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Cecil-Culp Procedure

The Cecil-Culp procedure is a two-stage reconstructive technique that uses the principle of temporarily embedding (marsupializing) the penis into the scrotum or perineum to provide vascularized tissue coverage for urethral reconstruction or penile-skin replacement, followed by a second-stage separation and tubularization.[1][2][3] Originally described for severe hypospadias repair, its conceptual framework has been adapted for urethral stricture disease, urethrocutaneous fistula repair, and penile trauma reconstruction.

Part I: Historical origins​

Arthur Bond Cecil (1885–1967) — an American urologist — first described his eponymous technique in the 1930s–1940s for repair of severe proximal hypospadias. The original Cecil procedure:

  1. Created a urethral channel from scrotal skin.
  2. Buried the ventral penile surface into the scrotum so that scrotal skin served as the ventral urethral wall.
  3. Separated the penis from the scrotum at a second stage after tissue maturation.

Ormond Skinner Culp (1910–1977) — a Mayo Clinic urologist — subsequently modified and popularized the technique, refining the scrotal-inlay approach and extending its applications. The combined "Cecil-Culp" designation reflects Culp's modifications, particularly in adapting the procedure for more complex hypospadias variants and urethral stricture disease.[1][4] Kelalis, Benson, and Culp (1977) reported 198 children operated upon between 1970–1975, with the modified two-stage Cecil urethroplasty one of three primary techniques used.[4]

Part II: The core concept — tissue transfer by temporary embedding​

The fundamental principle is a biological tissue-transfer concept:

  1. The scrotum (or perineum) serves as a vascularized tissue bed — its rich blood supply from the inferior external pudendal arteries and perineal arteries provides a reliable source of well-vascularized tissue for urethral reconstruction or skin coverage.[5]
  2. Temporary embedding allows neovascularization — burying the penis into the scrotum lets scrotal tissue develop a vascular connection to the penile structures over weeks to months.
  3. Staged separation preserves the new vascular supply — at the second stage, the penis is separated from the scrotum, and the newly vascularized tissue is tubularized or used as coverage.

This is conceptually identical to the "waltzed" / "delayed" flap principle used throughout plastic and reconstructive surgery — temporarily attaching tissue to a recipient site to establish a blood supply before definitive transfer.[2]

Part III: Indications​

A. Severe proximal hypospadias (original indication)​

  • Perineal or penoscrotal hypospadias where the urethral groove fails to develop adequately and the scrotal folds have failed to rotate caudally.[1]
  • Approximately 8% of hypospadias patients present with this degree of severity.[1]
  • Particularly useful when the urethral plate is absent or severely deficient and local penile tissue is insufficient for single-stage repair.

B. Recurrent urethrocutaneous fistula after hypospadias repair​

Ehle, Cooper, et al. (2001) applied the modified Cecil-Culp technique specifically for recurrent urethrocutaneous fistulas in boys who had failed previous fistula repairs and / or had deficient penile skin:[3]

  • 15 boys with hypospadias fistula underwent modified two-stage Cecil repair.
  • Average age at first stage: 3.5 years.
  • 5, 4, and 2 patients had undergone 1, 2, and 3 previous fistula repairs, respectively.
  • 4 boys had deficient penile skin at the time of repair.
  • Zero recurrent fistulas at average 21-month follow-up (range 1–62 months).
  • The authors concluded that the technique "takes advantage of penile mobility to place it in a scrotal location, ensuring excellent vascularized tissue coverage."[3]

C. Penile trauma with skin loss​

Weiss, Canning, et al. (2017) described a modified Cecil-Culp concept applied to a devastating penile trauma case:[2]

  • A 12-year-old boy sustained a close-range shotgun wound with buckshot to the penis and lower abdomen.
  • The proximal two-thirds of the corpora cavernosa was obliterated; the distal third was thrombosed; all dorsal penile skin was lost; the urethra remained intact.
  • After multiple debridements, the penis was marsupialized onto the suprapubic area (modification of the traditional scrotal embedding).
  • The penis remained embedded for 8 months.
  • A graft-delaying procedure was performed, followed by graft harvest 2 months later and penoplasty tubularization.
  • Demonstrated the versatility of the Cecil-Culp concept beyond hypospadias.[2]

