the concept of developing an epithelialized tube from a buried strip of skin in the management of urethral strictures was first described by duplay   and later browne .
johanson   used this principle in the management of urethral stricture in his description of a staged urethroplasty , which was later modified by leadbetter jr .
these principles are still considered to be the gold standard of management of penile urethral strictures , particularly complex strictures associated with failed urethroplasty , lichen sclerosis , and hypospadias . in 1980 , monseur   described the first dorsal urethroplasty . in 1996 , barbagli et al .   expanded the technique by placing buccal mucosa into the dorsal defect .
this surgical technique , although meant exclusively for the repair of bulbar urethral strictures , opened the door for further advancements in urethral reconstruction . in 2000 , kulkarni et al .   described a 1-stage buccal mucosal graft urethroplasty in patients with panurethral strictures due to lichen sclerosis .
these 1-stage techniques are becoming more commonly used by reconstructive experts and represent an alternative to traditional 2-stage repairs for penile urethral strictures . herein , a novel penoscrotal inversion technique , previously described for correction of peyronie disease , combined with the one - sided technique of kulkarni et al .  
preoperative evaluation included history , physical examination , urine culture , postvoid residual urine measurements , uroflowmetry , and retrograde cystourethrography .
the patient was placed in a frog - leg supine position , with pillows under the knees for support .
the skin of the suprapubic region and scrotum was shaved and this region was prepared and draped appropriately .
once identified , the penis was inverted bluntly , although scissor dissection could be utilized when necessary ( fig .
2 ) . once the penis was fully inverted and the urethra exposed , a stay stitch was placed in the right side of the glans lateral to the urethra .
only the ventral side of the penis was degloved . along the right side , the urethra remained attached to the corpora cavernosa for its full length , thus preserving its lateral vascular blood supply .
the urethra was dissected and rolled off the underlying tunica albuginea of the corpora cavernosa from left to right in the region of the stricture ( fig .
if the stricture extended to the meatus or fossa navicularis , the dissection was carried to the coronal sulcus . when the stricture extended to the meatus
, the penis was returned to its natural position and a dorsal urethrotomy was made along the glans and fossa navicularis ( fig .
the width of the urethrotomy should be 1 cm . the dorsal incision was carried as proximal as possible via the meatus . a catheter or forceps
could be placed into the meatus as it was invaginated , and the dorsal incision was continued into the exposed urethra ( fig .
if the stricture did not involve the meatus or fossa navicularis , once the urethra had been rolled off the corpora , a catheter was placed to the level of the stricture and used as a guide to incise the dorsal urethra at the midline .
the dorsal urethral incision was carried as proximal as necessary to expose the entire stricture .
if there was hypospadias , the skin on the ventral side of the urethra often could not be dissected and therefore was left intact .
the dorsal urethral plate could be sufficiently incised for graft placement by working from the distal and proximal end until 1 cm of albuginea was exposed .
this was due to the short nature of the hypospadias cases described herein ; longer hypospadias repairs would not allow this approach .
once the entire stricture had been incised , the length and width of the remaining urethral plate were measured .
the oral mucosal graft was trimmed to an appropriate size according to the length and width of the urethrotomy . if the meatus was involved , the graft was first sutured to the distal extent of the dorsal incision and quilted down in the region of the glans ( fig . 6 ) .
the graft was then tucked into the urethra and the penis was invaginated , at which point the graft was spread fixed over the underlying tunica ( fig .
the left margin of the graft was secured to the right lateral aspect of the exposed urethral plate .
the right margin of the graft was sutured to the left margin of the urethral plate .
if the meatus of the fossa navicularis was not involved , the graft could be placed in a standard dorsal onlay approach
. there may be a small section where the graft can not be reached to quilt , usually at the level of the fossa . here , the options are to create a ventral meatotomy in order to quilt , or , as performed herein , to use surgical glue to secure this portion of the graft ( fig
once the glue was in place , a catheter was quickly passed into the urethra , and pressure was held for a time according to the recommendations of the glue being used .
the remaining glue was used to secure the penile skin where it was dissected off the urethra ( fig .
all patients received lowdose suppressive antibiotics until the catheter was removed . at 3 weeks after surgery
, the bladder was filled with contrast , the catheter was removed , and voiding cystourethrography was obtained .
uroflowmetry and postvoid residual urine were repeated every 4 months for 1 year , then yearly .
when symptoms of decreased force of stream were present and uroflowmetry was less than 10 ml / s , retrograde urethrography was performed .
