Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures:does it make a difference?

Abstract

Objective To report our experience in managing complex anterior urethral strictures with a dorsally/dorsolaterally placed penile/preputial vascularized¯ap, and to discuss the advantages of this procedure over a traditional ventrally placed¯ap. Patients and methods Between 1995 and 1999, 40 patients (mean age 40.5 years) with recurrent strictures of the pendulous and/or bulbar urethra were treated with longitudinal penile/circumpenile¯ap substitution urethroplasty. Nineteen patients underwent dorsal placement of the¯ap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferior pubectomy to facilitate high proximal placement of the¯ap. Results Both groups had statistically similar ages, number of previous interventions, stricture site, length and follow-up. After a median follow-up of 27.5 months, the stricture recurred in three (24%) of the VO and two (11%) of the DO groups (P>0.05).One patient in the VO group required surgical closure of the urethral ®stula. Flap pseudo-diverticulum and/or sacculation with postvoid dribble occurred in six patients in the VO and none in the DO group (P=0.01). Conclusions Dorsal placement of the pedicled¯ap is anatomically and functionally more appropriate than the traditional VO placement. DO preputial/penile¯ap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.

Dorsal Onlay Buccal Mucosal Graft Urethroplasty in the Treatment of Urethral Strictures – Does the Stricture Length Affect Success?

“…The placement of the graft as dorsal, ventral or lateral still stays controversial. Some argue that dorsal onlay is superior to ventral [7,8], whereas others have reported excellent results with ventral onlay buccal mucosal grafts for urethroplasty [9]. Dorsally placed graft can have better results because of better mechanical support for the graft and richer vascular bed from the underlying corporal bodies [10,11].…”

Preputial/penile skin flap, as a dorsal onlay or tubularized flap: a versatile substitute for complex anterior urethral stricture

“…In the literature, the rate of occurrence of urethrocutaneous fi stula ranges from 0 to 13% [ 5,12,15,35,36 ] , and is higher for TFs. By contrast, in the present study, only two patients (5%) developed a urethrocutaneous fi stula in Group 1 and there were none in Groups 2 or 3.…”

“…The incidence of pseudodiverticular formation in fl ap repair ranges from 0 to 5% [ 5,12,17,35,36 ] in various series. In the present series, diverticula did not develop in Groups 1 and 3 but they were noted in 5% cases in the TF group (Group 2).…”

“…Necrosis of the penile skin proximal to the fl ap results when the vascular supply of the sub-dermal plexus is compromised and its incidence varies between 2 and 27% [ 5, 12,15,17,19,35,36 ] . Although minor in most cases, it can result in delayed healing and prolonged hospitalization.…”

“…For DOF repair, the fasciocutaneous fl ap was then brought on to the exposed dorsally opened portion of the urethra and sutured to adjoining edges of the urethra ( Fig. 6 ) using continuous sutures over a 16-F Foley catheter, as we have previously described [ 12 ] .…”