Skip to main content

Laminated Gracilis Flap Urethroplasty

A prelaminated gracilis–buccal mucosa composite has been described as staged salvage for selected devastated bulbar urethras with inadequate native urethral tissue for conventional repair, when a corporal or residual urethral bed can support the dorsal graft.[1][2] Unlike a gracilis flap placed beneath a conventional onlay in the same operation, the mucosal graft is allowed to vascularize on the muscle before transfer.[1][2]

Terminology​

Pribaz and Fine introduced prelamination for the implantation of tissue or other devices into a flap before transfer, and proposed restricting prefabrication to the implantation of a vascular pedicle.[3] By that definition the gracilis–buccal composite is a prelaminated flap: the muscle keeps its native pedicle and only the mucosal lining is added. The 2022 multicenter report uses the term "prefabricated composite gracilis–buccal mucosal flap" for the same operation.[2]

Indications​

The published cases involve a devastated bulbar urethra: bulbar necrosis, failed fasciocutaneous repairs or a "watering can" perineum, in which reliable local tissue is scarce.[1] In the five-patient series, all men had a suprapubic tube and at least one prior failed repair (1–9).[2] Gracilis is a reliable, expendable muscle that lies outside many pelvic radiation fields, which is why it is also used for interposition in radiated urethral beds and in complex fistula repair (see Gracilis Flap). The prelaminated composite itself has been reported only in the devastated bulbar urethra.

Bulbar urethral necrosis has been described after vascular compromise in pelvic fracture urethral injury and its repair.[4] At one tertiary referral center from 1995 to 2023, 145 men had bulbar urethral necrosis, representing 10.8% of that center's pelvic fracture urethral injury cases and 40.3% of its complex cases.[4] Necrosis typically followed prior PFUI repair; the authors proposed a retrograde-urethrographic classification.[4] A further case report described the same two-stage reconstruction in a 67-year-old man with a 5-cm missing bulbar segment and a double block after trauma and a previous urethral diverticulectomy.[5]

Preoperative Evaluation​

  • Urinary drainage and infection. Suprapubic drainage is established and infection controlled before stage 1.[1][2]
  • Defect mapping. Combined antegrade and retrograde imaging defines the length of the missing segment and any proximal or distal block; in the 2025 case it showed a 5-cm gap with obstruction at both ends.[5]
  • Donor sites. Assess oral mucosal area for both neourethral plates; the index case used two buccal grafts, whereas the 2025 case used two buccal grafts and one lower-labial graft.[1][5] Assess the medial thigh for prior surgery, scarring or vascular disease that could compromise the gracilis pedicle (see Gracilis Flap).
  • Counseling. The operation needs at least two stages, a buccal and a thigh donor site, and suprapubic drainage between stages; the alternatives below are discussed at the same visit.[2]

Relevant Gracilis Anatomy​

The dominant gracilis pedicle has variable origins and reported entry landmarks. StatPearls describes a descending medial circumflex femoral branch or a direct profunda femoris branch and places its entry approximately 10 cm below the pubic tubercle between adductor longus and magnus.[6] In CT angiography of 40 patients, Macchi et al. found direct deep femoral and adductor-branch origins in 45% and 46%, respectively, with mean entry 10 ± 1 cm from the ischiopubic attachment.[13] Identify the actual proximal pedicle during harvest.[6] Study-by-study variation in pedicle origin and entry point is summarized on the Gracilis Flap page.

Reconstructive Concept​

After controlling infection and establishing urinary drainage, stage 1 creates two independently supported mucosal surfaces: BMG quilted to the corporal or urethral bed forms a dorsal plate and temporary augmented perineal outlet; a second BMG is quilted to exposed distal gracilis. Once both surfaces have healed, the muscle–graft composite is mobilized on its proximal vascular pedicle and tunneled into the perineum. Its mucosal edges are joined to the dorsal plate to reconstruct the ventral urethra. The result is two mucosa-lined hemi-plates joined to each other, not a circumferential muscle tube.[1][2]

The published initial case used an eight-week interval; the later five-patient cohort averaged 6.2 weeks. The interval in the later series ranged from 1 to 10 weeks. Healing, graft take and patient factors determine timing, and an observed leak should resolve before catheter removal.[1][2]

