Skip to main content

Scrotal Flap Glanuloplasty (Mazza and Cheliz Technique)

The Mazza / Cheliz scrotal flap glanuloplasty is a two-stage pedicled scrotal flap reconstruction that transfers scrotal skin to the penile stump to create a neoglans after partial penectomy. First described in 2001, it remains the largest single-technique flap-based neoglans series to date (n = 34, mean follow-up 73.2 months) and was specifically designed to address three post-penectomy problems: lack of penile skin, stump retraction into the scrotum, and neomeatal stenosis.[1]

For the urethral-flap alternatives, see Inverted Urethral Flap (IUF) Glanuloplasty (Belinky / Chavarriaga) and Gulino Everted Urethral Flap Glanuloplasty. For the comparative umbrella, see Glanuloplasty With Flaps. For the STSG-based standard, see Glansectomy With STSG. Decision framework: Penile Reconstruction.

For scrotal-flap applications to penile shaft (rather than neoglans), see Bipedicled Anterior Scrotal Flap (Fakin), Yao Butterfly, Murányi tunnel, Total Anterior Scrotal Flap (Zhao), Staged Bipedicled (Pribaz / McLaughlin), Reverse Bilateral (Gao), and Sensate EPAP Hemi-Scrotal (Tsukuura).

Historical Context and Rationale​

Before 2001, partial-penectomy patients were often left with an uncovered penile stump that retracted into the pubic fat pad — poor cosmesis, voiding difficulty, no intercourse. Mazza and Cheliz recognized that scrotal skin — thin, elastic, well-vascularized, anatomically adjacent — was an ideal donor.[1]

Developed at the same Buenos Aires institution where Cheliz later co-authored the Belinky inverted urethral flap (2011), suggesting an evolution from scrotal flap to urethral flap approaches at this center.[1][2]

Benderev (1988) had previously described a suprapubic + scrotal pedicled flap for proximal-shaft preservation, though not specifically for neoglans creation.[3]

Anatomical Basis​

Scrotal vascular anatomy (Carrera 2009, 15 cadavers)[4]​

Three cutaneous territories supplied by two systems and widely inter-anastomosed:

  1. Inferior external pudendal arteries (femoral branches) — supply two lateral cutaneous territories, accessing at the midpoint of the scrotal root and fanning over the corresponding hemiscrotum
  2. Perineal arteries (internal pudendal branches) — supply the central cutaneous territory via two main scrotal arteries running deeply alongside the scrotal septum from the posterior face

Scrotal-skin tissue properties​

  • Thin and elastic — among the thinnest skin in the body; dartos fascia provides smooth-muscle elasticity[6]
  • Well-vascularized dartos arterial network
  • Redundant — adequate donor without compromising scrotal / testicular coverage
  • Hair-bearing — the principal disadvantage; follicles persist after transfer → depilation needed in a subset
  • Sensate — anterior scrotal nerves (ilioinguinal branches) and posterior scrotal nerves (perineal branches)[5]

Indications​

  • Partial penectomy for penile cancer — primary indication in the original series
  • Traumatic partial amputation when the stump requires coverage + neoglans
  • Any partial penectomy with inadequate skin coverage and retraction risk

Particularly useful when:

  • The urethral stump is too short for IUF / Gulino techniques
  • The penile stump has retracted into the scrotum and requires exteriorization
  • Sufficient scrotal redundancy is available for flap harvest

Surgical Technique — Two-Stage​

Stage 1 — Scrotal Flap Transfer​

  1. Penectomy and stump preparation — partial penectomy with negative-margin confirmation; hemostasis at corporal tips; identify urethral stump
  2. Scrotal flap design — pedicled anterior-scrotal flap based on the anterior scrotal artery (branch of inferior external pudendal); dimensions matched to stump; distal end designed to wrap around and cover the corporal tips
  3. Flap elevation and transfer — elevate on the pedicle preserving vascular supply at the base; transfer the distal extreme to the penile stump
  4. Neomeatus creation — suture the urethral end to a hole created in the scrotal flap → neomeatus
  5. Flap fixation — suture flap borders to adjacent tunica albuginea of the corpora; sculpt to natural-glans contour
  6. Pedicle maintenance — leave the scrotal-skin bridge intact; supplies the flap during neovascularization from the underlying corporal bed; penis remains tethered to scrotum during this interval

Interval — 4–6 weeks​

Sufficient neovascularization develops from the underlying wound bed to sustain the flap independently of the original pedicle.

