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Glanuloplasty With Flaps

Glanuloplasty with flaps covers reconstructive techniques that use pedicled tissue flaps rather than free skin grafts to create a neoglans after partial penectomy, glansectomy, or traumatic glans loss. The four principal flap-based approaches are the inverted urethral flap (IUF, Belinky / Chavarriaga), distal urethral reconstruction (Gulino), scrotal flap (Mazza / Cheliz), and rectus abdominis myofascial flap (Shaeer).[1][2][3][4]

For STSG-based neoglans creation after invasive disease, see Glansectomy With STSG. For superficial / organ-sparing disease, see Glans Resurfacing. For the broader decision framework, see Penile Reconstruction.

Overview​

TechniqueTissue sourceStagesBest suited forKey advantageKey limitation
Inverted urethral flap (IUF)Distal urethra (inverted)1Partial penectomy with adequate urethral lengthMoist mucosal surface; excellent sensation; no donor siteRequires sufficient urethral length; ~ 10% ventral curvature
Distal urethral reconstruction (Gulino)Distal urethra (everted)1Glansectomy or distal shaft amputationRapid; 100% thermal / tactile sensationSmall series; limited long-term data
Scrotal flap (Mazza / Cheliz)Pedicled anterior scrotal skin2Partial penectomy with significant skin loss; stump retractionRobust vascularized tissue; prevents retractionTwo-stage; hair-bearing skin → depilation in ~ 18%
Rectus abdominis myofascial flap (Shaeer)Infraumbilical rectus muscle1Traumatic glans amputation; complex reconstructionMost glans-like consistency and colorAbdominal donor morbidity; technically complex

1. Inverted Urethral Flap (IUF) — Belinky / Chavarriaga​

The most extensively studied flap-based glanuloplasty (largest cohort: Chavarriaga n = 74, median follow-up 72 months).[5] For the dedicated in-depth atlas page covering full anatomical basis, step-by-step technique, all published series, oncologic-safety analysis, complete PROM data, psychosexual context, and surveillance, see Inverted Urethral Flap (IUF) Glanuloplasty. Summary below.

Principle​

After partial penectomy a segment of distal urethra longer than needed for voiding is preserved and inverted over the closed corporal tips, providing a moist mucosal neoglans that mimics native tissue.[1][5]

Surgical technique​

  1. Partial penectomy with frozen-section confirmation of negative margins at the corpora and urethral stump
  2. Urethral preservation — transect the urethra 2–3 cm distal to the corporal transection line; preserve sufficient length for the flap without tension
  3. Corporal closure with absorbable suture
  4. Urethral flap creation — invert the preserved distal urethral segment over the closed corporal tips with mucosa facing outward
  5. Neoglans shaping — suture the inverted flap circumferentially to the shaft skin at the corporal-transection level, creating a corona-like ridge
  6. Neomeatus fashioned at the tip of the neoglans
  7. Urethral catheter 7–10 days

Oncologic outcomes — Chavarriaga 2022 (n = 74, median follow-up 72 mo)[5]​

OutcomeResult
6-year overall survival86.5%
6-year RFS90.5%
6-year PFS85.1%
ILND performed39.2% (29 / 74)
DSNB performed83.8% (62 / 74)

Functional outcomes — Chavarriaga[5]​

DomainResult
Mean EQ-5D-3L-VAS global health84.6 ± 10.4
Mean IIEF-517.3 ± 7 (mild-moderate ED)
Mean ICIQ-MLUTS1.7 ± 3.2 (minimal voiding symptoms)

Original Belinky series (n = 10)[1]​

  • 0% flap necrosis; 0% neomeatal stenosis
  • 10% local recurrence (1 / 10); 10% ventral penile curvature (without penetration difficulty)

Advantages​

  • Single-stage with the partial penectomy
  • No separate donor site
  • Mucosal surface mimics native glans
  • Excellent long-term oncologic safety (6-y RFS 90.5%)
  • Minimal voiding symptoms

Limitations​

  • Requires sufficient urethral length beyond the corporal transection
  • ~ 10% ventral curvature from differential tissue elasticity
  • Theoretical oncologic concern with preserving a longer urethral stump (not borne out in the Chavarriaga data)

2. Distal Urethral Reconstruction — Gulino​

Closely related but distinct technique (n = 14, mean follow-up 13 mo).[3] For the dedicated in-depth atlas page covering full anatomical basis, the eversion-vs-inversion distinction, step-by-step technique, all PROMs including 100% sensation preservation, comparison tables, psychosexual context, and future directions, see Gulino Everted Urethral Flap Glanuloplasty. Summary below.

