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Quartey Flap (Transverse Preputial / Distal Penile Cutaneous Island Flap)

Quartey flap vs Q-flap — distinct techniques. The Quartey flap (Quartey 1983) and the Q-flap (Morey / Tran / Zinman 2000) are related but not identical. The Quartey flap is the original 1983 transverse preputial / distal-penile island flap. The Q-flap is a 2000 modification that adds a ventral midline extension to a circumferential flap (creating the "Q" outline) to lengthen reach for panurethral strictures (mean 17 cm, range 15–24 cm). For the modification, see Q-Flap (Morey).

The Quartey flap is a single-stage, pedicled fasciocutaneous flap for urethral reconstruction, first described by John K. Quartey of Accra, Ghana in 1983.[1][2] It uses a transversely oriented island of distal penile or preputial skin supplied axially by the superficial external pudendal vessels. Its pedicle can be constructed so that the skin can reach anywhere from the external meatus to the prostatic urethra — one of the longest-reaching penile skin flaps available (up to 12–15 cm). In the original series, Quartey reported survival of all flaps with no permanent fistula.[1]

For the longitudinal precursor, see Orandi Flap. For the circular variant, see McAninch Transverse Circular Penile Skin Flap. For the Q-flap modification for panurethral strictures, see Q-Flap (Morey). For the broader anatomy and other penile flap variants, see Pedicled Penile / Preputial Skin Flap. For graft alternatives, see Buccal Mucosa Graft.

Historical Context and Significance​

Quartey's contribution was a critical bridge between the Orandi longitudinal flap (1968) and the McAninch circular flap (1993):[1][2][27]

  • Transverse orientation — by harvesting the skin island transversely (circumferentially) rather than longitudinally, Quartey dramatically increased available flap length: the circumference of the distal penis / prepuce provides up to 12–15 cm of tissue vs only 6–8 cm with the longitudinal Orandi flap.
  • Axial blood supply from the superficial external pudendal vessels — Quartey identified that the distal penile / preputial skin is supplied axially by the superficial external pudendal arteries (branches of the femoral artery), providing a reliable named-vessel pedicle rather than relying solely on the random-pattern subdermal plexus.
  • Hairless tissue — distal penile and preputial skin is relatively hairless, suitable for urethral reconstruction without intraurethral hair complications (though 3 fine hairs were noted in 2 of his original 10 patients).[1]
  • Versatility as patch or tube — the flap could be configured as either an onlay patch (augmentation) or tubularized (substitution).[1]
  • Long reach — the pedicle can be constructed so the flap reaches from the external meatus to the prostatic urethra — essentially the entire length of the male urethra.[1]

Quartey's place in the evolution of penile skin flaps​

SurgeonYearFlap TypeOrientationPedicleMax Length
Orandi[27]1968Longitudinal ventral penile skinLongitudinalDartos fascia6–8 cm
Quartey[1][2]1983Transverse preputial islandTransverseSuperficial external pudendal vessels12–15 cm
McAninch[6]1993Circular fasciocutaneousCircumferentialDartos vascular pedicle with fascial support15 cm
Srivastava[7]2012CircumpenileCircumferentialDartos fasciavariable

Joshi, Bandini, and Kulkarni 2022 described the dartos fascia — the practical pedicle conduit for the Quartey flap — as "the winner" among all pedicles in genitourinary reconstruction.[5]

Anatomy and Vascular Basis​

Superficial external pudendal artery (SEPA)​

The Quartey flap is based on the SEPA, the named axial vessel supplying the distal penile and preputial skin:[1][3]

  • Cadaveric study — found in 46/50 sides (92%); 45/46 arose from the femoral artery and one from profunda femoris. Origin was 0.8–8.5 cm below the inguinal ligament
  • Diameter — 1.2 to 3.8 mm at its origin (sufficient for a reliable axial pedicle)
  • Variants — single artery in 30%, duplicated in 46%, common trunk in 24%
  • Course — courses medially from the femoral triangle, crosses the spermatic cord, and enters the penile skin where it ramifies into the subdermal plexus of the dartos fascia
  • Preputial supply — the preputial skin receives additional blood supply from perforators of the dorsal penile artery, creating a dual blood supply to the distal penile / preputial skin.[4]

