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Pedicled Preputial Tube Urethroplasty

The pedicled preputial tube urethroplasty is a single-stage urethral reconstruction technique in which a transverse island of inner preputial skin, raised on a dartos fascia pedicle, is tubularized around a catheter to create a complete neo-urethra that replaces the excised strictured segment. It is primarily indicated for obliterative strictures where no usable urethral plate remains. It provides single-stage circumferential replacement with vascularized tissue. In retrospective series, tubularized repairs recur more often than onlay augmentation, but the two groups differ in urethral-plate quality. Diverticulum, fistula and stricture recurrence are the main problems.[1][2][3][4]

For onlay alternatives, see Quartey Flap, McAninch Transverse Circular Penile Skin Flap, and Orandi Flap. For staged BMG-based circumferential reconstruction, see the staged-complex section. For the modern free-graft alternative, see Buccal Mucosa Graft.

Historical Context and Origins​

The technique has two historical lineages: adult urethral stricture disease and pediatric hypospadias repair.

Adult stricture disease​

  • Quartey 1983. In his transverse preputial island flap description, Quartey stated the pedicle could be constructed so the skin reaches from the external meatus to the prostatic urethra "for reconstruction as a patch or tube." This was an early adult-stricture description of both configurations.[5]
  • McAninch 1993, 1998. Extended the concept with the circular fasciocutaneous penile flap, which can also be tubularized. In the 1998 series of 66 patients, recurrent stenosis occurred in 7 of 12 tubularized repairs (58%) and 7 of 54 onlay repairs (13%).[2][6]

Pediatric hypospadias​

  • Duckett 1980. Described the transverse preputial island flap (TPIF) technique for one-stage repair of severe hypospadias, using inner preputial skin tubularized around a catheter to bridge the gap between the proximal meatus and the glans tip. The technique became known as the Duckett procedure.[7]
  • Glassberg 1987. Described the "Augmented Duckett Repair" for very proximal hypospadias where insufficient inner foreskin existed for the full pedicle tube. A proximal add-on neo-urethra fashioned from non-hair-bearing interscrotal tissue or ventral penile skin (Thiersch-Duplay) was anastomosed to the distal Duckett tube.[8]

Anatomy and Vascular Basis​

Tissue source — inner preputial skin​

  • The inner (mucosal) surface of the prepuce is the preferred tissue. It is hairless, thin and pliable, and resembles mucosa.[5][9]
  • Inner preputial skin is specialized skin, not urethral mucosa; assess its quality, hair and inflammatory disease.

Pedicle — dartos fascia​

  • The flap is raised on a dartos fascia pedicle containing the subdermal vascular plexus fed by branches of the superficial external pudendal artery (SEPA).[5][9]
  • Joshi, Bandini, and Kulkarni 2022 described the dartos fascia as "the winner" among all pedicles in genitourinary reconstruction.[9]

Flap dimensions for tubularization​

  • Width. Size the island to the intended lumen, recipient anatomy and available donor skin. A reported adult tubularized penile flap used a 2.5 cm island around an 18 Fr catheter; Lyu et al. used a 1.5–1.8 cm island around an 8 Fr feeding tube in pediatric TPIF.[33][30]
  • Length. The island must bridge the stricture, but its harvestable length is limited by the circumference and quality of distal penile or preputial skin; Quartey's meatus-to-prostatic-urethra statement describes pedicle reach.[5] The circular fasciocutaneous flap usually provides 13–15 cm.[10]

Surgical Technique​

Positioning and exposure​

Position supine or in lithotomy according to stricture location.[2] Limit time in exaggerated/high lithotomy when proximal exposure is needed: lower-extremity neurovascular complications occurred in 4 of 66 men in a circular penile-flap series after prolonged positioning.[2] Deglove the penis through a circumcoronal incision and assess the full stricture extent with urethrography, urethroscopy or intraoperative palpation. For proximal hypospadias, use an intraoperative erection test after degloving, release abnormal ventral connective tissue, and determine whether urethral-plate transection is needed. Reassess curvature after release or transection and correct persistent corporeal curvature before flap design and urethral reconstruction.[29]

