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Male Urethroplasty — Incisions & Approaches

For male urethroplasty, the surgeon's first decisions are how to incise the skin and how to access the urethra. This reference page organizes the choices by skin incision, penile-stricture exposure, anterior urethrotomy approach, posterior approach, graft / tissue placement, flap-based technique, and one-stage vs staged. Outcomes for individual named techniques live on their own pages, cross-linked below.

For decision principles (graft selection, tension, spongiofibrosis), see Principles of Urethral Reconstruction. For the Master Decision Framework.

1. Perineal Skin Incisions​

Three principal perineal skin incisions are described for bulbar and posterior urethroplasty:

IncisionDescriptionSSI rateNotes
Midline perineal verticalLongitudinal incision in the perineal raphe1.9–3.1%Lowest wound-complication rate; shorter LOS; cadaveric studies show 1.6–2.0× fewer damaged neurovascular structures vs inverted-U with equivalent operative exposure[1]
Inverted-U (curvilinear)U-shaped incision curving around the perineum16.4–18.6% (p < 0.05)Historically popular; significantly higher SSI and longer LOS; greater neurovascular injury[1]
Lambda perineal incision (LPI)Inverted-Y / lambda shape extending laterally from midline23.3% (vs 11.9% midline)Bascom 2016 (n = 540 bulbar urethroplasties): independently associated with increased 90-day wound complications, primarily superficial wound-edge separation (10.7% vs 0%); no urethroplasty-success advantage[2]

The midline vertical incision is the contemporary default for bulbar perineal access — used for both the loop and 7-flap PU pathways and as the foundation of the algorithmic midline approach to perineal urethrostomy.

For penile urethral strictures, the three penile-skin incisions are described in the next section.

2. Penile-Stricture Exposure — Three Approaches​

For penile urethral strictures specifically, three exposure strategies dominate contemporary practice. The Abramowitz multi-institutional review found no significant difference in outcomes by incision approach for penile urethroplasty — choice is driven by stricture characteristics and surgeon experience.[3]

2a. Degloving / circumcising incision​

Subcoronal circumferential incision (identical to a circumcision incision); penile skin retracted proximally to "deglove" the shaft, exposing the entire penile urethra from glans to penoscrotal junction.[4]

  • Advantages: excellent circumferential exposure; standard for penile-skin-flap harvest (Orandi, Quartey, Q-flap, McAninch circular) and for staged urethroplasty; allows simultaneous fasciocutaneous flap harvest.
  • Disadvantages: disrupts dartos blood supply circumferentially; risk of penile edema / skin necrosis (especially in redo cases); requires circumcision in uncircumcised patients.
  • Best for: isolated penile strictures, staged repair, cases requiring fasciocutaneous flap harvest, LS strictures requiring complete plate excision.

2b. Kulkarni penile invagination (perineal-only)​

Standard perineal midline incision with the penis invaginated (telescoped) into the perineal wound — no penile incision. One-sided urethral mobilization preserves the contralateral neurovascular bundle and central perineal tendon attachments. The graft is placed as a dorsolateral onlay.[3][5]

  • Advantages: no penile incision; preserved penile-skin blood supply; single-stage repair of panurethral / peno-bulbar strictures (mean 13–14 cm) through a single perineal incision; preserved erectile function (SHIM unchanged); 84–90% success at long-term follow-up; lower complication rate than circumferential dorsal Barbagli (16% vs 38%, p = 0.046).[3][5]
  • Disadvantages: penile chordee in up to 25% (usually transient); post-void dribbling up to 45%; limited distal-penile / fossa-navicularis exposure; steep learning curve; not suitable for LS involving the glans / meatus.
  • Best for: long-segment and panurethral strictures (especially > 8 cm), peno-bulbar strictures, and cases where penile-skin preservation is a priority.
  • Canonical technique page: Kulkarni One-Sided Dorsolateral BMG.

2c. Midline ventral penile incision​

Direct longitudinal incision along the ventral raphe — preserves lateral dartos pedicles and avoids circumferential degloving. Used for modified Orandi dorsal-skin-flap repair, penile fracture repair, and penoscrotal-junction strictures.[3][4]

  • Advantages: preserves lateral penile-skin vascularity; simpler / faster than full degloving (60 min in one series); avoids circumcision; can be combined with perineal invagination for penoscrotal-junction strictures.
  • Disadvantages: limited exposure for long penile strictures; visible ventral scar; not suitable for fasciocutaneous flap harvest.
  • Best for: focal / short penile strictures, modified Orandi dorsal-skin-flap repairs, penoscrotal-junction strictures, penile-fracture repair.

3. Anterior Urethrotomy Approaches​

How the urethra itself is opened once exposed — the choice drives graft placement, blood-supply preservation, and operative time.

