Skip to main content

Bracka Two-Stage Urethroplasty

The Bracka two-stage urethroplasty is a two-stage reconstruction described by Arul Bracka in 1995 for complex hypospadias and later adopted for adult urethral stricture disease.[1] It is distinguished from the classic Johanson two-stage urethroplasty by the active placement of a free graft at Stage 1 to create a new urethral plate, rather than marsupializing the native urethra. The original two-stage free-graft concept was first described by Cloutier in 1962, but Bracka popularized and refined it into the modern paradigm.[1]

For the BMG / oral-mucosa graft material details, see Buccal Mucosa Graft. For the Johanson-style marsupialization variant, see Johanson Two-Stage Urethroplasty. For the related Kulkarni one-sided dorsolateral approach for panurethral disease, see Kulkarni One-Sided Dorsolateral BMG.

Fundamental Principles​

A free graft of suitable inner preputial skin or oral mucosa is placed onto the corpora cavernosa at Stage 1, allowed to mature and revascularize, then tubularized into a neourethra at Stage 2.[7][9] This creates a grafted plate when native tissue is inadequate; modern staged operations often combine graft augmentation with preservation of useful native plate.[2][3][4]

Surgical Technique​

Stage 1 — Chordee correction, scar excision, and graft placement​

StepDetail
1. DeglovingCircumcoronal or ventral midline incision; degloving; full exposure of the strictured / scarred urethral segment
2. Chordee correctionIn proximal hypospadias, assess curvature with an artificial erection test after degloving and repeat it after urethral plate transection if curvature persists. Ventral tunical slits or dorsal plication may be used to correct residual curvature before graft placement. In stricture cases, preserve usable native plate and vascular support; excision depends on tissue quality, hair and the planned reconstruction.[2][5][25]
3. Scar excisionRemove tissue that cannot contribute to a viable reconstruction, while preserving suitable plate and graft bed; a universal wide excision of all fibrosis is not required[3][6]
4. Proximal voiding outletIn failed-hypospadias reoperation, a proximal cutaneous urethrostomy may be created; in primary proximal hypospadias, the ectopic meatus may remain the outlet; in adult stricture repair, a ventrally displaced meatus provides voiding during graft maturation.[3][15][25]
5. Graft harvestPrimary pediatric series have used suitable inner preputial skin or oral mucosa; for adult stricture urethroplasty, the AUA names oral mucosa as the first-choice graft . Buccal mucosa can be harvested from the inner cheek, and Snodgrass and Elmore suggested thinner inner-lip mucosa for glanular reconstruction.[3][7][9][13]
6. Graft insetDefat and quilt the graft (multiple interrupted fixation sutures) onto the ventral surface of the corpora cavernosa, creating a flat neourethral plate from the proximal voiding outlet toward the intended distal meatus; Furr's adult stricture technique prioritized caliber rather than reaching the glans tip[3][8][15]
7. Glans split (hypospadias)In hypospadias cases, glans is split ventrally so that the graft can extend to the tip and a terminal slit-like meatus can be created at Stage 2[9]
8. Bolster dressingTie-over or compressive bolster over the graft to ensure contact with the corporal bed and promote imbibition / inosculation[8]

Andrich and Mundy size the Stage-1 graft to a normal penile urethral caliber of about 26–28 Fr, harvesting oral mucosa at least 2.6–2.8 cm wide to allow for an estimated 5–10% contraction after prolonged air exposure, and quilt the graft centrally to the tunica albuginea with a small amount of dartos included in the lateral fixation sutures to ease mobilization of the graft edges at Stage 2.[19][20] These depend on individual urethral caliber and available donor tissue.[19][20]

Maturation interval​

Healing and the plate are assessed before closure. Staged-repair intervals vary. For staged penile-stricture repair, the EAU 2026 guideline recommends offering at least four to six months before the second stage when the first-stage outcome is satisfactory .[3][15][18] In Palminteri’s small LS cohort, a first-to-last-stage interval under 12 months was associated with failure (adjusted OR 27; 95% CI 1.36–537.55).[10]

Stage 2 — Tubularization​

StepDetail
1. Graft assessmentInspect the matured graft. Snodgrass and Elmore reported complete take in 22/25 (88%) failed-hypospadias reoperations; focal scar or contracture in the other three was patched before tubularization.[3]
2. TubularizationIn one primary proximal-hypospadias Bracka cohort, the surgeon repeated an artificial erection test before tubularization to check for residual curvature.[25] Tubularize the graft plate over a catheter with running or interrupted absorbable suture (e.g., 6-0 polyglactin)
3. Waterproofing layerMobilize a dartos fascia or tunica vaginalis flap as a second layer over the suture line. Snodgrass: one fistula among 18 second-stage patients with a barrier layer; not a randomized comparison[3]
4. GlansplastyClose glans wings over the neourethra to create a conical glans with a vertical slit neomeatus[3][9]
5. ClosureClose penile skin. In one pediatric Bracka cohort, the catheter was removed on postoperative day 12.[25] After adult Stage-2 tubularization, an indwelling catheter is commonly left for two to three weeks; assess extravasation by urethrography before catheter removal , and retain drainage and repeat assessment after one week for a significant leak.[24]