Stage 2 — Pedicle Division​

  1. Pedicle assessment at 4–6 weeks
  2. Pedicle resection — divide and free the penis from the scrotum; close remaining scrotal skin primarily; trim and suture the flap edges on the penile stump for a smooth, circumferential neoglans surface

Outcomes — Mazza / Cheliz 2001 (n = 34)[1]​

Demographics​

ParameterValue
n34
Mean age43.2 y
IndicationPartial penectomy (cancer and trauma)
Mean follow-up73.2 months (~ 6.1 y)
Stages2
Interval between stages4–6 weeks

Functional and cosmetic outcomes​

OutcomeResultDetails
Penile appearance"Normal-appearing"—
Urinary flow100% unobstructed—
Penile retraction0% (0 / 34)No stump retraction into scrotum
Sexual potency20.5% (7 / 34)Preserved in 7 men
IntercoursePossible in select cases"Vaginal penetration possible in certain cases"

Complications​

ComplicationRateManagement
Definite depilation required17.6% (6 / 34)Electrolysis / laser for neoglans hair
Partial flap necrosis5.8% (2 / 34)Skin grafts
Meatal stenosis2.9% (1 / 34)Minor surgical procedures

Key Findings​

Zero penile retraction — the primary clinical achievement[1]​

0% stump retraction across all 34 patients at mean 73.2 mo is the most clinically significant finding. Retraction into the pubic fat pad is a recognized and debilitating post-partial-penectomy complication that compromises voiding (requiring sitting to void) and eliminates intercourse. The scrotal flap provides a tethering and stabilizing effect, anchoring the stump to surrounding tissue.

Low sexual potency — the principal limitation​

20.5% potency is substantially below other reconstruction techniques:

TechniqueSexual / erectile functionn
Mazza scrotal flap20.5% potency34
Belinky / Chavarriaga IUFIIEF-5 17.3 (mild-moderate ED)74
Gulino urethral eversion71% rigid erections14
STSG neoglans (Pang SR)91.1% preserved327
Zhao scrotal flap (shaft defects)83% satisfied intercourse18

Likely drivers:[1][13]

  • Cohort age (mean 43.2 y) does not explain it
  • Two-stage pedicle phase with 4–6 weeks of penile-scrotal tethering may cause corporal fibrosis or neurovascular compromise
  • Likely more proximal amputations than urethral-flap cohorts → worse sexual outcomes
  • Keratinized, hair-bearing scrotal skin lacks the sensory richness of urethral mucosa — reduced erogenous sensation and tactile-stimulated erection

Hair growth — unique complication​

17.6% depilation rate is unique to scrotal-flap reconstruction (not seen with STSG, urethral flap, or OMG). Scrotal hair follicles persist after transfer → definite depilation needed for acceptable cosmesis.

Gil-Vernet 1995 — insulated-needle thermocoagulation; average 3 sessions at 4-week intervals; no infections. The median area around the scrotal raphe is nearly hairless — flap design can exploit this to minimize hair burden.[14][15]

Comparison With Other Neoglans Reconstruction Techniques​

ParameterMazza scrotal flapIUF (Chavarriaga)Gulino eversionSTSG SR (Pang)
n347414327
Follow-up73.2 mo mean72 mo median13 mo mean40.7 mo mean
Stages2111
Tissue typeKeratinized skin (hair-bearing)Mucosal (urethral)Mucosal (urethral)Keratinized skin (glabrous)
Donor siteScrotumNoneNoneThigh
Penile retraction0%n/r0%n/r
Erectile function20.5% potencyIIEF-5 17.371% rigid91.1% preserved
Meatal stenosis2.9%0%0%8.1%
Flap / graft loss5.8%0%0%6.1%
Depilation needed17.6%NoNoNo
Sensationn/rn/r100%83.7%
Voiding100% unobstructedICIQ-MLUTS 1.7n/r75.6% standing
Cosmetic satisfaction"Normal-appearing"n/r"Appreciable"86.3%
Ventral curvaturen/r10% (Belinky)0%n/r

