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McAninch Transverse Circular Penile Fasciocutaneous Flap

The McAninch transverse circular penile fasciocutaneous skin flap is a single-stage, pedicled flap technique for reconstruction of complex, long-segment anterior urethral strictures, first described by Jack W. McAninch at San Francisco General Hospital and UCSF in 1993. It preserves the dartos vascular pedicle, supported by the superficial fascial lamella described in the original technique, and provides up to 15 cm of hairless tissue. It can be used across the anterior urethra as an onlay or a tubularized flap, or combined with grafts. In the UCSF retrospective series (124 patients without lichen sclerosus, median follow-up 7.3 years), overall estimated stricture-free survival was 84% at 5 years and 79% at 10 years.[1][2][3]

For graft alternatives, see Dorsal Onlay OMG Urethroplasty and Ventral Onlay OMG Urethroplasty. For the underlying penile / preputial skin flap anatomy and other variants, see Pedicled Penile / Preputial Skin Flap. For graft material, see Buccal Mucosa Graft.

Historical Context and Evolution​

Predecessors

  • Orandi (1968). First longitudinal ventral penile skin island flap based on the dartos fascia pedicle; established the principle of using pedicled penile skin for urethral reconstruction.
  • Quartey (1983). Introduced the transverse distal penile or preputial cutaneous island flap supplied by the superficial external pudendal vessels, demonstrating that a transversely oriented flap could reach from the meatus to the prostatic urethra.[6]
  • McAninch (1993). Refined and popularized the circular fasciocutaneous flap concept, preserving the dartos vascular conduit with fascial support.[1]

The History of Urethral Surgery places the flap among the earlier penile skin flaps.

McAninch's innovation. McAninch harvested the distal penile skin circumferentially on its fascial vascular pedicle. The resulting flap has the following properties.

  • Vascularized skin. External-pudendal branches carried in the dartos pedicle and its subdermal plexus
  • Length. Up to 15 cm, sufficient to reconstruct the entire anterior urethra from meatus to membranous urethra
  • Hairless tissue. Distal penile skin is generally hairless, avoiding intraurethral hair growth when selected carefully; ventral skin near the raphe may bear hair, so inspect the entire planned island and exclude hair-bearing skin from the urethral lining.[24][20]
  • Versatility. Can be used as onlay (augmentation) or tubularized (substitution), and combined with other tissue transfer techniques[1][4]

Anatomy and Vascular Basis​

The skin island is supplied through the tunica dartos vascular pedicle, with external-pudendal arterial branches. The historical description of Buck's fascia as a conduit refers to fascial support of that pedicle; Carney and McAninch distinguish this from the deep dorsal neurovascular structures.[1][4]

Preserve the superficial vascular pedicle and subdermal plexus during harvest. The flap is not based on retrograde flow through the deep dorsal penile arteries, and the deep dorsal neurovascular bundle must not be raised as its pedicle. Orandi and circular flaps share the dartos vascular basis; the principal differences are skin-island design, pedicle mobilization and reach.

Surgical Technique​

The technique as described by McAninch and Carney.[1][2][4]

Patient positioning​

  • Lithotomy position (exaggerated lithotomy for bulbar access)
  • Limit time in exaggerated lithotomy to prevent neurovascular lower-extremity complications (4 cases in the original 66-patient series).[2]
  • Synchronous distal and proximal disease. For a repair spanning the penile and bulbar segments, the distal flap harvest and repair can be completed with the patient supine and the penile incision closed before repositioning to lithotomy for the perineal or bulbar exposure; this confines lithotomy time to the portion of the case that needs it and limits urethral blood loss from the incised corpus spongiosum during the supine portion.[22][23]

Urethral exposure​

  • A perineal incision for bulbar access, a penile degloving incision for penile urethral access, or both
  • Identify the stricture, open the urethra longitudinally (ventral or dorsal urethrotomy), and extend the incision into healthy, normal-caliber urethra before joining the flap to the urethral mucosa.[28]
  • Stricture length and extent of spongiofibrosis assessed
  • Plate assessment. Passing a small (8 Fr) feeding tube into the bladder through the urethrotomy has been described as an intraoperative check of plate caliber and uniformity; for a focal segment of severe narrowing, excision with a short dorsal buccal mucosa patch, or lateral advancement sutures when fibrosis is not extreme, have been described to salvage an otherwise usable plate before committing to flap coverage.[22] If poor plate quality or extensive scarring still prevents a sound single-stage repair, convert to a staged plan; counsel the patient before surgery that this may be necessary .[27]

