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Orandi Flap (Longitudinal Ventral Penile Skin Flap)

The Orandi flap (longitudinal ventral penile skin island flap) is the original pedicled penile skin flap for urethral reconstruction, first described by Amin Orandi in 1968.[1] It was the first technique to use a vascularized island of penile skin based on the dartos fascia pedicle for single-stage urethroplasty, establishing the foundational principle upon which all subsequent penile skin flap techniques (Quartey, McAninch, Srivastava) were built. In its classic ventral onlay configuration, success rates range from 78–90% at intermediate follow-up, and Greenwell / Mundy 1999 declared it the "gold standard" for patch urethroplasty of penile urethral strictures.[2][3][5]

For the transverse / circular variants, see McAninch Transverse Circular Penile Skin Flap. For the broader penile / preputial flap anatomy, see Pedicled Penile / Preputial Skin Flap. For graft alternatives, see Dorsal Onlay OMG Urethroplasty.

Historical Significance and Evolution​

The original Orandi technique (1968)​

Amin Orandi described a one-stage urethroplasty using a longitudinally oriented island of ventral penile skin, raised on a pedicle of dartos fascia, and transposed as a ventral onlay patch to augment the strictured urethra.[1][6] This was a landmark contribution:

  • The first pedicled island flap used for urethral reconstruction — prior techniques relied on free grafts (no inherent blood supply) or staged procedures.
  • Demonstrated that dartos fascia could serve as a reliable vascular pedicle, carrying the subdermal vascular plexus to nourish the skin island.
  • Established the principle of single-stage substitution urethroplasty — reconstructing the urethra in one operation rather than the traditional two-stage approach.
  • Proved that hairless penile skin was a suitable urethral substitute.

Subsequent developments​

The Orandi flap directly inspired the next generation of penile skin flap techniques:

  • Quartey 1983 — extended the concept to a transverse distal penile / preputial island flap based on the superficial external pudendal vessels, achieving up to 15 cm by harvesting circumferentially.[7]
  • McAninch 1993 — developed the circular fasciocutaneous flap using Buck's fascia (rather than dartos) as the pedicle, providing more robust blood supply and up to 15 cm of tissue.[8]
  • Srivastava 2012 — described the circumpenile flap for circumcised patients, using remaining penile shaft skin as a dorsal onlay flap.[5]
  • Barbagli / Kulkarni 2019 — modified the Orandi flap to a dorsal onlay configuration, eliminating the sacculation / diverticulum problem of the classic ventral placement.[2]

Anatomy and Vascular Basis​

Dartos fascia — the universal penile flap pedicle​

All penile skin flaps are fundamentally based on the dartos fascia, which Joshi, Bandini, and Kulkarni (2022) described as "the winner" among all pedicles in genitourinary reconstruction.[6]

  • Dartos fascia lies between the penile skin and Buck's fascia.
  • It contains a rich subdermal vascular plexus fed by branches of the external pudendal arteries.
  • The dartos is continuous, highly elastic, and can be mobilized extensively without compromising its blood supply.
  • When a skin island is raised on a dartos pedicle, the pedicle maintains perfusion through the subdermal plexus — the fundamental Orandi flap principle.[6]

Flap dimensions​

  • Orientation — longitudinal (along the long axis of the penis); the defining feature distinguishing the Orandi flap from the transverse Quartey and circular McAninch flaps.
  • Width — typically 1.5–2.5 cm (sufficient for onlay augmentation).
  • Length — up to 6–8 cm; limited by the longitudinal dimension of the penile shaft skin (shorter than transverse / circular flaps which can achieve 12–15 cm by harvesting circumferentially).[2][6][8]
  • Skin source — ventral penile shaft skin (classic Orandi) or lateral / dorsolateral penile skin (modifications).