Mazza vs Other Scrotal-Flap Applications​

Distinguish Mazza (neoglans) from other scrotal-flap uses for shaft coverage:

StudynIndicationStagesPotency / erectionNotes
Mazza / Cheliz 200134Neoglans after penectomy220.5%Normal-appearing
Zhao 2009[12]18Shaft defects (trauma / tumor)283% satisfied intercourseBilateral / total anterior
Fakin 2017[17]43Shaft defects (siliconoma)2100% erection abilityBipedicled anterior; 4.37 / 5 satisfaction
Mendel 2023[18]22Shaft defects (buried penis, foreign body)1–2EHS 3.5 / 48 / 10 satisfaction; 22.7% testicular ascension
McLaughlin 2024[19]8Shaft defects (various)2SatisfactoryBipedicled
Yao 2022[20]7Foreskin defects1n/rModified bilateral butterfly

Shaft-defect series report much higher erectile function (83–100%) vs Mazza neoglans (20.5%) — likely because shaft-defect patients retain their native glans with its sensory and erogenous function.

Modern Innovations That Address Mazza's Limitations​

InnovationAuthorYearAdvantage
Modified bilateral "butterfly" flapYao[20]2022Single-stage bilateral design (no pedicle phase)
Bipedicled anterior scrotal flapFakin[17]2017n = 43, 100% erection, 4.37 / 5 satisfaction
Sensate EPAP hemi-scrotal flapTsukuura[5]2025Sensate (anterior scrotal nerve preservation); inconspicuous lateral scar; wider rotation arc
Bilateral pedicledMendel[18]2023EHS 3.5 / 4, satisfaction 8 / 10 despite higher complication profile

Depilation Techniques for Scrotal-Flap Hair[14][15]​

ApproachDetails
Electrolysis (thermocoagulation)Gil-Vernet insulated-needle technique; average 3 sessions, 4-wk intervals; no infections
Laser hair removalNd:YAG, alexandrite, or diode for permanent reduction on transferred skin
Preoperative depilationTreat planned flap donor site before reconstruction; flap transferred already hairless; requires 3–6 mo planning
Flap-design optimizationIncorporate the median raphe (nearly hairless) midline strip to minimize neoglans hair

Psychosexual Impact​

The 20.5% sexual-potency rate has substantial psychosexual implications:[21][22][23][24]

  • Harju 2021 (n = 107) — lack of sexual activity is the dominant QoL compromiser in penile-cancer survivors; HRQoL significantly lower than age-standardized general-population averages
  • Kieffer 2014 (n = 90) — (partial) penectomy significantly worse than penile-sparing on orgasm (effect size 0.54), appearance concerns (0.61), life interference (0.49), urinary function
  • Roumieux 2025 — "voyage of sexual re-discovery"; need for pre-surgical information and post-surgical psychosexual support
  • EAU-ASCO — partial penectomy is associated with poorer sexual outcomes than organ-sparing surgery

Guideline Context​

Neither NCCN nor EAU-ASCO mentions the Mazza technique specifically.[16][24]

  • NCCN — after glansectomy, "treatment is followed in certain instances with an STSG or FTSG to create a neoglans"; partial penectomy is the standard for high-grade primary tumors when a functional stump can be preserved with negative margins
  • EAU-ASCO — strong recommendation for organ-sparing surgery with reconstruction for confined disease (PeIN, Ta, T1–T2); does not endorse a specific reconstruction technique

Mazza is consistent with the principle of reconstruction after confirmed negative margins but is not specifically endorsed.