Flap design and harvest​

  • The flap is designed on the distal penile shaft, oriented transversely (circumferentially) around the penis
  • Uncircumcised patients. Inner preputial skin provides ample hairless tissue
  • Circumcised patients. Remaining distal penile shaft skin is used; the flap can still be raised though available tissue may be somewhat less[1][8][17]
  • For onlay augmentation, Kim et al. marked the second circumferential incision 15–20 mm proximal to the first; a circular flap can provide up to 15 cm of length.[26][1]
  • Measurement. The flap is measured with the penis on stretch, for example with a glans traction suture, to avoid designing a redundant, oversized island. For onlay augmentation, Carney and McAninch describe a 17–20 mm skin island, rarely widened past 20 mm because a wider onlay increases the risk of pseudodiverticulum, and a wider (approximately 25 mm) island when the flap is tubularized for complete replacement, tailored to a lumen of approximately 26 Fr.[21][23]
  • The distal incision enters the plane deep to the vascular pedicle; the proximal incision stays superficial to it, preserving the dartos blood supply attached to the skin island
  • Mobilize the skin/fascial unit while protecting both its subdermal plexus and the underlying deep neurovascular structures

Pedicle development​

  • Develop the dartos vascular pedicle, preserving its fascial support and avoiding dissection into the deep dorsal neurovascular bundle
  • Pedicle developed proximally for sufficient length to reach the strictured segment
  • Pedicle must be wide enough for adequate blood supply but narrow enough to allow rotation without kinking
  • Avoid a scrotal tunnel when an alternative route can reach the defect. Tunneling the flap through the scrotum to gain proximal reach has been associated, in editorial experience, with erection-related tethering of the penis, and is best avoided in young, sexually active patients.[21]

Flap transfer and configuration​

ConfigurationIndicationNotes
Ventral onlay (most common)Augmentation of a strictured urethra with intact dorsal plateFlap rotated and laid over the ventral urethrotomy as an onlay; sutured with absorbable sutures (5-0 / 6-0 PDS / Vicryl)
Dorsal onlayStrictures where dorsal mobilization is feasibleUrethra mobilized circumferentially; flap placed dorsally against the corpora; urethra rotated back over the flap. May reduce sacculation risk vs ventral.[7]
Tubularized substitutionSelected complete-segment defects when an onlay is not feasible and staged or combined reconstruction is unsuitableThe vascularized flap is tubularized around a catheter. In the 1998 observational cohort, recurrence occurred in 7/12 tubularized repairs versus 7/54 onlays; the groups differed in plate quality. AUA 2023 describes a tubularized flap as an option when no alternative exists.[2][20]
Combined with graftsStrictures exceeding available flap length (up to 15 cm)McAninch's original circular-flap report used a penile-skin graft to bridge an 18 cm stricture and a bladder-mucosa graft for a 21 cm stricture.[1] Later BMG combinations in a Q-flap case and an Orandi-type series used distinct flap designs.[14][18]

Closure​

  • Penile skin closed over the flap pedicle
  • Urethral catheter (16–18 Fr) placed
  • Suprapubic catheter may be placed for diversion
  • Drains as needed
  • Dressing. A scrotal support with gentle compression protects the repair; a circumferential penile compression bandage is avoided. Securing the urethral catheter to the lower abdominal wall keeps the penis in its anatomic position and avoids pressure on the ventrally positioned flap.[23]

Postoperative care​

  • Catheter removal at 2–3 weeks after VCUG confirms no extravasation
  • Follow-up with uroflowmetry, RUG, and / or cystoscopy

