Urethral Reconstruction

Urethral reconstruction restores unobstructed micturition — ideally from a glanular meatus with good cosmesis — along the length of the urethra. The disease differs by segment: an anterior urethral stricture is a scarring of the epithelium and the surrounding corpus spongiosum (spongiofibrosis), whereas the posterior urethra, which has no corpus spongiosum, suffers a distraction defect after pelvic fracture rather than a true stricture. This page covers reconstruction of the fossa navicularis, penile, and bulbar urethra and of the pelvic-fracture urethral distraction defect (PFUDD). The underlying disease, graft biology, and lichen sclerosus are covered in the Penis & Urethra Surgery topic; acute pelvic-fracture trauma is in the Trauma topic.

Reconstructive Principles

• Graft vs flap — a flap is moved with its blood supply; a graft is laid in a new bed and develops one by take (~96 h: imbibition ~48 h, then inosculation ~48 h).
• Graft choice — the oral mucosal graft (buccal, labial, or lingual) is first choice (buccal has a panlaminar plexus, excellent tissue, low harvest morbidity); bladder and rectal mucosa, skin grafts (the posterior-auricular Wolfe graft takes best of extragenital skin), and dartos-based skin island flaps follow; tunica vaginalis grafts do poorly in the urethra. In lichen sclerosus, genital skin must not be used — use oral mucosa.
• EPA vs substitution — excision and primary anastomosis (EPA) is preferred where feasible (simple, most effective, no donor-site morbidity); when the defect is too long, use an onlay graft or flap — never tubularised. Avoid EPA in the penile urethra (tethering and chordee) and after prior hypospadias repair (the retrograde glanular blood supply may be absent).

Evaluation

• Retrograde urethrography / VCUG defines stricture location and length; ultrasound is the most accurate way to gauge the graft length needed; MRI helps only in PFUI (distorted anatomy) or when urethral carcinoma is suspected.
• Calibrate with Bougie-à-Boule sounds and pass a flexible cystoscope; palpate the urethra for induration (spongiofibrosis) and record stretched penile length (a longer SPL favours EPA). A normal 30-Fr urethra has a 10-mm outer diameter.

Fossa Navicularis Reconstruction

The etiology drives the choice: a post-instrumentation stricture (e.g. after TURP) behaves very differently from one due to lichen sclerosus (LS/BXO). LS rarely responds to dilation or urethrotomy and fails with skin flaps, so it needs oral-mucosa substitution; childhood meatal stenosis (ventral fusion from balanitis) responds to simple meatotomy.

• Skin-flap techniques (Y-V principle; not for LS) — Cohney (transverse random flap, retrusive meatus), Blandy-Tresidder (dartos V-flap, leaving a coronal meatus), Brannen and De Sy (more aggressive advancement for better cosmesis), and the Jordan transverse ventral skin island on a dartos pedicle (near-normal cosmesis — not for LS or hypospadias).
• Graft (Devine resurfacing) — buccal mucosa (or skin, but not in LS) onto the glans bed, with the graft suture line placed dorsally to avoid overlapping suture lines.
• Combined flap + graft (Gelman) — a single-stage dorsal buccal onlay plus ventral skin flap for obliterative distal strictures or a deficient plate (not for LS).
• Staged repair — for a deficient or replaceable plate (hypospadias failure, LS): quilt a dorsal buccal graft, then reconstitute the urethra 4–6 months later.

Penile Urethra Reconstruction

Most penile strictures are repaired in one stage with penile skin flaps or grafts; anastomotic urethroplasty is avoided here (even for short strictures) because tethering and chordee result. Complex or failed cases may be staged, and LS strictures take buccal mucosa.

• McAninch distal penile circular fasciocutaneous flap — a versatile hairless flap up to 15 cm (width 2.0–2.5 cm) for strictures from the fossa to the bulbar urethra: the degloved circular skin island on a circumferential pedicle is divided ventrally, rotated, and sewn as an onlay over a 16-F catheter (it can be tunnelled under a raised "glans cap" to reach the meatus).
• Orandi (longitudinal ventral flap on a lateral pedicle) and Turner-Warwick (ventral-pedicle flap — the bilateral "BiPIPS," useful for bulbar repair via a scrotal tunnel) — both elongated-hexagon ventral skin islands that may incorporate hair-bearing skin proximally.
• Dorsal onlay buccal graft (Barbagli) — the urethra is mobilised and rotated ~180°, opened dorsally to a 28-F calibre, and the buccal graft is quilted to the tunica albuginea of the corpora (ventral grafts are avoided here because the penile spongiosum is thin).
• Ventral-approach dorsal graft (Asopa) — a dorsal graft placed through a ventral urethrotomy (simpler dissection, preserves collateral supply, but adds a urethrotomy).
• Kulkarni — penile invagination with one-sided urethral dissection (preserving one side's neurovascular supply) to reconstruct the whole urethra through a single perineal incision.
• Two-stage (Johanson) — when penile skin is scarce or unsuitable (multiple prior operations, LS): open and marsupialise the urethral plate first (± buccal graft laterally), then tubularise a 28-mm-wide plate at the second stage.