preoperative evaluation included history , physical examination , urine culture , postvoid residual urine measurements , uroflowmetry , and retrograde cystourethrography .
the patient was placed in a frog - leg supine position , with pillows under the knees for support .
the skin of the suprapubic region and scrotum was shaved and this region was prepared and draped appropriately .
once identified , the penis was inverted bluntly , although scissor dissection could be utilized when necessary ( fig .
once the penis was fully inverted and the urethra exposed , a stay stitch was placed in the right side of the glans lateral to the urethra .
only the ventral side of the penis was degloved . along the right side , the urethra remained attached to the corpora cavernosa for its full length , thus preserving its lateral vascular blood supply .
the urethra was dissected and rolled off the underlying tunica albuginea of the corpora cavernosa from left to right in the region of the stricture ( fig .
if the stricture extended to the meatus or fossa navicularis , the dissection was carried to the coronal sulcus . when the stricture extended to the meatus
, the penis was returned to its natural position and a dorsal urethrotomy was made along the glans and fossa navicularis ( fig .
4 ) . the width of the urethrotomy should be 1 cm . the dorsal incision was carried as proximal as possible via the meatus .
a catheter or forceps could be placed into the meatus as it was invaginated , and the dorsal incision was continued into the exposed urethra ( fig .
if the stricture did not involve the meatus or fossa navicularis , once the urethra had been rolled off the corpora , a catheter was placed to the level of the stricture and used as a guide to incise the dorsal urethra at the midline .
the dorsal urethral incision was carried as proximal as necessary to expose the entire stricture . if there was hypospadias , the skin on the ventral side of the urethra often could not be dissected and therefore was left intact .
the dorsal urethral plate could be sufficiently incised for graft placement by working from the distal and proximal end until 1 cm of albuginea was exposed .
this was due to the short nature of the hypospadias cases described herein ; longer hypospadias repairs would not allow this approach .
once the entire stricture had been incised , the length and width of the remaining urethral plate were measured .
the oral mucosal graft was trimmed to an appropriate size according to the length and width of the urethrotomy .
if the meatus was involved , the graft was first sutured to the distal extent of the dorsal incision and quilted down in the region of the glans ( fig . 6 ) .
the graft was then tucked into the urethra and the penis was invaginated , at which point the graft was spread fixed over the underlying tunica ( fig .
the left margin of the graft was secured to the right lateral aspect of the exposed urethral plate .
the right margin of the graft was sutured to the left margin of the urethral plate .
if the meatus of the fossa navicularis was not involved , the graft could be placed in a standard dorsal onlay approach
. there may be a small section where the graft can not be reached to quilt , usually at the level of the fossa . here
, the options are to create a ventral meatotomy in order to quilt , or , as performed herein , to use surgical glue to secure this portion of the graft ( fig . 8) .
once the glue was in place , a catheter was quickly passed into the urethra , and pressure was held for a time according to the recommendations of the glue being used .
the remaining glue was used to secure the penile skin where it was dissected off the urethra ( fig .
at 3 weeks after surgery , the bladder was filled with contrast , the catheter was removed , and voiding cystourethrography was obtained .
uroflowmetry and postvoid residual urine were repeated every 4 months for 1 year , then yearly .
when symptoms of decreased force of stream were present and uroflowmetry was less than 10 ml / s , retrograde urethrography was performed .
five patients ( mean age , 58 years ; range , 4667 years ) underwent a one - sided dorsal oral mucosal graft urethroplasty for penile urethral strictures through the penoscrotal inversion technique .
the cause of stricture was previous urethral instrumentation in 2 cases ( 40% ) , lichen sclerosis in 1 case ( 20% ) , and hypospadias in 2 cases ( 40% ) .
all 5 patients had received previous dilations or urethrotomies ; 2 patients ( the hypospadias patients ) had undergone prior urethroplasties .
clinical outcome was considered a failure if any postoperative instrumentation was needed , including dilation . in all patients ,
of the 5 patients , 4 had successful outcomes and 1 had a failed outcome during the follow - up period .
he had been performing self - dilation for several years before he researched the penile inversion approach to stricture repair .
he was counseled on all the options , including a staged repair given the nature of his stricture ; however , he elected to attempt to undergo the dorsal onlay approach .
he developed a penile hematoma that became infected . once the infection was drained and cleared , his catheter was removed , and a distal stricture recurred .
surprisingly , the graft was mostly intact , and he was managed with a short 0.5-cm meatotomy .