Clinical Outcomes — UCSF / SFGH Series​

StudynStricture lengthConfigurationPrimary successLong-term successFollow-upKey Findings
McAninch 1993 (original)[1]108–21 cm9 onlay, 1 tubularized10/10 without recurrence—mean 14.4 moMean Qmax 21.7 mL/s; all reported normal erectile function; 2 repairs used supplemental grafts for 18 and 21 cm strictures
McAninch / Morey 1998 (expanded)[2]669.08 cm54 onlay, 12 tubularized79% overall (87% onlay, 42% tubularized)95% including secondary procedures41 mo (1–7 yr)Onlay significantly better than tubularized (p < 0.05); 4 neurovascular extremity complications from prolonged lithotomy
Whitson 2008 (long-term)[3]124median 8.2 cm——Estimated overall stricture-free survival: 95% at 1 yr; 89% at 3 yr; 84% at 5 yr; 79% at 10 yrmedian 7.3 yr (range 1 mo–19.5 yr)Predictors of failure: smoking (HR 4.0), hypospadias history (HR 4.4), stricture 7–10 cm (HR 7.0); lichen sclerosus excluded

Key observations​

  • Onlay outperformed tubularization. In McAninch and Morey 1998, recurrent stenosis occurred in 7 of 54 onlay repairs (13%) and 7 of 12 tubularized repairs (58%), giving success of 87% and 42%. These observational groups differed in plate quality and disease complexity. The data support preferring onlay when a usable plate remains.[2]
  • Independent circular-flap series. In Kim et al.'s retrospective cohort, 20/29 patients needed no further instrumentation at median 19 months; 23/29 had no recurrence at the flap site, a different endpoint. Postmicturition dribbling occurred in 12/29 (41.3%). Nine repairs were combined with another procedure.[26]
  • Long-term follow-up. Whitson 2008 is a retrospective series with median follow-up of 7.3 yr (maximum 19.5 yr). Overall estimated stricture-free survival was 79% at 10 yr, declining gradually from 95% at 1 yr.[3]
  • Independent multivariate predictors of failure:[3]
    • Smoking (HR 4.0, 95% CI 1.2–12.9, p = 0.02)[3]
    • History of hypospadias repair (HR 4.4, 95% CI 1.3–14.6, p = 0.01)[3]
    • Stricture length 7–10 cm (HR 7.0, 95% CI 1.4–34.7, p = 0.02)
  • Secondary procedures salvage most failures. Most recurrences in McAninch and Morey 1998 were managed with a single subsequent procedure (repeat urethroplasty in 5, optical urethrotomy or dilation in 6), bringing overall long-term success to 95%.[2]

Modified circular flap (Zhao 2026)​

A recent modification splits the circular fasciocutaneous flap longitudinally on the dorsal side of the penis and transfers it to the ventral side, rather than rotating the intact circular flap.[8]

In 54 patients at 15-month mean follow-up:

  • Stricture recurrence: 0/54 observed at a mean follow-up of 15 months[8]
  • Penile skin necrosis or fistula: 0/54 observed[8]
  • 24.1% post-micturition dribbling
  • 14.8% mild penile torsion
  • Successfully performed in 6 circumcised patients without skin shortage

Mean Qmax rose from 6.3 to 18.6 mL/s, and IIEF-5 was unchanged (23.9 to 23.5).[8]

Complications​

The rates below come from different cohorts and flap designs, including the original circular, modified circular and other penile-skin flaps.[2][8][9][24]

