Joshi P.M.Navarro J.Ratanapornsompong W.Ocampo M.A.De Win G.Thiessen F.Wood D.Kulkarni S.B.Mahidol University2026-02-062026-02-062026-12-01World Journal of Urology Vol.44 No.1 (2026)07244983https://repository.li.mahidol.ac.th/handle/123456789/114483Purpose: Bulbar urethral necrosis (BUN) represents one of the most complex sequelae of pelvic fracture urethral injury. This study aimed to evaluate the outcomes of substitution urethroplasty using pedicled flaps for BUN and to propose a management algorithm. Methods: We conducted a retrospective analysis of a prospectively maintained database including patients who underwent flap-based substitution urethroplasty for BUN at a single high-volume centre between June 2022 and April 2024. Variables included pelvic fracture type, BUN type, flap type, follow-up duration, surgical success, and complications. Results: A total of 41 patients were included (mean age, 34.9 years). Most cases (75.6%) were redo surgeries, with a median of one prior urethroplasty and a median follow-up of 20 months (IQR 14–24 months). The most common pelvic fracture was APC1 (36.6%), and the most frequent BUN type was type 3 (51.2%). Pedicled preputial tube was the most used flap (61%), followed by distal penile skin (24.4%) and Q-flap (9.8%). The primary success rate was 66%, and the secondary success rate was 78%. Pedicled preputial tubes and Q-flaps achieved the highest primary success (76% and 75%, respectively), while distal penile skin flaps achieved 40%. The overall complication rate was 14.6%, mostly Clavien–Dindo grade I, with two grade IIIB events. Conclusions: Pedicled flap urethroplasty can provide an effective reconstructive option for BUN, with acceptable success rates and low morbidity in severe cases. Proper preoperative evaluation and flap selection are key to optimizing outcomes.MedicineArticleSCOPUS10.1007/s00345-026-06223-52-s2.0-1050284128831433872641575585