one patient with a 5-cm lichen sclerosis stricture experienced postoperative chordee that has since resolved .
the success of the dorsal onlay technique , using a onesided dissection , for bulbar and panurethral strictures has been well described via a perineal incision .
this is the first report of a penoscrotal incision to access the penile urethra for dorsal onlay graft urethroplasties .
the potential advantages of this approach will be explored . because the penoscrotal inversion technique allows the patient to stay in the supine position , the complication of neurapraxia is theoretically the same as with any supine surgical procedure . by contrast , if the perineal incision is utilized , the peroneal nerve neurapraxia rate has been reported at 15.8% . in a second study ,
lower - extremity complications were reported at 10% ; this included a 6.5% neurapraxia rate , a 1% rate of rhabdomyolysis , and a 1% rate of compartment syndrome .
for example , whitson et al .   reported a series of 124 patients in low lithotomy with a neurapraxia rate of 3.4% and compartment syndrome seen in only 1 patient ; complications were also noted to increase if the lithotomy position was over 5 hours .
however , with the aforementioned supine approach , then this operation has clear advantages over approaching the stricture through a perineal incision .
first , a patient must void through a proximal urethral defect or empty the bladder via a suprapubic tube after the first stage for some time until the urethra is stable enough for the second stage of repair .
second , a 2-stage repair is associated with a high revision rate . in a recent report on staged urethroplasty
, only 56% underwent the retubularization procedure , 26% required revision of the first- or second - stage procedure , and the success rate was 90% ( including those who underwent 1-stage repair ) .
while the previous report noted a 90% success rate , others have not noted as much success with staged urethroplasty . a direct comparison between 1-stage buccal mucosal graft urethroplasty and 2-stage urethroplasty for long segment strictures showed a success rate of 83% versus 64% .
however , when the above authors reported their success in patients treated for lichen sclerosis with a 1-stage buccal mucosal repair versus a 2-stage operation , the success favored the 1-stage approach : 86% success versus 52% , respectively .
fistula can occur in up to 3% to 20% of cases of fasciocutaneous flap urethroplasty   and up to 10% of staged urethroplasty .
patients who undergo a fasciocutaneous flap experience a higher rate of complications compared to buccal mucosal urethroplasty .
complications include torsion , hematoma , sacculations , penile skin necrosis , complaints of irregular skin elevation , and penile skin scarring .
additional complications of 2-stage urethroplasty include 10% wound dehiscence and 5% wound infection or abscess . using a penoscrotal approach limits skin complications of the penile urethra .
one case in our series developed a penile hematoma that converted to an abscess requiring drainage . after this
, we began to use surgical glue to secure the penile skin over the urethra after the repair was complete .
since we started using the glue , we have had no additional cases of hematomas .
the few numbers of patients and the short follow - up are clearly the limiting factors of this surgical approach .
the idea of a penile inversion has been well described , although not through a penoscrotal approach .
although the advantages listed previously are present , they have not been fully tested with a large number of patients with long - term follow - up .
next , for the most complicated urethral strictures , the use of 1-stage urethroplasty is not recommended .
previously , lichen sclerosis was included on this list ; however , kulkarni et al .  
has shown that onesided buccal mucosal urethroplasty is an effective treatment for cases of lichen sclerosis .
herein , we used the approach for a distal stricture associated with lichen sclerosis with success .
patient preference and the short nature of the strictures were the impetus for attempting the 1-stage approach .
one case was successful , and the second had a distal recurrence at the level of the meatus , distal to the initial stricture site .
the ventral dissection was not possible at the site of previous repair given the adherent nature of the penile skin to the underlying tubularized urethra .
however , the length of the urethral stricture was short and therefore access to the dorsal plate was possible .
the dorsal approach would not be possible in failed hypospadias if the stricture was longer or the prior hypospadias repair was longer .
as a routine , the use of this approach would not be recommended in the setting of failed hypospadias .
because the penoscrotal inversion technique allows the patient to stay in the supine position , the complication of neurapraxia is theoretically the same as with any supine surgical procedure .
by contrast , if the perineal incision is utilized , the peroneal nerve neurapraxia rate has been reported at 15.8% . in a second study ,
lower - extremity complications were reported at 10% ; this included a 6.5% neurapraxia rate , a 1% rate of rhabdomyolysis , and a 1% rate of compartment syndrome .