ApproachDescriptionImplication
Ventral urethrotomyUrethra opened on its ventral surfaceTraditional approach; supports ventral onlay BMG and the Asopa dorsal inlay (dorsal wall incised through the ventral opening). Less urethral mobilization required[6][7]
Dorsal urethrotomy (Barbagli)Urethra mobilized circumferentially and rotated 180° to expose the dorsal surfaceMore extensive dissection; supports dorsal onlay BMG (Barbagli)[6][8]
Dorsolateral (Kulkarni)One-sided urethral dissection; contralateral blood supply preservedMinimizes urethral devascularization; particularly useful for long penile strictures; the basis of the Kulkarni one-sided dorsolateral BMG technique[6]
Non-transectingCorpus spongiosum is not fully transected — antegrade blood flow preservedCotter 2019 multi-institutional data: + 430% increase in non-transecting excisional repairs over a 7-year period. Includes Jordan vessel-sparing EPA, non-transecting bulbar, and the entire ANTA / MsANTA / MANTA / ntAAU family[9]

4. Posterior Urethroplasty Approaches​

For posterior urethral distraction defects (PFUI) and post-prostatectomy / post-radiation membranous-urethral / VUAS strictures:

ApproachUsed inIndication
Perineal anastomoticFirst-line for PFUIStandard; adequate for gaps ≤ 2.5 cm after bulbar mobilization. Success ~ 90–95%[10][11]
Elaborated perineal (Webster steps 1–4)Webster step frameworkBulbar mobilization → corporal splitting → inferior pubectomy → supracrural rerouting. Pubectomy used in ~ 10% of cases; corporal splitting ~ 17%[11][12]
Supracrural rerouting (step 4)Rare (~ 3% of PFUI repairs)Mobilized bulbar urethra rerouted around one penile crus to shorten distance to prostatic apex. Underperforms abdominoperineal repair — Kizer 2007: 75% recurrence vs 80% success[11]
Transpubic (abdominoperineal)Reserved for complex casesCombined abdominal + perineal with partial inferior pubectomy (preferred over abandoned total pubectomy). For gaps > 2.5–3 cm, failed prior repairs, RUF / periurethral cavities. Success 92–98% (Koraitim, Pratap). See Abdominoperineal (Transpubic) Urethroplasty[12][13][14]
Modified perineal (Quartey 1988)NicheStandard perineal-prostatectomy incision with division of the urogenital diaphragm in the midline; improved membranous-urethra exposure without pubectomy[15]
Robotic transabdominalContemporary alternative for VUAS / BNCAUA 2023 Conditional Grade C. ~ 39% require combined robotic + open perineal. See Robotic Posterior Urethroplasty[16]

5. Graft / Tissue Placement Configurations​

For substitution urethroplasty, the graft (most commonly buccal mucosa — AUA 2023 first-choice[16]) can be placed in several configurations:

ConfigurationEponymVascular bedIndication
Dorsal onlayBarbagliTunica albugineaBulbar strictures, ~ 88% success[17][18]
Ventral onlayMorey / McAninchCorpus spongiosumBulbar strictures, ~ 89%; lower transient ED for proximal bulbar[19][20][17]
Dorsal inlayAsopaDorsal urethral plate (no circumferential mobilization)Shorter OR / less EBL than dorsal onlay; ~ 87% success[7][8]
Dorsolateral onlayKulkarniOne-sided dorsolateral urethral plateLong penile / panurethral; preserves contralateral NVB[6]
Two-sided dorsal + ventralPalminteri double-faceTunica + spongiosumTight / near-obliterative bulbar strictures; ~ 88–90%, 0% post-op ED. See Palminteri Double-Face[21][17]
Augmented anastomoticGuralnick / WebsterHybrid — excise + onlayFocal-obliterative bulbar with healthier flanks. Redmond 2020 HR 4.8 recurrence signal vs pure dorsal onlay — declining use[6]

For combined graft-and-flap configurations, see Combined Dorsal BMG + Ventral Fasciocutaneous Flap (Erickson) and Ventral BMG + Gracilis Muscle Flap (Vanni / Zinman).

6. Flap-Based Techniques — Declining Role​

Penile fasciocutaneous flaps (Orandi, Quartey, Q-flap, McAninch circular) historically dominated long penile and panurethral reconstruction. Cotter 2019 multi-institutional data:[9]

  • Fasciocutaneous-flap use declined ~ 86% over 7 years.
  • Dorsal-graft repairs increased ~ 280% over the same period.

The 2024 GURS survey confirms ~ 90% of contemporary reconstructive surgeons prefer multiple BMGs over combined graft / flap for panurethral strictures.[22] Flap-based techniques remain valuable in specific scenarios:

  • Compromised graft bed (radiation, severe spongiofibrosis) — flap brings its own blood supply.
  • Depleted oral mucosa — preputial / penile flap or preputial spiral graft.
  • Resource-limited settings — no specialized graft material required.