Operative Steps​

Stage 1

  1. Assess the affected segment and either excise nonviable tissue to healthy proximal and distal urethra or prepare a retained urethral plate for dorsal inlay augmentation.[1][2][5]
  2. Quilt a buccal mucosal graft onto the corpora cavernosa, or onto the residual urethral bed, to form the dorsal neourethral plate.[1][2] Mature its edges to perineal skin to create a temporary augmented perineal urethrostomy; the index operation placed a catheter in the outlet and applied a tie-over dressing.[1]
  3. Expose distal gracilis through a medial-thigh skin opening and suture the muscle to the skin edges. Quilt oral mucosa to the exposed muscle for the future ventral plate; both case reports protected the graft with a tie-over dressing for one week.[1][5]
  4. Keep suprapubic drainage in place while both grafts mature.[1][2]

Stage 2

  1. Confirm graft take on the perineal and gracilis plates and assess contraction or temporary-urethrostomy stenosis before transfer. The index case proceeded at eight weeks, the series at a mean of 6.2 weeks (range 1–10), and the 2025 case at 12 weeks.[1][2][5] Mobilize the gracilis–mucosa composite on its proximal pedicle.[1]
  2. Identify and preserve the dominant proximal pedicle, then divide the distal gracilis tendon and minor distal pedicles needed for transfer. Pass the composite through a wide tunnel into the perineum.[1]
  3. Anastomose the mucosal edges of the gracilis plate to the edges of the dorsal plate to close the neourethra. In the index operation, the muscle was sutured to the corpora as a second layer over the suture line, and a drain was left in the thigh harvest bed.[1][5]
  4. Obtain contrast imaging before urethral catheter removal. In the index case, a small leak at three weeks resolved by five weeks; the suprapubic catheter remained clamped during a successful voiding trial and was removed six weeks after urethral catheter removal.[1] In the 2025 case, urethrography at five weeks showed no leak.[5]

Evidence and Counseling​

The 2022 two-center series included five men with prior failed repairs and mean stricture length 7.2 cm.[2] No recurrence was reported at mean 61-month follow-up; four completed postoperative questionnaires.[2] The five-patient series describes feasibility in selected patients, without comparative or reliable success estimates. Counseling covers donor-site morbidity, multiple operations, recurrent narrowing or fistula, and the alternatives of a permanent perineal outlet or urinary diversion.[2] The EAU 2026 urethral-stricture guideline recommends routine follow-up for at least one year , flexible cystoscopy at three months , and a risk-adjusted protocol . For graft or flap substitution, its proposed standard-risk schedule includes uroflowmetry, patient-reported outcomes and anatomic assessment.[14]

The index patient, a 57-year-old man with penetrating trauma to a previously reconstructed urethra, had normal voiding and continence at 8 months.[1] In the 2025 case, urethroscopy showed a patent neourethra at six months. At 12 months, a telephone interview found self-reported normal voiding and no reported fistula or overactive-bladder symptoms; there was no repeat anatomical assessment.[5] The published human experience consists of two case reports and one five-patient series.

Complications​

  • Thigh donor site. Among 104 free gracilis transfers (43 in patients younger than 18), 10/104 (9.6%) had an in-hospital donor-site complication. Of 62 survey respondents, 15% reported temporary reduced leg strength lasting a mean of six months.[7]
  • Graft failure, fistula or recurrent narrowing. These are the expected failure modes of any two-plate reconstruction and are listed in the counseling above.[2]
  • Staged burden. The patient lives with a perineal outlet and suprapubic drainage between stages.[1]

Comparison With Alternatives​

OptionEvidenceReported resultNotes
Prelaminated gracilis–BMG composite5-patient series; 2 case reports[1][2][5]No recurrence at mean 61 months in the seriesStaged; muscle and buccal donor sites
Ventral BMG with same-stage gracilis supportSingle-center series, n = 20; expanded 20-year cohort, n = 30[8][9]Success 80% at mean 40 months; 76.7% at mean 32 months, with 23.3% later needing an AUS for incontinenceSingle stage; requires urethral margins for a ventral BMG onlay; gracilis supplies the vascularized graft bed
Pedicled tubularized penile flaps for bulbar necrosisSeries, n = 41[10]At median 20 months (IQR 14–24), primary success 66% and secondary success 78%; primary success by flap was 76% for preputial tube, 75% for Q-flap and 40% for distal penile skin; complications 14.6%Requires adequate penile skin
Colonic substitution (entero-urethroplasty)Case report[11]Ascending colon substitution described in one man with ischemic bulbar necrosis after failed anastomotic urethroplastyAdds a bowel anastomosis
Perineal urethrostomyRetrospective comparison in complex anterior strictures, 45 PU versus 64 BMG urethroplasties; staged repairs excluded[12]Satisfied or very satisfied 86.7% versus 89.1%[12]Single stage; permanent perineal meatus

