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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. While it provides single-stage circumferential urethral replacement with vascularized tissue, it carries higher recurrence in selected historical cohorts than onlay augmentation; the groups differ in urethral-plate quality and are not directly interchangeable, with particular susceptibility to diverticulum formation, fistula, and stricture recurrence.[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​

Two parallel historical lineages — adult urethral stricture disease and pediatric hypospadias repair.

Adult stricture disease​

  • Quartey 1983 — in his landmark transverse preputial island flap description, Quartey explicitly 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." An early adult-stricture description of both configurations.[5]
  • McAninch 1993, 1998 — extended the concept with the circular fasciocutaneous penile flap, which could also be tubularized. In the 1998 series of 66 patients, 12 underwent tubularized repairs with a 58% recurrence rate vs 13% for the 54 onlay repairs.[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. 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 — hairless, thin, pliable, with a mucosal-like quality well-suited for urethral reconstruction.[5][9]
  • Inner preputial skin is specialized skin, not urethral mucosa; assess its quality, hair and inflammatory disease rather than assuming mucosal equivalence.

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 — must be sufficient to create a tube of adequate caliber when rolled around a catheter. Typically 2.5–3.5 cm of skin width is needed to create a tube that accommodates a 16–18 Fr catheter.
  • Length — determined by the stricture length; the transverse preputial harvest allows up to 12–15 cm.[5]

Surgical Technique​

Positioning and exposure​

Supine or lithotomy; penis degloved through a circumcoronal incision; full extent of the strictured urethra assessed (RUG, urethroscopy, intraoperative palpation).

Stricture excision​

Unlike onlay techniques (which preserve the urethral plate), the tubularized approach requires complete circumferential excision of the strictured segment. 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.

Tubularization​

  • The skin island is rolled around a 16–18 Fr urethral catheter with the epithelial surface facing inward (toward the lumen).
  • Edges sutured together with continuous or interrupted absorbable sutures (5-0 or 6-0 PDS / Vicryl) to create a watertight tube.
  • Suture line typically placed along the ventral or lateral aspect.
  • Hayashi 2001 reported one complication among 13 pediatric hypospadias repairs using two-layer closure and spongiosal coverage; the uncontrolled series does not demonstrate a reduction or establish adult-stricture outcomes.[11]

Anastomosis​

  • Proximal anastomosis — tube sutured to the spatulated proximal urethra with absorbable sutures.
  • Distal anastomosis — tube sutured to the spatulated distal urethra or brought out to the glans tip (in hypospadias repair).
  • Both anastomoses performed over the indwelling catheter.

Pedicle coverage and closure​

  • The dartos pedicle is wrapped around the exterior of the tubularized neo-urethra, providing a second vascularized tissue layer that reinforces the repair and may reduce fistula risk.[9][11]
  • Penile skin closed over the repair.
  • Urethral catheter left in place for 2–3 weeks, with removal after VCUG confirms no extravasation.

Outcomes — Adult Urethral Stricture Disease​

The following retrospective series generally favor onlay when a viable plate remains. Tubularized repairs treat more severe tissue loss, so these comparisons do not isolate a causal effect of configuration.

Studyn (tube)ConfigurationSuccess (tube)Comparator (onlay)Follow-upKey Findings
McAninch / Morey 1998[2]12Tubularized circular flap42% (5/12)87% (47/54) onlay41 mo58% recurrence in tube vs 13% onlay; "onlay repairs appear to be more successful"
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 modification40% at 30 moNo recurrence among available dorsal-onlay follow-up19 moOnly five tube repairs; 30-month denominator for onlay follow-up not specified
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"

