Substitution urethroplasty for posterior urethral stenosis

Introduction

Posterior urethral stenosis is characterized by luminal narrowing of the urethra spanning the bladder neck, prostatic urethra, and membranous urethra. As opposed to anterior urethral narrowing, which is termed “stricture” and characterized by spongiofibrosis, posterior urethral narrowing is more accurately deemed “stenosis” due to the lack of investing corpus spongiosum surrounding these segments of the urethra (1). Anterior urethral stricture is significantly more common than posterior urethral stenosis, representing 92% of all urethral stricture, and as such posterior urethral stenosis is comparatively less well-studied (2).

Posterior urethral stenosis most commonly occurs following traumatic urethral injury or iatrogenically after treatment for benign prostatic hyperplasia (BPH) or prostate cancer. Outlet procedures for BPH, including transurethral resection, holmium laser enucleation, photoselective vaporization, and other modalities, are estimated to lead to posterior urethral stenosis in 0.3–9.7% of patients (3). Treatment for prostate cancer leads to posterior urethral stenosis in 1–5% of patients, with rates varying by modality between patients who undergo radical prostatectomy, external beam radiation therapy, brachytherapy, or ablative techniques such as cryotherapy or high-intensity focused ultrasound (4-6). The etiology of stenosis will impact the location of the scar. After prostatectomy, for example, the vesicourethral anastomotic stenosis (VUAS) remains near the level of the membranous urethra, with the bladder brought down distally (often facilitated by a Rocco stitch). For pelvic fracture urethral disruption, the bladder may be displaced superiorly due to hematoma, and therefore, the location will be more difficult to access perineally. In some cases, an abdominal approach may be more suitable.

Like anterior urethral stricture, mainstays of treatment for posterior urethral stenosis include endoscopic dilation or incision, and reconstruction via endoscopic, excisional, or substitution urethroplasty. Here, we outline our technique for an open perineal approach to substitution urethroplasty of posterior urethral stenosis, which expands upon the principles of dorsal onlay buccal mucosa graft (BMG) placement with unilateral urethral dissection as described by Barbagli et al. and Kulkarni et al. (7,8). We highlight important perioperative considerations, possible pitfalls, and methods to avoid them, and briefly discuss outcomes of substitution urethroplasty compared to alternative reconstructive techniques. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-566/rc).

Preoperative preparations and requirements

Preoperative workup for posterior urethral stenosis includes a thorough history and physical exam, labs, imaging, and several important adjunctive studies. Patients should be questioned specifically on urologic history, including urinary symptoms, the nature and timeframe of their primary complaint, infectious history, as well as history of pelvic trauma, urethral or pelvic surgery, or other intervention such as radiotherapy. Particular attention should be paid to characterizing the presence and degree of urinary incontinence, including stress or urgency symptoms, as well as current and prior pad usage to determine if stenosis is now masking leakage. For oral mucosa harvest, it is prudent to inquire about the patient’s preferred laterality of mastication; for instance, in predominantly right-sided chewers, buccal mucosa should be harvested from the left cheek when possible. At the time of surgery, communication with the anesthesia team is important to ensure the endotracheal tube is taped toward the contralateral side of planned harvest. History of oral surgery or radiation to the head and neck and smoking history should also be noted.

Multiple validated questionnaires are provided to patients preoperatively both to elicit necessary history and symptoms, and to allow for objective changes postoperatively. These patients reported outcome measures include the International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), Male Sexual Health Questionnaire, and Urethral Stricture Symptom and Impact Measure, among others (9,10).

Regarding laboratory testing, a urinalysis with microscopic examination and urine culture are always indicated. Hemoglobin A1c should be assessed, and strict preoperative glycemic control emphasized in diabetic patients. Prostate-specific antigen should be sent in patients with prostate cancer to screen for recurrence.