Stricture excision​

Pediatric TPIF can bridge a gap after curvature correction and plate transection without excising a strictured segment.[30] Unlike an onlay, adult tubularized stricture repair with an unsalvageable urethral plate may involve circumferential excision and replacement of the diseased segment; the following excision-and-anastomosis steps describe this adult setting. The proximal and distal healthy urethral ends are spatulated to facilitate anastomosis. This step is necessary because tubularization is indicated when no usable urethral plate remains (obliterative stricture, dense spongiofibrosis, severely damaged plate).[1][10]

Flap harvest​

A transverse island of inner preputial skin is incised and raised with the dartos pedicle attached to its deep surface. The pedicle is developed by dissecting the dartos off the underlying Buck's fascia, maintaining continuity with the axial blood supply. The pedicle must be of sufficient length and mobility to allow the tubularized flap to reach the stricture site without tension or kinking.

For salvage of long-segment bulbar necrosis after a failed PFUDD repair, a described sequence raises the outer circumferential incision to the superficial dartos and the inner circumferential incision deep to dartos but superficial to Buck's fascia, mobilizing the prepuce to the penile base on its dartos pedicle. Because the flap's blood supply runs dorsally, the skin and dartos are divided ventrally toward the penoscrotal junction before the flap is tunneled into the perineum; the inner preputial leaf is tubularized to bridge the gap and the outer leaf is sacrificed. Distal penile skin has been described as an alternative donor site when the prepuce is unavailable.[27]

Tubularization​

  • For adult stricture reconstruction, tubularize the skin island around an appropriately sized catheter with epithelium toward the lumen; a described preputial-tube technique used 16 Fr. Select a child-appropriate caliber for hypospadias repair; Lyu et al. used an 8 Fr feeding tube.[32][30]
  • Edges sutured together with continuous or interrupted absorbable sutures (5-0 or 6-0 PDS / Vicryl) to create a watertight tube.
  • In traditional pediatric TPIF, place the tube seam dorsally against the corporal bodies; the described in-situ modification places it ventrally and covers it with dartos.[30]
  • Hayashi 2001 reported one complication (a fistula) among 13 pediatric hypospadias repairs using two-layer closure and spongiosal coverage.[11]

Anastomosis​

  • Proximal anastomosis. Tube sutured to the spatulated proximal urethra with absorbable sutures.
  • Distal anastomosis. In adult stricture repair, suture the tube to the spatulated distal urethra. In hypospadias repair, bring it through the glans or join it to the distal urethral plate according to the selected technique, then develop and close glans wings over the neourethra.[29][30]
  • Both anastomoses performed over the indwelling catheter.

Pedicle coverage and closure​

  • The dartos pedicle provides the flap's vascular base.[9] A pediatric TPIF technique describes draping the pedicle over the neo-urethral suture line as coverage.[30] Hayashi's 13-boy modification instead covered only the proximal anastomosis with corpus spongiosum; one fistula occurred.[11]
  • Penile skin closed over the repair.
  • For adult urethroplasty, a catheter commonly remains for 2–3 weeks. Before removal, assess extravasation with pericatheter RUG, RUG or VCUG; keep drainage and repeat imaging if a significant leak persists.[31] Pediatric hypospadias drainage follows the selected repair, with no established optimal stent duration.[29]

Outcomes — Adult Urethral Stricture Disease​

The following retrospective series generally favor onlay when a viable plate remains. Tubularized repairs treat more severe tissue loss.

