors do
[28]
not recommend this technique as the primary treatment for post-radiation urethral strictures .

Currently, the evidence shows that flaps and pedicle flaps do not have a significant benefit in the application
of urethral stenosis in irradiated patients; however, in combination with other techniques, they can be
useful.