For almost all men with urethral strictures, the initial treatment option is an endoscopic procedure. An endoscopic optical internal urethrotomy (OIU) or dilatation, performed through the urethra, is used to widen the stricture. This offers stricture relief for months and, in many cases, years. Unfortunately, for many patients, the stricture returns, and with each recurrence, the stricture lengthens, the scar tissue becomes increasingly dense, and the endoscopic techniques become more limited.
Urethroplasty is the solution to this cycle. This is the open reconstruction of the urethra. This definitive procedure removes the segment of the urethra, along with the stricture, and replaces it with healthy tissue. This restores a normal urinary function and, at five to ten years, has a success rate of 80 to 95 percent. For many patients who are trapped in an endless cycle of repeated endoscopic procedures, or who have a stricture that endoscopic procedures cannot address due to length or complexity, urethroplasty is the answer and the hope of a permanent solution.
Surgical reconstruction of the urethra is called urethroplasty. This method is used to treat a narrowing of the urinary passage (urethral stricture) which happens as a result of scar tissue. Urethroplasty entails the removal of the tissue or the segment (part) of the urethra which is affected by the stricture. This tissue is then replaced by flap of normal healthy tissue. Consequently, a large and an unobstructed urinary passage (channel) is created.
This process is done by making an incision (cut) onto the skin. This is usually done on the perineum (skin area in between the scrotum and anus) for hind (bulbar and posterior) urethral stricture. An incision can also be made on the underside (ventral) part of the penis for stricture of the urethra on the penis. The technique which is used is determined by the length and site of the stricture, as well as the characteristics of the tissue in that area. The surgical history of the patient also needs to be assessed. A summary of the major techniques of urethroplasty is below:
Urethroplasty Type | Best Suited For | Key Feature |
Excision & Primary Anastomosis (EPA) | Short (<2 cm) fibrotic bulbar strictures | Stricture excised; healthy ends joined directly |
Buccal Mucosa Graft — Augmentation | Long bulbar strictures (2–8 cm+) | Graft widens the strictured segment; no excision |
BMG — Substitution Urethroplasty | Circumferential long strictures; failed EPA | Full replacement of diseased urethral segment |
Posterior Urethroplasty | Pelvic fracture urethral distraction defect | Fibrous obliteration excised; deep perineal anastomosis |
Staged Urethroplasty | Complex, lichen sclerosus, densely scarred cases | Two-stage reconstruction — lining then tubularisation |
Penile Skin Flap Urethroplasty | Penile urethral strictures; lichen sclerosus | Skin flap from penile shaft used to augment urethra |
Buccal mucosa graft (BMG) urethroplasty is the most established and the benchmark method for long bulbar urethral strictures across the globe. During this procedure, a small fragment of the inner lining of the mouth is harvested, and the donor site heals in one to two weeks. Buccal mucosa is patch and widen the narrowed urethral segment lining. The inner pouch of the cheek it is hairless, moist, elastic, and well vascularized, so otorhinolaryngologic structures are highly resistant to infectious processes. For these reasons, buccal mucosa lining is highly ideal for urethral reconstruction.
Excision and primary anastomosis (EPA) are techniques reserved for short, bulbar strictures of about two centimeters, where the diseased segment is completely excised, and the healthy ends of the urethra are directly joined. Stricture-free rates of 90-95% at 10 years mark EPA as one of the most ideal techniques when it comes to the management of short bulbar strictures. It is noted that rejoining and excising longer segments of the urethra also risks recurrence, tension, and penile shortening.
The urethra is the tube that conveys urine from the bladder out of the body. Urethral stricture is the narrowing of the urethra due to a gradual build-up of scar tissue that substitutes the normal urethral lining, which is elastic. This build-up of sub tissues is unyielding, meaning that it gets progressively worse with time. The scar tissue eventually damages other parts of the urinary system, including the bladder, ureters, and kidneys. The following causes produce urethral strictures that are too long, too dense, and/or too complex to manage endoscopically with confidence. This makes urethroplasty the preferred treatment.
