Distal Urethral Reconstruction Glanuloplasty (Gulino Technique)
The Gulino technique is a pioneering urethral-flap-based neoglans reconstruction first described by Gulino, Sasso, Falabella, and Bassi (2007), using the distal urethral segment everted over the corporal tips to create a sensate mucosal neoglans after glansectomy or distal shaft amputation. Its landmark result is 100% preservation of thermal and tactile sensation — the best sensory outcome reported for any neoglans reconstruction.[1]
For the related inversion variant that has the largest evidence base, see Inverted Urethral Flap (IUF) Glanuloplasty (Belinky / Chavarriaga). For the comparative overview of all four flap-based glanuloplasty options (IUF, Gulino, scrotal, rectus), see Glanuloplasty With Flaps. For the STSG-based standard, see Glansectomy With STSG. Decision framework: Penile Reconstruction.
Historical Context and Innovation
Before 2007 no satisfactory technique replaced both anatomy and function of the glans after radical surgery for penile carcinoma. Existing STSG reconstruction recreated cosmesis but used keratinized skin that differed fundamentally from native mucosal glans epithelium — reduced sensation and a dry surface.[1][2]
Gulino recognized that the distal penile urethra — mucosal, richly innervated, independently vascularized by the spongiosal supply — was the ideal autologous neoglans donor. The technique was described as "innovative, easy and rapid" with "appreciable functional and esthetic results."
This inspired the Belinky 2011 inverted urethral flap and the Chavarriaga 2022 n = 74 cohort — same fundamental principle (distal urethral mucosa over corporal tips), but inversion rather than eversion.[3][4]
Anatomical Basis
Vascular supply
- Urethral / bulbar artery (internal pudendal branch) supplies the corpus spongiosum and anastomoses with the dorsal artery at the glans — robust independent flap supply[5][6]
- Dual proximal + distal urethral supply enhances flap viability
- 6–10 cavernospongious arterial anastomoses per specimen provide collateral flow[7][8]
- Dorsal arteries principally perfuse glans and spongiosum with perforators to the distal corpora (4 / 5 specimens)
Neural supply
- Urethral mucosa is richly innervated with thermal and tactile receptors — the basis of the 100% sensation preservation[1][6]
- Dorsal nerves (somatic) lie in Buck's fascia (absent at 12 o'clock); perineal nerves to ventral skin / frenulum; cavernosal nerves (autonomic) for erection
Tissue properties
- Non-keratinized mucosa — closely mimics native glans epithelium, unlike STSG
- Buck's fascia envelops corpora + spongiosum, providing structural support
Indications
| Indication (Gulino 2007) | Cohort |
|---|---|
| Simple glansectomy for penile SCC confined to the glans | 8 / 14 |
| Amputation of the distal third of the shaft for more extensive disease | 6 / 14 |
Applicable when:
- Sufficient distal urethral length can be preserved beyond the corporal transection
- Urethra not involved by tumor (frozen-section confirmed)
- Patient desires functional + cosmetic reconstruction
Surgical Technique
Eversion vs inversion — the key distinction
| Feature | Gulino (eversion) | Belinky / Chavarriaga (inversion) |
|---|---|---|
| Manipulation | Urethral segment rolled outward over corporal tips (like rolling back a sleeve) | Urethral segment folded back proximally over corporal tips |
| Mucosal surface orientation | Outward (same) | Outward (same) |
| Tissue distribution | Symmetric over corporal tips | Differential ventral/dorsal elasticity |
| Resulting ventral curvature | 0% | ~ 10% (Belinky) |
Step-by-step (Gulino)[1]
- Tumor resection — simple glansectomy (over Buck's, preserving corporal tips + distal urethra) or distal shaft amputation; preserve urethra longer than the corporal transection
- Frozen-section analysis — corporal bed and urethral stump margins; proceed only if all negative (per NCCN / EAU-ASCO principles)[9][10]
- Corporal closure — interrupted absorbable suture to the tunica albuginea; smooth rounded surface
- Urethral flap eversion — preserved distal urethral segment, still on spongiosal pedicle, rolled outward over the closed corporal tips:
- Mucosal (luminal) surface outward — the external neoglans surface
- Serosal / adventitial surface inward against corpora
- Spongiosal tissue provides bulk and vascular supply