for example , whitson et al .   reported a series of 124 patients in low lithotomy with a neurapraxia rate of 3.4% and compartment syndrome seen in only 1 patient ; complications were also noted to increase if the lithotomy position was over 5 hours . however , with the aforementioned supine approach , then this operation has clear advantages over approaching the stricture through a perineal incision .
first , a patient must void through a proximal urethral defect or empty the bladder via a suprapubic tube after the first stage for some time until the urethra is stable enough for the second stage of repair .
second , a 2-stage repair is associated with a high revision rate . in a recent report on staged urethroplasty
, only 56% underwent the retubularization procedure , 26% required revision of the first- or second - stage procedure , and the success rate was 90% ( including those who underwent 1-stage repair ) .
while the previous report noted a 90% success rate , others have not noted as much success with staged urethroplasty . a direct comparison between 1-stage buccal mucosal graft urethroplasty and 2-stage urethroplasty for long segment strictures showed a success rate of 83% versus 64% .
however , when the above authors reported their success in patients treated for lichen sclerosis with a 1-stage buccal mucosal repair versus a 2-stage operation , the success favored the 1-stage approach : 86% success versus 52% , respectively .
fistula can occur in up to 3% to 20% of cases of fasciocutaneous flap urethroplasty   and up to 10% of staged urethroplasty .
patients who undergo a fasciocutaneous flap experience a higher rate of complications compared to buccal mucosal urethroplasty .
complications include torsion , hematoma , sacculations , penile skin necrosis , complaints of irregular skin elevation , and penile skin scarring .
additional complications of 2-stage urethroplasty include 10% wound dehiscence and 5% wound infection or abscess .
one case in our series developed a penile hematoma that converted to an abscess requiring drainage .
after this , we began to use surgical glue to secure the penile skin over the urethra after the repair was complete .
since we started using the glue , we have had no additional cases of hematomas .
the few numbers of patients and the short follow - up are clearly the limiting factors of this surgical approach .
the idea of a penile inversion has been well described , although not through a penoscrotal approach .
although the advantages listed previously are present , they have not been fully tested with a large number of patients with long - term follow - up .
next , for the most complicated urethral strictures , the use of 1-stage urethroplasty is not recommended .
previously , lichen sclerosis was included on this list ; however , kulkarni et al .  
has shown that onesided buccal mucosal urethroplasty is an effective treatment for cases of lichen sclerosis .
herein , we used the approach for a distal stricture associated with lichen sclerosis with success .
patient preference and the short nature of the strictures were the impetus for attempting the 1-stage approach .
one case was successful , and the second had a distal recurrence at the level of the meatus , distal to the initial stricture site .
the ventral dissection was not possible at the site of previous repair given the adherent nature of the penile skin to the underlying tubularized urethra .
however , the length of the urethral stricture was short and therefore access to the dorsal plate was possible .
the dorsal approach would not be possible in failed hypospadias if the stricture was longer or the prior hypospadias repair was longer . as a routine , the use of this approach would not be recommended in the setting of failed hypospadias .
the technique of dorsal onlay buccal mucosal urethroplasty through a penoscrotal penile inversion technique is a viable option for noncomplex penile urethral strictures .
 purposethis article describes a novel technique for the repair of penile urethral strictures and establishes the safety , feasibility , and efficacy of this innovative surgical approach.materials and methodspatients with urethral strictures underwent a one - sided anterior dorsal oral mucosal graft urethroplasty through a penoscrotal inversion technique . 
 the clinical outcome was considered a failure when any instrumentation was needed postoperatively , including dilatation.resultsfive patients underwent the novel procedure . 
 the patients ' mean age was 58 years . 
 the cause of stricture was instrumentation in 2 cases ( 40% ) , lichen sclerosis in 1 case ( 20% ) , and failed hypospadias repair in 2 cases ( 40% ) . 
 the mean stricture length was 3 cm . 
 the overall mean ( range ) follow - up was 6 months ( range , 39 months ) . 
 of the 5 patients , 4 ( 80% ) had a successful outcome and 1 ( 20% ) had a failed outcome . 
 the failure was successfully treated by use of a meatotomy.conclusionsthe penile inversion technique through a penoscrotal incision is a viable option for the management of penile urethral strictures with several advantages to other techniques : namely , no penile skin incision , a single - stage operation , and supine positioning . 
INTRODUCTION
MATERIALS AND METHODS
1. Preoperative work-up
2. Surgical procedure
3. Postoperative care
RESULTS
DISCUSSION
1. Supine positioning
2. Single stage
3. No penile incisions
4. Limitations
CONCLUSIONS