Technique​

  1. After glansectomy (8) or distal shaft amputation (6), preserve the distal urethra
  2. Evert (rather than invert) the urethral tissue and sculpt it over the corporal tips
  3. Mucosal surface faces outward → moist, sensitive neoglans

Functional outcomes​

DomainResult
Thermal + tactile sensation100% (14 / 14)
Rigid erections (spontaneous / induced)71% (10 / 14)
IIEF ejaculation domain changeNot significant
IIEF orgasm domain changeNot significant
Local recurrence0%
Penile retraction0%

100% sensation preservation reflects the rich sensory innervation of the urethral mucosa. Ejaculation and orgasm IIEF domains were preserved unlike STSG-based reconstructions.

3. Scrotal Flap Glanuloplasty — Mazza / Cheliz​

Two-stage pedicled scrotal flap (n = 34, mean follow-up 73.2 months — longest of any glanuloplasty series).[2] For the dedicated in-depth atlas page covering full anatomical basis, the two-stage technique with pedicle phase, all PROMs, hair-depilation protocols, comparison with modern single-stage / sensate scrotal-flap modifications, and psychosexual context, see Scrotal Flap Glanuloplasty (Mazza / Cheliz). Summary below.

Surgical technique — two-stage​

Stage 1:

  1. After partial penectomy, design a pedicled scrotal flap from the anterior scrotum, based on the anterior scrotal artery[2][6]
  2. Transfer the distal end of the flap to the penile stump
  3. Suture the urethral end through a hole created in the scrotal flap → establishes the neomeatus
  4. Suture flap borders to the adjacent tunica albuginea, securing the neoglans
  5. Pedicle remains attached to the scrotum for the initial healing phase

Stage 2 (4–6 weeks later):

  1. Divide the flap pedicle, completing separation from the scrotum
  2. Trim the pedicle stump and close

Outcomes (n = 34, mean follow-up 73.2 mo)[2]​

OutcomeResult
Normal-appearing penisAll patients
Unobstructed urinary flowAll patients
Sexual potency preserved20.5% (7 / 34)
Definitive depilation required17.6% (6 / 34)
Partial flap necrosis5.8% (2 / 34, required grafting)
Meatal stenosis2.9% (1 / 34, minor procedure)

Advantages​

  • Robust well-vascularized tissue (anterior scrotal artery)
  • Prevents penile stump retraction into the scrotum
  • Adequate bulk for a natural-appearing neoglans
  • Longest follow-up of any glanuloplasty technique (73 mo)
  • Scrotal skin elasticity and thickness similar to penile shaft

Limitations​

  • Two-stage — second operation 4–6 wk later
  • Hair-bearing donor — depilation in ~ 18%
  • Lower sexual-potency preservation (20.5%) — likely reflects more extensive penectomies in this cohort rather than the flap itself
  • Partial flap necrosis ~ 6%

For penile shaft skin coverage rather than glanuloplasty:

  • Zhao n = 18, 2.3-y follow-up — 100% sensation recovery, 83% satisfactory intercourse[6]
  • McLaughlin n = 8 bipedicled — all satisfactory, only minor complications[8]
  • Fakin n = 43 bipedicled anterior scrotal for siliconoma — satisfaction 4.37 / 5, all patients with postoperative erection and intercourse[9]

See Bipedicled Anterior Scrotal Flap (Fakin) and related shaft-flap pages for these applications.

4. Rectus Abdominis Myofascial Flap Neoglans — Shaeer​

Novel single-case-report technique for traumatic glans amputation.[4] For the dedicated in-depth atlas page covering DIEA pedicle anatomy, the myofascial-vs-myocutaneous distinction, full operative technique with corona-by-tucking and urethral elongation, comparison with other rectus-abdominis penile applications, phalloplasty integration, and detailed limitations, see Rectus Abdominis Myofascial Neoglans (Shaeer). Summary below.

Technique​

  1. Harvest 12 × 4 cm infraumbilical rectus abdominis muscle as a pedicled flap on the inferior epigastric vessels via paramedian incision
  2. Partially deglove the penis through a circumferential incision 1 cm below the summit
  3. Use the distal penile skin to elongate the urethra so the meatus sits at the neoglans tip
  4. Reflect and tunnel the flap subcutaneously beneath the mons veneris and alongside the penis to emerge distal to the penile summit
  5. Sculpt the flap into glans shape and secure around the neourethra
  6. Create a corona by tucking the proximal edge of the flap to its undersurface

Outcomes (6-month follow-up, n = 1)[4]​

  • Neoglans with similar consistency, color, and shape to the native glans
  • Functional urethral meatus at the tip
  • Satisfactory cosmetic result

Advantages​

  • Most natural glans-like consistency and color of any technique (muscle mimics spongy texture)
  • Single-stage
  • Can be combined with phalloplasty for total penile reconstruction[10][11]

Limitations​

  • Abdominal donor morbidity — abdominal wall weakness / bulging / hernia (up to 26% in other VRAM contexts)[10][12]
  • More technically complex than urethral / scrotal options
  • Single case report — no long-term oncologic or functional data