- Neoglans shaping — sculpt to native-glans contour; suture circumferentially to penile shaft skin at the corporal-transection level → corona-like ridge
- Neomeatus creation — opening at the tip; evert and suture meatal edges to prevent stenosis; directed urinary stream
- Foley catheter through the neomeatus for the postoperative period
Outcomes — Gulino 2007 (n = 14)[1]
Demographics
| Parameter | Value |
|---|---|
| n | 14 |
| Mean age | 54 y |
| Histology | SCC (all) |
| Procedure | Simple glansectomy 8, distal shaft amputation 6 |
| Mean follow-up | 13 months |
Functional outcomes
| Outcome | Result | Details |
|---|---|---|
| Thermal sensation | 100% (14 / 14) | Subjective and objective thermal epicritic sensibility in the neoglans area |
| Tactile sensation | 100% (14 / 14) | Subjective and objective tactile epicritic sensibility in the neoglans area |
| Rigid erections | 71% (10 / 14) | Spontaneous and / or induced |
| IIEF ejaculation domain | No significant change | Pre vs post |
| IIEF orgasm domain | No significant change | Pre vs post |
| Patient satisfaction | "Appreciable" | Functional and esthetic |
| Partner satisfaction | Evaluated | Included in assessment |
Oncologic outcomes
| Outcome | Result |
|---|---|
| Local recurrence | 0% (0 / 14) |
| Penile retraction | 0% (0 / 14) |
| Meatal stenosis | 0% |
| Flap necrosis | 0% |
| Ventral curvature | 0% |
Key Findings
100% sensation preservation — the standout result
The best sensory outcome reported for any neoglans reconstruction:
| Technique | Sensation preservation | n |
|---|---|---|
| Gulino (urethral eversion) | 100% | 14 |
| Glansectomy + STSG (Pang SR) | 83.7% (63.6–91.2%) | 327 |
| Glansectomy + STSG (Falcone 2022) | 91.2% | 34 |
| Partial penectomy without reconstruction | Variable, often absent | — |
Attributed to the rich sensory innervation of the urethral mucosa itself — unlike STSG which requires reinnervation of a denervated graft from the wound bed (incomplete and variable). The urethral flap retains native sensory nerve endings in continuity with the spongiosal pedicle.[1][12][16][17]
Preserved ejaculation and orgasm — unique among reconstruction techniques
IIEF ejaculation and orgasm domain scores did not significantly change post-operatively, contrasting with broader partial-penectomy literature:[1][17][18][19]
- Whyte SR — partial penectomy generally decreases all IIEF domains including orgasm
- Kieffer (n = 90) — significantly more problems with orgasm (effect size 0.54, p = 0.031) vs penile-sparing surgery
- Falcone 2024 (n = 99) — IIEF-15 fell after glansectomy (− 12.955, p = 0.002) and WLE (− 14.1, p = 0.025)
The preservation may reflect intact urethral mucosal sensory pathways contributing to the ejaculatory reflex and orgasmic sensation.
Zero local recurrence (13-month follow-up)
Consistent with the oncologic safety of organ-sparing surgery when negative margins are confirmed by frozen section. Comparative data:[1][20][10][4]
- Parnham (STSG, n = 177): 9.3% LR at median 41.4 mo
- Chavarriaga IUF (n = 74): 6-y RFS 90.5%
- EAU-ASCO SR: cumulative 5-y RFR of 82% for organ-sparing
Zero penile retraction and zero ventral curvature
Eversion appears to distribute urethral tissue symmetrically over the corporal tips, whereas inversion creates differential ventral / dorsal elasticity that can produce ventral curvature (10% in Belinky).[1][3]
Gulino vs Belinky / Chavarriaga — Side-by-Side
| Parameter | Gulino (eversion) | Belinky / Chavarriaga (inversion) |
|---|---|---|
| Year described | 2007 | 2011 / 2022 |
| Flap manipulation | Eversion | Inversion |
| Primary indication | Glansectomy or distal shaft amputation | Partial penectomy |
| Urethral length preserved | Not specified (sufficient for eversion) | 2–3 cm beyond corporal transection |
| Largest cohort | 14 | 74 |
| Longest follow-up | 13 mo (mean) | 72 mo (median) |
| Sensation | 100% thermal + tactile | n/r (good) |
| Erectile function | 71% rigid erections | IIEF-5 17.3 (mild-moderate ED) |
| Ejaculation / orgasm | No significant IIEF change | n/r |
| Meatal stenosis | 0% | n/r (implied 0%) |
| Flap necrosis | 0% | 0% |
| Local recurrence | 0% (13 mo) | 9.5% (6-y RFS 90.5%) |
| Ventral curvature | 0% | 10% (Belinky) |
| Penile retraction | 0% | n/r |
Gulino advantages: 0% ventral curvature; documented 100% sensation; documented IIEF ejaculation / orgasm preservation. Belinky / Chavarriaga advantages: vastly larger evidence base, validated long-term oncologic and functional outcomes.