Studyn (tube)ConfigurationSuccess (tube)Comparator (onlay)Follow-upKey Findings
McAninch / Morey 1998[2]12Tubularized circular flap42% (5/12)87% (47/54) onlayMean 41 mo (66 patients)58% recurrence in tube vs 13% onlay; "onlay repairs appear to be more successful"
Barbagli 2008[25]— (18 flaps total)One-stage penile flap (various)Tube subgroup not reported80% (36/45) one-stage graftMean 55 moAcross one-stage penile repairs, grafts had higher observed success (80%, 36/45) than flaps (67%, 12/18)
de la Rosette 1991[26]50Pedicled island flap (various)Not reported for tubes (32% recurrence in the mixed flap cohort)——Fistula 20%, recurrence 32%; recurrence clustered in men with 3 or more prior urethrotomies
Srivastava 2012[1]54Tubularized preputial flap75% at 3 yr85% DOF at 3 yr40.1 moDOF less likely to lead to diverticula and postvoid dribbling; TF higher failure rate
Tijani 2009[3]5Tubularized Quartey modification80% immediate; 40% at 30 mo100% immediate (21 dorsal onlays); no recurrence in those available at 30 moMean 19 moCircumcised West African men; only five tube repairs
Greenwell / Mundy 1999[4]—Two-stage free graft vs one-stage flap———"Two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra"

Carney and McAninch 2002 stated: "Onlay reconstruction is preferable to flap tubularization and has provided a better initial and long-term outcome."[10]

Outcomes — Hypospadias Repair (Duckett TPIF)​

The largest body of outcome data for the pedicled preputial tube comes from the pediatric hypospadias literature.

StudynApplicationOverall complicationFistulaStrictureDiverticulumFollow-up
Wang 2019 (15-yr experience)[12]320Proximal hypospadias (TPIF)39.1%16.6%9.7%12.8%40.2 mo
Ghali 1999 (12-yr)[13]418 flap repairs (148 Duckett)Primary hypospadias22% initial across all flap types (95% final success after a mean 1.4 procedures)Duckett higher than onlayDuckett higher than onlay—23 mo
Wiener 1997[14]74 (tube) vs 58 (onlay)Proximal hypospadiasTube 36% vs Onlay 31%14% vs 17% (NS)NSTube 12.2% vs Onlay 0% (p = 0.016)20.3 mo
Zheng 2013[15]53 (25 primary, 28 secondary)Primary and secondary, older Chinese patients with severe chordeePrimary 24%, Secondary 53.6% (p = 0.028)———38.7 mo
Hayashi 2001 (modified TPTIF)[11]13Moderately severe hypospadias7.7% (1/13)1 fistula00—
Soutis 2003 (salvage)[16]21 (boys aged 4-18)Multiple failed hypospadias repairs (3–13 prior)24% (5/21)1 fistula1 stenosis2 diverticula—

Key lessons from the hypospadias literature​

  1. Diverticulum formation is the hallmark complication of tubularization. Wiener 1997 found diverticula in 12.2% of tubularized versus 0% of onlay repairs (p = 0.016).[14] Wang 2019 reported 12.8% diverticula in 320 patients, with 31.7% of diverticula associated with concomitant strictures (p < 0.001).[12][14]
  2. Tube and onlay outcomes differ by series. Ghali 1999 reported more overall complications in 148 Duckett repairs than in 42 onlays (p < 0.05).[13] Wiener 1997 found similar overall complication rates after 74 tubes and 58 onlays (36% versus 31%), but more diverticula after tubes (9/74 versus 0/58; p = 0.016).[14] These retrospective groups differ in plate status.
  3. Late complications warrant surveillance. In Wang 2019, 26/125 patients with complications presented at or after one year and 16/125 at or after five years; only 39/320 patients were followed beyond five years.[12] The 2026 EAU pediatric guideline recommends long-term follow-up for stricture, voiding dysfunction, recurrent curvature, ejaculatory problems and patient satisfaction.[29]
  4. Secondary (reoperative) cases have worse outcomes. Zheng 2013: complication rates 24% primary versus 53.6% secondary hypospadias (p = 0.028) using Duckett.[15]

Why Configuration Matters​

A tubularized flap supplies the entire urethral circumference and requires a longitudinal tube closure plus proximal and distal anastomoses. An onlay retains a viable native urethral plate.[1][2]

