no single approach is appropriate for all urethral strictures . for surgical repairs , proper procedure selection and surgical expertise . the reconstructive surgeon should be fully familiar with the use of both flaps and grafts to deal with any condition of the urethra at time of surgery . penile skin flaps , which have ample vascular pedicle , were considered the most reliable material for reconstruction of long or complex strictures . dorsal placement of penile skin flaps and free grafts has yielded superior outcomes compared to ventral placement . the objective of this prospective study is to present the results of reconstruction of long ( > 5  cm ) , penile , bulbar , and bulbopenile urethral strictures by penile skin flap as dorsal onlay in one - stage procedure . during the period from january , 1998 to december , 2004 , 18 patients had long penile , bulbar , or bulbopenile strictures repaired utilizing long penile skin flaps placed as dorsal onlay flap in one stage . all patients underwent routine laboratory investigations ( e.g. , complete blood count , blood urea and serum creatinine , bleeding profile , and random blood sugar ) , upper tract evaluation by us and intravenous urography , uroflowmetry ( the mean peak flow rate was 7.3  ml / s . ) , retrograde urethrography ( rug ) both dynamic and static , micturating cystourethrography ( mcug ) , and sonourethrography in some cases . the age of patients was 2865 years ( mean 39.3 year ) . the etiology of stricture was iatrogenic in 8 cases and post - infective urethritis in 10 cases . the stricture length was 5.613.2 , located at the penile urethra in 6 cases , bulbar urethra in 2 cases , and combined in 10 cases . all patients were primarily repaired and had ample healthy penile skin with variable flap length , where it was 6  cm in 6 cases subjected to orandi flap ( figure 1 ) , 710  cm in 8 cases with circular fasciocutaneous penile flap ( figure 2 ) , and 1015  cm in 4 cases with spiral flaps ( figure 3 ) . as regards the technique , the urethra was completely mobilized from the underneath corpora cavernosa and rotated 180 degrees , then , dorsal stricturotomy was done , penile skin flap was applied as a dorsal onlay , and the urethra was fixed to its bed . if penile skin is deficient , u - shaped scrotal flaps were raised for coverage . mcug was performed after catheter removal , if any leakage occurred , cystocath drainage was delayed . followup of all patients after reconstruction included urine flow rate at weekly intervals , rug at 612 weeks , and urethrocystoscopy at 12 and 18 months . the urethra was patent in 14 patients ( 77%).the mean peak flow rate improved to 22.7  ml / s . the radiographic picture of the reconstructed urethra in rug was excellent and close to that of a normal urethra in 14 patients in terms of caliber and a smooth transition of the dye into the urethra at both ends . failure was considered when there was a need for any subsequent urethral procedure as visual internal urethrotomy , urethral dilatation , or urethroplasty . two patients ( 11% ) showed curvature on erection that does not interfere with sexual intercourse . diverticulum ( in penile urethra ) was seen in one patient ( 5.5% ) and it contained stones ( figure 4 ) and was excised surgically . penile island flap urethroplasty provides well - vascularized , versatile , and reliable tissue for urethral substitution . it is an ideal procedure for long strictures in the distal urethra .   in our small series of patients , circular   ( 710  cm in 8 patients ) and spiral flaps   ( 1015  cm in 4 patients ) were fashioned and rotated to be dorsally quilted into the dorsally opened strictured part of the urethra either in penile , bulbar , or bulbopenile uerthra without vascular compromise . the longitudinally fashioned flaps ( 6  cm in 6 patients ) orandi   were comfortably used for penile strictures . the success rate for all penile skin flaps was 77% in our hands approaching that recorded by others [ 911 ] see table 1 . some authors reported that although there is no reported comparison of dorsally and ventrally quilted onlay flap urethroplasty , in our initial experience dorsal placement was better than ventral placement because ( a ) the postoperative radiographic studies showed a near - normal restoration of the anatomical appearance of the urethra ; ( b ) there is no sagging , sacculation , and resultant postvoid dribbling , as seen in ventral placements ; because the flap sits on the roof of the urethra and is fused with crura ( c ) the incidence of postoperative fistula is very low . dorsal placement of the flap is particularly advantageous in the following situations : extension of the flap for meatal and glanular stricture reconstruction and , extension proximally up to the bulbomembranous region and in situations where the reconstruction requests combined flap and free graft . most of the complications with skin flap urethroplasty are recurrent stricture , troublesome postvoid dribbling , and diverticulum formation . in previous study , of 17 patients with penile skin urethroplasty , urethral pseudodiverticulum developed in two patients ( 11.7% ) . one patient developed a large urethral diverticulum 1 year after procedure and the other 10 years after the procedure . in our study one patient only developed a diverticulum ( 5.5% ) containing stones which was removed surgically . in other studies , the stricture recurred in five patients ( 11% ) within a median followup of 27.5 months , and of 30 patients with pedicled dorsally quilted penile skin flaps , urethral stricture recurred in 5 ( 16.6% ) . long - term results with skin flap urethroplasty show a decreasing success rate with time . dorsally quilted penile skin flap urethroplasty seems anatomically more logical ; in our hands the early outcome of this technique is encouraging , but we are in need for long - term followup to evaluate the outcomes especially the restructure . free penile skin flaps offer good results ( functional and cosmetic ) in long penile and/or bulbar urethral strictures . meticulously fashioned longitudinal , circular , or spiral penile skin flaps could bridge urethral defects up to 15  cm long .
objective . to present the results of reconstruction of long ( > 5  cm ) , penile , bulbar , and bulbopenile urethral strictures by penile skin flap as dorsal onlay in one - stage procedure . patients and methods . between january , 1998 and december , 2004 , 
 18 patients ( aged from 28 - 65 years ) presented with long urethral strictures , 5.613.2  cm ( penile in 6 , bulbar in 2 and combined in 10 cases ) , those were repaired utilizing long penile skin flaps placed as dorsal onlay flap in one stage ( orandi flap 6  cm in 6 cases , circular flaps 710  cm in 8 , and spiral flaps 1015  cm in 4 ) . 
 followup of all patients after reconstruction included urine flow rate at weekly intervals , rug at 612 weeks , and urethrocystoscopy at 12 and 18 months . 
 results . the urethral patency was achieved in 77% of patients . 
 the complications were fistula in one patient ( 5.5% ) , restricture occurred in 3 patients ( 16.6% ) that required visual internal urethrotomy and two patients ( 11% ) showed curvature on erection that dose not interfere with sexual intercourse . 
 diverticulum ( penile urethra ) was seen in one patient ( 5.5% ) containing stones and was excised surgically . 
 there was penile skin loss in 3 patients ( 16.6% ) . 
 all patients completed at least one - year followup period . 
 conclusion . 
 free penile skin flaps offer good results ( functional and cosmetic ) in long penile and/or bulbar urethral strictures . 
 meticulously fashioned longitudinal , circular or spiral penile skin flaps could bridge urethral defects up to 15  cm long .