Imaging typically includes retrograde urethrography (RUG) and/or voiding cystourethrography (VCUG). Cross-sectional imaging via computed tomography or magnetic resonance imaging can be useful, particularly in cases with traumatic etiology, or where there is concern for upper urinary tract insult or concomitant fistula. Uroflowmetry and post-void residual volume measurement is typically performed, and formal urodynamic testing can be helpful in patients where the nature of voiding dysfunction is not clear. Cystourethroscopy can be helpful for preoperative planning to assist in determining the location and caliber of the stenosis, the quality of the urethral tissue, the presence of calcification or necrosis, and the proximity to the urethral sphincter.

A period of urethral rest is necessary to allow for maturation of scar tissue in order to accurately stage the length and degree of stenosis at the time of repair (11). This is accomplished by avoidance of urethral instrumentation, typically for a period of 4 to 6 weeks. In those who retain urine or develop severe symptoms or infection from outlet obstruction, suprapubic catheter (SPT) placement is warranted to achieve urethral rest (12).

The procedure is performed in an operating theater under general anesthesia, typically by an experienced urologist often with specialty training in genitourinary reconstruction. As with any specialized surgical procedure, a consistent and well-versed surgical team is paramount for quality control, maintaining intraoperative safety, and affording good outcomes.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Individual consent for the retrospective analysis was waived.

Step-by-step description

Our patients receive culture-directed antibiotics prior to incision; in the absence of a positive urine culture, combination prophylaxis is preferred using a first- or second-generation cephalosporin (e.g., cefazolin) with gentamicin. If an SPT is in place, the bladder is irrigated with antibiotic solution (saline mixed with vancomycin and gentamycin) while the patient is still supine. Subcutaneous heparin and sequential compression devices are administered for deep vein thrombosis prophylaxis as appropriate based on individualized risk stratification (13).

The patient is placed in a moderate lithotomy position, and mild Trendelenburg tilt may be applied for ease of visualization. We begin with antegrade or retrograde cystoscopy. In the case of an indwelling SPT, antegrade cystoscopy is performed through the suprapubic tract towards the urethra until the strictured lumen is encountered. A wire is then placed in antegrade fashion, externalized through the urethral meatus, and secured outside the body. A council-tip catheter is inserted over the wire through the suprapubic tract and advanced antegrade until gentle resistance is met at the proximal margin of the stenosis, at which point the catheter is fixed in place with a Kelly clamp (Figure 1). Methylene blue is injected into the urethral meatus using an angiocatheter in order to differentially stain urethral mucosa (Figure 2). An 18-French red rubber catheter is inserted alongside the wire through the urethral meatus until resistance is encountered at the distal margin of the stenosis. This catheter is affixed to the wire using a transparent sterile adhesive dressing in order to prevent migration during the procedure. The perineal Bookwalter retractor is positioned, and electrocautery is set to 35 Watts pure-cut and 35 Watts coagulation.

Figure 1 Patient positioning for posterior urethroplasty, including antegrade wire and council-tip Foley catheter placement via suprapubic tract.

Figure 2 Instillation of intraurethral methylene blue via angiocatheter.

A midline perineal incision is made. Skin is incised sharply, and subcutaneous tissue and Colles’ fascia are divided with electrocautery until the bulbospongiosus muscle is encountered. Rake blades are used with the perineal Bookwalter retractor to provide adequate exposure (Figure 3). The periurethral tissue at the superior aspect of the muscle is incised to create separation between the muscle and the urethra. This plane is carried laterally to clear off the corpus cavernosum adjacent to the urethra on one side (typically the patient’s left side). For cases without complete urethral obliteration, dissection is performed unilaterally to limit unnecessary disturbance of normal anatomy on the contralateral side, as previously described by Kulkarni et al. (8,14). A narrow Deaver retractor is placed on the corpus cavernosum and slid downward, taking care not to dig into the muscle or bulb. The assistant holds the Deaver outward to retract the muscle away from the urethra and corpora, and the surgeon uses DeBakey forceps positioned vertically to grab the muscle in a paramedian fashion just lateral to the midline urethral attachments (Figure 4). The bulbospongiosus is then divided with cautery, thereby exposing the urethra (Figure 4). Alternatively, if circumferential urethral exposure is necessary (as in the case of complete obliteration) the bulbospongiosus is split at the midline tendinous raphe and retracted laterally. A ratcheted Richardson retractor for the perineal Bookwalter is exchanged in place of rake retractors in order to retract the muscle atraumatically. Three 4-0 polydioxanone (PDS) stay sutures are placed at the 3 o’clock position along the exposed urethra and passed to the patient’s right side to aid exposure of the left dorsal corporal-urethral margin (Figure 5).

