Johanson Two-Stage Urethroplasty
The Johanson two-stage urethroplasty is a classic reconstructive technique for complex anterior urethral strictures, originally described by Bengt Johanson in 1953 for the management of penile urethral strictures.[1][2] It remains a cornerstone of urethral reconstruction, particularly when single-stage repair is not feasible.
For the BMG / oral-mucosa graft material, see Buccal Mucosa Graft. For the related panurethral one-sided BMG approach, see Kulkarni One-Sided Dorsolateral BMG. For the active-Stage-1-grafting variant (preferred for hypospadias cripples and LS), see Bracka Two-Stage Urethroplasty. For permanent first-stage-only solutions, see Blandy Perineal Urethrostomy and Midline Perineal Urethrostomy.
Historical Background
Johanson originally described the procedure as a marsupialization-and-closure technique for penile urethral strictures.[1] The concept was later modified by Leadbetter (the "Johanson-Leadbetter" technique) and by Fernandes and Draper for bulbomembranous strictures without splitting the scrotum.[3][4] The technique has evolved to incorporate modern graft materials — particularly buccal mucosal grafts (BMG) — replacing the original reliance on local genital skin.[5][6]
Surgical Technique
The procedure is performed in two distinct stages, separated by a maturation interval.
Stage 1 — Marsupialization
| Step | Detail |
|---|---|
| 1 | Strictured segment exposed via ventral midline incision along the penile shaft (or perineum for bulbar strictures) |
| 2 | Urethra opened longitudinally through the full length of the stricture until healthy mucosa is reached proximally and distally |
| 3 | All fibrotic / spongiofibrotic tissue is excised or incised |
| 4 | Marsupialization — urethral edges sutured to surrounding penile skin, creating a flat open urethral plate (essentially a hypospadiac-type urethrostomy) |
| 5 | In modern practice, a buccal mucosa graft may be quilted onto the opened urethral bed to augment the plate when native tissue is insufficient or diseased[6][7] |
| 6 | Suprapubic catheter for ~ 3 weeks of urinary diversion[8] |
Maturation interval
Stage 2 is typically performed 2–6 months after Stage 1 to allow graft / marsupialized tissue maturation and adequate vascularity.[8][9] A time interval shorter than 12 months between first and last stages has been identified as an independent predictor of treatment failure.[9]
Stage 2 — Tubularization
| Step | Detail |
|---|---|
| 1 | Matured urethral plate (with or without incorporated graft) tubularized over a 14–16 Fr catheter |
| 2 | Plate edges mobilized and closed in a tension-free, watertight fashion with absorbable suture |
| 3 | Dartos fascia or spongiosal flap interposed as a second layer to reinforce closure and reduce fistula risk |
| 4 | Suprapubic catheter for ~ 3 weeks[8] |
Indications
The Johanson two-stage approach is preferred over single-stage repair in the following scenarios:[1][2][10]
- Complex penile urethral strictures — particularly circumferential strictures requiring complete urethral plate reconstruction.
- Lichen sclerosus (BXO) — genital skin diseased and unsuitable for flap-based repair.[7][9]
- Failed hypospadias repair — scarred, unhealthy local tissue.[7][11]
- Long-segment strictures (≥ 4–8 cm), multiple strictures, or panurethral disease.[8][12]
- Salvage after multiple failed prior urethroplasties or endoscopic treatments.[8][11]
- Unhealthy local tissue — fistulae, scarring, or prior radiation.[8]
- Patient preference or medical comorbidities precluding extended single-stage operative time.[14]
The AUA 2023 urethral stricture guideline amendment recommends that surgeons may reconstruct long, multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or combinations (Moderate Recommendation, Grade C). Oral mucosa is the first-choice graft material.[13]
Outcomes
| Outcome | Result | Source |
|---|---|---|
| Anatomical success (staged urethroplasty, mixed cohorts) | 89% at median 53 mo | Zimmerman 2010[1] |
| Long-term success — BMG-only staged repair | 96.4% at median 57 mo | Furr 2021[15] |
| Long-term success — STSG staged repair | 53% | Furr 2021[15] |
| Two-stage penile urethroplasty (systematic review) | 90.5% vs 75.7% one-stage penile | Mangera 2011[10] |
| Salvage cohort, improved urine flow | 94% (mean Qmax 17.4 mL/s) | Al-Ali 2001[8] |
| Patient satisfaction (PRO) | 93.5% satisfied / very satisfied | Minami 2025[14] |
A multi-institutional analysis of long-segment strictures (≥ 8 cm, n = 466) found that second-stage Johanson urethroplasty had a higher recurrence rate (35.7%) vs 17.5% for one-stage BMG urethroplasty (p < 0.05).[12] This likely reflects selection bias — staged repairs are reserved for the most complex cases.