Bulbar Urethra Reconstruction

The bulbar urethra is forgiving — its thick, richly perfused corpus spongiosum (paired bulbar arteries) supports many techniques, so almost any bulbar stricture is reconstructible. Plan from the retrograde urethrogram (length, location, and quality of the urethral plate).

• Excision and primary anastomosis (EPA) — the preferred repair for short strictures (generally < 2 cm), and applicable to longer ones whose distal end lies in the lower perineum, especially in men with SPL > 14 cm. Excise the fibrosis, spatulate the distal stump dorsally (≥ 26 F) and the proximal stump ventrally (≥ 28 F), place 8–12 sutures 2–3 mm apart (dorsal full-thickness, ventral urethra-only), parachute a 16-F catheter, and finish with a spongioplasty. Avoid EPA for distal bulbar strictures > 2 cm (chordee/shortening risk).
• Onlay buccal mucosal graft — for non-obliterative strictures: a ventral onlay in the wide central/proximal bulb (graft + plate width ≤ 3 cm → final 26–30 F, closed under a spongioplasty) and a dorsal onlay in the narrower distal bulb (quilted to the corpora — the penile dorsal-onlay technique adapted to the bulb).
• Dorsal + ventral overlapping graft — when the incised plate is < 5 mm, augment it dorsally to a neourethral plate of ~1.5 cm, then add a ventral onlay.
• Augmented anastomotic urethroplasty (AAU) — for strictures too long for EPA with a focal obliterative segment: excise the worst part, then anastomose and onlay-augment the remaining plate.
• Non-transecting EPA — preserves the spongiosal blood supply where transection is risky (hypospadias, prior transection, radiation, recurrent strictures, existing/planned artificial urinary sphincter): mobilise, rotate, and incise dorsally, then close transversely (Heineke-Mikulicz) or as a dorsal onlay.

Posterior (Pelvic Fracture) Reconstruction

A pelvic fracture urethral distraction defect (PFUDD) is a separation — not a stricture — at the bulbomembranous junction, accompanying ~10% of pelvic fractures; defects are usually short (~2 cm) and the external sphincter is often preserved.

• Acute management — drain with an ultrasound-guided suprapubic cystostomy (16-Fr or larger) sited away from the fracture, and delay definitive repair ≥ 3 months for the pelvic hematoma to resolve. Endoscopic realignment is an option but controversial (experienced hands only); open realignment is not recommended.
• Evaluation — a synchronous up-and-down (antegrade + retrograde) urethrogram and cystogram plus examination under anaesthesia with rigid and flexible cystoscopy; assess bladder-neck competency (a truly open/incompetent neck may warrant a continent stoma rather than urethroplasty).
• Repair (progressive perineal approach) — through a midline perineal incision, mobilise and transect the distal urethra, excise the intervening scar, and spatulate both ends to accept a 32-F sound. Escalate stepwise only as needed for a tension-free anastomosis — corporal splitting → inferior pubectomy (up to ~50% of the symphysis) → supracrural rerouting (needed in < 10% of cases) — then complete a spatulated anastomosis (~12 sutures) and fix the urethra to the corpora so postoperative erections do not tension it. A graft or flap is rarely needed.
• Postoperative care — divert with the suprapubic tube (the urethral catheter acts only as a stent); obtain a descending urethrogram at ~14 days (to 3–4 weeks) before removing the catheters. Outcomes: ~80–90% patency at 5 years (curative rates in the high-90s at experienced centres), continence > 90% unless the bladder neck is damaged; ED is often a consequence of the original injury.

Complications and Follow-up

• Stricture recurrence is the most important late complication (commoner after graft repairs; EPA fails in < 10%, usually within the first year) — follow with symptoms, uroflowmetry, and flexible cystoscopy; short recurrences are treated endoscopically.
• Sexual/ejaculatory — permanent ejaculatory dysfunction in up to 20% and temporary ED in up to 20% (resolving by ~6 months, < 3–4% permanent); careful bulbospongiosus reapproximation and two-layer spongiosal closure limit these. Ventral chordee/penile shortening is avoided by not performing EPA on distal bulbar strictures > 2 cm.
• Positioning — lengthy lithotomy risks lower-limb neuropraxia, DVT/PE, and compartment syndrome; protect the common peroneal nerve (foot drop) and use DVT prophylaxis.
• Wound — scrotal ecchymosis is common and self-limited; large hematomas, infection, and urethrocutaneous fistula are rare. Give a single antibiotic dose before catheter removal, and confirm healing with a VCUG before catheter removal (≈ 2 weeks after EPA, ≈ 3 weeks after grafts).