Dorsal or ventral placement of the preputial/penile skin onlay flap for anterior urethral strictures: does it make a difference?

Objective To report our experience in managing complex anterior urethral st rictures with a dorsally/dorsolaterally placed penile/preputial vascularize d nap, and to discuss the advantages of this procedure over a traditional v entrally placed nap. Patients and methods Between 1995 and 1999, 40 patients (mean age 40.5 year s) with recurrent strictures of the pendulous and/or bulbar urethra were tr eated with longitudinal penile/circumpenile nap substitution urethroplasty. Nineteen patients underwent dorsal placement of the flap as an onlay (DO), whereas 21 patients had a ventral onlay (VO). Five patients needed inferio r pubectomy to facilitate high proximal placement of the flap. Results Both groups had statistically similar ages, number of previous inte rventions, stricture site, length and follow-up. After a median follow-up o f 27.5 months, the stricture recurred in three (24%) of the VO and two (11% ) of the DO groups (P>0.05). One patient in the VO group required surgical closure of the urethral fistula. Flap pseudo-diverticulum and/or sacculatio n with postvoid dribble occurred in six patients in the VO and none in the DO group (P=0.01). Conclusions Dorsal placement of the pedicled nap is anatomically and functi onally more appropriate than the traditional VO placement. DO preputial/pen ile flap urethroplasty is a versatile procedure and can be applied even for long anterior urethral strictures, including reconstruction of the meatus and high proximal bulbar strictures.