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Q-Flap (Morey / Tran / Zinman)

The Q-flap is a circumferential distal penile skin flap with a ventral midline extension (the resulting outline resembles the letter "Q"), designed by Allen Morey, Tran, and Zinman in 2000 for single-stage reconstruction of panurethral strictures.[1] The ventral extension gave a mean flap length of 17 cm (range 15–24 cm), and no supplemental graft was needed in the original selected cohort of 15 men.[1]

Q-flap versus Quartey flap. The Q-flap is not the same as the Quartey flap (Quartey 1983). The Quartey flap is the original 1983 transverse preputial / distal-penile island flap. The Q-flap is a Morey 2000 modification that extends the circumferential flap with a ventral midline limb, creating the "Q" outline and adding length specifically for panurethral disease. The terms are sometimes used loosely in practice, but the two are distinct flap designs with different lengths and indications.

For the original 1983 Quartey flap, see Quartey Flap. For the alternative free-graft panurethral strategy, see Preputial Spiral Graft Urethroplasty (PSGU) and Kulkarni One-Sided Dorsolateral BMG. For broader penile-flap principles, see Pedicled Penile / Preputial Flap. For combined-tissue-transfer alternatives, see Combined Dorsal BMG + Ventral Fasciocutaneous Flap (Erickson).

Design — Why the "Q" Shape​

The Q-flap starts with a distal circumferential penile skin flap (analogous to the McAninch and Quartey concept), then adds a ventral midline extension along the penile shaft. The resulting outline on the marked penile skin resembles the letter "Q": circumferential loop with a tail.[1][2]

The added ventral limb provides additional skin length that the circumferential portion alone cannot supply, which allowed single-stage reconstruction of the entire anterior urethra in the original series.[1] The ventral segment has been described as extending up to 8 cm along the penile shaft, in addition to the circumferential portion.[7]

Indications​

  • Panurethral anterior urethral strictures were repaired with a single-stage Q-flap in Morey’s selected 15-patient series.[1][2] Multiple oral-mucosal grafts are another option for long defects.[5]
  • Uncircumcised patients with adequate distal penile and preputial skin are candidates. All 15 patients in the original series were uncircumcised.[1][2]
  • Surgeon preference. The Q-flap suits a surgeon who prefers a single-stage flap-based panurethral repair over combined graft and flap (Erickson, Combined Dorsal BMG + Ventral Fasciocutaneous Flap) or staged reconstruction (Bracka two-stage, Johanson two-stage).[3] The 2026 EAU guideline recommends panurethral repair in a specialised centre and combining techniques if one cannot treat the full stricture (both Weak).[8]

The Q-flap requires adequate healthy distal penile or preputial skin and ventral shaft skin; in a circumcised patient, feasibility depends on the remaining tissue. Before a planned single-stage repair for a penile stricture, counsel that adverse intraoperative findings may require conversion to a staged procedure .[8] For lichen sclerosus-related penile strictures, the 2026 EAU guideline recommends against genital-skin augmentation and recommends single-stage oral-mucosal graft repair when local conditions permit .[8] All 15 men in Morey’s Q-flap series were uncircumcised.[1]

Technique Highlights​

StepDetail
1. MarkingOutline a circumferential distal penile skin flap with a ventral midline extension along the shaft — the "Q" shape; the flaps obtained measured up to 24 cm[1]
2. Flap harvestRaise as a fasciocutaneous flap on the dartos pedicle, approximately 2 cm wide and tailored to the urethral plate, with its axial blood supply from the superficial external pudendal vessels (same vascular basis as the Quartey flap)[1][4][6]
3. Urethrotomy and positioningOpen the panurethral stricture along its full length. Limit time in high lithotomy during the repair; a related 66-patient circular-flap series reported four lower-extremity neurovascular complications after prolonged high lithotomy.[9] In a separate retrospective series of 185 urethroplasties, 18 position-related lower-extremity complications occurred (four severe), and longer lithotomy time was associated with risk; the authors harvested penile flaps supine before repositioning for perineal transfer.[11]
4. Flap insetConfigure as an onlay to augment the urethral plate; the ventral limb of the "Q" reaches the proximal extent of the stricture, the circumferential portion covers the more distal segments. An onlay presupposes an adequate urethral plate; if the plate is compromised, reassess the reconstructive plan rather than extending an onlay across that segment.[10] The flap is kept on stretch during suturing to limit redundancy and sacculation, and the dartos pedicle is mobilized far enough to remain tension-free with the penis fully stretched, since inadequate mobilization can rotate the penis toward the pedicle during erection; where the flap is transferred through a scrotal tunnel for proximal reach, a tunnel of approximately 4 cm in diameter has been described.[6] If the repair reaches the fossa navicularis, plan distal inset with glans wings or a glans-preserving approach.[12]
5. ClosureStandard layered closure with a urethral catheter