Surgical Technique — Classic Ventral Onlay​

Step 1 — Positioning and exposure. Supine or lithotomy depending on stricture location; penis degloved through a circumcoronal or ventral midline incision; strictured urethra identified by palpation, urethral sound, or RUG.

Step 2 — Flap design. Longitudinal skin island marked on the ventral penile shaft skin, oriented parallel to the long axis. Width 1.5–2.5 cm; length matches stricture length (up to 6–8 cm).

Step 3 — Flap harvest. Skin island incised circumferentially. Dissection deep to the skin but superficial to Buck's fascia, preserving the dartos fascia attached to the deep surface. Dartos pedicle developed by dissecting it off the underlying Buck's fascia, maintaining continuity with the skin island. Pedicle developed with sufficient length to allow tension-free reach to the strictured segment.

Step 4 — Urethrotomy. Strictured urethra opened along its ventral surface through the full length of the stricture; lumen inspected and spongiofibrosis assessed.

Step 5 — Flap placement (ventral onlay). Skin island rotated on its dartos pedicle and laid over the ventral urethrotomy. Flap edges sutured to urethrotomy edges with absorbable sutures (5-0 or 6-0 PDS / Vicryl). Skin surface of the flap faces the urethral lumen (epithelial side inward). Dartos pedicle covers the external surface.

Step 6 — Closure and catheterization. Penile skin closed over the repair; urethral catheter (16–18 Fr) placed; catheter removal at 2–3 weeks after VCUG confirms no extravasation.

Barbagli / Kulkarni Modification — Dorsal Onlay (2019)​

Barbagli, Joshi, and Kulkarni 2019 described a critical modification — repositioning the longitudinal penile skin flap as a dorsal onlay rather than the traditional ventral onlay. The modification was designed to eliminate sacculation and diverticulum formation inherent to ventral placement.[2]

Modified technique​

  1. Midline ventral penile incision.
  2. Urethra fully dissected from the corpora cavernosa (circumferential mobilization).
  3. Urethra opened longitudinally along its dorsal surface.
  4. Longitudinal penile skin island on the dartos pedicle harvested from the ventral penile skin (same as classic Orandi).
  5. Skin island moved over the corpora cavernosa to the dorsal surface.
  6. Opened urethra rotated and sutured over the penile skin flap — flap now sits dorsally, supported by the corpora cavernosa.

Results​

ParameterResult
Number of patients12
Success rate83.3% (10/12)
Failures2
Operating time60 min
Fistula0%
Urethral diverticulum0%
[2]

The key finding was the complete elimination of fistula and diverticulum formation — the two most troublesome complications of the classic ventral Orandi flap. The remarkably short operative time (60 min) also highlights the technical simplicity of this approach.

Dorsal vs. Ventral Onlay — The Sacculation Problem​

The most important clinical distinction between dorsal and ventral flap placement is the risk of pseudo-diverticulum / sacculation and postvoid dribbling, definitively demonstrated by Bhandari, Dubey, and Verma 2001 in 40 patients.[4]

ParameterVentral Onlay (n = 21)Dorsal Onlay (n = 19)p value
Stricture recurrence24% (3/21)11% (2/19)> 0.05 (NS)
Pseudo-diverticulum / sacculation29% (6/21)0% (0/19)0.01
Postvoid dribblingPresent in sacculation casesNone—
Urethrocutaneous fistula1 case0—

Why ventral onlay causes sacculation​

When a flap is placed ventrally, it lacks the rigid structural support of the corpora cavernosa. During voiding, intraluminal pressure causes the unsupported ventral patch to balloon outward, creating a pseudo-diverticulum. The sacculation traps urine, leading to postvoid dribbling in 24–41.7% of patients with ventral onlay repairs.[4][9]

Why dorsal onlay prevents sacculation​

When the flap is placed dorsally, it is supported by the rigid tunica albuginea of the corpora cavernosa, acting as a mechanical backstop preventing outward ballooning — the same principle Barbagli described for dorsal onlay BMG urethroplasty.[2][4]

