Endoscopic Urethroplasty
Endoscopic urethroplasty refers to fully transurethral delivery of a buccal mucosa graft (BMG) into the posterior urethra using an endoscopic suturing platform — an emerging approach for selected membranous-urethral and vesicourethral-anastomotic stenoses. The aim is graft augmentation without an external incision; the small published cohorts do not establish durability equivalent to established reconstruction. Two named techniques are described — the Warner technique (Ungerer 2023, n = 1) for membranous urethral stricture and the Doležel endourethroplasty (2024, n = 11) for refractory PUS / VUAS.[1][2]
For the broader VUAS / posterior-urethral-stenosis decision framework, see Bladder Neck Reconstruction & VUAS. For the open perineal benchmark, see Dorsal Onlay BMG Urethroplasty. For the standalone graft material, see Buccal Mucosa Graft. For the related transmeatal anterior-urethral application, see Transmeatal OMG Ventral Inlay.
Why Endoscopic Posterior BMG
Endoscopic treatment outcomes for posterior stenosis vary substantially with etiology, luminal patency, radiation exposure and prior treatment; a single recurrence percentage should not be applied to all posterior stenoses. Established reconstruction may use excision and anastomosis, a flap, or graft augmentation, with different morbidity and continence risks.[3][6] Endoscopic BMG urethroplasty was developed to deliver the augmentation principle through the lumen, sparing the perineum.
Warner Technique — Membranous Urethral Stricture (Ungerer 2023)
Index case. Male with prostate-cancer-related radiation therapy and an 8 mm flow-limiting membranous urethral stricture — a population where open repair carries higher recurrence and morbidity.[1]
Step-by-step.[1]
| Step | Detail |
|---|---|
| 1. Stricture dilation | Membranous stricture dilated to allow resectoscope passage; defines proximal / distal extent |
| 2. Graft-bed preparation | Resectoscope used to resect a 1 cm-wide strip of superficial mucosa from the bladder neck across the strictured segment, creating a vascularized recipient bed for imbibition / inosculation |
| 3. BMG harvest | Standard inner-cheek BMG; defatted and trimmed on the back table |
| 4. Pulley delivery | With graft outside the urethra, the RD 180 endoscopic suturing device is passed transurethrally; a suture is placed through the proximal graft, then through the bladder neck, then back through the graft. Pulling the suture advances the graft into the correct intraluminal position |
| 5. Anchoring | Graft anchored against the prepared bed using secure straps from the suturing device |
| 6. Catheter | Catheter holds the graft flat against the bed during healing; removed at 4 weeks |
Outcome (n = 1).[1]
| Metric | Result |
|---|---|
| Operative time | 2.5 hours |
| EBL | 50 mL |
| Discharge | Same day |
| Catheter | Removed POD 28 |
| Cystoscopy at 10 wk | Good graft viability |
| Qmax | 4 → 20 mL/s |
| 6-month follow-up | No recurrence; no complications |
Potential advantages. Entirely transurethral delivery and same-day discharge were feasible in this case. Comparative efficacy and safety, including in irradiated tissue, remain unestablished.
Limitations. Single-case-report evidence; requires the RD 180 suturing device and endoscopic-suturing skill; only 6-month follow-up; reproducibility across centers not yet demonstrated; graft fixation relies on suture anchoring + catheter compression alone (no quilting sutures as in the Nikolavsky ventral inlay).
Key instrumentation. The RD 180 endoscopic suturing device is the enabling technology — its pulley mechanism is what allows graft delivery into the confined posterior-urethral space without an external incision. The same device is also used in TUITMR mucosal-realignment techniques.[1][3]
Doležel Endourethroplasty — PUS / VUAS (2024)
Series. Single Czech institution, 1999–2022, 38 consecutive patients with refractory posterior urethral stenosis (PUS) or vesicourethral-anastomotic stenosis (VUAS) after failed prior endoscopic treatment. Twenty-seven patients (71%) had a perineal approach; 11 patients (29%) had endourethroplasty (EUP). Etiologies included post-radical-prostatectomy VUAS and post-TURP / post-radiation membranous stenosis.[2]
Technique. Transurethral delivery of BMG configured as either onlay or tubular graft into the stenotic segment:[2]
- Endoscopic assessment of stenosis length, location, and degree of obliteration.
- Stenotic segment dilated and / or incised endoscopically to open the lumen and create space for graft placement.
- Standard inner-cheek BMG harvest.
- Endourological delivery of the graft into the dilated / incised stenosis — onlay (laid onto the opened stricture bed, analogous to open onlay urethroplasty) or tubular (fashioned into a tube to replace a circumferential defect).
- Graft secured in position; catheter placed for stenting during healing.
Auxiliary cold-knife DVIU. A pragmatic feature of the Doležel protocol: if PUS or VUAS recurs as a short stenosis within the first 12 months, it is transected by a single cold-knife DVIU. The report presents both recurrence-free survival and survival allowing this additional treatment. An auxiliary DVIU remains a reintervention and must be counted when comparing treatment burden.[2]
Outcomes.[2]
| Cohort | 3-yr stricture-recurrence-free survival |
|---|---|
| Endourethroplasty (n = 11) | 73% |
| Perineal approach (n = 27) | 63% |
| Whole cohort | 65% |
| Whole cohort with permitted auxiliary DVIU | 81% |
De novo incontinence occurred in 2 of 18 preoperatively continent patients across both groups. This is not an endourethroplasty-specific rate and cannot establish a continence advantage over separate robotic series.
