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Two staged modified substitution urethroplasty using appendix-free flap

Reconstruction of long posterior urethra defect is technically challenging. Substitution urethroplasty is used in long, complex, recurrent posterior urethral strictures. This article presents a modified technique and the clinical outcome of two-stage substitution urethroplasty with appendix free flap and microvascular anastomosis. A three-year-old boy with a 5 cm iatrogenic posterior urethral defect was managed by urethral substitution using the appendix. An appendix-free flap was used according to anatomic limitations, employing the transposed inferior epigastric artery and saphenous vein to maintain conduit blood supply. The conduit was buried in the scrotum for 3 weeks and its viability monitored until the final reconstructive stage. Two-year follow-up with ultrasound and cystoscopy revealed satisfactory results. A well-vascularised bed and flap are the mainstays of substitution urethroplasty, so we suggest inferior epigastric artery perineal transposition and staged reconstruction as alternatives that may improve the blood supply of the neourethra.