Traumatic Stricture Due to Pelvic Fracture or Straddle Injury
Trauma is the most common cause of severe urethral stricture among young men. A straddle injury occurs when the individual falls across a hard object such as a crossbar or a fence. This injury compresses the bulbar urethra against the pubic bone, where bruising and tearing occur, followed by scar formation. The resulting stricture occurs in the mid to proximal bulbar urethra, with extensive spongiofibrosis, and makes endoscopic treatment ineffective. Another cause of injury is a pelvic fracture accompanied by road traffic accidents. Such an injury shears the membranous urethra completely, creating a distraction defect that is also filled with a scar. These injuries also require a special technique, posterior urethral reconstruction, and are known to be some of the most complex procedures in reconstructive urology.
Inflammatory Stricture From Infection (Gonorrhoea, TB, Lichen Sclerosus)
Gonococcal urethritis due to n eisseria gonorrhoeae is associated with inflammation over the entire length of the urethra. This leads to multiple lesions and strictures in the penile and bulbar urethra. These strictures are difficult to deal with surgically due to their multi locational, lengthy, and complex spongiofibrosis. Lichen sclerosus, previously called balanitist xerotica obliterans (BXO), denotes a chronic, progressive inflammatory condition of the skin, leading to scarring of the glans, prepuce, and distal urethra, which can progress to the proximal urethra as well. Lichen sclerosus strictures also require complex and/or staged urethral reconstruction employing buccal mucosa which is the only graft material that is not affected by this condition. Urogenital tuberculosis can lead to strictures at any level of the urethra that are typically resistant to basic endoscopic interventions, and thus require treatment of the underlying condition along with surgical urethral reconstruction.
Iatrogenic Stricture After Catheterisation or Endoscopic Surgery
Iatrogenic urethral stricture is becoming more common due to more frequent interactions with doctors due to strictures. Commonly caused by deliberate urethral catheterization, TURP, urethroscopy, bladder tumor resections, hypospadias repairs, and radical prostatectomies. The cause is trauma to the urethra which causes a fibrotic response and scarring. When short in length and early in time, iatrogenic strictures at the meatus, fossa navicularis, and bulbar urethra generally respond to OIU. When longer, and particularly when they recur, urethroplasty becomes the procedure of choice. Strictures caused by surgery to connect the bladder and the urethra at the bladder-urethral junction (anastomosis) might require other forms of endoscopic or open surgery.
Long Segment & Recurrent Strictures That Failed OIU
The most common indication for urethroplasty referral is for a recurring urethral stricture that has responded to OIU but has recurred several times within decreasing intervals, and for which the recurrence is accompanied by a prolonged, denser scar. With each OIU, the scarring extends, the spongiofibrosis increases, and the stricture worsens. This deteriorating spiral makes the stricture less and less amenable to correction by endoscopic means. At best, the international consensus prompts the consideration of urethroplasty after the unsuccessful performance of two OIU procedures.
Posterior Urethral Stricture After Pelvic Trauma
Injury to the membranous urethra occurs due to the stretching and rupture of the urethra resulting in complete fibrous tissue obliteration of the contractual space between the prostatic apex and the bulbar urethra in cases of pelvic injury due to high energy trauma. An occasional complication of this kind of injury is the formation of a fibrous stricture where there used to be mucosal stricture. The resection of the obstructed segment of the fibrous stricture followed by perineal deep and skin anastomosis is required to correct this problem. This process involves removal of a section of the pubic bone in complex or repeat surgeries to gain adequate surgical field access.
Compared to symptoms manageable endoscopically, the symptoms that give rise to the need for urethroplasty are, for the most part, more serious, more chronic, and more complex and represent the effects of years of progressive obstruction and multiple interventions.
Severely Weak or Completely Blocked Urine Flow
At the urethroplasty stage, many patients describe a urine stream that is little more than a trickle. Initiating a stream requires significant effort and then produces only a thin filament that takes many minutes to void. In the most severe cases, catheters cannot be passed via the normal route, and a suprapubic catheter has been placed as an emergency measure. This level of obstruction is a surgical emergency.