ComplicationIncidenceNotes
Stricture recurrence / overall failure7/54 (13%) onlay recurrences in UCSF 1998[2]; 21% estimated overall failure by 10 yr in the full UCSF 2008 cohort (79% stricture-free survival)[3]Most 1998 recurrences were managed with one secondary procedure.[2]
Stricture recurrence (tubularized)58% (UCSF 1998)Significantly worse than onlay; avoid when possible[2]
Postvoid dribbling24% (Zhao 2026); 32% (9/28, Dubey 2007 flap arm)Sacculation / pseudodiverticulum at the flap site has been reported with ventral placement (6 of 21 ventral vs 0 of 19 dorsal onlay in Bhandari 2001)[7][8][9]
Superficial penile skin necrosis16–21% (flap arms in RCTs: Hussein 3/19, Dubey 6/28)Dubey's superficial cases healed with conservative care; one separate case of extensive skin loss required skin grafting[9][10]
Penile torsion7–15% (Dubey: slight torsion, angle unreported; Zhao: <30°)2 of 28 in Dubey; 8 of 54 in Zhao (rotation < 30° during erection)[8][9]
Urethrocutaneous fistula0–5% in three cited cohorts (0/54 Zhao; 1/19 Hussein, at the fossa navicularis; 1/26 Tijani)Counts from distinct flap designs and follow-up periods.[8][10][11]
Neurovascular extremity complications6% (4/66 in UCSF 1998)Prolonged exaggerated lithotomy; reduce risk by limiting positioning time and monitoring pressure points[2]
Penile hypoesthesia3/28 (10.7%) in the Dubey mixed-flap armSensory morbidity in a trial combining circumferential and longitudinal flap designs.[9][24]
Erectile dysfunctionIncompletely quantifiedAll 10 patients in the original report had normal erectile function at mean 14.4-month follow-up; stable IIEF in the 54-patient modification.[1][8]
Penile shortening / cosmetic deformityRareMore concern in circumcised patients with limited remaining skin[8][17]

Comparison with Buccal Mucosal Graft Urethroplasty​

These studies test different comparisons. Free penile skin grafts (PSG) are not pedicled skin flaps. Dubey and Ali directly compared penile skin flaps with BMG, while PeeBuSt and Alrefaey compared free penile-skin grafts with BMG; Ali pooled three flap designs (including 24 McAninch repairs).[9][25][12][13]

StudynDesignReported success in listed groupsOR TimeKey Differences
Dubey 2007 RCT[9]55Dorsal onlay PSF (28) vs dorsal onlay BMG (27)24/28 (85.7%) vs 24/27 (88.9%) without further urethral procedure (NS)224 vs 162 min (p = 0.001)Flap: more superficial skin necrosis (6/28, 21%), penile torsion (2/28, 7%), troublesome postvoid dribbling (9/28, 32% vs 4/27, 15%); at 6 mo, 89% of BMG vs 65% of flap patients said they would recommend the procedure
Tyagi 2022 PeeBuSt RCT[13]100 randomized; 95 analyzedPSG vs BMG42/47 vs 44/48 at 18 mo (p = 0.70)—Both arms are free grafts; success required any one of Qmax >15 mL/s, 16 Fr catheter passage or 17 Fr cystoscope passage, with postoperative intervention counted as failure; no significant difference in success, IPSS or sexual function
Alrefaey 2025 RCT[12]98 randomized; 92 analyzedPSG vs BMG41/44 vs 47/48 at 12 mo (p = 0.346)—Both arms are free grafts; mean stricture length 6.4 vs 7.9 cm (p = 0.11)
Hussein 2011 RCT[10]37Circular skin graft (18) vs circular skin flap (19)13/18 (72.2%) vs 15/19 (78.9%); no statistically significant difference reported203 vs 282 min (p = 0.000)Graft: shorter OR; Flap: 3 cases skin necrosis, 1 fistula; similar postvoid dribbling
Ali 2019 RCT[25]84Dorsolateral onlay BMG (42) vs ventral onlay penile skin flap (42; 24 McAninch, 9 Orandi, 9 Q)39/42 vs 36/42 (p = 0.5)—Short mean follow-up, reported inconsistently (flap 13.1 months in Results, 9.1 in Table 3; BMG 16.5 and 12.5 months, respectively); flap outcomes pooled across three designs, with no McAninch-only success estimate

Summary of flap vs BMG evidence​

  • Direct flap versus BMG evidence is limited. Dubey randomized 55 patients and Ali randomized 84; neither reported a statistically significant success difference. Ali pooled McAninch, Orandi and Q flaps. PeeBuSt and Alrefaey compared free graft materials.[9][25][12][13]
  • Operative time. In the Dubey trial, BMG operations were shorter (162 vs 224 min); the authors describe penile flap procedures as technically more complex.[9]
  • Morbidity. In the Dubey trial, the flap arm had more superficial skin necrosis (6 of 28), penile torsion (2 of 28) and troublesome postvoid dribbling (9 of 28, 32%, versus 4 of 27, 15%).[9]
  • Patient preference. At 6 months in the Dubey trial, 89% of BMG patients and 65% of flap patients said they would recommend the procedure.[9]
  • Blood supply. The flap carries its own blood supply. Carney and McAninch consider this the basis of its results in compromised urethral beds where a graft might not take.[4]

