Salvage Urethroplasty With a Modified Tubularized Distal Penile/Preputial Skin Flap for Bulbar Urethral Necrosis After Failed Anastomotic Urethroplasty in Circumcised Patients: A Retrospective Multicenter Study

Abstract Introduction and Objective: Bulbar urethral necrosis (BUN) is an uncommon but severe complication of anastomotic urethroplasty for pelvic fracture urethral injury (PFUI). This study describes a modified bilateral tubularized distal penile/preputial skin flap for reconstruction of segmental bulbar urethral loss in selected circumcised patients. The objective was to describe the technique and evaluate procedural success and functional urethral patency at standardized follow-up. Materials and Methods: This retrospective multicenter cohort study included a highly selected population of circumcised patients who developed BUN after anastomotic urethroplasty for PFUI at four tertiary reconstructive urology centers between 2015 and 2024. Although tubularized preputial/penile skin flap reconstruction has previously been described mainly in uncircumcised patients with an intact prepuce, the present study evaluated its adaptation to circumcised patients who retained sufficient residual distal penile/preputial skin adjacent to the circumcision line. Eligibility required this residual tissue to be sufficiently mobile, well vascularized, and long enough to construct the flap without excessive tension. The primary endpoint was procedural success at 2 years, defined as functional urethral patency (Qmax > 15 mL/s) without any therapeutic endoscopic or instrumental intervention for restenosis.