D. Complex urethral stricture disease​

The scrotal-inlay concept was historically used for:

  • Posterior urethral strictures — Coffield and Weems (1977) reported delayed scrotal-inlay urethroplasty in 11 patients with posterior urethral injuries, with zero incidence of stricture, incontinence, or impotence (compared with 77% stricture rate with primary repair).[6]
  • Complex anterior urethral strictures — as a salvage technique when local tissue is insufficient for single-stage repair.[7][8]
  • However, Koraitim (1995) found that urethroscrotal inlay procedures were "doomed to failure in 57% of cases" for posterior urethral strictures, and recommended restricting them to strictures involving extensive segments of both posterior and anterior urethra.[8]

Part IV: Surgical technique — step by step​

Stage 1 — urethral reconstruction and penile embedding​

  1. Chordee correction (orthoplasty) — if present, ventral curvature is corrected by excising fibrous tissue and performing dorsal plication as needed.
  2. Urethral plate preparation — the ventral penile surface is opened and the strictured or absent urethra is addressed:
    • Hypospadias — urethral groove opened from existing meatus to the desired endpoint (typically the glans).
    • Fistula repair — fistula tract excised and urethra repaired.
    • Stricture — strictured segment opened ventrally (marsupialized).
  3. Scrotal inlay — the ventral penile surface (with the open urethral plate or repaired urethra) is buried into the scrotum:
    • An incision is made in the anterior scrotal wall.
    • The ventral penile surface is sutured to the edges of the scrotal incision, embedding the penis into the scrotum.
    • Scrotal skin now forms the ventral wall of the urethral channel.
    • Scrotal tissue provides a rich vascular bed that promotes healing and neovascularization.
  4. Catheter placement — urethral catheter or suprapubic tube for urinary drainage.
  5. Maturation period — the penis remains embedded for a minimum of 6 weeks to several months (typically 2–3 months for hypospadias; up to 8 months in the trauma case described by Weiss et al.).[1][2][3]

Stage 2 — separation and tubularization​

  1. Timing — typically 6 weeks to 3+ months after Stage 1.
  2. Incision — scrotal skin surrounding the embedded penis is incised, freeing the penis from the scrotum.
  3. Tubularization — scrotal skin that served as the ventral urethral wall is tubularized around a catheter to create the neourethra.
  4. Skin closure — scrotal defect is closed primarily; the penile shaft is covered with remaining scrotal skin or local tissue.
  5. Catheter management — urethral catheter left in place for 10–14 days.

Marshall modification (1979)​

Marshall et al. modified the Cecil procedure by adding concurrent scrotoplasty — rotating the scrotum caudally from its high location (common in penoscrotal hypospadias) during Stage 1. This modification:[1]

  • Eliminated tension and acute angulation that contributed to frequent complications in the original technique.
  • Extended the urethra from behind the penoscrotal junction to the glans at Stage 2.
  • Produced satisfactory results in their 13-year series.

Part V: Comparison with the Johanson urethroplasty​

The Cecil-Culp and Johanson techniques are closely related two-stage procedures that share the principle of marsupialization followed by tubularization, but differ in key respects:

FeatureCecil-CulpJohanson
Original indicationSevere proximal hypospadiasUrethral stricture disease
Stage 1 conceptPenile embedding into scrotumMarsupialization of strictured urethra to perineal / scrotal skin
Tissue sourceScrotal skin as ventral urethral wallPerineal / scrotal skin as urethral plate
Stage 2Separation of penis from scrotum + tubularizationTubularization of marsupialized urethral plate
Inter-stage interval6 weeks to months2–3 months typically
Success rate (stricture)Variable; 43–57% failure for posterior strictures64% success for long-segment strictures (vs. 82.5% for BMG)
Modern roleFistula repair, trauma, salvageSalvage for complex / panurethral strictures
[1][3][4][9][10]