The AUA Urethral Stricture Disease Guideline (2023) states that, in properly selected patients undergoing single-stage penile urethroplasty, success rates with penile fasciocutaneous flaps and oral mucosal grafts appear similar regardless of tissue and technique used, and recommends that surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination .[20]

Indications and Patient Selection​

Ideal indications[1][2][3]​

  1. Long, complex anterior urethral strictures when a flap has a specific advantage, such as poor urethral-bed vascularity or the need for one-stage tubularized tissue transfer.[24] EAU 2026 recommends a graft when both are equally indicated and a flap for poor urethral-bed vascularity .[24]
  2. Panurethral strictures. Can reach from the meatus to the membranous urethra.
  3. Strictures with a compromised urethral bed. Where spongiofibrosis is severe and a free graft may not take due to poor vascularity.
  4. Failed prior urethroplasty. Well-vascularized flap can overcome the scarred, poorly vascularized tissue bed that contributed to prior graft failure.
  5. Patients with limited oral mucosa. When BMG donor sites are depleted or when oral pathology (e.g., submucous fibrosis) precludes BMG harvest.[17]
  6. Combined with BMG. For very long strictures, the flap can be combined with BMG to achieve single-stage reconstruction of the entire anterior urethra.[14][18]

Contraindications / limitations​

  • Lichen sclerosus. Genital skin (including penile skin) is susceptible to LS and should not be used in patients with LS-related strictures. Oral mucosa is the preferred substitute.[15][16][20]
  • Unhealthy penile skin. Assess irradiation, scarring, or dermatosis of the donor penile skin and vascular pedicle before flap harvest; unusable donor tissue precludes it. Irradiation of the urethral bed alone may favor a healthy vascularized flap: EAU 2026 recommends a graft when graft and flap are equally indicated , but a flap for poor urethral-bed vascularity .[24]
  • Insufficient penile skin. Severely circumcised patients with very limited remaining penile skin may not have adequate tissue, though the technique can be performed in circumcised men with sufficient remaining skin.[1][8][17]
  • Hair-bearing skin. The AUA guideline states that surgeons should not use hair-bearing skin for substitution urethroplasty .[20] Inspect the entire proposed distal penile island: ventral skin near the raphe can bear hair, as can more proximal shaft skin, and neither should form the urethral lining.[20][24]

Comparison of Penile Skin Flap Configurations​

Flap TypeOrientationPedicleMax LengthKey Feature
McAninch circular fasciocutaneous[1][2]Transverse / circumferentialDartos vascular pedicle with fascial supportUp to 15 cmLong circular skin island
Orandi longitudinal[5]Longitudinal (ventral originally; dorsal in Barbagli 2019, 10/12 successful)Dartos fasciaLimited by penile lengthSimpler; used for penile strictures
Quartey transverse preputial island[6]TransverseSuperficial external pudendal vesselsReach from meatus to prostatic urethra as describedUses distal penile or preputial skin; 10 cases in the original report
Circumpenile (Srivastava)[17]Circumferential (shaft skin)Dartos fasciavariableFor circumcised patients; uses remaining shaft skin
Modified circular (Zhao 2026)[8]Circular, dorsally splitDartos vascular pedicle with fascial supportsimilar to McAninchDorsal split avoids rotation; 0/54 observed recurrences at mean 15 mo follow-up

Combination Techniques — Flap + Graft​

For long penile strictures with a damaged urethral plate, combining a dorsal BMG with a ventral penile skin flap has been described as a single-stage alternative to staged urethroplasty. The evidence is one case report and one 12-patient series.[14][18]

Karapanos 2024 described a technique preserving the native urethral plate and corpus spongiosum, combining a dorsal onlay BMG quilted to the corpora cavernosa with a longitudinal ventral penile skin flap (Orandi-type), achieving 91.7% success after a median follow-up of 38 months in 12 patients with narrow penile strictures (median 5 cm). The preserved corpus spongiosum was wrapped around the flap ventrally for reinforcement. No sacculation or diverticula formed. Three transient fistulas healed with prolonged urinary diversion, and 41.7% (5 of 12) reported postvoid dribbling.[18]