Figure 3 Initial perineal dissection of subcutaneous tissue, highlighting positioning of rake retractors for the perineal Bookwalter.

Figure 4 Unilateral division of the bulbospongiosus muscle. A Deaver retractor is used to create atraumatic lateral tension.

Figure 5 Placement of urethral retraction sutures for lateral and posterior dissection. Note the inferolateral perineal Bookwalter retractor arm has been replaced by a Richardson retractor for atraumatic retraction of the bulbospongiosus muscle.

The urethra is sharply dissected from the corpora cavernosa posteriorly (Figure 6). The septum is crossed, and the triangle created by the crural divergence is exposed. The dissection should be extensive enough to allow for a urethrotomy to extend approximately 1cm proximal and distal to the stenotic segment. Care should be taken to limit dorsal dissection in order to preserve longitudinal rhabdosphincter fibers related to continence (14). In addition to striated muscle of the sphincteric urethra, the membranous urethra contains smooth muscle fibers dorsally, which provide support and assist in urethral closure, and may impact continence if disrupted during dissection (15). The urethral red rubber catheter is exchanged for a bougie a boule, and a dorsal longitudinal urethrotomy is created over the bougie using a #15 blade, until the methylene blue staining the urethral mucosa is visualized (Figure 7). The urethrotomy is extended distally until healthy mucosa and patent lumen are encountered. Stay sutures of 4-0 PDS are placed on the urethral cut edge in an inside-out then outside-in fashion, then clamped and rotated laterally to the right in order to reflect the urethral edge and aid in hemostasis (Figure 8). The urethrotomy is then carried proximally using Metzenbaum scissors, and additional stay sutures are placed as necessary. At this point, a fresh 15-blade on a long handle is used to continue the dorsal urethrotomy. When possible, the distal end of the wire is delivered through the urethrotomy and the RaViNi-C retractor (lighted urethral speculum with council-tip adapter) is advanced over the wire (Figure 9). A wedge-shaped segment of fibrotic tissue is excised between the 11 and 1 o’clock positions (Figure 10). The retractor is periodically advanced and spread wider as possible. Once the lumen can accommodate 18 French, the RaViNi-B retractor (lighted urethral speculum with blunt-tip suction adapter) is placed into the urethra (Figure 10). The RaViNi lighted urethral speculum was specifically designed for deep perineal dissection, and while it has not been previously published, their use in the posterior urethra greatly facilitates dissection and visualization. In the case of SPT, proximal urethrotomy is extended until the tip of the previously-placed council-tip catheter is encountered, which is then backed out of the way. Excision of fibrosis is continued until we have achieved a smooth graft bed and the desired degree of patency.

Figure 6 Sharp lateral (A) and posterior (B) dissection of the urethra to free it from the corpora cavernosa.

Figure 7 Urethrotomy creation via direct incision onto a bougie a boule. Note the visualization of methylene-blue-stained urethral mucosa.

Figure 8 Placement of urethral mucosal retraction sutures via an in-to-out (A), out-to-in (B) technique, facilitating lateral reflection of the mucosal cut edge (C).

Figure 9 Urethral exposure using the RaViNi-C lighted urethral speculum with council-tip adapter.

Figure 10 Urethral scar excision and exposure using the RaViNi-B lighted urethral speculum with blunt-tip suction adapter.