Dartos fascia as the pedicle conduit​

While Quartey described the flap as supplied by the superficial external pudendal vessels, the practical pedicle is the dartos fascia — containing the subdermal vascular plexus fed by the SEPA. The dartos serves as the conduit through which the SEPA branches reach the skin island.[1][5]

The McAninch circular flap also preserves the dartos vascular conduit. Historical references to Buck's fascia describe fascial support; they do not make the deep dorsal penile arteries the skin-flap pedicle.[6]

Surgical Technique​

Patient positioning and exposure​

  • Supine or lithotomy depending on stricture location
  • Penis degloved through a circumcoronal incision (uncircumcised patients) or a subcoronal / ventral midline incision
  • Strictured urethra identified

Flap design​

  • Skin island designed on the inner preputial skin (uncircumcised) or distal penile shaft skin (circumcised, more challenging)
  • Oriented transversely — perpendicular to the long axis of the penis
  • Width — typically 2–3 cm (sufficient for onlay; wider if tubularization is planned)
  • Length — determined by the circumference of the distal penis / prepuce; can extend up to the full circumference (12–15 cm)
  • The Morey Q-flap is a distinct extension of a circumferential skin island; the Quartey flap should not be relabeled as that modification.

Flap harvest​

  • Skin island incised circumferentially
  • Dissection proceeds in the plane between the skin and the dartos fascia on the outer surface of the flap, while preserving the dartos fascia attached to the deep surface of the skin island
  • The dartos pedicle is developed by dissecting it off the underlying Buck's fascia
  • Pedicle developed proximally toward the base of the penis, maintaining the axial blood supply from the superficial external pudendal vessels
  • Pedicle must be of sufficient length to allow the flap to reach the strictured segment without tension

Urethrotomy and stricture assessment​

  • Strictured urethra opened longitudinally (ventral or dorsal urethrotomy depending on planned configuration)
  • Stricture length and extent of spongiofibrosis assessed
  • Urethral plate quality evaluated to determine onlay vs tubularization

Flap transfer and configuration​

ConfigurationIndicationNotes
Ventral onlay (classic Quartey)Augmentation with intact dorsal plateFlap rotated and laid over ventral urethrotomy; skin surface faces lumen; sutured with 5-0 / 6-0 PDS / Vicryl[1]
Dorsal onlay (Tijani / Bhandari modification)Augmentation; urethra mobilized circumferentiallyFlap placed dorsally against corpora cavernosa; urethra rotated back over the flap. Less sacculation observed in a small comparison (0/19 vs 6/21; not proof of zero risk)[8][9]
Tubularized substitutionObliterative strictures with no urethral plateFlap tubularized around catheter to create neo-urethra. Significantly higher failure (40–58% recurrence) vs onlay (11–13%)[6][8]
Combined with dorsal BMGComplex strictures with damaged urethral plateBMG augments urethral plate dorsally while flap provides ventral coverage[12][13]

Closure and postoperative care​

  • Penile skin closed over the flap pedicle
  • Urethral catheter (16–18 Fr) placed
  • Catheter removal at 2–3 weeks after VCUG

Clinical Outcomes​

Quartey's original series​

StudynFollow-upSuccessKey Findings
Quartey 1983 (preliminary)[1]105 wk – 6 mosurvival of all flaps; no anastomotic stenosis; no permanent fistula1 residual stricture (incomplete excision); 3 fine hairs in 2 patients; mucocutaneous bridges in 4 (divided easily)
Quartey 1985 (expanded)[2]27since Aug 1981—Confirmed technique with vascularized island of distal penile / preputial skin

Subsequent series using Quartey or modifications​

StudynConfigurationSuccessFollow-upKey Findings
Bhandari 2001[9]40 (19 DO, 21 VO)Dorsal vs ventral onlayNo significant recurrence difference; VO count/percentage inconsistent in abstractMedian 27.5 moSacculation 29% VO vs 0% DO (p = 0.01); fistula in 1 VO patient
Tijani 2009 (Lagos)[8]26 (21 DO, 5 TF)Dorsal onlay vs tubularizedDO 100%; TF 40%mean 19 mo (DO out to 30 mo)Quartey modification in circumcised West African men; 1 skin necrosis, 1 fistula, 2 postvoid dribbling
Srivastava 2012 (TPIF DOF subset)[7]60 (transverse preputial DOF)Dorsal onlay90% at 1 yr; 85% at 3 yr40.1 moDOF superior to tubularized (75% at 3 yr)
Mathur 2014[10]58Preputial flap onlay81%42 moDiabetes (RR 5.21), smoking (RR 4.19) predict failure; preferred over BMG in regions with oral dyskeratosis
de la Rosette 1991[11]50Pedicled island (various)68%—20% fistula; 32% recurrence; worst outcomes with ≥3 prior urethrotomies