These heterogeneous series should not be pooled into a fixed relative-failure multiplier. Carney and McAninch 2002 stated explicitly: "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]148 (Duckett)Primary hypospadias22% initial (95% final after reoperations)higher than onlayhigher than onlayhigher than onlay23 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 secondaryPrimary 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]21Multiple failed urethroplasties (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 vs 0% of onlay repairs (p = 0.016). Wang 2019 reported 12.8% diverticula in 320 patients, with 31.7% of diverticula associated with concomitant strictures (p < 0.001).[12][14]
  2. Duckett's tubularized repair has higher complication rates than onlay — Ghali 1999 directly compared 148 Duckett tubularized repairs with 42 onlay preputial island flaps and found significantly higher overall complications including fistulae, strictures, meatal stenoses, and tubular abnormalities (p < 0.05).[13]
  3. Late complications are common — Wang 2019 found 20.8% of complications presented after ≥1 year, and 12.8% after ≥5 years, emphasizing the need for long-term follow-up well beyond the typical 2–3 year window.[12]
  4. Secondary (reoperative) cases have worse outcomes — Zheng 2013: complication rates 24% primary vs 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. These are anatomically different repairs; there is no valid general formula that multiplies circumference by stricture length to calculate suture-line length.[1][2]

Potential problems include anastomotic restenosis, ischemia if the pedicle is compromised, fistula, and ballooning of an unsupported segment. Distal obstruction may coexist with or contribute to diverticulum formation. Dorsal support may limit sacculation but does not guarantee its absence.[10][12][14]

Adult stricture outcomes and pediatric hypospadias complication rates should be discussed separately. A catheter size appropriate for an adult reconstruction must not be transferred to a child.

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) — no meatal stenosis, stricture, or diverticulum.[11]
  2. Augmented Duckett (Glassberg 1987) — proximal Thiersch-Duplay neo-urethra (from ventral penile skin) anastomosed to the distal Duckett tube; bridges larger gaps without a free graft.[8]
  3. Dartos fascia wrap — wrapped circumferentially around the tubularized neo-urethra, providing a second vascularized tissue layer that reinforces the suture line.[9][11]
  4. Staged hypospadias reconstruction — can be considered for severe curvature and an unsuitable plate. The 39.1% complication rate in the cited 320-patient single-stage cohort is not a randomized comparison against the separate staged series.[12]
  5. Combined dorsal BMG + 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. 64% primary / 79% secondary success at median 2.5 yr for strictures averaging 9.75 cm.[18]

Alternatives and Limits of Cross-Study Comparison​

TechniqueStagesTissue SourceSuccessKey AdvantageKey Limitation
Pedicled preputial tube[1][2][3]1Inner preputial skin (pedicled)40–75%Single-stage; carries own blood supplyHighest failure rate; diverticula; fistula
Two-stage BMG urethroplasty[4]2Buccal mucosa (free graft)80–90%Oral mucosa avoids genital skin and hair; LS may still affect the repairRequires 2 operations; 4–6 mo interval
Two-stage mesh graft[19]2Split-thickness skin graft80%Non-hair-bearing; ample tissueRequires 2 operations; graft contracture risk
Combined dorsal BMG + ventral flap[18]1BMG + penile skin flap64–79%Single-stage; avoids full tubularizationRequires both healthy oral mucosa and penile skin

These are noncomparative study estimates with different populations, follow-up and success definitions. They cannot rank procedures for an individual defect. A preputial spiral free graft augments a usable urethral plate; it is not an established single-stage tube substitute for complete circumferential tissue loss.[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 — the primary indication, where augmentation (onlay) is not possible because there is no native tissue to augment.[1][10]
  2. Severe spongiofibrosis with complete destruction of the urethral lumen — where the scarred urethral bed cannot support a free graft.[9]
  3. Proximal hypospadias with severe chordee requiring urethral plate transection — the classic Duckett indication.[7]
  4. Failed prior urethroplasty with loss of the urethral plate — particularly when oral mucosa donor sites are depleted or unsuitable.[16]
  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 — genital skin flaps and grafts should be avoided; AUA advises against genital skin for LS-related strictures; oral mucosa is the preferred graft.[23]
  2. Circumcised patients — insufficient preputial tissue for tubularization (though dorsal penile skin can sometimes be used as salvage).[16]
  3. Preserved urethral plate — if a usable plate exists, consider onlay augmentation 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​