Outcomes​

Morey 2000 reported 15 uncircumcised men without prior urethroplasty. No supplemental graft was used. Ten had excellent results. Complications were recurrent stricture in two, and one each of urethrocutaneous fistula, meatal stenosis, femoral neuropathy, cerebrovascular accident and prolonged catheterization for focal extravasation.[1] The broader penile-skin-flap literature lists the Q-flap as a pedicled option for selected panurethral disease when single-stage flap-only reconstruction is desired.[2]

Long-term and comparative cohort data specific to the Q-flap are limited. In a 2022 survey of Society of Genitourinary Reconstructive Surgeons members (134 responses from 350 invited), 90% preferred multiple buccal grafts over a combined graft and flap for panurethral strictures.[5] Preputial Spiral Graft Urethroplasty (PSGU) is a free-graft alternative using preputial tissue, but the published method requires an intact prepuce and excludes previously circumcised patients.[13]

Comparison Table — Quartey vs Q-Flap​

FeatureQuartey Flap (1983)Q-Flap (2000)
OriginatorJ.K.M. QuarteyMorey, Tran, Zinman
Flap designTransverse preputial / penile islandCircumferential flap + ventral midline extension ("Q" shape)
LengthNot standardized; the original report describes reach from the meatus to the prostatic urethra[4]Mean 17 cm (15–24 cm)[1]
Primary indicationAnterior urethral strictures (segmental, long)Panurethral strictures
Need for supplemental graftsMay be required for very long stricturesNot required in the original 15 patients
Vascular pedicleDartos / superficial external pudendal vesselsSame (dartos / SEPA)
PrerequisiteAdequate distal penile or preputial skinAdequate healthy distal and ventral shaft skin; original cohort entirely uncircumcised[1]

Limitations​

  • The flap requires enough healthy, hairless distal penile and ventral shaft skin; all 15 men in the original series were uncircumcised, so outcomes in circumcised men were not reported.[1]
  • Lichen sclerosus. Penile skin is unreliable in lichen sclerosus, so oral mucosa is preferred.
  • Proximal penile skin ischemia or necrosis can occur after extensive pedicled penile-flap reconstruction and may lead to wound infection or flap disruption.[12]
  • Published long-term data are limited compared with the McAninch circular flap and BMG urethroplasty.
  • Choice among oral-mucosal grafts, pedicled flaps, staged reconstruction and perineal urethrostomy depends on tissue quality and patient priorities. Superiority of the newer spiral graft over the Q-flap has not been shown.

References​

1. Morey AF, Tran LK, Zinman LM. Q-flap reconstruction of panurethral strictures. BJU Int. 2000;86(9):1039-1042. doi:10.1046/j.1464-410x.2000.00974.x.

2. 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.

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. Quartey JK. One-stage penile/preputial cutaneous island flap urethroplasty for urethral stricture: a preliminary report. J Urol. 1983;129(2):284-287. doi:10.1016/s0022-5347(17)52051-0.

5. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139-143. doi:10.1016/j.urology.2024.06.019.

6. Guidice C. Panurethral Strictures. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:231–248.

7. Munien K, Rahman A, Desai D, Joshi PM. Flaps in Bulbar Urethroplasty. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:105–115. doi:10.1007/978-981-97-5196-9_14

8. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males." 2026. Guideline.

9. McAninch JW, Morey AF. "Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures." J Urol. 1998;159(4):1209-1213. doi:10.1016/S0022-5347(01)63558-4

10. 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-E1108. doi:10.1111/j.1464-410X.2012.11296.x

11. Anema JG, Morey AF, McAninch JW, Mario LA, Wessells H. "Complications related to the high lithotomy position during urethral reconstruction." J Urol. 2000;164(2):360-363. doi:10.1016/S0022-5347(05)67360-0

12. Martins FE, Kulkarni SB, Joshi P, Warner J, Martins N. "Management of long-segment and panurethral stricture disease." Adv Urol. 2015;2015:853914. doi:10.1155/2015/853914

13. Bandini M, Joshi P, Bafna S, et al. "Establishing the role of single-stage preputial spiral graft urethroplasty for panurethral stricture." BJU Int. 2025;136(4):640-646. doi:10.1111/bju.16796