Recurrent Urinary Tract Infections (UTIs)
Chronic urethral obstruction can lead to recurrent urinary tract infections. Residual urine collects, damaging the urine’s ability to defend against infection. Additionally, a catheter may be present which essentially becomes a breeding ground for bacteria. For men who have suffered three urinary tract infections (UTIs) in a twelve month period, or who have been hospitalized for urosepsis due to a caused by obstruction on their urinary tract, conservative endoscopic methods of management are no longer effective. Recurring urinary infections also create a cycle of worsening urethral obstruction because each infection results in inflammation, which promotes fibrosis in the urethral wall.
Urinary Retention & Need for Emergency Catheterisation
Acute urinary retention, which is the inability to pass urine, is a urological emergency in patients known to have a urethral stricture. If the stricture is so dense that a urethral catheter cannot be negotiated, a suprapubic catheter is quickly placed. A patient who has had one or more episodes of urinary retention due to their stricture is an excellent candidate for urethroplasty, especially if all other endoscopic options have already been employed.
Bladder Stone Formation Due to Chronic Obstruction
Chronic partial urinary bladder voiding due to urethral narrowing is caused by a longstanding urethral obstruction. Over months to years, minerals in stagnant residual urine in the bladder precipitate and form urinary bladder stony concretions, causing pain and hematuria, and urinary stream interruption. This indicates that both the bladder and urinary system are compromised and have been severely obstructed for a long time. The bladder stony concretions are managed both preoperatively and postoperatively around the time of urethroplasty and are done mainly by endoscopic procedures.
Hydronephrosis & Back Pressure on Kidneys
The obstruction of the urethra for a long enough period causes hydroureteronephrosis, which is the dilation of one or both ureters and one or both kidneys due to pressure from the obstruction in the bladder. When the pressure inside the bladder becomes so high that emptying becomes impossible, the pressure is then transmitted to the ureters and kidneys, causing the kidneys to Dilate and deteriorate. The sharp dilation of both kidneys due to the pressure obstruction of the urethra causes renal failure and obstructive kidney disease. The presence of hydronephrosis of any grade along with stricture of the urethra is an emergency condition that requires immediate intervention.
Failed Previous OIU or Dilatation Procedures
The usual case for referral for urethroplasty is a patient who has undergone two or more OIU or urethral dilation procedures with the stricture recurring each time — with shorter periods of relief. Such patients usually spend many years in this cycle until a urologist recommends urethroplasty. The failure of a second OIU for the same stricture is the indicator for commencing urethroplasty. At this point, the literature strongly recommends open urethral stricture reconstruction.
A detailed pre-operative assessment is mandatory. The surgeon must know the exact location, length, multiplicity and tissue characteristics of the stricture before choosing the operative technique. A urethroplasty planned without adequate imaging is a poorly planned urethroplasty.
Retrograde Urethrogram (RGU) & MCU for Stricture Mapping
The RGU-MCU combination is the final radiological map of the whole urethra. RGU is performed under fluoroscopy, with the retrograde injection of contrast dye into the urethral meatus. The anterior urethra is filled and the position, length and severity of any stricture is demonstrated as a filling defect. MCU adds to this by visualising the posterior urethra during voiding and showing the proximal extent of the stricture and any additional pathology at the bladder neck. Together they show the entire length of the stricture, the presence of multiple strictures and the condition of the posterior urethra which are all important for surgical planning.
Urethral Ultrasound for Spongiofibrosis Assessment
Urethral ultrasound or sonourethrography is RGU’s Achilles’ heel in that it delineates the extent and depth of spongiofibrosis in the corpus spongiosum around the urethra. RGU only shows the urethral lumen, while urethral ultrasound shows the full cross-sectional extent of the fibrotic process — directly relevant to graft sizing and reconstruction planning. Strictures characterized by dense, deep spongiofibrosis require greater tissue excision and a larger graft compared to those with superficial scarring. This study is particularly helpful in complex recurrent strictures and in lichen sclerosus.
Uroflowmetry & Post-Void Residual Urine Test
Uroflowmetry offers an objective measure of the degree of urethral obstruction by measuring the maximum and mean rates of urine flow, and establishes a reproducible baseline against which the results of surgery can be compared. Bladder ultrasound for post-void residual (PVR) measurement quantifies the volume of residual urine, assesses the efficiency of bladder emptying and the influence of chronic obstruction on bladder contractility. These measurements, combined with the IPSS symptom score, give a complete functional picture of the severity of stricture.