Dorsal vs. Ventral Onlay — The Critical Distinction​

Dorsal support may reduce sacculation. The principal comparisons are small observational cohorts, not definitive trials of flap orientation.

Bhandari 2001 — nonrandomized comparison of 40 patients:[9]

  • No significant recurrence difference. The abstract inconsistently reports three VO recurrences as 24% of 21; an exact VO rate cannot be confidently extracted
  • Pseudo-diverticulum / sacculation — VO 29% vs DO 0% (p = 0.01, highly significant)
  • Postvoid dribbling — present in all sacculation cases (VO group only)
  • Fistula — 1 case in VO group, 0 in DO group

The corpora cavernosa provide rigid structural support that prevents outward ballooning of the flap during voiding when placed dorsally — the same mechanical principle Barbagli described for dorsal-onlay BMG urethroplasty.

Tijani 2009 confirmed this in circumcised West African men: no recurrence among dorsal-onlay patients available at 30 months, versus 40% reported success with tubularization; the comparison involves different defects and only five tubularized cases, and cannot establish that dorsal placement eliminates dribbling.[8]

Srivastava 2012 validated the dorsal onlay approach in 60 TPIF patients (90% at 1 yr, 85% at 3 yr) and concluded that dorsal onlay flaps are less likely to lead to diverticula formation and postvoid dribbling vs tubularized flaps.[7]

Quartey Flap + BMG Combination​

For complex strictures with a damaged urethral plate, combining the Quartey flap with a dorsal BMG has emerged as a powerful single-stage strategy. This leverages the strengths of both tissues — BMG augments the urethral plate dorsally while the pedicled flap provides well-vascularized ventral coverage.[12][13]

Anadani 2025 — case report of a combined dorsal BMG + ventral onlay Q penile skin flap for a 5 cm recurrent stricture (failed prior urethroplasty with extra-anatomical bypass and diverticulum). Well-patent urethra at 3 months on RUG.[12]

Erickson, Breyer, McAninch 2012 — single-stage segmental urethral replacement using dorsal onlay BMG + ventral onlay fasciocutaneous flap in 14 men with long-segment strictures (mean 9.75 cm):[13]

  • Primary success 64% (9/14) at median 2.5 yr
  • Secondary success (including single endoscopic procedure) 79% (11/14)
  • Recurrences had longer strictures (12.8 vs 8.7 cm, p = 0.04)

Iselin and Webster 1999 — in 4 of 29 patients undergoing dorsal onlay graft urethroplasty, the procedure was combined with an Orandi flap because the stricture extended significantly into the penile urethra. Overall success 97% (28/29) at median 19 months.[14]

The AUA guideline permits combinations for selected multi-segment strictures, without endorsing a particular named combined operation: surgeons may reconstruct long multi-segment strictures with oral mucosal grafts, penile fasciocutaneous flaps, or a combination (Moderate Recommendation; Grade C).[24]

Quartey-Type Flap in Hypospadias Repair​

The transverse preputial island flap (TPIF) — based on Quartey's principles — has been extensively used in pediatric hypospadias repair. This represents the largest body of outcome data for the Quartey-type flap, though the clinical context differs from adult stricture disease.