For a stricture longer than the available skin island, placing the pedicled flap in the pendulous urethra and the free graft in the bulbar segment, where the corpus spongiosum is more vascular, has been described as a configuration for the two tissue sources.[23]

The AUA guideline permits combined tissue transfer for appropriate multi-segment strictures; it does not endorse a particular named combination: surgeons may reconstruct long multi-segment strictures with oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques .[20]

Preputial Spiral Graft — A Modern Alternative​

Kulkarni, Joshi, Basile and Bandini first described preputial spiral graft urethroplasty (PSGU) for panurethral stricture in 2023; Bandini and colleagues reported a larger multicenter series in 2025. PSGU uses the prepuce as a free graft (not a flap), harvested in a spiral configuration to maximize length.[29] In a prospective multicenter series of 114 patients with median stricture length 16 cm, recurrence occurred in 11 (9.6%) at median follow-up of 16 months (success defined as Qmax > 10 mL/s without symptoms).[19] The technique requires an intact prepuce, and active lichen sclerosus was absent in the series. The AUA guideline against genital skin in LS-proven strictures still applies .[19][20]

Key Takeaways​

The McAninch transverse circular penile fasciocutaneous flap is used for complex, long-segment anterior urethral strictures. It offers length (up to 15 cm), a preserved dartos vascular supply and flexibility (onlay, tubularized, or combined with grafts). In the UCSF series overall estimated stricture-free survival was 79% at 10 yr.[1][2][3] Oral mucosal graft is the AUA-preferred first choice when a graft is used.[20] In Dubey’s randomized 55-patient comparison, BMG took less operative time and had less penile morbidity than mixed penile-skin flap designs, with no significant difference in reported success.[9] In a later 84-patient randomized trial of long penile strictures, study-reported success was 39/42 with dorsolateral BMG versus 36/42 with ventral penile-skin flaps (p = 0.5) at intermediate follow-up; Orandi, McAninch, and Q-flap designs were pooled.[25] The circular flap is used when a pedicled, well-vascularized tissue transfer is wanted: long strictures, scarred urethral beds, failed prior grafts and depleted oral mucosa donor sites.[2][3] It should not be used in lichen sclerosus.[15][20]

Videos​

McAninch Fasciocutaneous Penile Flap for Urethral Stricture
Dr Venkatanaidu V (2023)

References​

1. McAninch JW. Reconstruction of extensive urethral strictures: circular fasciocutaneous penile flap. J Urol. 1993;149(3):488-91. doi:10.1016/s0022-5347(17)36125-6.

2. McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol. 1998;159(4):1209-13. doi:10.1016/s0022-5347(01)63558-4

3. Whitson JM, McAninch JW, Elliott SP, Alsikafi NF. Long-term efficacy of distal penile circular fasciocutaneous flaps for single stage reconstruction of complex anterior urethral stricture disease. J Urol. 2008;179(6):2259-64. doi:10.1016/j.juro.2008.01.087.

4. Carney KJ, McAninch JW. Penile circular fasciocutaneous flaps to reconstruct complex anterior urethral strictures. Urol Clin North Am. 2002;29(2):397-409. doi:10.1016/s0094-0143(02)00046-0.

5. Barbagli G, Joshi PM, Kulkarni SB, et al. Penile urethroplasty using Orandi's dorsal skin flap: a new technique. BJU Int. 2019;124(5):892-896. doi:10.1111/bju.14881.

6. Quartey JK. One-stage penile / preputial cutaneous island flap urethroplasty for urethral stricture: a preliminary report. J Urol. 1983;129(2):284-7. doi:10.1016/s0022-5347(17)52051-0.

7. Bhandari M, Dubey D, Verma BS. Dorsal or ventral placement of the preputial / penile skin onlay flap for anterior urethral strictures: does it make a difference? BJU Int. 2001;88(1):39-43. doi:10.1046/j.1464-410x.2001.02257.x.