  1. Substitute tissue around the whole circumference. The tube has no native plate to support it.[10]
  2. Loss of spongiosal support. A thin-walled tube may balloon during voiding and form a pseudo-diverticulum, and diverticula were more frequent after tubularized than onlay hypospadias repair in one series.[14]
  3. Ischemia along the suture line. The seam lies furthest from the pedicle's blood supply if the pedicle is compromised.[9][10]
  4. Two circumferential anastomoses. Each is a potential site of stricture recurrence.[1][2]
  5. Distal obstruction. It may coexist with or contribute to diverticulum formation.[12][14] Dorsal support may limit sacculation.[12][14]

Modifications to Improve Tubularized Outcomes​

  1. Two-layer closure (Hayashi 2001). Neo-urethra with two-layer closure plus corpus spongiosum wrapping at the proximal anastomosis. 7.7% complication rate (1/13), with no meatal stenosis, stricture, or diverticulum.[11]
  2. Augmented Duckett (Glassberg 1987). A proximal Thiersch-Duplay neo-urethra from interscrotal tissue or ventral penile skin is anastomosed to the distal Duckett tube. It bridges larger gaps without a free graft.[8]
  3. Dartos fascia wrap. The pedicle is wrapped around the neo-urethra as a second vascularized layer over the suture line. Joshi 2022 describes the dartos as the preferred pedicle. Hayashi 2001 wrapped only the anastomosis with corpus spongiosum tissue.[9][11]
  4. Staged hypospadias reconstruction. When proximal hypospadias has severe curvature and the urethral plate cannot be preserved, discuss staged repair. The 2026 EAU pediatric guideline cites a meta-analysis reporting complications in 414/1,984 (21%) staged foreskin free-graft or pedicled-flap repairs versus 285/680 (42%) single-stage foreskin pedicled tubes.[29][35] Wang reported complications in 125/320 children (39.1%) after single-stage TPIF repair of proximal hypospadias at mean 40.2-month follow-up.[12] Staged TPIF has also been described: a 2023 retrospective cohort reported complications in 9/81 staged TPIF versus 22/55 single-stage TPIF plus Duplay repairs, with shorter median follow-up after staging (18 versus 31 months); patients who did not complete stage two and first-stage events corrected at stage two were excluded.[36] A separate retrospective cohort reported 7/55 complications after staged TPIF and 7/62 after Bracka repair at about 20 months mean follow-up.[37]
  5. Combined dorsal BMG and ventral flap (Erickson, Breyer, McAninch 2012). A dorsal BMG replaces an unsalvageable plate segment against the corpora and a ventral skin flap completes the lumen. This is circumferential replacement using two tissue sources; a triangular plate-preserving variant belongs to the later Karapanos technique, not the original Erickson operation. Primary success was 9 of 14 (64%) and overall success 11 of 14 (79%) at median 2.5 yr for strictures averaging 9.75 cm; two men needed repeat urethroplasty.[18]

Alternatives and Limits of Cross-Study Comparison​

TechniqueStagesTissue SourceSuccessKey AdvantageKey Limitation
Pedicled preputial or penile skin tube[1][2][3]1Preputial or penile skin (pedicled)40% at 30 mo (Tijani); 42% initial (McAninch); 75% primary at 3 yr (Srivastava)Single-stage; carries own blood supplyRecurrence, diverticula and fistula
Staged free-graft urethroplasty (including oral mucosa)[4][28]2 or moreFree graft; oral mucosa is one current optionGreenwell 1999 reported better results with staged free grafts than one-stage flaps for total circumferential penile repairOral mucosa avoids genital skin and hair; LS may still affect the repairRequires staged surgery; EAU proposes at least 4–6 mo before tubularization if the first stage heals satisfactorily
Staged mesh graft[19]2, sometimes moreThigh split-thickness skin (17/20) or full-thickness foreskin (3/20)12/15 (80%) after closure at median 38 mo; 5/20 had not undergone closureNon-hair-bearing tissue; ample tissue when availableSix of 20 needed revision before closure; graft contracture risk
Combined dorsal BMG + ventral flap[18]1BMG + penile skin flap64% primary, 79% overall (n = 14)Single-stage; avoids full tubularizationRequires both healthy oral mucosa and penile skin
Preputial spiral graft[20][21]1Preputial skin (free graft, spiral harvest)103/114 (90.4%) without VCUG-confirmed recurrence at median follow-up 16 mo (IQR 7–24); study-defined success used Qmax >10 mL/s without symptomsReaches up to 20 cm; single stageNeeds an intact prepuce; not used in active lichen sclerosus