Urethroscopy for Direct Visualisation of Stricture
Flexible or rigid urethroscopy (direct visual inspection of the urethral lumen) provides information about the size of the residual urethral lumen, the character of the mucosal surface, the length and number of stricture segments, and the condition of the proximal urethra above the stricture. Urethroscopy is also performed at the time of urethroplasty, immediately prior to the incision, to confirm the position of the stricture and plan the precise extent of reconstruction.
Kidney Function Tests & Urine Culture Before Surgery
Pre-operative assessment of renal function (serum creatinine, eGFR and renal ultrasound) is mandatory in patients with long-standing urethral obstruction, as back pressure may have caused silent impairment of renal function. Pre-operative identification of renal impairment allows appropriate anaesthetic and post-operative management. A urine culture is taken prior to surgery to detect any active urinary tract infection that must be cleared before urethroplasty. Operating through infected tissue significantly increases the risk of wound breakdown, fistula formation and graft failure.
Urethroplasty is a complex reconstructive procedure with excellent outcomes when performed by experienced surgeons – but, like all surgical procedures, it has potential risks and complications that every patient should be aware of prior to giving informed consent.
Temporary Urinary Incontinence After Surgery
You may have temporary trouble controlling urine (urgency, frequency, or stress incontinence) during the first few weeks after urethroplasty with the catheter in, or immediately after it is removed. The bladder, blocked for months or years, needs time to adapt to the suddenly unblocked outflow, producing overactive bladder symptoms while it adapts. True permanent incontinence after urethroplasty is rare and primarily a risk in posterior urethral reconstruction close to the external sphincter. Within weeks, most patients will be fully continent as the bladder and sphincter normalize.
Erectile Dysfunction Risk & How It Is Minimised
The cavernosal nerves that provide erection run close to the posterior urethra and external sphincter, which are near the operative field in bulbar and posterior urethroplasty. Transient erectile dysfunction occurs in 10 to 20 percent of patients after bulbar urethroplasty and is most commonly self-limited within three to six months. Permanent erectile dysfunction after urethroplasty is rare, <5% of bulbar urethroplasties in published series. This risk is increased in posterior urethroplasty for pelvic fracture injuries, where the injury itself often damages the cavernous nerves. Dr Vikas Singh attempts to employ nerve sparing techniques i.e. delicate dissection, minimal traction and meticulous tissue handling to prevent iatrogenic nerve injury.
Wound Infection & Fistula Formation
Any perineal or penile surgery carries a risk of surgical site infection, particularly in patients with an active pre-operative urinary tract infection, diabetes, immunocompromise or prior perineal surgery that compromises tissue vascularity. Antibiotics and wound care are used to treat wound infections. Most heal without any adverse effects. Urethral fistula—an abnormal tract from the urethra to the skin surface through which urine leaks—occurs in approximately two to five percent of urethroplasties. This is most commonly due to wound infection, tension on the repair, or graft failure. Small fistulas may close on their own, larger ones require surgical repair after adequate healing.
Stricture Recurrence After Urethroplasty
Urethroplasty may not be a permanent fix, with about 10 to 20 percent of patients having recurrence at five years, most often at the anastomotic junctions. Longer strictures, complex reconstructions, lichen sclerosus and sub-optimal post-operative catheter management or follow-up are associated with higher recurrence rates. A significant practical advantage of OIU over urethroplasty failure is that recurrence after urethroplasty is typically amenable to a one-time endoscopic procedure at the anastomotic junction, while failure of OIU usually requires escalation to open surgery.
Mouth Numbness or Tightness After Buccal Graft Harvesting
Buccal mucosa graft urethroplasty involves taking a strip of lining from the inside of one or both cheeks. The buccal mucosa has a good blood supply, so the mouth heals fast, typically within one to two weeks. Some patients have temporary numbness or tightness in the cheek from which the graft was taken during healing, and occasionally have difficulty with wide mouth opening for the first few days, and less frequently a small area of permanent reduced sensation. Once initial healing has occurred, there is no visible external facial change, no effect on speech, and no impairment of eating from the donor site. The majority of patients report mild, transient mouth discomfort.