What the series adds. It reports a three-year recurrence endpoint and documents technical feasibility. The small, nonrandomized groups cannot establish superiority over the perineal approach.
Limitations. Small, heterogeneous cohort (n = 11 EUP); single-center retrospective design; the published report describes the graft transfer as "endourological" but does not specify the suturing device or fixation method in the same detail as the Warner technique; auxiliary-DVIU protocol complicates head-to-head comparison with techniques that count any reintervention as failure.
Published Technique Comparison
| Feature | Warner (Ungerer 2023) | Doležel Endourethroplasty (2024) |
|---|---|---|
| Target anatomy | Membranous urethral stricture | PUS / VUAS (membranous + bladder neck) |
| Graft configuration | Onlay (on resected mucosal bed) | Onlay or tubular |
| Graft-bed preparation | Resectoscope mucosal-strip resection (1 cm wide) | Dilation / incision of stenosis |
| Graft delivery | RD 180 suturing device + pulley technique | Endourological (device not specified) |
| Graft fixation | Suture straps + catheter compression | Not detailed |
| Catheter duration | 4 weeks | Not specified |
| Sample size | 1 (case report) | 11 (institutional series) |
| Follow-up | 6 months | 3 years |
| Reported outcome | Patent at 6 months (1 patient) | 73% three-year SRFS in 11 endourethroplasty patients; 81% with auxiliary DVIU applies to all 38 patients |
| De novo incontinence | None (1 patient) | 2 / 18 continent patients (combined groups) |
| Auxiliary DVIU | None used | Permitted within 12 months as protocol |
| Primary etiology | Post-radiation | Mixed (post-prostatectomy, post-TURP, post-radiation) |
| Technical-detail published | High (step-by-step + device specifics) | Moderate |
Open Perineal D-BMGU as Benchmark
For context, these observational series describe open perineal dorsal onlay BMG urethroplasty (D-BMGU) in selected posterior stenosis populations:
- Angulo 2021 (multi-institutional, n = 107, membranous / bulbomembranous after endoscopic prostate procedures): mean follow-up 59.3 months; 9.35% recurrence; 0.9% de novo SUI. Independent recurrence predictors: postoperative complications (OR 12.5), prior radiation (OR 8.3), and ≥ 2 prior dilations (OR 8.3).[4]
- Sterling 2024 (multi-institutional, n = 45, post-prostatectomy / post-radiation VUAS): 7 recurrences at median 21 months; no de novo incontinence; 86.6% satisfaction (GRA ≥ +2).[5]
These are different populations and treatment settings, not a direct comparison. Their results do not establish equivalent success, lower morbidity, or an approach-independent radiation effect. Larger prospective comparative studies are needed.
Where It Fits
Endoscopic posterior BMG urethroplasty remains an emerging technique with limited clinical evidence. Published applications include:
- Post-radiation membranous stricture in patients unfit for or declining open / robotic perineal reconstruction.
- Post-prostatectomy VUAS where the bladder-neck stenosis is short and amenable to endoluminal graft placement.
- Centers with established endoscopic-suturing experience and access to the RD 180 platform.
Selection requires reconstructive assessment of stenosis location, obliteration, tissue quality, bladder function and continence goals. Complete posterior obliteration should not undergo endoluminal incision. The tubular graft configurations reported in this series should not be generalized into a routine recommendation; established guidance discourages single-stage tubularized free graft reconstruction.[6][7] See BNC / VUAS for the broader treatment pathway.
References
1. Ungerer G, Kemble J, Sischka M, Balzano FL, Warner JN. Endoscopic urethroplasty using buccal graft for male membranous urethral stricture. Urology. 2023;181:e200-e203. doi:10.1016/j.urology.2023.05.059.
2. Doležel J, Hrabec R, Uher M, et al. Substitution urethroplasty with buccal mucosal graft in the management of stricture of vesicourethral anastomosis or membranous urethra: single-institution long-term experience with perineal approach and endourethroplasty. Urology. 2024;192:126-132. doi:10.1016/j.urology.2024.05.034.
3. Hudson CN, Damm T, Monn MF. Minimally invasive treatments for posterior urethral stenosis. J Endourol. 2025. doi:10.1177/08927790251371037.
4. Angulo JC, Dorado JF, Policastro CG, et al. Multi-institutional study of dorsal onlay urethroplasty of the membranous urethra after endoscopic prostate procedures: operative results, continence, erectile function and patient-reported outcomes. J Clin Med. 2021;10(17):3969. doi:10.3390/jcm10173969.
5. Sterling J, Simhan J, Flynn BJ, et al. Multi-institutional outcomes of dorsal onlay buccal mucosal graft urethroplasty in patients with post-prostatectomy, post-radiation anastomotic stenosis. J Urol. 2024;211(4):596-604. doi:10.1097/JU.0000000000003848.
6. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. 2026. Guideline.
7. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210:64-71. doi:10.1097/JU.0000000000003482.