8. Zhao T, Ji F, Liu Y, Wang L, Lyu X. Preliminary experience and outcomes of modified distal penile circular fasciocutaneous flap for the treatment of anterior urethral strictures. World J Urol. 2026;44(1):191. doi:10.1007/s00345-026-06289-1.

9. Dubey D, Vijjan V, Kapoor R, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007;178(6):2466-9. doi:10.1016/j.juro.2007.08.010.

10. Hussein MM, Moursy E, Gamal W, et al. The use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: a prospective randomized study. Urology. 2011;77(5):1232-7. doi:10.1016/j.urology.2010.08.064.

11. Tijani KH, Adesanya AA, Ogo CN, Osegbe DN. Penile fasciocutaneous flap urethroplasty: recent experience and challenges in a sub-Saharan African teaching hospital. Urology. 2009;74(4):920-3. doi:10.1016/j.urology.2009.05.041.

12. Alrefaey A, Anwar MA, Abdelmagid ME, et al. Comparative outcomes of penile skin grafts versus buccal mucosal grafts in urethroplasty for the treatment of extensive anterior urethral strictures. Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w.

13. Tyagi S, Parmar KM, Singh SK, et al. 'Pee'BuSt trial: a single-centre prospective randomized study comparing functional and anatomic outcomes after augmentation urethroplasty with penile skin graft versus buccal mucosa graft for anterior urethral stricture disease. World J Urol. 2022;40(2):475-481. doi:10.1007/s00345-021-03843-x.

14. Anadani A, Obaidin A, Badawi B, Lutfi MY. One-stage urethroplasty using a combination of buccal mucosa graft and penile skin flap for a complicated urethral stricture: a challenging case report. Medicine. 2025;104(12):e41888. doi:10.1097/MD.0000000000041888.

15. Stewart L, McCammon K, Metro M, Virasoro R. SIU/ICUD consultation on urethral strictures: anterior urethra — lichen sclerosus. Urology. 2014;83(3 Suppl):S27-30. doi:10.1016/j.urology.2013.09.013.

16. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol. 2009;55(4):945-54. doi:10.1016/j.eururo.2008.07.046.

17. Srivastava A, Vashishtha S, Singh UP, et al. Preputial / penile skin flap, as a dorsal onlay or tubularized flap: a versatile substitute for complex anterior urethral stricture. BJU Int. 2012;110(11 Pt C):E1101-8. doi:10.1111/j.1464-410X.2012.11296.x.

18. Karapanos L, Halbe L, Storz E, et al. Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures. Int J Urol. 2024;31(10):1095-1101. doi:10.1111/iju.15521.

19. Bandini M, Joshi P, Bafna S, et al. Establishing the role of single-stage preputial spiral graft urethroplasty for panurethral stricture. BJU Int. 2025. doi:10.1111/bju.16796.

20. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

21. Breyer BN, McAninch JW. Penile Skin Flaps for Urethral Reconstruction. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:219–230. doi:10.1007/978-1-4614-7708-2_16

22. Myers JB, Morey AF. Anterior Urethral Reconstruction: Penile Island Flaps. In: Montague DK, Gill IS, Angermeier KW, Ross JH, eds. Textbook of Reconstructive Urologic Surgery. Informa Healthcare; 2008:473–479.

23. Carney KJ, McAninch JW. Penile Circular Fasciocutaneous Flaps for Complex Anterior Urethral Strictures. In: Schreiter F, Jordan GH, eds. Urethral Reconstructive Surgery. Springer; 2006:145–152. doi:10.1007/3-540-29385-x_18

24. EAU Guidelines Office. "EAU Guidelines on Urethral Strictures: Tissue Transfer." EAU Guidelines. 2026, §9.1. https://uroweb.org/guidelines/urethral-strictures/chapter/tissue-transfer

25. Ali AI, Hamid AA, Abdel-Rassoul MA, et al. "Buccal mucosal graft versus penile skin flap urethroplasty for long segment penile urethral stricture: a prospective randomized study." Cent European J Urol. 2019;72(2):191–197. doi:10.5173/ceju.2019.1899

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27. EAU Guidelines Office. "EAU Guidelines on Urethral Strictures: Disease Management in Males." EAU Guidelines. 2026, §6.3.1. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males

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