Fernandes and Draper (1975) reported a 12-year experience with 200 patients undergoing two-stage Johanson urethroplasty (including modifications for bulbomembranous strictures without splitting the scrotum), with no patient requiring urethral dilation after urethroplasty.[9]

Warner et al. (2015) — the largest multi-institutional series of long-segment strictures (466 patients) — found that second-stage Johanson urethroplasty had a significantly higher recurrence rate than single-stage BMG urethroplasty (35.7% vs. 17.5%, p<0.05).[10]

Part VI: Advantages and disadvantages​

Advantages

  • Excellent vascularized tissue coverage — the scrotum provides one of the most reliable vascular beds in the body, supplied by the inferior external pudendal arteries and perineal arteries.[5][11]
  • Versatility — applicable to hypospadias, fistula, stricture, and trauma.[1][2][3]
  • Salvage capability — useful when local penile tissue is scarred, deficient, or previously operated — situations where single-stage repairs have high failure rates.[3]
  • Zero fistula recurrence in the Ehle et al. series for recurrent fistulas.[3]
  • Technically straightforward — does not require microsurgical expertise or free tissue transfer.
  • No donor-site morbidity from distant graft harvest (unlike buccal mucosa or skin grafts).

Disadvantages

  • Two-stage procedure — at least two operations separated by weeks to months, with associated increased hospitalization, time away from work / school, and anesthetic exposure.[12]
  • Cosmetic concerns — temporary penile embedding in the scrotum creates an abnormal appearance during the inter-stage period.
  • Hair-bearing skin — scrotal skin is typically hirsute, and if hair-bearing skin is incorporated into the neourethra, complications include hair-ball formation, stone formation, diverticula, and recurrent UTI.[7][13]
    • Mitigated by using hairless scrotal areas or performing epilation (electrolysis or laser hair removal) before or after surgery.[14][11]
    • Jordan (2002) argued that scrotal and perineal flaps have been "unfairly maligned" — hairless scrotal areas can be mobilized, and the skin overlying the perineal artery is non-hirsute in many individuals.[11]
  • Stricture recurrence — scrotal-inlay procedures have historically had higher failure rates than anastomotic urethroplasty or BMG grafting for urethral stricture disease.[8][10]
  • Diverticulum formation — scrotal skin may be more compliant than urethral tissue, leading to pseudodiverticulum and post-void dribbling.[7][13]
  • Urine-induced dermatitis — prolonged urine contact with scrotal skin during the marsupialization phase can cause skin changes.[7]

Part VII: Modern context — where does Cecil-Culp fit today?​

The shift away from scrotal skin​

Contemporary urethral reconstruction has largely moved away from scrotal and genital skin flaps toward buccal mucosal grafts (BMG) as the preferred tissue source for substitution urethroplasty:[15][16][17][18]

  • BMG is non-hair-bearing, resistant to urine-induced dermatitis, and has excellent graft-take characteristics.
  • The AUA Urethral Stricture Disease Guidelines (2023) recommend urethroplasty using oral mucosal grafts or penile fasciocutaneous flaps for penile strictures, with staged approaches preferred for lichen sclerosus.[17]
  • Fuchs et al. (2018) documented the trend at a major reconstructive center: BMG use remained stable at ~61%, penile skin flap use decreased from dominant to 21.6%, and perineal urethrostomy increased from 4.3% to 38.7% of cases over a decade.[18]

Remaining niche indications for Cecil-Culp​

Despite the shift toward BMG, the Cecil-Culp concept retains value in specific scenarios:

  1. Recurrent urethrocutaneous fistula after hypospadias repair with deficient penile skin — the Ehle series demonstrated 100% success in this challenging population.[3]
  2. Penile trauma with extensive skin loss — the Weiss case demonstrated adaptability of the concept to non-urethral indications.[2]
  3. Failed previous urethroplasty with scarred, devascularized penile tissue where free graft take is questionable.[13]
  4. Resource-limited settings where BMG-harvest expertise or staged BMG techniques are unavailable.
  5. Salvage situations where other reconstructive options have been exhausted.