StudynApplicationComplicationFistulaStrictureDiverticulumFollow-up
Wang 2019 (15-yr experience)[15]320Proximal hypospadias39.1%16.6%9.7%12.8%40.2 mo
Wang 2019 (staged TPIF)[16]102Proximal hypospadias (staged)14.7% (2nd stage)7.8%4.9%1.9%52.4 mo
Chen 2016 (staged TPIF vs Byars)[17]87 (42 TPIF, 45 Byars)Proximal hypospadias with severe chordeeTPIF 7.1% vs Byars 26.7% (p < 0.05)4.8% vs 23.2% (p < 0.05)2.4% vs 4.4% (NS)2.4% vs 0%—
Wang 2023 (3 techniques)[18]152Proximal hypospadiasStaged TPIF 11.1% vs TPIF + Duplay 40% vs Koyanagi 50% (p < 0.01)4.9% vs 21.8% (p = 0.01)———

Key findings:

  • Selected retrospective proximal-hypospadias cohorts reported lower complications after staged TPIF; treatment selection and surgeon effects limit generalization.[16][18]
  • In Wang 2023, defect length >4.55 cm was a data-derived univariate cutoff associated with complications, not a universally validated threshold.[18]
  • Diverticula and strictures are associated — 31.7% of patients with diverticula also had strictures.[15]
  • Late complications (>1 yr) occur in 20.8% of patients with complications, and 12.8% present after ≥5 yr — emphasizing long-term follow-up.[15]

Comparison with Other Techniques​

Quartey vs McAninch circular flap​

FeatureQuartey (Transverse Preputial)McAninch (Circular Fasciocutaneous)
Year1983[1]1993[6]
PedicleExternal-pudendal branches in dartosDartos vascular pedicle with fascial support
Max length12–15 cm15 cm
Requires prepuceTypically yes (best with intact prepuce)No (can use in circumcised)
Vascular principlePreserve superficial axial branches and subdermal plexusPreserve superficial axial branches and subdermal plexus
Technical complexityModerateMost complex
Long-term dataLimited (mostly intermediate-term series)Extensive (79% at 10 yr, Whitson 2008)[19]
Best indicationLong anterior strictures in uncircumcised patientsLong / complex anterior strictures regardless of circumcision status

Quartey vs BMG urethroplasty​

These trials compare different tissue transfers. Only Dubey tests a penile skin flap versus BMG. PeeBuSt and Alrefaey test free penile skin grafts, so their findings cannot establish flap outcomes. Nonsignificant differences do not prove equivalence:

RCTnComparisonSuccessKey signals
Dubey 2007[20]55DO penile skin flap vs DO BMG85.6% vs 89.9% (NS)Flap: 224 vs 162 min OR (p = 0.001); skin necrosis 21% vs 0%; penile torsion 7% vs 0%; PVD 34% vs 15% (p = 0.001); 65% vs 89% would recommend (p = 0.001)
Tyagi 2022 PeeBuSt[28]100 randomized; 95 analyzedPenile skin graft vs BMG42/47 vs 44/48 at 18 mo (p = 0.70)Powered for a large difference, not equivalence
Alrefaey 2025[29]98 randomized; 92 analyzedPenile skin graft vs BMG41/44 vs 47/48 at 12 mo (p = 0.346)Superiority design; important baseline stricture imbalances limit interpretation

Synthesis — Dubey found no significant patency difference, but more morbidity with flaps (skin necrosis, penile torsion, postvoid dribbling, longer OR time). The Quartey flap's enduring advantage is its pedicled blood supply — critical for scarred, poorly vascularized urethral beds where a free graft may not take.

Hussein 2011 — penile circular graft (n = 18) vs penile circular flap (n = 19) for long bulbo-penile strictures. OR time PCG 203 vs PCF 282 min (p = 0.000); skin necrosis 0% vs 16%; recurrence 27.7% vs 21% (NS) — reinforces the flap-vs-graft morbidity differential within the penile-skin family itself.[30]

Advantages​

  1. Exceptional length (12–15 cm) — transverse orientation provides significantly more tissue than the longitudinal Orandi flap (6–8 cm), approaching the reach of the McAninch circular flap.[1][2]
  2. Named-vessel axial pedicle — SEPA provides reliable, anatomically defined blood supply.[1][3]
  3. Hairless tissue — inner preputial skin is naturally hairless.[1]
  4. Versatility — onlay (patch) or tubularized (tube); reach from meatus to prostatic urethra.[1]
  5. Pedicled (carries own blood supply) — does not depend on the recipient bed for initial survival; critical in scarred, poorly vascularized urethral beds.[5][12]
  6. Combinable with BMG — can be combined with dorsal BMG for complex strictures with damaged urethral plates.[12][13]
  7. Moderate technical complexity — less demanding than the McAninch circular flap.[5]