Comparative Analysis​

ParameterIUF (Belinky / Chavarriaga)GulinoScrotal (Mazza / Cheliz)Rectus (Shaeer)
Largest series (n)7414341 case
Longest follow-up72 mo median13 mo73.2 mo mean6 mo
Stages1121
Donor siteNone (autologous urethra)None (autologous urethra)ScrotumAbdomen
Sensation preservationn/r (good)100% thermal / tactilen/rn/r
Erectile functionIIEF-5 17.371% rigid erections20.5% potencyn/r
Flap necrosis0%n/r5.8%0% (n = 1)
Meatal stenosis0%n/r2.9%0% (n = 1)
Depilation neededNoNo17.6%No
Penile curvature~ 10% (ventral)0%n/rn/r
Local recurrence0–10%0%n/rn/a (trauma)
6-year OS86.5%n/rn/rn/a
6-year RFS90.5%n/rn/rn/a
Glans-like appearanceGood (mucosal)Good (mucosal)AcceptableBest (muscle / spongy mimic)

Comparison With STSG-Based Neoglans​

FeatureFlap-based (IUF / Gulino / scrotal / rectus)STSG neoglans
Sensation100% thermal / tactile (urethral flap)83.7% (range 63.6–91.2%) (Pang SR)[13]
Donor siteNone (urethral) or scrotum / abdomenThigh
Tissue qualityMucosal flap = moist; rectus = spongy / muscleKeratinized skin
Sexual functionIUF mean IIEF-5 17.391.1% preserved erection (Pang SR)
Evidence baseSmaller cohorts (largest n = 74 IUF)Largest evidence (327 procedures across 14 studies in Pang SR) — referenced in NCCN / EAU-ASCO

STSG remains the most standardized neoglans reconstruction; flaps are selected for specific advantages (mucosal surface, stump retraction prevention, traumatic-loss complexity).[14][13][15]

Guideline Context​

Neither NCCN nor EAU-ASCO 2023 mandates a specific reconstructive technique for neoglans creation:[14][15]

  • NCCN — glansectomy is "followed in certain instances with an STSG or FTSG to create a neoglans"
  • EAU-ASCO — strong recommendation for organ-sparing surgery with reconstructive techniques but no specific flap or graft type

Choice is left to surgeon expertise and patient anatomy.

Postoperative Surveillance​

Regardless of flap technique used, surveillance after oncologic reconstruction:[5][15]

  • Clinical examination every 3 months × 2 years, then every 6 months × years 3–5
  • Patient self-examination education
  • Biopsy of any suspicious lesion
  • Salvage organ-sparing surgery for small recurrences not involving the corpora cavernosa

Key Takeaways​

  • IUF (Chavarriaga n = 74) is the largest and best-validated flap-based glanuloplasty — 6-year OS 86.5%, RFS 90.5%, IIEF-5 17.3, 0% flap necrosis / neomeatal stenosis
  • Gulino everted-urethral variant preserves 100% thermal and tactile sensation — rare among reconstructive options
  • Scrotal flap (Mazza / Cheliz) has the longest follow-up (73 mo) but is two-stage and ~ 18% of patients need depilation
  • Rectus abdominis myofascial flap (Shaeer) offers the most natural glans-like consistency / color but carries abdominal-wall morbidity and is supported only by a single case report
  • STSG remains the most widely used and best-evidenced neoglans technique; flaps are reserved for specific advantages (mucosal surface, stump retraction, complex / traumatic loss)
  • Sensation is the primary functional advantage of urethral-flap variants over STSG (100% vs 83.7%)

Cross-references​

References​

1. 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

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

3. 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

4. Shaeer O, El-Sebaie A. "Construction of Neoglans Penis: A New Sculpturing Technique From Rectus Abdominis Myofascial Flap." J Sex Med. 2005;2(2):259–65. doi:10.1111/j.1743-6109.2005.20237.x

5. 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

6. 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

7. Kristinsson S, Johnson M, Ralph D. "Review of Penile Reconstructive Techniques." Int J Impot Res. 2021;33(3):243–250. doi:10.1038/s41443-020-0246-4

8. 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

9. 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

10. Küntscher MV, Mansouri S, Noack N, Hartmann B. "Versatility of Vertical Rectus Abdominis Musculocutaneous Flaps." Microsurgery. 2006;26(5):363–9. doi:10.1002/micr.20253

11. Santi P, Berrino P, Canavese G, et al. "Immediate Reconstruction of the Penis Using an Inferiorly Based Rectus Abdominis Myocutaneous Flap." Plast Reconstr Surg. 1988;81(6):961–4. doi:10.1097/00006534-198806000-00026

12. Combs PD, Sousa JD, Louie O, et al. "Comparison of Vertical and Oblique Rectus Abdominis Myocutaneous Flaps for Pelvic, Perineal, and Groin Reconstruction." Plast Reconstr Surg. 2014;134(2):315–323. doi:10.1097/PRS.0000000000000324

13. 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

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

15. 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