These are noncomparative study estimates with different populations, follow-up and success definitions. The preputial spiral graft is described as augmenting a usable urethral plate.[20][21]

Greenwell, Venn, and Mundy 1999 concluded: "Two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra."[4]

Indications and Contraindications​

Indications​

  1. Obliterative urethral stricture with no usable urethral plate is the primary indication, where augmentation (onlay) is not possible because there is no native tissue to augment.[1][10]
  2. Severe spongiofibrosis with destruction of the urethral lumen may require circumferential reconstruction using a vascularized flap.[9] Plate loss does not exclude a free graft: a selected single-stage repair used dorsal buccal mucosa to recreate the excised urethral plate with a ventral flap completing the lumen, and staged graft repair is another option.[18][28]
  3. Proximal hypospadias with severe chordee requiring urethral plate transection is the classic Duckett indication.[7]
  4. Failed prior repair with loss of the urethral plate: Soutis described salvage of boys after multiple failed hypospadias operations.[16] In adult stricture repair, unsuitable oral mucosa is a separate reason to consider penile skin.[22] Long-segment bulbar necrosis after failed anastomotic repair of a pelvic fracture urethral distraction defect (PFUDD) is a described salvage setting for this option.[27] A 2026 single-center retrospective series of 41 men with bulbar necrosis reported that 61% received a preputial tube and that 76% of the tube subgroup met its primary-success endpoint; median follow-up of the full cohort was 20 months (IQR 14–24).[34]
  5. Patients with unsuitable oral mucosa (e.g., oral submucosal fibrosis from gutkha / betel nut consumption) who require circumferential reconstruction and cannot undergo staged BMG urethroplasty.[22]

Contraindications​

  1. Lichen sclerosus. The AUA guideline states that surgeons should not use genital skin for reconstruction in lichen sclerosus-proven stricture , and oral mucosa is the preferred graft.[23]
  2. Insufficient healthy penile donor skin. Circumcision removes preputial donor skin but does not rule out a penile-skin island flap: Soutis et al. used dorsal penile skin in four boys whose prepuce had been resected.[16] For adults with strictures after failed hypospadias repair, the EAU recommends avoiding penile skin grafts or flaps when lichen sclerosus or scarred skin is present .[28]
  3. Preserved urethral plate. If a usable plate exists, onlay augmentation is considered before sacrificing viable tissue.[1][2][10]
  4. Hair-bearing skin. AUA Clinical Principle: surgeons should not use hair-bearing skin for substitution urethroplasty.[23]

Complications​

ComplicationLikely mechanismManagement
RestenosisIschemia at the suture line; fibrosis at anastomosesDetermine site, length and degree of obliteration first. Options are dilation or urethrotomy for short recurrences and redo urethroplasty. Repeated endoscopy is not a durable default for long recurrent penile disease.[1][2][23]
Diverticulum and postvoid poolingLack of spongiosal support; distal obstructionAssess for distal obstruction as well as inadequate support. Diverticulectomy with urethroplasty if symptomatic. Wang's pediatric cohort found concurrent stricture in 13 of 41 diverticula.[12]
Urethrocutaneous fistulaSuture-line breakdown; ischemiaDelayed fistula closure.[12][14]
Meatal or anastomotic stenosisDistal or anastomotic contractureMeatotomy, meatoplasty or dilation; Soutis treated these successfully in his series.[16]
Skin loss and torsionPedicle compromise, tension, asymmetric mobilizationConservative care for superficial loss and skin grafting for extensive loss. In the Dubey trial these occurred after dorsal onlay skin flaps.[17]
Hair in the neo-urethra, stones, infectionIncorporation of hair-bearing skinAvoid hair-bearing tissue for the lumen. Late obstructive or infectious symptoms are investigated. Laser epilation or revision for hair.[5][23]