Clinical Outcomes​

StudynFlap typeConfigurationStricture LengthSuccessFollow-upKey Findings
Barbagli / Kulkarni 2019[2]12Orandi longitudinalDorsal onlaypenile83.3%—0% fistula, 0% diverticulum; 60-min OR time
Bhandari 2001[4]40Longitudinal / circumpenile19 dorsal, 21 ventralpendulous / bulbar76% (VO), 89% (DO)27.5 moSacculation 29% VO vs 0% DO (p = 0.01)
Srivastava 2012[5]144Preputial DOF (60), TF (54), circumpenile DOF (30)Dorsal onlay or tubularizedpendular / bulbar85–93.3% (1-yr); 75–86.7% (3-yr)40.1 moDOF superior to TF; circumpenile flap effective in circumcised patients
Mathur 2014[11]58Preputial flapOnlaymedian 4.85 cm81%42 moDiabetes (RR 5.21) and smoking (RR 4.19) predict failure
Dubey 2007 RCT (flap arm)[10]28Penile skin flapDorsal onlaycomplex anterior85.6%comparableHigher morbidity vs BMG; 34% postvoid dribbling; 65% would recommend
Fuchs 2018 (flap group)[12]87Penile skin flapvariousmedian 4.5 cm78.2%50.7 moFlap use declining; comparable to BMG (78.5%); PU superior (94.8%)
de la Rosette 1991[13]50Pedicled island flapvariouscomplicated68%—20% fistula; 32% recurrence; worse outcomes with ≥ 3 prior urethrotomies
Greenwell / Mundy 1999[3]79Various incl. OrandiPatch / circumferentialbulbar / penile——Orandi declared "gold standard" for penile patch urethroplasty; 2-stage better for circumferential

Combination Technique — Orandi Flap + Dorsal BMG​

For narrow penile strictures with a damaged urethral plate, combining a dorsal BMG with a ventral Orandi flap has emerged as a powerful single-stage alternative to staged urethroplasty. Karapanos 2024 described this combined approach with preservation of the native urethral plate and corpus spongiosum:[9]

Technique​

  1. Dorsal onlay BMG quilted to the corpora cavernosa.
  2. Longitudinal ventral penile skin flap (Orandi-type) transposed ventrally.
  3. The flap is sutured to the scarred native urethral mucosa on one side and to the BMG on the other, forming a neourethra of triangular cross-section.
  4. The preserved corpus spongiosum is wrapped around the flap ventrally for reinforcement.

Results (12 patients, median 38-mo follow-up)​

  • 91.7% success
  • 0% sacculation or diverticula (the spongiosal wrap prevents ballooning)
  • 3 transient fistulas (healed with prolonged catheterization)
  • 41.7% postvoid dribbling (despite no sacculation — likely related to the ventral flap component)
  • Median stricture length 5 cm (IQR 3.8–7)

This combined approach was also described by Iselin and Webster 1999 (dorsal onlay penile skin grafts + Orandi flap in 4 of 29 patients when stricture extended into the penile urethra) and by Morey 2001 (dorsal BMG to salvage an inadequate urethral plate during penile island flap onlay).[14][15][20]

Comparison of Penile Skin Flap Types​

FeatureOrandi (Longitudinal)Quartey (Transverse Preputial)McAninch (Circular)Circumpenile (Srivastava)
Year described1968[1]1983[7]1993[8]2012[5]
OrientationLongitudinalTransverseCircumferentialCircumferential
PedicleDartos fasciaSuperficial external pudendal vesselsBuck's fasciaDartos fascia
Maximum length6–8 cm12–15 cm15 cmvariable
Requires prepuceNoYes (typically)NoNo (designed for circumcised)
Technical complexitySimplestModerateMost complexModerate
Operative time60 min (Barbagli dorsal)—224 min (Dubey RCT)—
Best indicationPenile strictures ≤6–8 cmLong anterior stricturesLong / complex anterior stricturesCircumcised patients

