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Turner-Warwick Two-Stage Scrotal Inlay Urethroplasty

The Turner-Warwick urethroplasty is a two-stage scrotal inlay technique for bulbomembranous urethral strictures, named after Richard Turner-Warwick (1925–2010) of The Middlesex Hospital and the Institute of Urology, London. Stage 1 marsupializes the strictured urethra to scrotal skin; Stage 2 tubularizes the matured plate ~4–6 months later. In Reid's 60-patient series, success was approximately 90%.[1] The technique has been largely superseded by modern two-stage BMG urethroplasty owing to the well-known limitations of hair-bearing scrotal skin, but Turner-Warwick's broader contributions — staged-reconstruction philosophy, transpubic posterior urethroplasty, and the principles of vascularized tissue transfer — remain foundational.[1][2][3][4]

For the related Cecil / Culp / Pierce / Johanson scrotal-based two-stage lineage, see Cecil-Culp Procedure. For the longitudinal ventral penile skin flap (often mistakenly attributed to Turner-Warwick), see Orandi Flap. For modern BMG-based staged repair, see Buccal Mucosa Graft.

Important nomenclature note. A "Turner-Warwick longitudinal ventral penile flap" is not a recognized technique in the reconstructive urology literature. The longitudinal ventral penile skin flap is Amin Orandi's 1968 contribution.[12] Turner-Warwick's principal eponymous urethroplasty technique is the two-stage scrotal inlay described here.

Richard Turner-Warwick — The Man and His Contributions​

Richard Turner-Warwick (1925–2010) was a British urological surgeon based at The Middlesex Hospital and the Institute of Urology, London — widely regarded as one of the founding fathers of modern urethral reconstructive surgery. His major contributions:[1][2][4]

  1. Two-stage scrotal inlay urethroplasty ("the Turner-Warwick urethroplasty") — staged technique for complex bulbomembranous strictures.
  2. Transpubic approach for posterior urethral distraction injuries.
  3. Classification systems for urethral stricture disease.
  4. Principles of urethral reconstruction — tissue transfer, the importance of vascularized tissue, the role of staged procedures.
  5. Training and mentorship — Turner-Warwick trained a generation of reconstructive urologists, including Anthony Mundy, who succeeded him at the Institute of Urology and continued to refine the techniques.

For the surgeon profile, see Richard Turner-Warwick.

The Two-Stage Scrotal Inlay Technique​

Stage 1 — marsupialization and scrotal inlay​

  • The strictured urethra is opened along its ventral surface (ventral urethrotomy) through the full length of the stricture.
  • The opened urethral edges are sutured to the surrounding scrotal / perineal skin, creating a marsupialized urethral trough — the urethra is laid open, and the patient voids through a perineal opening.
  • This allows the strictured segment to heal in an open configuration, with the scrotal skin providing a vascularized bed for epithelialization.
  • The patient voids through the perineal opening for typically 4–6 months while the tissue matures.

Stage 2 — tubularization (closure)​

  • After tissue maturation and once the urethral bed is healthy, the marsupialized trough is tubularized — the scrotal skin edges are rolled inward and sutured together to recreate a tubular urethra.
  • A urethral catheter is placed and the patient is followed for stricture recurrence.

Reid 1975 outcomes (60 patients)[1]​

  • Overall success approximately 90%
  • Initial difficulties with stomal stenosis at the proximal and distal ends after Stage 1, largely eliminated by use of nitrofurazone-hydrocortisone (Furacin-HC) urethral suppositories.
  • Modifications included placement of urethral sutures prior to scrotal mobilization and abandonment of suprapubic cystotomy at Stage 2.
  • Patients with strictures following prostatectomy had problems with urinary control, but not if prostatectomy was performed after Stage 1.

Alexander 1977 reviewed 59 cases of urethral stricture treated at Charity Hospital of Louisiana (including Turner-Warwick procedures) and reported overall success of 72% across all techniques (internal urethrotomy, Johanson-Leadbetter, patch-graft, Turner-Warwick, dismembered).[6]

Turner-Warwick vs. Johanson — The Two Staged Techniques​

The Turner-Warwick two-stage urethroplasty is closely related to the Johanson 1953 staged urethroplasty. Both involve marsupialization followed by tubularization, but with important differences:[1][2][7][8]

FeatureJohanson (1953)Turner-Warwick
Primary indicationAnterior (penile / bulbar) stricturesBulbomembranous strictures
Stage 1Ventral urethrotomy + marsupialization to penile / perineal skinVentral urethrotomy + scrotal inlay
Stage 2Tubularization of the marsupialized troughTubularization with scrotal mobilization
Tissue sourceLocal penile / perineal skinScrotal skin
Key advantageSimpler; applicable to anterior stricturesReaches bulbomembranous junction; more tissue available
Key limitationLimited reach for posterior stricturesHair-bearing scrotal skin; diverticula; urine-induced dermatitis