Comparison With STSG-Based Neoglans
| Parameter | Gulino | STSG SR (Pang) | STSG (Parnham) |
|---|---|---|---|
| n | 14 | 327 | 177 |
| Follow-up | 13 mo | 40.7 mo | 41.4 mo |
| Tissue type | Mucosal (urethral) | Keratinized skin | Keratinized skin |
| Donor site | None (autologous urethra) | Thigh | Thigh |
| Stages | 1 | 1 | 1 |
| Sensation | 100% | 83.7% (63.6–91.2%) | n/r |
| Erectile function | 71% rigid | 91.1% (50–100%) | n/r |
| Ejaculation / orgasm | No significant change | n/r specifically | n/r |
| Meatal stenosis | 0% | 8.1% (0–14.3%) | 9% requiring intervention |
| Graft / flap loss | 0% | 6.1% (0–17.6%) | 9% requiring intervention |
| Local recurrence | 0% (13 mo) | 9.1% (0–25%) | 9.3% |
| Cosmetic satisfaction | "Appreciable" | 86.3% (68.2–100%) | n/r |
| Standing voiding | n/r specifically | 75.6% (66.7–100%) | n/r |
Gulino shows superior sensation (100% vs 83.7%) and zero meatal stenosis (0% vs 8.1%). STSG retains a vastly larger evidence base, longer follow-up, and is the only reconstruction explicitly named in NCCN guidelines.
Comparison With Other Organ-Sparing Approaches (Falcone 2024)[19]
| Parameter | TGR (n = 22) | WLE (n = 29) | Glansectomy (n = 48) | Gulino (n = 14) |
|---|---|---|---|---|
| IIEF-15 change (0–12 mo) | − 3.08 (NS, p = 1.0) | − 14.1 (p = 0.025) | − 12.96 (p = 0.002) | No significant change (ejaculation / orgasm) |
| Overall satisfaction | 86.36% (all combined) | — | — | "Appreciable" |
| Negative voiding impact | 18.18% (all combined) | — | — | 0% (implied) |
Gulino's preservation of IIEF ejaculation / orgasm is comparable to the non-significant decline seen with TGR, and superior to glansectomy and WLE.
Guideline Context
Neither NCCN nor EAU-ASCO mention Gulino or any urethral-flap reconstruction by name, but the technique aligns with their principles:[9][10]
- NCCN — neoglans creation with STSG / FTSG "in certain instances" after glansectomy; mandatory frozen-section margins
- EAU-ASCO — strong recommendation for organ-sparing surgery with reconstruction for confined disease (PeIN, Ta, T1–T2); frozen section in cases of doubt (weak)
- EAU-ASCO notes sexual and erectile functions vary; penile-preserving surgery generally preserves erection but glans sensation and orgasm can be affected
Psychosexual Considerations
The Gulino technique addresses several documented psychosexual concerns:[1][18][21][22]
- Body image — Romero 2005: 50% of sexually abstinent post-partial-penectomy patients cited shame from absent glans as the main reason for not resuming intercourse; Gulino creates a natural-appearing neoglans
- Orgasm — Kieffer 2014 effect size 0.54 worse with (partial) penectomy vs penile-sparing; Gulino's preserved IIEF orgasm domain is clinically meaningful
- Overall QoL — Roumieux 2025 narrative review emphasized organ-sparing surgery preserves sexual function but more invasive treatment compounds declines; rigorous prospective PROMs needed
- Multidisciplinary support — Torres Irizarry 2024: individualized sexual therapy, support groups, family counseling are essential regardless of surgical technique
Advantages
- 100% sensation preservation — best of any neoglans reconstruction
- Preserved ejaculation and orgasm — IIEF domains unchanged
- Zero meatal stenosis — vs 8.1% with STSG
- Zero flap necrosis, zero local recurrence (13 mo), zero penile retraction, zero ventral curvature — uniquely among urethral-flap techniques
- Single-stage — performed simultaneously with tumor resection
- No separate donor site — eliminates thigh / oral donor morbidity
- Moist mucosal surface — biologically mimics native glans
- "Easy and rapid" by authors' description
Limitations
- Small sample size (n = 14) — single published series
- Short follow-up (mean 13 mo) — insufficient for definitive oncologic conclusions
- Single-center single-surgeon — no external validation
- No validated QoL instruments — satisfaction qualitative ("appreciable")
- No long-term oncologic data — 0% LR at 13 mo cannot compare to 9.1% at 40.7 mo in Pang SR
- No standardized cosmetic-satisfaction data
- Not specifically referenced in NCCN / EAU-ASCO
- Lower rigid erection rate (71%) than STSG SR preserved erectile function (91.1%) — may reflect inclusion of distal-shaft-amputation patients (6 / 14) undergoing more extensive surgery
- No direct comparison with the Belinky / Chavarriaga inversion technique