Acquired Urethral Diverticula — The Long-Term Consequence​

Cinman, McAninch, Glass, Zaid, Breyer 2012 (UCSF) described 22 men with acquired urethral diverticula over an 11-year period — in a tertiary reconstructive practice, with histories that included hypospadias, stricture, trauma or prolonged catheterization:[24]

  • Most common presentations: recurrent UTI, urinary dribbling, incontinence, weak stream
  • 54.5% (12/22) underwent diverticulectomy and urethroplasty[24]
  • 13.5% (3/22) underwent ileal conduit diversion: two had paraplegia with neurogenic retention and large diverticula, and one had an irradiated, multiply operated urethra with infection; none was among the five men referred after prior substitution urethroplasty.[24]
  • 32% (7/22) were managed nonoperatively; five of these seven had diverticula that could be emptied by postvoid manual decompression.[24]
  • After diverticulectomy, 1 of 11 patients in the reported surgical outcome analysis had recurrent diverticulum (9%). Median follow-up for the mixed cohort was 2.3 years.[24]

Acquired diverticula can require excision with urethroplasty or, in this series, urinary diversion. Small, asymptomatic diverticula in an unobstructed urethra that empty with manual decompression were managed nonoperatively.

Current Role and Guideline Context​

AUA Urethral Stricture Disease Guideline Amendment 2023[23]​

  • Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination .[23]
  • The guideline permits single-stage or multistage repair. It does not state a preference for either technique.
  • Surgeons should use oral mucosa as the first choice when using grafts .[23]
  • Surgeons should not use genital skin for reconstruction in lichen sclerosus-proven stricture .[23]

Contemporary practice​

Contemporary alternatives depend on whether a usable urethral plate remains:

  1. Staged free-graft urethroplasty (including BMG) for circumferential penile urethral reconstruction. Greenwell 1999 reported better results with staged free grafts than one-stage flaps for this indication; the 2026 EAU guideline describes staged oral-mucosa graft repair as a current option.[4][28]
  2. Combined dorsal BMG and ventral onlay flap for selected single-stage circumferential replacement, with a graft-supported dorsal wall and a vascularized flap floor.[18]
  3. Preputial spiral graft urethroplasty (Kulkarni and Bandini 2023–2025), a selected augmentation option when a viable plate remains. In the 114-patient spiral-graft cohort, 11 (9.6%) had VCUG-confirmed recurrence and 103 (90.4%) had no confirmed recurrence at median 16-month follow-up; tubularized reconstruction was not compared.[20][21]

The technique retains a niche role:

  • Oral mucosa unavailable (depleted donor sites, oral submucosal fibrosis)[22]
  • Single stage strongly preferred with a completely destroyed urethral plate[1]
  • Resource-limited settings, where one operation may be preferred for logistical reasons (surgeon consensus; Tijani's flap series comes from a sub-Saharan African center)[3]
  • Salvage of multiple failed hypospadias repairs. Soutis 2003 used the Duckett island-flap technique in 21 boys aged 4 to 18 years with 3–13 prior failed repairs. Five had complications (24%), all treated successfully. In 4 boys the prepuce had been resected and dorsal penile skin was used instead.[16]