Olsson and Krane 1978 directly compared single-stage vs multi-staged urethroplasties (including Johanson, Leadbetter-Johanson, Turner-Warwick) and concluded that no advantage was seen when initial or final success rates were compared, while the multi-staged approaches carried the burden of increased hospitalization, absence from employment, and morbidity of multiple anesthetics.[2]

Limitations of the Scrotal Inlay Approach​

The Turner-Warwick scrotal inlay technique, while historically important, has well-documented limitations that led to its decline:[5][9][10][11]

  1. Hair-bearing scrotal skin — scrotal skin is typically hair-bearing; intraurethral hair growth, hair-ball formation, and stone formation are characteristic complications. Provet 1989 emphasized the importance of using hairless skin and aggressive tailoring.[10]
  2. Diverticula formation — scrotal skin, being thin and pliable, tends to balloon outward during voiding, creating pseudo-diverticula that trap urine and cause postvoid dribbling.[9][10]
  3. Urine-induced dermatitis — prolonged contact of urine with scrotal skin during the marsupialized phase can cause chronic dermatitis, compromising tissue quality for Stage 2 closure.[9]
  4. Two-stage morbidity — two separate operations with months of perineal voiding between stages imposes significant quality-of-life burden.[2]
  5. Stricture recurrence — despite the staged approach, recurrence rates remain significant, particularly at the proximal and distal anastomotic sites.[1]

Jordan 2002 defended scrotal and perineal flaps, arguing that claims of poor waterproofing, diverticula, and hair importation were "unfairly maligned" — noting that hairless scrotal areas can be mobilized as skin islands, and the skin overlying the perineal artery is non-hirsute or nearly non-hirsute in many individuals.[11]

Distinguishing Turner-Warwick from the Orandi Flap​

The longitudinal ventral penile skin flap is the Orandi flap (1968) — not a Turner-Warwick technique:

FeatureTurner-Warwick UrethroplastyOrandi Flap
Year1960s–1970s[1][2]1968[12]
StagesTwo-stage (marsupialization → tubularization)Single-stage (pedicled island flap)
Tissue sourceScrotal / perineal skinVentral penile shaft skin
PedicleNone (scrotal skin used as local tissue bed)Dartos fascia pedicle (vascularized island flap)
Primary indicationBulbomembranous stricturesPenile urethral strictures
Hair-bearingYes (scrotal skin)No (distal penile skin is hairless)
Current statusLargely replaced by modern BMG staged urethroplastyStill used (Barbagli dorsal modification 2019)

Turner-Warwick's Broader Legacy​

While the specific scrotal inlay technique has been largely superseded, Turner-Warwick's broader contributions remain foundational:[4][5][13]

  1. Principles of tissue transfer — Turner-Warwick was among the first to articulate the principles of using vascularized tissue for urethral reconstruction (well-vascularized tissue heals better and resists stricture recurrence).
  2. Staged-approach philosophy — recognition that some strictures are too complex for single-stage repair. Secrest 2002 emphasized that "staging a urethroplasty should not be considered a step backwards" and listed indications including chronic inflammation, fistula, false passage, urethral stones, diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures, and long strictures.[5]
  3. Transpubic approach for posterior urethral distraction injuries — provided excellent exposure and visualization of the involved anatomy. Brock and Kaplan 1981 used this approach in 5 children, 2 of whom had concomitant closure of a failed first-stage Turner-Warwick scrotal inlay.[3]
  4. Training the next generation — Turner-Warwick's trainees, particularly Anthony Mundy at the Institute of Urology, continued to advance the field. Greenwell, Venn, and Mundy 1999 documented the transition from Turner-Warwick-era flap techniques to modern BMG urethroplasty, concluding that buccal mucosal free grafts are now the material of choice for bulbar patch urethroplasty, while the Orandi procedure remains the "gold standard" for penile patch urethroplasty, and two-stage repairs give much better results than one-stage repairs for total circumferential reconstruction of the penile urethra.[4]

Modern Evolution — From Scrotal Inlay to BMG Staged Urethroplasty​

The Turner-Warwick scrotal inlay concept has been modernized by replacing scrotal skin with buccal mucosal grafts (BMG) or split-thickness skin grafts (mesh grafts) in the staged approach.[5][9][14]

Mesh graft urethroplasty (Schreiter / Noll 1989; Carr / MacDiarmid / Webster 1997)[9][14]​

  • Scrotal skin replaced with meshed split-thickness skin graft from the thigh or full-thickness foreskin.
  • Advantages over scrotal inlay — non-hair-bearing, easier to size, seemingly less permeable to urine penetration.
  • Carr 1997 — 20 men, 80% success at median 38 months.
  • Schreiter / Noll 1989 — 96 patients with excellent anatomical and functional results in all but 1 patient.

Modern two-stage BMG urethroplasty​

The current standard for staged urethroplasty uses BMG rather than scrotal skin or mesh grafts:[4][5][15]

  • Stage 1 — strictured urethra opened; BMG quilted to the corpora cavernosa or urethral bed to create a new urethral plate.
  • Stage 2 (4–6 months later) — matured BMG plate is tubularized to recreate the urethra.
  • Eliminates the hair-bearing skin problem, provides a mucosal surface resistant to urine-induced dermatitis, and has become the standard for complex penile strictures, lichen sclerosus, and failed prior repairs.