None of these options has been compared with the prelaminated composite in a controlled study. A staged composite has been described for selected devastated bulbar segments when local urethral tissue or penile skin is insufficient, provided the corporal or residual urethral bed can support the stage-1 dorsal graft. Permanent perineal urethrostomy is an alternative when sphincteric continence is preserved and a patent proximal outlet can be created; proximal bulbar or membranous stenosis may require an augmented PU.[15][16] Urinary diversion remains an alternative for patients considering the staged burden.[1][2]

See Also​

References​

1. Nikolavsky D. Prelaminated gracilis flap with buccal mucosal graft for salvage of devastated urethra. Case Rep Urol. 2015;2015:490518. doi:10.1155/2015/490518. Full text.

2. Sterling J, Schardein J, Joshi PM, Kulkarni SB, Nikolavsky D. Long-term outcomes from a multi-institutional experience with prefabricated composite gracilis-buccal mucosal flap for reconstruction of devastated urethras. Int Urol Nephrol. 2022;54(5):1047-1052. doi:10.1007/s11255-022-03154-z.

3. Pribaz JJ, Fine NA. "Prelamination: Defining the Prefabricated Flap. A Case Report and Review." Microsurgery. 1994;15(9):618–623. doi:10.1002/micr.1920150903

4. Joshi P, Navarro J, Ocampo MA, et al. "Bulbar Urethral Necrosis: Current Concept and Novel Comprehensive Classification." BJU Int. 2025;136(1):103–108. doi:10.1111/bju.16710. PMID 40094160

5. Soeroto AA, Aulia I, Purnomo AT, Wahyudi I. "Devastated Urethra With Double Block After Urethral Diverticulectomy Procedure: A Nightmare Case Salvaged With Two-Staged Prelaminated Gracilis Flap With Buccal Mucosal Graft." Urol Case Rep. 2025;62:103124. doi:10.1016/j.eucr.2025.103124. PMID 40686506

6. Gracilis Tissue Transfer. StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 32644472; NCBI Bookshelf.

7. Carr MM, Manktelow RT, Zuker RM. "Gracilis Donor Site Morbidity." Microsurgery. 1995;16:598–600. doi:10.1002/micr.1920160904

8. Palmer DA, Buckley JC, Zinman LN, Vanni AJ. "Urethroplasty for High Risk, Long Segment Urethral Strictures With Ventral Buccal Mucosa Graft and Gracilis Muscle Flap." J Urol. 2015;193(3):902–905. doi:10.1016/j.juro.2014.09.093

9. Rozanski AT, Vanni AJ. "Ventral Buccal Mucosa Graft Urethroplasty With Gracilis Muscle Flap for High Risk, Long Segment Urethral Strictures: A 20-Year Experience." Urology. 2020;140:178–180. doi:10.1016/j.urology.2020.03.008. PMID 32197989

10. Joshi PM, Navarro J, et al. "Pedicled Tubularized Flaps for the Treatment of Bulbar Urethral Necrosis." World J Urol. 2026. doi:10.1007/s00345-026-06223-5. PMID 41575585

11. Tajudeen M, et al. "Entero-Urethroplasty for Bulbar Urethral Necrosis." Cureus. 2025. PMID 40821235; PMC12355295 doi:10.7759/cureus.88053

12. Colakoglu Y, Ayten A, Gelmis M, Zilan A, Savun M, Simsek A. "Is Perineal Urethrostomy a Last Resort or a Viable Alternative? Comparative Analysis With Buccal Mucosal Graft Urethroplasty." World J Urol. 2025;43(1):411. doi:10.1007/s00345-025-05800-4. PMID 40618310

13. Macchi V, Vigato E, Porzionato A, et al. "The Gracilis Muscle and Its Use in Clinical Reconstruction: An Anatomical, Embryological, and Radiological Study." Clin Anat. 2008;21(7):696–704. doi:10.1002/ca.20685

14. Lumen N, Campos-Juanatey F, Dimitropoulos K, et al. EAU Guidelines on Urethral Strictures. EAU Guidelines Office; Arnhem, the Netherlands; 2026. Chapter 11, Follow Up. ISBN 978-94-92761-32-5. Guideline chapter. Accessed October 4, 2026.

15. Velarde Ramos L, Martins F. "Role of Perineal Urethrostomy in Reconstructive Urology." J Clin Med. 2026;15(11):4133. doi:10.3390/jcm15114133

16. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. 2026. Official guideline.