  • Restenosis: determine site, length and degree of obliteration before choosing an endoscopic salvage or redo reconstruction. Repeated endoscopy is not a durable default for long recurrent penile disease.[1][2][23]
  • Diverticulum and postvoid pooling: assess for distal obstruction as well as inadequate tissue support. Wang's pediatric cohort found concurrent stricture in 13/41 diverticula; this is not an adult tube-specific rate.[12]
  • Fistula, skin loss and torsion: risks depend on skin quality, flap perfusion, tension and operative design. The Dubey trial's complications occurred after dorsal onlay skin flaps and should not be relabeled as tube-repair rates.[17]
  • Hair, stones and infection: avoid hair-bearing tissue for the lumen and investigate late obstructive or infectious symptoms.[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 — many resulting from prior tubularized urethroplasty or hypospadias repair:[24]

  • Most common presentations — recurrent UTI, urinary dribbling, incontinence, weak stream
  • 54.5% (12/22) underwent diverticulectomy and urethroplasty
  • 13.5% (3/22) required ileal conduit urinary diversion
  • 32% (7/22) managed nonoperatively with postvoid manual decompression
  • 91% diverticulum recurrence-free rate at mean 2.3 yr

Diverticula from tubularized repairs can present years to decades after the original surgery and may require complex secondary reconstruction.

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 (Moderate Recommendation; Grade C).
  • The guideline permits individualized single- or multistage repair; do not attribute a technique-specific preference to an inferred guideline statement.
  • Surgeons should use oral mucosa as the first choice when using grafts (Expert Opinion).
  • Genital skin should be avoided in LS-related strictures.

Contemporary practice​

The pedicled preputial tube urethroplasty has been largely supplanted by:

  1. Two-stage BMG urethroplasty — for circumferential penile urethral reconstruction (current standard).[4]
  2. Combined dorsal BMG + ventral onlay flap — selected single-stage circumferential replacement with a graft-supported dorsal wall and a vascularized flap floor.[18]
  3. Preputial spiral graft urethroplasty (Kulkarni / Bandini 2023–2025) — a selected augmentation option when a viable plate remains; its 90.4% success in a 114-patient cohort does not establish replacement of tubularized reconstruction.[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 staged procedures impose unacceptable logistical burdens[3]
  • Salvage of multiple failed urethroplasties — Soutis 2003 demonstrated 76% success using the Duckett island-flap technique in 21 patients with 3–13 prior failed repairs (in 4 patients 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. Originally described by Quartey 1983 for adult strictures and Duckett 1980 for hypospadias, it provides the advantage of vascularized, hairless tissue that can bridge long urethral defects in a single operation.[5][7] However, it carries significantly higher failure rates (40–58%) compared to onlay repairs (11–15%), with particular susceptibility to diverticulum, fistula and recurrent narrowing; exact risks vary by population and technique.[1][2][3] The fundamental problem: 100% of the urethral circumference depends on substitute tissue, with a long suture line under radial tension and no spongiosal support.[10] Greenwell and Mundy 1999 concluded that two-stage free graft repairs give better results than one-stage flap tubularization for circumferential penile urethral reconstruction — a principle that has driven the shift toward staged BMG urethroplasty as the current standard for obliterative strictures.[4] The technique remains valuable in specific scenarios (salvage cases, patients with unsuitable oral mucosa, resource-limited settings) but should be considered a second-line option when onlay augmentation or staged BMG reconstruction is feasible.[1][16][22]

Videos​

Pedicled Preputial Tube Urethroplasty
Operative technique

References​

  1. 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.

  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.

  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.

  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.

  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.

  20. Bandini M, Joshi P, Bafna S, et al. Establishing the role of single-stage preputial spiral graft urethroplasty for panurethral stricture. BJU Int. 2025. doi:10.1111/bju.16796.

  21. Kulkarni SB, Joshi PM, Basile G, Bandini M. Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique. World J Urol. 2023;41(9):2459-2463. doi:10.1007/s00345-023-04514-9.

  22. 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.

  23. 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.

  24. Cinman NM, McAninch JW, Glass AS, Zaid UB, Breyer BN. Acquired male urethral diverticula: presentation, diagnosis and management. J Urol. 2012;188(4):1204-8. doi:10.1016/j.juro.2012.06.036.