Advantages​

  1. Zero penile retraction — the most clinically significant advantage
  2. Long follow-up — 73.2 months mean (among the longest for any neoglans technique)
  3. Large cohort — n = 34 (substantial for this rare condition)
  4. Normal-appearing penis — described qualitatively as achieving a normal cosmetic result
  5. 100% unobstructed voiding
  6. Low meatal stenosis (2.9%) vs 8.1% with STSG
  7. Well-vascularized tissue — dual scrotal blood supply
  8. Elastic thin skin matching penile-skin properties
  9. No distant donor site
  10. Applicable when urethral flap is not feasible — proximal amputations with insufficient urethral length

Limitations​

  1. Two-stage procedure with 4–6 wk pedicle phase
  2. Low sexual potency (20.5%) — substantially lower than IUF, Gulino, STSG
  3. Hair growth requiring depilation (17.6%) — unique to scrotal flap
  4. Partial flap necrosis (5.8%) — comparable to STSG (6.1%), higher than IUF (0%)
  5. Keratinized non-mucosal surface — does not mimic native glans epithelium
  6. Penile-scrotal tethering during pedicle phase — discomfort, functional limitation
  7. No validated QoL instruments — qualitative outcomes only
  8. Sensation not specifically reported
  9. Not specifically endorsed by NCCN / EAU-ASCO
  10. Single-center experience — no external validation
  11. Potential testicular ascension (Mendel 22.7% with bilateral scrotal flaps — though for shaft reconstruction)

Future Directions​

  • Single-stage modifications — perforator-based designs (e.g., EPAP) eliminating the pedicle phase[5]
  • Standardized preoperative depilation protocols (laser / electrolysis) of the planned donor site
  • Hybrid approaches — scrotal flap for shaft coverage + urethral flap for neoglans creation
  • Validated functional outcome assessment — prospective use of IIEF-15, IPSS, EQ-5D, EORTC QLQ-C30
  • Direct comparison of scrotal flap vs IUF vs STSG in matched cohorts
  • Sensate flap development incorporating the anterior scrotal nerve to improve sensory outcomes (EPAP precedent)[5]

Key Takeaways​

  • Largest single-technique flap-based neoglans series (n = 34, mean follow-up 73.2 mo)
  • Zero penile retraction — defining clinical achievement; anchors the stump and prevents pubic-fat-pad retreat
  • Low sexual potency (20.5%) — principal limitation vs urethral-flap (IIEF-5 17.3, Gulino 71%) and STSG (91.1% preserved) techniques
  • Hair growth in 17.6% is unique to scrotal flap and requires definite depilation
  • Two-stage — requires pedicle division at 4–6 weeks
  • Best suited when urethral length is inadequate for IUF / Gulino approaches, when stump retraction prevention is the priority, and when adequate scrotal donor tissue is available
  • Modern perforator-based (EPAP) and single-stage modifications (Yao butterfly) address several Mazza limitations

Cross-references​

References​

1. Mazza ON, Cheliz GM. "Glanuloplasty With Scrotal Flap for Partial Penectomy." J Urol. 2001;166(3):887–9.

2. Belinky JJ, Cheliz GM, Graziano CA, Rey HM. "Glanuloplasty With Urethral Flap After Partial Penectomy." J Urol. 2011;185(1):204–6. doi:10.1016/j.juro.2010.09.010

3. Benderev TV. "Preservation of Penile Length in Penile Cancer and Trauma by Use of a Pedicled Flap." J Urol. 1988;140(1):145–6. doi:10.1016/s0022-5347(17)41511-4

4. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the Scrotum: A Microvascular Study and Its Application to Urethral Reconstruction With Scrotal Flaps." BJU Int. 2009;103(6):820–4. doi:10.1111/j.1464-410X.2008.08167.x

5. Tsukuura R, Engmann T, Miyazaki T, Yamamoto T. "The Sensate External Pudendal Artery Perforator (EPAP) Hemi-Scrotal Flap for the Circumferential Skin Defect of the Penile Shaft." Microsurgery. 2025;45(7):e70123. doi:10.1002/micr.70123