Key Takeaways​

The pedicled preputial tube urethroplasty is a single-stage technique for circumferential urethral replacement using a tubularized island of inner preputial skin on a dartos fascia pedicle. Quartey (1983, adult strictures) and Duckett (1980, hypospadias) described it. It provides vascularized, hairless tissue that can bridge long urethral defects in one operation.[5][7] Retrospective series reported more favorable onlay results: 58% versus 13% recurrence in McAninch 1998[2], 40% tube success at 30 months versus no recurrence among onlay patients then available in Tijani 2009 (initial tube cohort n = 5; 30-month evaluable denominator unstated)[3], and 25% tubularized-flap versus 15% transverse-preputial dorsal-onlay failure at three years in Srivastava 2012 (circumpenile dorsal-onlay failure: 13.3%).[1] The groups differ in plate quality.[1][2][3] All of the circumference depends on substitute tissue, with a long suture line and no spongiosal support.[10] Greenwell 1999 favored two-stage free graft repair over one-stage flap tubularization for total circumferential penile reconstruction.[4] The 2026 EAU guideline recommends selecting single-stage or staged penile augmentation according to prior interventions and stricture characteristics , with counseling that adverse intraoperative findings may require conversion to a staged repair .[28] The technique is still used for salvage, unsuitable oral mucosa and resource-limited settings. It is a second-line option when onlay augmentation or staged BMG reconstruction is feasible.[1][16][22]

Videos​

Pedicled Preputial Tube Urethroplasty
Operative technique
Penile Skin Tube Flap Salvage for Bulbar Urethral Necrosis
Furukawa Y, et al. Urology Video Journal 2024 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

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  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. 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.

  4. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. 1999;83(6):631-5. doi:10.1046/j.1464-410x.1999.00010.x.

  5. 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.

  6. 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.

  7. Duckett JW. Transverse preputial island flap technique for repair of severe hypospadias. Urol Clin North Am. 1980;7(2):423-30. doi:10.1016/s0094-0143(21)01243-x

  8. Glassberg KI. Augmented Duckett repair for severe hypospadias. J Urol. 1987;138(2):380-1. doi:10.1016/s0022-5347(17)43153-3.

  9. Joshi PM, Bandini M, Kulkarni SB. Common flaps in genitourinary reconstruction. Urol Clin North Am. 2022;49(3):361-369. doi:10.1016/j.ucl.2022.04.001.

  10. 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.

  11. Hayashi Y, Sasaki S, Kojima Y, et al. One-stage repair of moderately severe hypospadias using a transverse preputial tubularized island flap. Int J Urol. 2001;8(4):165-70. doi:10.1046/j.1442-2042.2001.00275.x.

  12. Wang CX, Zhang WP, Song HC. Complications of proximal hypospadias repair with transverse preputial island flap urethroplasty: a 15-year experience with long-term follow-up. Asian J Androl. 2019 May-Jun;21(3):300-303. doi:10.4103/aja.aja_115_18.

  13. Ghali AM. Hypospadias repair by skin flaps: a comparison of onlay preputial island flaps with either Mathieu's meatal-based or Duckett's tubularized preputial flaps. BJU Int. 1999;83(9):1032-8. doi:10.1046/j.1464-410x.1999.00083.x.

  14. Wiener JS, Sutherland RW, Roth DR, Gonzales ET. Comparison of onlay and tubularized island flaps of inner preputial skin for the repair of proximal hypospadias. J Urol. 1997;158(3 Pt 2):1172-4. doi:10.1097/00005392-199709000-00123. PMID: 9258164.

  15. Zheng DC, Wang H, Lu MJ, et al. A comparative study of the use of a transverse preputial island flap (the Duckett technique) to treat primary and secondary hypospadias in older Chinese patients with severe chordee. World J Urol. 2013;31(4):965-9. doi:10.1007/s00345-012-0990-2.

  16. Soutis M, Papandreou E, Mavridis G, Keramidas D. Multiple failed urethroplasties: definitive repair with the Duckett island-flap technique. J Pediatr Surg. 2003;38(11):1633-6. doi:10.1016/s0022-3468(03)00580-3.

  17. 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.

  18. Erickson BA, Breyer BN, McAninch JW. Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures. BJU Int. 2012;109(9):1392-6. doi:10.1111/j.1464-410X.2011.10483.x.

  19. Carr LK, MacDiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J Urol. 1997;157(1):104-8. doi:10.1016/s0022-5347(01)65298-4

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