Urethroplasty is a technically challenging reconstructive surgery, where surgical experience, meticulous pre-operative planning and appropriate technique selection are directly related to long term results. Here’s why patients from all over Central India trust Dr. Vikas Singh for their urethroplasty:
Urethroplasty is the surgical repair of the urethra and is used to treat urethral stricture. It is indicated when the stricture is too long (over 1.5–2 cm) for successful endoscopic treatment, when the stricture recurs after one or two OIU procedures, when the stricture is caused by lichen sclerosus or dense trauma-related fibrosis, when the posterior urethra is involved after pelvic fracture, or when the patient prefers the most lasting possible result. Urethroplasty has five to ten year stricture-free rates of 80–95% — far superior to the 30–50% achieved by OIU.
The buccal mucosa is the inside lining of the cheek. It is a specialized mucous membrane that is moist, hairless, elastic, highly vascular and resistant to infection. A patch of urethral tissue is taken from the inside of one or both cheeks via a small mouth incision, and used to patch and widen the strictured urethral segment. The mouth heals quickly with little lasting discomfort within one to two weeks. Worldwide, buccal mucosa graft urethroplasty is the gold standard for long bulbar urethral strictures and is superior to any other graft material in terms of durability and resistance to infection.
After urethroplasty, a urethral catheter is kept in place for two to three weeks after surgery — much longer than after OIU (one to five days). This prolonged catheterisation is vital as the catheter acts as a stent to allow the graft or anastomosis to heal over it, keeping the reconstructed urethra open in its intended configuration during the critical healing period. A retrograde urethrogram is often performed at two to three weeks, prior to catheter removal, to confirm the integrity of the repair.
Yes, the goal and the expected result of urethroplasty is a urine flow that is completely normal. Most patients are amazed at the strength and quality of their stream after successful urethroplasty – many have forgotten what a normal stream felt like after years of stricture-related obstruction. Uroflowmetry six weeks post-operatively usually shows a significantly improved maximum flow rate often normalising to above 20 ml/s. And the majority of patients, 80 to 95 percent, maintain that improvement over the long term.
The length of time depends on the type and complexity of the procedure. A simple EPA for a short bulbar stricture takes 1.5 to 2 hours. A buccal mucosa graft urethroplasty for a moderate length stricture takes 2–3 hours. More complicated procedures such as posterior urethroplasty for pelvic fracture, staged urethroplasty, or redo urethroplasty may take 3 to 5 hours or more. All procedures are performed under general or spinal anaesthetic and the patient is comfortable throughout.
Most patients are in hospital for two to five days following urethroplasty. The urethral catheter is left in place for two to three weeks at home, and light daily activities are resumed gradually. Most patients are able to return to desk work within 1 to 2 weeks and to full physical activity within 4 to 6 weeks after removal of the catheter. Heavy manual work or contact sports are to be avoided until specific clearance is given by Dr. Vikas Singh.
Urethroplasty is most commonly performed under general anaesthetic, as the patient needs to be completely still for two to four hours in the lithotomy position to allow the surgeon adequate access to the perineum. Some patients receive spinal anaesthesia alone or with sedation. The choice is determined by the anaesthesiologist and surgeon based on the patient’s medical history, preferences and the anticipated duration of the procedure.
Yes—re-do urethroplasty after a failed prior repair is possible but more technically challenging. Previous surgery leads to scar tissue in the perineum resulting in obscured normal anatomical planes and decreased tissue vascularity. However, experienced surgeons can achieve good results in carefully selected redo cases, although the success rates are somewhat lower than with primary urethroplasty. Dr. Vikas Singh reviews each redo case individually with full imaging and review of previous operative report before suggesting the best revision plan.
Structured and life-long follow-up after urethroplasty. The usual follow-up is uroflowmetry and urine flow studies at six weeks, three months, six months and twelve months after the operation and then yearly. The first sign of recurrence is a decrease in flow rate on uroflowmetry prior to the return of symptoms, leading to early urethroscopic assessment. Patients are also asked to note any change in the urine stream between visits.
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