Keystone flaps in urethroplasty: Reconstruction in a complex case of panurethral stricture disease

Abstract

Panurethral strictures are a surgical challenge for a reconstructive urologist more so in situations where local tissue for reconstruction is deficient. Two-stage urethroplasty is the preferred option in such cases. In some complex stricture diseases where patients are not willing for multiple procedures, permanent perineal urethrostomy can give a good functional outcome. Keystone flaps have been used as a simple and effective method of wound closure in other areas of the body that would otherwise have required complex flap closure and skin grafting. We describe, for the first time, a case of inflammatory panurethral stricture disease complicated by Fournier gangrene with extensive penile, scrotal, and perineal skin deficit managed with a perineal urethrostomy, with the help of keystone design perforator island flaps with successful outcome.

Algorithm of rational approach to reconstruction in Fournier’s disease

“…Treatment of this condition is based on the management of the underlying cause with anti-inflammatory drugs and targeted antibiotics, as well as reconstructive techniques for the loss of substance [ 13 ]. Reconstructive strategies include flaps [ 14 , 15 ], granulation for second intention or vacuum-assisted closure therapy [ 16 ], and skin graft [ 17 ]. Moreover, other surgical techniques have been described to repair the loss of substance in Fournier’s disease, consisting an oblique rectus abdominal myocutaneous flap, superiority of medial circumflex femoral artery perforator flap, and posteromedial thigh propeller flap [ 18 , 19 , 20 ].…”