6. Hamad J, McCormick BJ, Sayed CJ, et al. "Multidisciplinary Update on Genital Hidradenitis Suppurativa: A Review." JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

7. Chavarriaga J, Becerra L, Camacho D, et al. "Inverted Urethral Flap Reconstruction After Partial Penectomy: Long-Term Oncological and Functional Outcomes." Urol Oncol. 2022;40(4):169.e13–169.e20. doi:10.1016/j.urolonc.2022.02.006

10. Gulino G, Sasso F, Falabella R, Bassi PF. "Distal Urethral Reconstruction of the Glans for Penile Carcinoma: Results of a Novel Technique at 1-Year of Followup." J Urol. 2007;178(3 Pt 1):941–4. doi:10.1016/j.juro.2007.05.059

11. Pang KH, Alnajjar HM, Muneer A. "Functional Outcomes of Glansectomy to Treat Localised Penile Cancer: A Systematic Review." Int J Impot Res. 2026;38(3):206–213. doi:10.1038/s41443-025-01062-1

12. Zhao YQ, Zhang J, Yu MS, Long DC. "Functional Restoration of Penis With Partial Defect by Scrotal Skin Flap." J Urol. 2009;182(5):2358–61. doi:10.1016/j.juro.2009.07.048

13. Whyte E, Sutcliffe A, Keegan P, et al. "Effects of Partial Penectomy for Penile Cancer on Sexual Function: A Systematic Review." PLoS One. 2022;17(9):e0274914. doi:10.1371/journal.pone.0274914

14. Gil-Vernet A, Arango O, Gil-Vernet J, Gelabert-Mas A, Gil-Vernet J. "Scrotal Flap Epilation in Urethroplasty: Concepts and Technique." J Urol. 1995;154(5):1723–6.

15. Osman OF. "Extended Use of Scrotal Septal Island Skin Flap for the Repair of Penile Hypospadias." Ann Plast Surg. 1994;33(5):525–9. doi:10.1097/00000637-199411000-00010

16. National Comprehensive Cancer Network. Penile Cancer. Updated 2025-11-12.

17. Fakin R, Zimmermann S, Jindarak S, et al. "Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap." J Urol. 2017;197(4):1166–1170. doi:10.1016/j.juro.2016.11.093

18. Mendel L, Neuville P, Allepot K, et al. "Bilateral Pedicled Scrotal Flaps as an Alternative to Skin Graft in Penile Shaft Defects Repair." Urology. 2023;176:206–212. doi:10.1016/j.urology.2023.03.025

19. McLaughlin MM, Abbassi B, Pribaz JJ. "Bipedicled Scrotal Flap for Penile Resurfacing." Plast Reconstr Surg. 2024;153(4):935–942. doi:10.1097/PRS.0000000000010811

20. Yao H, Zheng D, Xie M, et al. "A Modified Bilateral Scrotal Flap for Penile Skin Defect Repair." J Vis Exp. 2022;(189). doi:10.3791/64017

21. Harju E, Pakarainen T, Vasarainen H, et al. "Health-Related Quality of Life, Self-Esteem and Sexual Functioning Among Patients Operated for Penile Cancer — A Cross-Sectional Study." J Sex Med. 2021;18(9):1524–1531. doi:10.1016/j.jsxm.2021.06.015

22. Kieffer JM, Djajadiningrat RS, van Muilekom EA, et al. "Quality of Life for Patients Treated for Penile Cancer." J Urol. 2014;192(4):1105–10. doi:10.1016/j.juro.2014.04.014

23. Roumieux C, Royakkers L, Albersen M, Dancet E. "The Impact of Diagnosis and Treatment of Penile Cancer on Intimacy: A Qualitative Assessment." Int J Impot Res. 2025;37(9):759–765. doi:10.1038/s41443-024-00992-6

24. Brouwer OR, Albersen M, Parnham A, et al. "European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update." Eur Urol. 2023;83(6):548–560. doi:10.1016/j.eururo.2023.02.027