When there is complete urethral obliteration, a similar approach to a pelvic fracture urethral injury can be employed, with circumferential dissection of the bulbar urethra and transection at the level of the distal stenosis. In some cases, antegrade cystoscopy can be performed through a suprapubic tract, and a retrograde spinal needle passage can determine the correct plane of dissection. Alternative methods to guide dissection include placement of a curved van Buren dilator through the suprapubic tract to palpate from the distal aspect of the urethral disruption, or visualization of the light from an antegrade cystoscope passed through the suprapubic tract.

Once the proximal extent of the stenosis is traversed, the apical sutures are pre-placed using 5-0 double-armed PDS sutures. One of the needles is bent slightly to create a J-hook or “ski” needle (so-called for its resemblance to the tip of a ski-straight with a short distal curve), as described by Tuner-Warwick (Figure 11) (16). This needle is grasped in parallel with the needle driver and placed outside-in at the junction of the graft bed and the healthy proximal urethra. A second needle driver grabs the tip of the needle to pull it through (Figure 12). The ski needle is cut, and the two ends of the suture are secured. For very deep proximal defects, the RD-180^® suture device (LSI Solutions, Victor, NY, USA) can be used instead for ease of placement. Two additional apical sutures are placed, and the perineal wound is packed with a moist sponge.

Figure 11 The J-hook or “ski-shaped” needle configuration for deep proximal apical suture placement. Note that the needle is grasped parallel to the long axis of the needle driver.

Figure 12 Placement of the proximal apical sutures. Note the use of two needle drivers to facilitate passage of the J-hook or “ski” needle.

An appropriately-sized BMG harvest is then performed as previously described by Morey and McAninch (17). The BMG is secured distally to the exposed corpora with a temporary 5-0 PDS stay stitch. The needles of the pre-placed proximal apical sutures are then passed “outside-in” through the BMG (in through lamina propria, out through mucosa) in corresponding positions to the location along the proximal urethra (Figure 13). The graft is parachuted into place, and the sutures are tied. The distal fixation stitch is then cut, the graft stretched to span the urethral defect in a tension-free manner, trimmed, and again fixed at the distal apex. Quilting of the graft is then performed. The midline proximal apical suture (12 o’clock) is continuously run distally for quilting, and two additional quilting suture lines are run longitudinally on either side. Alternative methods of graft fixation include the use of the RD-180^® suture placement device, tissue adhesive such as fibrin sealant, or a surgical “sewing machine” device using barbed suture placed via a hollow-bore needle (18-21). The right-most apical suture is then run from proximal to distal to form the right-sided anastomosis, ensuring each bite is through urethra, periurethral backing, and graft (Figure 14). A second suture is run from the distal apex proximally along the right-sided anastomosis, and the two sutures are tied in the middle. The left-sided anastomosis is closed in a similar manner (Figure 15). Prior to completing the anastomosis, cystoscopy can be performed to assess graft placement and luminal caliber. A 16-French silicone catheter is passed into the meatus and out through the urethrotomy, then redirected through the proximal portion of the urethra and into the bladder, and the balloon is inflated (Figure 16).

Figure 13 Initial placement of BMG, including temporary distal fixation and apical suture passage. BMG, buccal mucosa graft.

Figure 14 Right-sided urethral anastomosis.

Figure 15 Left-sided urethral anastomosis.

Figure 16 Foley catheter placement, delivering the catheter through the urethral defect before passing into the bladder via the proximal reconstructed urethra.

The bulbospongiosus muscle is reapproximated with 3-0 PDS, and fibrin sealant is placed between the muscle and urethra (Figure 17). Colles’ fascia is closed in two layers, and the skin is reapproximated. Local anesthetic is injected along the incision, and topical tissue adhesive is applied. Figure 18 provides an illustrative depiction of the described technique for substitution urethroplasty.

Figure 17 Reapproximation of the bulbospongiosus muscle.

Figure 18 Illustrative depiction of substitution urethroplasty, including urethral dissection (A), excision of scar (B,C), graft placement (D,E), and urethral closure (F).