Limitations​

  1. Requires intact prepuce (ideally) — optimized for uncircumcised patients with abundant preputial skin. In circumcised patients, available tissue is significantly reduced; alternative flaps (circumpenile / Srivastava, McAninch circular) may be preferred.[1][7]
  2. Contraindicated in lichen sclerosus — AUA guideline states genital skin flaps and grafts should be avoided in LS-related strictures due to very high long-term failure. Oral mucosa is the preferred substitute.[21][22][24]
  3. Sacculation with ventral placement — one small ventral-onlay cohort reported 6/21 cases of pseudo-diverticulum; potentially reduced by dorsal placement, without proof that risk is eliminated.[9]
  4. Tubularization has high failure rates — when used as a tubularized flap (for obliterative strictures), recurrence rates are 40–58%, significantly worse than onlay.[6][8]
  5. Hair-bearing skin risk — AUA Clinical Principle: surgeons should not use hair-bearing skin. While inner preputial skin is hairless, care must be taken not to incorporate hair-bearing penile shaft skin.[1][24]
  6. Declining use — like all penile skin flaps, the Quartey flap has been increasingly supplanted by BMG urethroplasty due to BMG's technical simplicity, lower morbidity, and higher patient satisfaction.[20][23]
  7. Limited long-term data — unlike the McAninch circular flap (which has 10-yr Kaplan-Meier data from UCSF), the Quartey flap lacks large, long-term outcome studies from a single institution.[19]

Preputial Spiral Graft — A Modern Evolution​

A notable recent development building on the Quartey concept is the preputial spiral graft urethroplasty (PSGU) described by Bandini, Joshi, Kulkarni 2023, 2025. This technique uses the prepuce as a free graft (not a pedicled flap) harvested in a spiral / helicoidal configuration to maximize length from a 5-cm-wide preputial skin strip, achieving grafts up to 20 cm.[25][26]

FeatureQuartey Flap (Pedicled)Preputial Spiral Graft (Free Graft)
Tissue typePedicled fasciocutaneous flapFree mucocutaneous graft
Blood supplyCarries own (SEPA / dartos pedicle)Depends on recipient bed (imbibition → neovascularization)
Max length12–15 cmup to 20 cm
Stricture length treatedvariablemedian 16 cm (panurethral)
Success rate81–100% (varies by series / configuration)90.4% at 16 mo (114 patients, 5 centers)
Requires prepuceYes (ideally)Yes (mandatory)
LS contraindicationYesAvoid genital skin in LS-related strictures
Key advantagePedicled blood supply for scarred bedsLongest single-graft reach; simpler harvest

The PSGU represents a conceptual evolution from the Quartey flap — same donor tissue (prepuce), but as a free graft rather than a pedicled flap, with a spiral harvest technique that maximizes length.[25][26]

Predictors of Failure​

PredictorRisk / Hazard RatioSource
Diabetes mellitusRR 5.21 (CI 2.31–64.68, p = 0.003)Mathur 2014[10]
SmokingRR 4.19 (CI 1.54–45.0, p = 0.01)Mathur 2014[10]
SmokingHR 4.0 (CI 1.2–12.9, p = 0.02)Whitson / McAninch 2008[19]
History of hypospadias repairHR 4.4 (CI 1.3–14.6, p = 0.01)Whitson / McAninch 2008[19]
Stricture length >70 mmRR 3.25Mathur 2014[10]
Panurethral strictureRR 2.73Mathur 2014[10]
Previous urethroplastyRR 2.4Mathur 2014[10]
Severe peri-urethral fibrosisRR 2.37Mathur 2014[10]
≥3 prior urethrotomieshighest recurrence proportionde la Rosette 1991[11]
Tubularized configuration40–58% failure vs 11–13% onlayMcAninch 1998 / Tijani 2009[6][8]

Current Role and Indications​

Ideal indications​

  1. Long anterior urethral strictures (>5 cm) in uncircumcised patients with abundant preputial skin — the flap's greatest advantage is its length and the quality of inner preputial tissue.[1][2]
  2. Strictures with a compromised urethral bed — where spongiofibrosis is severe and a free graft (BMG) may not take; the pedicled flap brings its own blood supply.[5][12]
  3. Failed prior urethroplasty — well-vascularized flap can overcome the scarred tissue bed.[12]
  4. Patients with limited or unsuitable oral mucosa — when BMG donor sites are depleted, or oral pathology (e.g., submucous fibrosis from gutkha / betel nut) precludes BMG harvest.[10]
  5. Combined with dorsal BMG — for complex strictures with damaged urethral plates requiring both dorsal augmentation and ventral coverage.[12][13]
  6. Resource-limited settings — no specialized graft material required; uses readily available penile skin.[8]