Advantages​

  1. Technical simplicity — the simplest of all penile skin flap techniques. Barbagli reported a 60-min operative time for the dorsal modification, significantly shorter than the McAninch circular flap (224 min in the Dubey RCT).[2][10]
  2. No prepuce required — unlike Quartey, the Orandi flap uses penile shaft skin and can be performed in circumcised patients.[2][5]
  3. Reliable dartos pedicle — consistent, robust vascularity.[6]
  4. Versatility — ventral onlay (classic), dorsal onlay (Barbagli modification), or combined with dorsal BMG for complex strictures.[2][4][9]
  5. Penile urethral "gold standard" — Greenwell and Mundy 1999 stated that "for a patch urethroplasty of an uncomplicated stricture in the penile urethra, the Orandi procedure remains the 'gold standard'".[3]
  6. Preserved erectile function — no significant impact across all series.[2][5][9]

Limitations​

  1. Limited length (6–8 cm) — longitudinal orientation restricts the flap to shorter strictures. For strictures >8 cm, the McAninch circular flap or combined techniques are preferred.[6][8]
  2. Sacculation with ventral placement — classic ventral onlay carries a 29% risk of pseudo-diverticulum and postvoid dribbling — largely eliminated by dorsal placement.[4]
  3. Contraindicated in lichen sclerosus — AUA guideline states genital skin flaps and grafts should be avoided in LS-related strictures due to high long-term failure. Oral mucosa is preferred.[16][17][18]
  4. Requires healthy penile skin — patients with prior radiation, extensive scarring, dermatologic conditions, or insufficient skin are not candidates.[11]
  5. Hair-bearing skin risk — AUA Clinical Principle: surgeons should not use hair-bearing skin for substitution urethroplasty. Care to harvest only hairless distal penile skin.[16]
  6. Declining use — Fuchs 2018 documented significant decline in penile skin flap use over the past decade at a major reconstructive center (from a substantial proportion to 21.6%).[12]

Predictors of Failure​

PredictorHazard / Risk RatioSource
SmokingHR 4.0 (95% CI 1.2–12.9)Whitson / McAninch 2008[19]
SmokingRR 4.19 (CI 1.54–45.0)Mathur 2014[11]
History of hypospadias repairHR 4.4 (95% CI 1.3–14.6)Whitson / McAninch 2008[19]
Stricture length 7–10 cmHR 7.0 (95% CI 1.4–34.7)Whitson / McAninch 2008[19]
Diabetes mellitusRR 5.21 (CI 2.31–64.68)Mathur 2014[11]
Panurethral strictureRR 2.73Mathur 2014[11]
Previous urethroplastyRR 2.4Mathur 2014[11]
Severe periurethral fibrosisRR 2.37Mathur 2014[11]
≥3 prior urethrotomieshighest recurrence proportionde la Rosette 1991[13]

Orandi Flap vs. BMG​

The most clinically relevant comparison. Dubey 2007 RCT key findings:[10]

  • Success equivalent — BMG 89.9% vs penile skin flap 85.6% (p > 0.05).
  • BMG technically simpler — OR time 162 vs 224 min (p = 0.001).
  • BMG lower morbidity — penile skin necrosis 21% (flap) vs 0% (BMG); penile torsion 7% vs 0%.
  • BMG less postvoid dribbling — 14.8% vs 34.1% (p = 0.001).
  • BMG patient-preferred — 89% vs 65% would recommend (p = 0.001).

The Orandi flap retains a critical niche advantage — it carries its own blood supply (pedicled), making it suitable for scarred, poorly vascularized urethral beds where a free graft might not take (failed prior urethroplasty, radiation, extensive spongiofibrosis).[6][20]

Current Role and Guideline Context​

AUA Guideline 2023[16]​

  • Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination (Moderate Recommendation; Grade C).
  • Surgeons should use oral mucosa as the first choice when using grafts (Expert Opinion).
  • Genital skin flaps and grafts should be avoided in LS-related strictures.
  • Surgeons should not use hair-bearing skin for substitution urethroplasty (Clinical Principle).