7. One-Stage vs Staged​

SettingPreferred
Most bulbar stricturesOne-stage dorsal / ventral / dorsolateral onlay BMG (~ 88%)
Distal / primary penile stricturesOne-stage
Complex penile strictures with extensive spongiofibrosisStaged (Bracka or Johanson)
Lichen sclerosus with full-thickness involvementStaged (Bracka with BMG)
Failed hypospadias repair / hypospadias crippleStaged (Bracka)
Panurethral with healthy plateOne-stage Kulkarni dorsolateral BMG
Panurethral, plate destroyedCombined graft + flap (Erickson) or staged

Mangera 2011 SR: two-stage penile urethroplasty 90.5% vs one-stage penile 75.7%; bulbar disease shows comparable success across techniques.[17][23]

Contemporary Trends — Summary​

Multi-institutional data demonstrate clear shifts:[1][2][9]

  • Dorsal graft placement ↑ 280%; fasciocutaneous flap use ↓ 86%.
  • Non-transecting bulbar excisional repair ↑ 430%.
  • Midline perineal incision preferred over lambda or inverted-U for lower wound complications.
  • Buccal mucosa is the AUA-2023-anchored first-choice graft.

References​

1. Lin Y, Luo D, Liao B, et al. Perineal midline vertical incision versus inverted-U incision in urethroplasty: which is better? World J Urol. 2018;36(8):1267-1274. doi:10.1007/s00345-018-2267-x.

2. Bascom A, Ghosh S, Fairey AS, Rourke KF. Assessment of wound complications after bulbar urethroplasty: the impact of a lambda perineal incision. Urology. 2016;90:184-188. doi:10.1016/j.urology.2015.12.047.

3. Abramowitz D, Sam AP, Pachorek M, et al. Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes. Int J Urol. 2022;29(5):376-382. doi:10.1111/iju.14786.

4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

5. Takekawa K, Horiguchi A, Shinchi M, et al. One-sided dorsal onlay urethroplasty with penile invagination (Kulkarni urethroplasty) for complex anterior urethral strictures: a single-center experience. Int J Urol. 2025;32(6):749-755. doi:10.1111/iju.70048.

6. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493-503. doi:10.1111/iju.13356.

7. Pisapati VL, Paturi S, Bethu S, et al. Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. Eur Urol. 2009;56(1):201-205. doi:10.1016/j.eururo.2008.06.002.

8. Aldaqadossi H, El Gamal S, El-Nadey M, et al. Dorsal onlay (Barbagli technique) versus dorsal inlay (Asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: a prospective randomized study. Int J Urol. 2014;21(2):185-188. doi:10.1111/iju.12235.

9. Cotter KJ, Hahn AE, Voelzke BB, et al. Trends in urethral stricture disease etiology and urethroplasty technique from a multi-institutional surgical outcomes research group. Urology. 2019;130:167-174. doi:10.1016/j.urology.2019.01.046.

10. Koraitim MM. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005;173(1):135-139. doi:10.1097/01.ju.0000146683.31101.ff.

11. Kizer WS, Armenakas NA, Brandes SB, et al. Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol. 2007;177(4):1378-1381. doi:10.1016/j.juro.2006.11.036.

12. Koraitim MM. Transpubic urethroplasty revisited: total, superior, or inferior pubectomy? Urology. 2010;75(3):691-694. doi:10.1016/j.urology.2009.09.026.

13. Pratap A, Agrawal CS, Tiwari A, et al. Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol. 2006;175(5):1751-1754. doi:10.1016/S0022-5347(05)00974-2.

14. Koraitim MM. The lessons of 145 post-traumatic posterior urethral strictures treated in 17 years. J Urol. 1995;153(1):63-66. doi:10.1097/00005392-199501000-00024.

15. Quartey JK. A modified perineal approach to reconstruction of membranous urethra for stricture. J Urol. 1988;139(4):780-783. doi:10.1016/s0022-5347(17)42635-8.

16. 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.

17. 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.

18. Barratt R, Chan G, La Rocca R, et al. Free graft augmentation urethroplasty for bulbar urethral strictures: which technique is best? A systematic review. Eur Urol. 2021;80(1):57-68. doi:10.1016/j.eururo.2021.03.026.

19. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.

20. Mousa A, Eissa A, Raheem AA, Zoeir A. Ventral versus dorsal onlay buccal mucosal graft urethroplasty for non-traumatic proximal bulbar urethral strictures in sexually active men: erectile and urinary functions. World J Urol. 2025;43(1):87. doi:10.1007/s00345-025-05441-7.

21. Palminteri E, Berdondini E, Shokeir AA, et al. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. J Urol. 2011;185(5):1766-1771. doi:10.1016/j.juro.2010.12.103.

22. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139-143. doi:10.1016/j.urology.2024.06.019.

23. Campos-Juanatey F, Bugeja S, Dragova M, et al. Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures. Asian J Androl. 2020;22(2):134-139. doi:10.4103/aja.aja_78_19.