When to choose alternatives​

  • Circumcised patients — consider McAninch circular flap or Srivastava circumpenile flap.[6][7]
  • Lichen sclerosus — use oral mucosa exclusively; genital skin is contraindicated.[21][22][24]
  • Short bulbar strictures — consider anastomotic or graft-based options according to etiology and obliteration. Do not apply this rule to penile strictures, where excision may cause shortening or curvature.
  • Available oral mucosa with healthy graft bed — BMG urethroplasty is technically simpler and patient-preferred.[20]

Guideline Context​

The AUA Urethral Stricture Disease Guideline Amendment (2023):[24]

  • 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 for urethroplasty (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).

Key Takeaways​

The Quartey flap is the transverse-orientation founding technique that bridged the longitudinal Orandi (1968) and the circular McAninch (1993). Its key strengths are exceptional length (12–15 cm), named-vessel axial pedicle (SEPA via dartos fascia), and applicability to long anterior strictures in uncircumcised patients.[1][2] The Bhandari 2001 dorsal-vs-ventral data (29% vs 0% sacculation) and Tijani 2009 100%-DO-vs-40%-tubularized result support dorsal-onlay consideration but do not establish universal superiority.[8][9] While BMG urethroplasty has largely supplanted penile skin flaps as first-line substitution due to lower morbidity and higher patient satisfaction, the Quartey flap retains a critical role in complex strictures with scarred urethral beds, failed prior grafts, depleted oral donor sites, populations where oral mucosa is unsuitable (Mathur dyskeratosis populations), and combination techniques with dorsal BMG.[5][10][12][13][20] It is contraindicated in lichen sclerosus.[21][24]

References​

  1. 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.

  2. Quartey JK. One-stage penile / preputial island flap urethroplasty for urethral stricture. J Urol. 1985;134(3):474-5. doi:10.1016/s0022-5347(17)47244-2.

  3. La Falce OL, Ambrosio JD, Souza RR. The anatomy of the superficial external pudendal artery: a quantitative study. Clinics (Sao Paulo). 2006;61(5):441-4. doi:10.1590/s1807-59322006000500011.

  4. Lohasammakul S, Turbpaiboon C, Ratanalekha R, Ungprasert P, Yodrabum N. Inferior external pudendal artery anastomosis: additional approach to prevent skin necrosis in replanted penis. Plast Reconstr Surg. 2018;142(4):535e-540e. doi:10.1097/PRS.0000000000004818.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. Anadani A, Obaidin A, Badawi B, Lutfi MY. One-stage urethroplasty using a combination of buccal mucosa graft and Q penile skin flap for a complicated urethral stricture: a challenging case report. Medicine. 2025;104(12):e41888. doi:10.1097/MD.0000000000041888.

  13. 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.

  14. Iselin CE, Webster GD. Dorsal onlay graft urethroplasty for repair of bulbar urethral stricture. J Urol. 1999;161(3):815-8.

  15. 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.

  16. Wang C, Song H, Zhang W. Staged transverse preputial island flap urethroplasty for proximal hypospadias: a single-center experience. Pediatr Surg Int. 2019;35(7):823-827. doi:10.1007/s00383-019-04480-7.

  17. Chen C, Yang TQ, Chen JB, Sun N, Zhang WP. The effect of staged transverse preputial island flap urethroplasty for proximal hypospadias with severe chordee. J Urol. 2016;196(5):1536-1540. doi:10.1016/j.juro.2016.05.098.

  18. Wang YS, Song HC, Liu P, Fang YW, Zhang WP. Comparison of outcomes in three surgical techniques for proximal hypospadias: staged transverse preputial island flap urethroplasty versus single-stage repairs. Asian J Androl. 2023;25(5):616-620. doi:10.4103/aja2022106.

  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. 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.

  21. 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.

  22. 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.

  23. 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.

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