The evolution from Turner-Warwick-era techniques to modern practice has been dramatic:[4][16][17]

  • Greenwell and Mundy 1999 — documented the shift at the Institute of Urology from one-stage flap to two-stage free-graft procedures. Of 45 bulbar patch urethroplasties, 76% used BMG rather than flaps. Of 34 penile urethroplasties, 82% were two-stage procedures.[4]
  • Cotter 2019 — multi-institutional analysis of 2,098 anterior urethroplasties (2010–2017): fasciocutaneous flap is in decline (-86%) while single-stage dorsal repairs are increasing (+280%) in the penile urethra.[17]
  • Fuchs 2018 — over a decade at a major reconstructive center, penile skin flap use declined while perineal urethrostomy use increased from 4.3% to 38.7%.[16]

Guideline Context​

The AUA Urethral Stricture Disease Guideline Amendment (2023) — relevant recommendations regarding staged urethroplasty:[18]

  • Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination (Moderate Recommendation; Grade C).
  • Surgeons should use oral mucosa as the first choice when using grafts (Expert Opinion).
  • Genital skin flaps and grafts should be avoided in LS-related strictures.
  • Surgeons should not use hair-bearing skin for substitution urethroplasty (Clinical Principle) — directly addressing the primary limitation of the Turner-Warwick scrotal inlay technique.

Key Takeaways​

The Turner-Warwick urethroplasty is a two-stage scrotal inlay technique for bulbomembranous strictures — not a longitudinal ventral penile flap (that is the Orandi 1968 technique). Reid 1975 documented ~90% success in 60 patients.[1] The technique has been largely superseded by modern two-stage BMG urethroplasty, which eliminates the problems of hair-bearing skin, diverticula, and urine-induced dermatitis that plagued the original scrotal-inlay design.[5][9][14] Turner-Warwick's broader legacy — staged-reconstruction philosophy, the transpubic approach, principles of vascularized tissue transfer, and the training of Anthony Mundy and a generation of reconstructive urologists — remains foundational.[2][3][4][5]

References​

  1. Reid RE. Turner-Warwick urethroplasty and urethral stricture: results in 60 patients. Urology. 1975;6(6):711-5. doi:10.1016/0090-4295(75)90802-x.
  2. Olsson CA, Krane RJ. The controversy of single versus multistaged urethroplasty. J Urol. 1978;120(4):414-7. doi:10.1016/s0022-5347(17)57205-5.
  3. Brock WA, Kaplan GW. Use of the transpubic approach for urethroplasty in children. J Urol. 1981;125(4):496-501. doi:10.1016/s0022-5347(17)55085-5.
  4. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. 1999;83(6):631-5. doi:10.1046/j.1464-410x.1999.00010.x.
  5. Secrest CL. Staged urethroplasty: indications and techniques. Urol Clin North Am. 2002;29(2):467-75, viii-ix. doi:10.1016/s0094-0143(02)00040-x.
  6. Alexander RM, Spadaro JJ, Stripling JR, et al. Surgical treatment of urethral stricture. South Med J. 1977;70(12):1405-6. doi:10.1097/00007611-197712000-00007.
  7. Fernandes M, Draper JW. Two-stage urethroplasty: improved method for treating bulbomembranous strictures. Urology. 1975;6(5):568-75. doi:10.1016/0090-4295(75)90504-x.
  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):268-71. doi:10.1159/000052451.
  9. Carr LK, MacDiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J Urol. 1997;157(1):104-8.
  10. Provet JA, Surya BV, Grunberger I, Johanson KE, Brown J. Scrotal island flap urethroplasty in the management of bulbar urethral strictures. J Urol. 1989;142(6):1455-7; discussion 1457-8. doi:10.1016/s0022-5347(17)39124-3.
  11. Jordan GH. Scrotal and perineal flaps for anterior urethral reconstruction. Urol Clin North Am. 2002;29(2):411-6, viii. doi:10.1016/s0094-0143(02)00030-7.
  12. Orandi A. One-stage urethroplasty. Br J Urol. 1968;40(6):717-9. PMID: 4880395.
  13. Joshi PM, Bandini M, Kulkarni SB. Common flaps in genitourinary reconstruction. Urol Clin North Am. 2022;49(3):361-369. doi:10.1016/j.ucl.2022.04.001.
  14. Schreiter F, Noll F. Mesh graft urethroplasty using split thickness skin graft or foreskin. J Urol. 1989;142(5):1223-6. doi:10.1016/s0022-5347(17)39036-5.
  15. Naud E, Rourke K. Recent trends and advances in anterior urethroplasty. Urol Clin North Am. 2022;49(3):371-382. doi:10.1016/j.ucl.2022.04.002.
  16. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169-173. doi:10.1016/j.urology.2018.08.009.
  17. 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.
  18. 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.