When BMG-only staged repairs are analyzed separately, long-term success is excellent at 96.4%, while the addition of a split-thickness skin graft significantly reduces success to 53% (Furr 2021).[15]
Complications
- Fistula formation — most common Stage 2 complication, 6–8%.[7][8]
- Wound dehiscence — ~ 17% in some series.[7]
- Meatal stenosis — ~ 8%.[7]
- Postoperative UTI — ~ 9%.[8]
- First-stage revision before tubularization — required in 17–19%.[11][14]
- Late recurrence — recurrences tend to be delayed (median time to recurrence ~ 78 months); reinforces the need for long-term follow-up.[15]
- Erectile function — SHIM scores show no significant change postoperatively, indicating preservation of EF.[14]
- Cosmetic concerns — aesthetic appearance is the most affected patient-reported dimension.[9]
Modern Modifications and Graft Choice
The original Johanson technique used local penile or scrotal skin for the urethral plate. Modern practice has shifted decisively toward buccal mucosal grafts, which offer superior outcomes due to wet epithelial surface, thick lamina propria, resistance to lichen sclerosus, and favorable graft-take characteristics.[5][6][13] The AUA 2023 amendment recommends oral mucosa as the first-choice graft, with buccal and lingual mucosa considered equivalent alternatives.[13]
Some patients require a three-stage approach — when the first-stage Johanson alone does not provide an adequate urethral plate, an additional grafting stage is performed before final tubularization.[9]
Comparison With Alternatives
- Penile strictures — two-stage Johanson reports significantly better outcomes than one-stage approaches (90.5% vs 75.7%), though follow-up tends to be shorter for two-stage series.[10]
- Bulbar strictures — one-stage dorsal or ventral onlay BMG urethroplasty is generally preferred (~ 88% success with the advantage of a single operation).[10]
- Permanent perineal urethrostomy — essentially a permanent first-stage Johanson; an option when the patient is not a candidate for or declines second-stage closure.[13]
Videos
References
1. Zimmerman WB, Santucci RA. A simplified and unified approach to anterior urethroplasty. Nat Rev Urol. 2010;7(7):386-391. doi:10.1038/nrurol.2010.79.
2. Chapple C, Andrich D, Atala A, et al. SIU/ICUD consultation on urethral strictures: the management of anterior urethral stricture disease using substitution urethroplasty. Urology. 2014;83(3 Suppl):S31-S47. doi:10.1016/j.urology.2013.09.012.
3. Fernandes M, Draper JW. Two-stage urethroplasty: improved method for treating bulbomembranous strictures. Urology. 1975;6(5):568-575. doi:10.1016/0090-4295(75)90504-x.
4. Alexander RM, Spadaro JJ, Stripling JR, et al. Surgical treatment of urethral stricture. South Med J. 1977;70(12):1405-1406. doi:10.1097/00007611-197712000-00007.
5. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. 1999;83(6):631-635. doi:10.1046/j.1464-410x.1999.00010.x.
6. Palminteri E, Lazzeri M, Guazzoni G, Turini D, Barbagli G. New 2-stage buccal mucosal graft urethroplasty. J Urol. 2002;167(1):130-132.
7. Figler BD, Gomella A, Hubbard L. Staged urethroplasty for penile urethral strictures from lichen sclerosus and failed hypospadias repair. Urology. 2018;112:222-224. doi:10.1016/j.urology.2017.10.020.
8. Al-Ali M, Al-Hajaj R. Johanson's staged urethroplasty revisited in the salvage treatment of 68 complex urethral stricture patients: presentation of total urethroplasty. Eur Urol. 2001;39(3):268-271. doi:10.1159/000052451.
9. Palminteri E, Gobbo A, Preto M, et al. The role of multi-staged urethroplasty in lichen sclerosus penile urethral strictures. J Clin Med. 2022;11(23):6961. doi:10.3390/jcm11236961.
10. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011;59(5):797-814. doi:10.1016/j.eururo.2011.02.010.
11. Kozinn SI, Harty NJ, Zinman L, Buckley JC. Management of complex anterior urethral strictures with multistage buccal mucosa graft reconstruction. Urology. 2013;82(3):718-722. doi:10.1016/j.urology.2013.03.081.
12. Warner JN, Malkawi I, Dhradkeh M, et al. A multi-institutional evaluation of the management and outcomes of long-segment urethral strictures. Urology. 2015;85(6):1483-1487. doi:10.1016/j.urology.2015.01.041.
13. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.
14. Minami T, Horiguchi A, Shinchi M, et al. Surgical and patient-reported outcomes of staged urethroplasty for anterior urethral strictures: a comprehensive analysis. Int J Urol. 2025;32(4):441-446. doi:10.1111/iju.15679.
15. Furr JR, Wisenbaugh ES, Gelman J. Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence. World J Urol. 2021;39(10):3903-3911. doi:10.1007/s00345-021-03676-8.