Fuchs 2018 documented the evolving landscape over a decade:[12]

  • BMG use stable (~61% of complex reconstructions)
  • Penile skin flap use declined (from a major proportion to ~21.6%)
  • Perineal urethrostomy use increased (4.3% → 38.7%, p = 0.01)
  • Success — PU 94.8% > BMG 78.5% ≈ skin flap 78.2% (p = 0.003)

Despite the decline, the Orandi flap and modifications remain important in regions where oral mucosa is unavailable (e.g., dyskeratotic changes from gutkha / tobacco / betel-nut consumption per Mathur), in patients with depleted oral donor sites, and in complex strictures requiring vascularized tissue transfer.[6][11]

Special Considerations​

Circumcised patients​

The classic Orandi flap can be performed in circumcised patients using remaining penile shaft skin. Srivastava 2012 specifically studied the circumpenile flap in 30 circumcised patients, achieving 93.3% at 1 yr and 86.7% at 3 yr — comparable to or better than preputial flap results.[5]

Regional considerations​

In South Asia, where gutkha, tobacco, pan masala, and betel nut consumption causes oral submucosal fibrosis, buccal mucosa may be unsuitable for grafting. The Orandi penile skin flap remains a critical alternative. Mathur 2014 noted: "We prefer this technique in this part of the world where buccal mucosa cannot be used because of dyskeratotic changes."[11]

Key Takeaways​

The Orandi longitudinal ventral penile skin island flap is the founding technique of pedicled flap urethroplasty, first described in 1968 and still relevant today. Its key strengths are technical simplicity (60-min OR time in the Barbagli dorsal modification), reliable dartos-based vascularity, and applicability in circumcised patients and those with unsuitable oral mucosa.[1][2][5][11] The Barbagli / Kulkarni dorsal onlay modification (2019) represents the most important evolution, eliminating the sacculation and diverticulum formation that plagued the classic ventral configuration (29% vs 0%, p = 0.01).[2][4] While BMG urethroplasty has largely supplanted penile skin flaps as first-line substitution material due to lower morbidity and higher patient satisfaction, the Orandi flap retains a critical role in complex strictures with scarred urethral beds, failed prior grafts, depleted oral donor sites, and populations where oral mucosa is unavailable.[6][10][11][12] It is contraindicated in lichen sclerosus.[16][17]

Videos​

Penile Skin Flap Urethroplasty for Distal Penile Stricture
AINU Surgical Videos (2025)

References​

  1. Orandi A. One-stage urethroplasty. Br J Urol. 1968;40(6):717-9. PMID: 4880395.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Mathur RK, Nagar M, Mathur R, et al. Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: evaluation and determinants of success. BJU Int. 2014;113(1):120-6. doi:10.1111/bju.12361.
  12. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169-173. doi:10.1016/j.urology.2018.08.009.
  13. de la Rosette JJ, de Vries JD, Lock MT, Debruyne FM. Urethroplasty using the pedicled island flap technique in complicated urethral strictures. J Urol. 1991;146(1):40-2. doi:10.1016/s0022-5347(17)37709-1.
  14. Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol. 1999;161(3):815-8.
  15. Morey AF. Urethral plate salvage with dorsal graft promotes successful penile flap onlay reconstruction of severe pendulous strictures. J Urol. 2001;166(4):1376-8.
  16. 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.
  17. 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.
  18. Chung ASJ, Suarez OA. Current treatment of lichen sclerosus and stricture. World J Urol. 2020;38(12):3061-3067. doi:10.1007/s00345-019-03030-z.
  19. 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.
  20. 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.