The staged BMG urethroplasty — the modern successor​

The modern two-stage urethroplasty using buccal mucosal grafts has conceptually replaced the Cecil-Culp scrotal inlay for most staged reconstructions:[16][19][20]

  • Stage 1 — strictured urethra is opened; BMG is placed as a dorsal or ventral inlay graft on the opened urethral plate (or on the tunica albuginea if the plate is absent).
  • Stage 2 — after graft maturation (typically 4–6 months), the grafted plate is tubularized.
  • Meeks et al. (2009) — 86% success (13/15) with staged BMG urethroplasty for long-segment strictures (mean 8 cm) in adults with prior pediatric hypospadias repair, at median 22-month follow-up.[20]
  • Figler et al. (2018) — staged BMG urethroplasty in 20 patients (45% LS, 40% failed hypospadias): 60% underwent second-stage closure at median 277 days, with complications including dehiscence (17%), fistula (8%), and meatal stenosis (8%).[19]
  • Horiguchi et al. (2022) — 89.7% success in 29 adults with hypospadias-related strictures (75.9% staged urethroplasty), with 92% patient satisfaction.[21]

Part VIII: Scrotal and perineal flap vascular anatomy​

Understanding the vascular anatomy is critical for any Cecil-Culp or scrotal-flap procedure:

Carrera et al. (2009) performed a detailed microvascular study of scrotal skin in 15 cadavers:[5]

  • Two main vascular systems — inferior external pudendal arteries (lateral) and perineal arteries (posterior / central).
  • Three cutaneous territories — two lateral and one central, which are widely inter-anastomosed.
  • Each lateral territory receives an inferior external pudendal artery at the midpoint of the scrotal root, fanning out to cover the entire hemiscrotum.
  • The central territory is vascularized by branches of the main scrotal arteries (continuations of the perineal arteries), running deeply on both sides of the septum.
  • This anatomy enables construction of longitudinal median island scrotal flaps up to 20 cm in length with reliable axial vascularization.[14][5]

Gil-Vernet et al. (1997) exploited this biaxial vascularization to create a new scrotal flap design achieving 86% success in 37 patients with complex urethral stenosis, including reconstruction of the entire anterior urethra in some cases.[14]

Part IX: Complications and management​

ComplicationMechanismPrevention / management
Urethrocutaneous fistulaInadequate tissue coverage; tension on suture linesAdequate vascularized tissue interposition — the Cecil-Culp concept itself was designed to prevent this
Hair growth in neourethraIncorporation of hair-bearing scrotal skinUse hairless scrotal areas; pre- or post-operative epilation (electrolysis / laser)
Stone / hair-ball formationHair and debris serve as nidus for calculusEpilation; endoscopic removal if symptomatic
Diverticulum formationExcessive compliance of scrotal skin; inadequate tailoringAggressive flap tailoring; avoid excess tissue
Stricture recurrenceScarring at anastomotic sites; ischemiaTension-free anastomosis; adequate blood supply; consider BMG instead for long strictures
ChordeeInadequate release at Stage 1; tethering by scrotal tissueComplete orthoplasty before embedding; adequate mobilization at Stage 2
Meatal stenosisScarring at distal anastomosisMeatoplasty at Stage 2; adequate caliber at closure
Urine-induced dermatitisProlonged urine contact with scrotal skin during marsupializationMinimize inter-stage interval; suprapubic diversion
[1][2][3][7][8][10][13][22]

