Propeller Flap Urethroplasty
Propeller flap urethroplasty applies the propeller flap concept from plastic and reconstructive surgery to one urethroplasty scenario: revision of a stenotic perineal urethrostomy (PU) when local perineal tissues are scarred or depleted. It is not a standardized urethroplasty class. The published urethroplasty experience is a single case report by Schulster 2021.[1]
For flap anatomy and design, see Propeller Flap in foundations.
For the commonly used pedicled flap option in urethroplasty, see McAninch Distal Penile Circular Fasciocutaneous Flap. For the canonical PU technique, see Blandy Perineal Urethrostomy and Midline Perineal Urethrostomy.
Schulster 2021 — Propeller Flap PU Revision
Indication. For a stenotic PU, management options include periodic dilation, V-Y plasty, augmentation, complete redo and urinary diversion.[4] A posterior-thigh propeller flap has been described for one complex revision at high risk for re-stenosis.[1] Schulster's index case had a long history of failed urethral reconstructions with scarred and depleted local perineal tissue, and standard revision approaches were considered unlikely to succeed.[1]
Technique.[1]
| Step | Detail |
|---|---|
| Preparation and positioning | In the reported case, culture-driven antibiotic prophylaxis was given, the patient was placed in lithotomy, and the perineum plus medial and posterior thighs were prepared and draped.[1] |
| Stenosis assessment | In the reported case, bougie-à-boule calibration identified an 8 Fr stenosis with maximal narrowing 1.75 cm proximal to the skin. The authors dilated the PU to 16 Fr and used flexible cystourethroscopy to confirm proximal urethral and bladder patency.[1] |
| Stenosis exposure | Incise the stenotic PU to expose the urethral lumen |
| Perforator mapping | Identify posterior thigh perforators; confirm the individual vascular anatomy with handheld Doppler |
| Flap design | Island flap with long axis along the posterior thigh, designed around the perforator closest to the defect |
| Elevation and rotation | Raise on the perforator pedicle and rotate axially to place the flap apex into the urethrostomy defect.[1] After rotation, check the pedicle for twisting or buckling; after securing the flap, assess color, capillary refill and bleeding.[6] |
| Tubularization | Partially tubularize the flap apex with absorbable sutures at the level of the urethrotomy, calibrated to 30 Fr |
| Donor site | Closed primarily |
Outcome. Cystoscopy showed a patent PU at 6 months.[1] At 17 months, the single patient reported good voiding and continence, with postvoid residuals below 100 mL.[1]
Why a Propeller Flap for PU Revision
The rationale for a propeller flap in PU revision is the one that drives propeller flap use elsewhere in perineal reconstruction:
- Tissue from outside the zone of injury. A posterior-thigh flap can recruit healthy tissue outside the local injury zone when that donor site is suitable.[1]
- Perforator-based blood supply. The flap keeps an identified vessel. Superiority over other local flaps has not been shown.
- Single stage. No delay or staged division is needed.
- Primary donor closure. The authors described minimal morbidity in the single reported patient.[1]
- Thickness. Posterior-thigh tissue augments urethrostomy caliber without excess bulk.[1]
For broader complication, perforator-anatomy, and venous-congestion considerations, refer to the foundations propeller flap article.
Comparison With Established Urethroplasty Flaps
| Feature | Propeller Flap (Schulster) | Distal Penile Circular Fasciocutaneous (McAninch) | Dartos / Penile Skin Flap |
|---|---|---|---|
| Pedicle | Perforator-based island | Axial dartos fascia | Axial dartos fascia |
| Tissue source | Posterior thigh / regional perforator | Distal penile skin | Penile skin |
| Relation to scar | Outside the scarred perineum in Schulster’s case[1] | Distal penile donor skin may be scarred after failed hypospadias repair[8] | Penile donor skin may be scarred after failed hypospadias repair[8] |
| Movement | 90–180° axial rotation | Transposition / rotation | Transposition |
| Hair-bearing | Posterior thigh may be hair-bearing; assess donor hair before design and avoid hair-bearing skin at the urethral inset.[5] | Select hairless distal penile skin | Select hairless penile skin |
| Reported setting | Stenotic PU revision in Schulster’s case[1] | Complex anterior stricture without lichen sclerosus in Whitson’s series[2] | Penile or long multisegment anterior stricture in the AUA guideline[3] |
| Evidence base | Single case report (urethral)[1] | Retrospective series of 124 men without lichen sclerosus; 79% estimated overall stricture-free survival at 10 years (median follow-up 7.3 years)[2] | Multiple retrospective series |
The McAninch distal penile circular fasciocutaneous flap has substantially more published urethroplasty outcome data: in Whitson’s retrospective series of 124 men without lichen sclerosus, Kaplan–Meier estimates of overall stricture-free survival were 95%, 84% and 79% at 1, 5 and 10 years; primary stricture-free survival at 10 years was 61%.[2] The AUA 2023 urethral stricture guideline amendment states that success rates of single-stage penile fasciocutaneous flaps and oral mucosal grafts appear similar in properly selected patients with penile urethral strictures.[3] In Schulster’s single case, a posterior-thigh flap revised a complex stenotic PU considered at high risk for re-stenosis.[1] A distinct lotus-petal perforator-flap series included two non-islanded PU revisions without further instrumentation at 22 and 29 months.[7]
Limitations and Current Status
- The published urethroplasty experience is limited to a single case report.[1]
- No comparative data exist against any standard flap or graft urethroplasty.
- Schulster described the technique in one complex stenotic PU revision at high risk for recurrent stenosis.[1]
- Collaboration with plastic surgery may be needed for perforator dissection.
- Long-term stricture recurrence and functional voiding outcomes in larger cohorts are unknown.
References
1. Schulster ML, Dy GW, Vranis NM, et al. Propeller flap perineal urethrostomy revision. Urology. 2021;148:302-305. doi:10.1016/j.urology.2020.12.002.
2. 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):2259-2264. doi:10.1016/j.juro.2008.01.087.
3. 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.
4. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males." 2026. Guideline.
5. American Urological Association. Urethral Stricture Disease: AUA Guideline (published 2016; amended 2023), unabridged version. Guideline.
6. D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. "Propeller flaps: a review of indications, technique, and results." Biomed Res Int. 2014;2014:986829. doi:10.1155/2014/986829
7. Reilly DJ, Sham EK, Chee JBL, Chauhan A. "A novel application of the lotus petal flap in high-risk perineal urethrostomy: principles and outcomes." Australas J Plast Surg. 2018;1(1):134–138. doi:10.34239/ajops.v1i1.17
8. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. 2026. Guideline.