- Requires sufficient urethral length — not feasible for proximal amputations or urethra-involving tumors
Future Directions
- Larger multicenter validation with standardized PROMs (IIEF-15, IPSS, EQ-5D, EORTC QLQ-C30)
- Long-term oncologic follow-up (≥ 5 y) confirming the safety of preserving longer urethral stumps
- Direct prospective or matched comparison of eversion (Gulino) vs inversion (Belinky / Chavarriaga)
- Histological characterization of everted urethral mucosa over time — keratinization, metaplasia, or retention of native mucosal character
- Objective neurophysiological assessment (somatosensory evoked potentials, biothesiometry) to quantify the sensory advantage over STSG
- Hybrid approaches — BMG meatoplasty + urethral flap for neoglans
Key Takeaways
- The pioneering urethral-flap neoglans technique (2007) — predates and inspired the Belinky / Chavarriaga IUF
- Eversion (not inversion) distinguishes the Gulino technique — produces 0% ventral curvature vs 10% with inversion
- 100% thermal and tactile sensation preservation — best documented sensory outcome of any neoglans reconstruction; attributed to intact urethral mucosal innervation on the spongiosal pedicle
- No change in IIEF ejaculation / orgasm domains — unique among partial-penectomy reconstructive techniques
- Zero meatal stenosis, zero flap necrosis, zero local recurrence (13 mo), zero penile retraction
- Small single-center series (n = 14, 13-mo follow-up) — limits definitive long-term oncologic conclusions; the Belinky / Chavarriaga IUF remains the larger-evidence sister technique
Cross-references
- Inverted Urethral Flap (IUF) Glanuloplasty — sister inversion technique with the largest evidence base
- Glanuloplasty With Flaps — comparative overview of all four flap-based options
- Glansectomy With STSG — graft-based standard
- Glans Resurfacing — superficial-disease organ-sparing alternative
- Penile Reconstruction — full decision framework
- Penile Skin Grafting
- Penile Replantation — for traumatic-amputation context
References
1. 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
2. Palminteri E, Berdondini E, Lazzeri M, Mirri F, Barbagli G. "Resurfacing and Reconstruction of the Glans Penis." Eur Urol. 2007;52(3):893–8. doi:10.1016/j.eururo.2007.01.047
3. 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
4. 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
5. Lee JY, Spratt DE, Liss AL, McLaughlin PW. "Vessel-Sparing Radiation and Functional Anatomy-Based Preservation for Erectile Function After Prostate Radiotherapy." Lancet Oncol. 2016;17(5):e198–208. doi:10.1016/S1470-2045(16)00063-2
6. Yiee JH, Baskin LS. "Penile Embryology and Anatomy." ScientificWorldJournal. 2010;10:1174–9. doi:10.1100/tsw.2010.112
7. Droupy S, Giuliano F, Jardin A, Benôit G. "Cavernospongious Shunts: Anatomical Study of Intrapenile Vascular Pathways." Eur Urol. 1999;36(2):123–8. doi:10.1159/000067983
8. Diallo D, Zaitouna M, Alsaid B, et al. "What Is the Origin of the Arterial Vascularization of the Corpora Cavernosa? A Computer-Assisted Anatomic Dissection Study." J Anat. 2013;223(5):489–94. doi:10.1111/joa.12094
9. National Comprehensive Cancer Network. Penile Cancer. Updated 2025-11-12.
10. 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
12. 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
16. Falcone M, Preto M, Blecher G, et al. "The Outcomes of Glansectomy and Split Thickness Skin Graft Reconstruction for Invasive Penile Cancer Confined to Glans." Urology. 2022;165:250–255. doi:10.1016/j.urology.2022.01.010
17. 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
18. 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
19. Falcone M, Preto M, Gül M, et al. "Functional Outcomes of Organ Sparing Surgery for Penile Cancer Confined to Glans and Premalignant Lesions." Int J Impot Res. 2024. doi:10.1038/s41443-024-00967-7
20. Parnham AS, Albersen M, Sahdev V, et al. "Glansectomy and Split-Thickness Skin Graft for Penile Cancer." Eur Urol. 2018;73(2):284–289. doi:10.1016/j.eururo.2016.09.048
21. Roumieux C, Vandermaesen K, Dancet E, Albersen M. "Penile Cancer Treatment and Sexuality: A Narrative Review." Int J Impot Res. 2025. doi:10.1038/s41443-025-01095-6
22. Torres Irizarry VM, Paster IC, Ogbuji V, et al. "Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review." Cancers. 2024;16(7):1309. doi:10.3390/cancers16071309