Summary — key principles of the Cecil-Culp procedure​

  1. Core concept — temporary embedding of the penis into the scrotum (or perineum / suprapubic area) to provide vascularized tissue for urethral reconstruction or skin coverage, followed by staged separation and tubularization.[1][2]
  2. Original indication — severe proximal (penoscrotal / perineal) hypospadias where the urethral groove is absent and scrotal folds have failed to rotate caudally.[1]
  3. Expanded indications — recurrent urethrocutaneous fistula (100% success in Ehle et al. series), penile trauma with skin loss, and salvage urethral reconstruction.[2][3]
  4. Two stages — Stage 1 = urethral repair + penile embedding into scrotum; Stage 2 = separation + tubularization (minimum 6 weeks apart).[1][3]
  5. Advantages — excellent vascularized tissue coverage, no distant donor site, technically straightforward, high success for fistula repair.[3][11]
  6. Disadvantages — two operations required, hair-bearing skin complications, higher stricture recurrence than BMG for long strictures, cosmetic concerns during inter-stage period.[7][8][10]
  7. Modern context — largely supplanted by staged BMG urethroplasty for most indications, but retains value for recurrent fistula with deficient penile skin, penile trauma, and salvage scenarios.[16][18][19]
  8. Vascular basis — the scrotum has a rich, redundant blood supply from the inferior external pudendal and perineal arteries, making it one of the most reliable tissue sources in the body for urethral reconstruction.[5][14]

Cross-references​

References​

1. Marshall M, Johnson SH, Price SE, Barnhouse DH. "Cecil urethroplasty with concurrent scrotoplasty for repair of hypospadias." J Urol. 1979;121(3):335–338. doi:10.1016/s0022-5347(17)56777-4

2. Weiss DA, Smith ZL, Taylor JA, Canning DA. "Old tools, old problems, new solution: the use of a modified Cecil-Culp concept in the trauma setting." Urology. 2017;106:196–199. doi:10.1016/j.urology.2017.04.023

3. Ehle JJ, Cooper CS, Peche WJ, Hawtrey CE. "Application of the Cecil-Culp repair for treatment of urethrocutaneous fistulas after hypospadias surgery." Urology. 2001;57(2):347–350. doi:10.1016/s0090-4295(00)00997-3

4. Kelalis PP, Benson RC, Culp OS. "Complications of single and multistage operations for hypospadias: a comparative review." J Urol. 1977;118(4):657–658. doi:10.1016/s0022-5347(17)58141-0

5. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps." BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

6. Coffield KS, Weems WL. "Experience with management of posterior urethral injury associated with pelvic fracture." J Urol. 1977;117(6):722–724. doi:10.1016/s0022-5347(17)58601-2

7. Carr LK, MacDiarmid SA, Webster GD. "Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty." J Urol. 1997;157(1):104–108.

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

9. 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

10. 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

11. Jordan GH. "Scrotal and perineal flaps for anterior urethral reconstruction." Urol Clin North Am. 2002;29(2):411–416. doi:10.1016/s0094-0143(02)00030-7

12. Olsson CA, Krane RJ. "The controversy of single versus multistaged urethroplasty." J Urol. 1978;120(4):414–417. doi:10.1016/s0022-5347(17)57205-5

13. 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):1455–1458. doi:10.1016/s0022-5347(17)39124-3

14. Gil-Vernet J, Arango O, Gil-Vernet A, Gil-Vernet J, Gelabert-Mas A. "A new biaxial epilated scrotal flap for reconstructive urethral surgery." J Urol. 1997;158(2):412–420.

15. Dugi DD, Simhan J, Morey AF. "Urethroplasty for stricture disease: contemporary techniques and outcomes." Urology. 2016;89:12–18. doi:10.1016/j.urology.2015.12.012

16. Andrich DE, Mundy AR. "What is the best technique for urethroplasty?" Eur Urol. 2008;54(5):1031–1041. doi:10.1016/j.eururo.2008.07.052

17. 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

18. 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

19. 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

20. Meeks JJ, Erickson BA, Gonzalez CM. "Staged reconstruction of long-segment urethral strictures in men with previous pediatric hypospadias repair." J Urol. 2009;181(2):685–689. doi:10.1016/j.juro.2008.10.013

21. Horiguchi A, Asanuma H, Shinchi M, et al. "Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults." Int J Urol. 2022;29(12):1470–1475. doi:10.1111/iju.15015

22. Snodgrass WT, Bush NC. "Management of urethral strictures after hypospadias repair." Urol Clin North Am. 2017;44(1):105–111. doi:10.1016/j.ucl.2016.08.014