Postoperative considerations and tasks

Posterior urethroplasty patients are typically admitted overnight. A Foley catheter is left in place for 3 weeks, at which point RUG is performed to ensure no extravasation of contrast prior to decatheterization. If the patient has an indwelling SPT, it is typically left in place and capped for an additional 2 to 3 weeks, as a safety mechanism in case of urinary retention. The patient is seen at 4-month intervals for the first year, with uroflowmetry, assessment of post-void residual volume, and health questionnaires. Cystoscopy is performed at 1 year to evaluate the repair. Patients are seen annually thereafter. Typical criteria used to determine operative success include patient-reported outcome measures, uroflowmetry, and urethral calibration, often via cystoscopy.

The oral mucosa harvest site is typically left open to heal secondarily, and patients are discharged with “magic mouthwash” (lidocaine, aluminum hydroxide, magnesium hydroxide) as needed for comfort. Diet is advanced as tolerated, with patients counseled on the option of soft foods or liquids to start.

There are conflicting practices regarding graft site closure in the literature. While some have argued that closing the harvest site assists in immediate hemostasis and wound healing, others contend that wound closure leads to increased postoperative pain, numbness, and difficulty opening the mouth widely. A number of randomized trials have been performed comparing closure to non-closure of buccal harvest site (22-26). Systematic review and meta-analysis of these trials have shown no significant long-term differences in pain, oral contracture, or perioral numbness, however immediate postoperative pain levels may be slightly higher in those whose wounds are closed (27,28).

Tips and pearls

Unilateral dissection of the bulbospongiosus muscle and urethra limits disturbance of normal anatomy, including neurovascular supply and muscular support, which may improve postoperative outcomes such as continence (8,14).

There are several ways to visualize the posterior urethra, including a 12-French nasal speculum, Turner-Warwick/Teale grooved gorget, or a lighted urethral speculum (RaViNi). The authors have used each of these options and prefer the lighted speculum when possible.

RaViNi retractors were specially built for deep perineal dissection, with beak diameter and length, angle, and variations for council-tip, suction, and lighting. Their use greatly facilitates the dissection and visualization of the posterior urethra.

Limit dorsal dissection to prevent rhabdosphincter injury and maximize preservation of continence (14,15).

Avoid cautery in the graft bed site due to the risk of nerve injury. Placement and quilting of the graft are usually effective at achieving adequate hemostasis.

There are different techniques for graft fixation. Here, we described running sutures; however, other methods include the use of the RD-180^® suture placement device, adhesive solution such as fibrin sealant, and the use of a barbed suture through a hollow-bore needle (18-21).

Discussion

While direct comparison of urethroplasty techniques is challenging due to the variety of outcome measures used throughout the literature, substitution urethroplasty offers several unique advantages over excision with primary anastomosis (EPA) for the treatment of posterior urethral stenosis. Commonly cited outcomes include postoperative urinary continence, sexual function, patient satisfaction, and procedure success. This last point has a variable definition and may be defined as need for retreatment, recurrent stenosis on cystoscopy, poor peak flow rate on uroflowmetry, and/or weak stream on patient questionnaire (29). Success of EPA for posterior stenosis, as defined by not requiring repeat instrumentation or intervention, has been cited between 65% and 95% (30-33). Success rates of substitution urethroplasty in this setting are similar, ranging from 63% to 91% (34-38). Excisional urethroplasty for posterior urethral stenosis has historically demonstrated poor outcomes with regards to continence, with rates of de novo incontinence ranging from 18% to 50% (31-33,39). This is thought to be related to anatomic disruption of sphincteric muscle fibers and nerves, which are in close proximity to the membranous urethra (40). Transecting the urethra also disrupts circular and longitudinal smooth muscle fibers within the urethral wall that contribute to intrinsic continence, which may predispose patients to incontinence. By avoiding complete urethral transection, these important structures are relatively preserved in substitution urethroplasty. Accordingly, rates of de novo incontinence after substitution urethroplasty with BMG are significantly better, with recent cohorts ranging from 0% to 11% (34-36,38).

Policastro et al. reported results from a multi-institutional cohort of patients who underwent dorsal onlay urethroplasty for radiation-induced posterior urethral stenosis, noting recurrence rate of 17.7% and a de novo incontinence rate of 8.1% (34). A subsequent study by Sterling et al., which included 45 patients with post-radiation posterior stenosis, found a recurrence rate of 15.6% following dorsal onlay BMG urethroplasty, with zero incidents of de novo incontinence at a mean follow-up of 21 months (36). Angulo et al. reported multi-institutional outcomes following dorsal onlay urethroplasty for posterior stenosis after endoscopic prostate procedures, citing a 9.35% recurrence rate with only one case of new-onset urinary incontinence in a cohort of 107 patients (0.9%) (35). Vetterlein et al. studied a cohort of 47 patients who underwent ventral onlay urethroplasty for radiation-induced stricture, noting a 33% recurrence rate, defined as symptomatic need for any instrumentation (37). Recently, results of a single-center cohort of 27 patients undergoing posterior BMG urethroplasty published by Doležel et al. showed a recurrence rate of 37%, with de novo incontinence reported in 11% of patients (38). A subset of patients from our own institution with VUAS following a combination of prostatectomy and radiation included 18 patients across a 10-year period who underwent dorsal onlay BMG urethroplasty using the technique described herein. At a median follow-up of 39.9 months, success was seen in 89% of patients, with no cases of de novo incontinence (41).

To date, there have been no prospective randomized trials directly comparing EPA to substitution urethroplasty for posterior urethral reconstruction, however the Scandinavian Urethroplasty Study compared EPA to BMG urethroplasty for bulbar urethral strictures (42). In a population of 151 patients who underwent urethroplasty, those who received EPA reported higher rates of penile complications such as decreased glans filling (19% vs. 6.8%), and penile shortening (26% vs. 5.4%) when compared to BMG urethroplasty, though overall erectile function did not differ between groups (42). Stricture recurrence rate, defined as need for additional intervention, was similar between the two groups at 12-month follow-up (12.9% overall), though the study was notably not designed to detect differences in recurrence (42).

One additional benefit to using BMG is the ability to treat longer or multifocal strictures. Excisional urethroplasty is limited by length, as longer segments of disease would lead to high-tension anastomosis and/or penile shortening. This is reflected in European Association of Urology guidelines, which recommend that stenoses longer than 2.5 cm be treated with augmentation urethroplasty (43). Furthermore, buccal mucosa can be used to repair other areas of urethral stricture in addition to posterior stenosis if present, such as bulbar, pendulous, or meatal/fossa navicularis, whereas multifocal excisional urethroplasty may compromise urethral blood flow.

Conclusions

In summary, substitution urethroplasty with the use of BMG is an effective technique for posterior urethral reconstruction. This approach offers notable advantages over excisional anastomotic urethroplasty with regards to penile complications and de novo development of stress urinary incontinence. Our technique combines previously-described methods and innovative technologies to present a simplified and reproducible approach to an otherwise challenging operation. Important maneuvers include unilateral urethral dissection, graft fixation using laparoscopic suturing devices, fibrin glue, or barbed suture sewing machine, and use of the RaViNi lighted urethral speculum for improved exposure.

Acknowledgments

We would like to acknowledge Gabriela A. Nikolavsky for illustrations of Figure 18.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jay Simhan and Samuel Ivan) for the series “A Contemporary Approach to Complex Posterior Urethral Reconstruction” published in Translational Andrology and Urology. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-566/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-566/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-566/coif). The series “A Contemporary Approach to Complex Posterior Urethral Reconstruction” was commissioned by the editorial office without any funding or sponsorship. D.N. serves as secretary treasurer for the Society of Genitourinary Reconstructive Surgeons (GURS). He received a patent for the hollow-needle suturing device which is described in this manuscript. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Individual consent for retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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