At tubularization, Andrich and Mundy avoid over-mobilizing the graft edges and favor an oval lumen over a circular tube to limit disruption of the graft's vascularity; they close through the dermis rather than the epidermis and add dartos coverage, particularly at the corona, to reduce fistula risk.[19]

Indications​

  • Proximal hypospadias with severe chordee requiring urethral plate transection.[5][9]
  • Hypospadias cripples. Patients with multiple (3–16) prior failed hypospadias repairs.[2][3]
  • Complex penile urethral strictures. Particularly circumferential strictures requiring complete urethral plate reconstruction.[4]
  • Lichen sclerosus (BXO) with adverse local conditions precluding a suitable single-stage oral-graft repair; avoid genital skin. In a nine-center retrospective cohort of LS penile strictures that excluded meatal strictures <2 cm, bulbar involvement, and panurethral strictures >10 cm, five-year stricture-free estimates were 82% after single-stage oral grafting (127 men), 76% after staged repair (44), and 75% after perineal urethrostomy (60), without a detectable difference between approaches (P = .6).[6][11][22]
  • Failed prior urethroplasty with a scarred or absent urethral plate.[6]
  • Severe proximal hypospadias as primary repair when one-stage techniques are not feasible.[12]

Graft Material — Preputial Skin vs Buccal Mucosa​

The original Bracka description used inner preputial skin, and both suitable inner prepuce and buccal mucosa are used in primary pediatric hypospadias repair.[7][8][9] For adult stricture reconstruction, the AUA 2023 guideline names oral mucosa as the first-choice graft .[13]

FeatureInner Preputial SkinBuccal Mucosa
Complication rate (Bracka hypospadias)31%20% [7]
Cosmetic result (HOPE scale)Good in earlier preputial-graft cohortMore favorable scores in later BMG cohort; nonconcurrent comparison[7]
LS-related recurrenceGenital skin unsuitable in LSOral mucosa preferred, but recurrence can still occur
Graft takeDepends on bed and fixationDepends on bed and fixation; small histologic series are not a universal 100% take estimate [8]
Histology after maturationKeratinization possibleMinimal keratinization, good vascularity
AvailabilityRequires suitable prepuceMay be limited by oral disease or prior harvest
Thickness for glanular urethraMay be too thickInner-lip mucosa is thinner but has its own donor morbidity; select individually

Manasherova compared 108 patients with preputial grafts to 112 with BMG in Bracka hypospadias repair: 23/112 (20%) versus 33/108 (31%) complications, with more favorable cosmetic scores in the later BMG cohort.[7] The graft groups were treated in different eras (2013–2016 versus 2001–2013).[7] In 31 patients, Mokhless reported excellent BMG uptake within 5 days, good vascularization at 6 months, and only mild focal keratinization after prolonged air exposure.[8]

The AUA urethral stricture guideline (amended 2023) states that surgeons should use oral mucosa as the first choice when using grafts and may use buccal or lingual mucosa as equivalent alternatives .[13] It states that surgeons should not use genital skin for reconstruction in lichen sclerosus-proven stricture .[13] The EAU guideline gives the same advice on genital skin in LS .[18]

Outcomes — Hypospadias Repair​

After childhood staged repair, the EAU 2026 pediatric guideline recommends long-term follow-up to detect urethral stricture, voiding dysfunction, recurrent penile curvature and ejaculatory problems, and to assess patient satisfaction. Uroflowmetry can identify worsening obstruction even in asymptomatic children.[27]

SeriesnPopulationOutcome
Gill / Hameed 2011[2]100Hypospadias cripples (3–16 prior surgeries)Meatal tip 94%, straightening 96%, fistula 9%
Ziylan 2025[23]122Boys after broader two-stage oral-graft redo hypospadias; median follow-up 121 moAny complication 36.8%; further intervention 23.8%
Snodgrass / Elmore 2004[3]25 first stage; 20 second stageFailed hypospadias (avg 4.4 prior surgeries)Graft take 22/25; one fistula in 18 with barrier flap; four partial glans dehiscences
Manasherova 2020[7]220Proximal hypospadias (preputial vs BMG)Complications: preputial 31% vs BMG 20%
Wani 2020 RCT[5]142Bracka vs Byars (proximal hypospadias)Fistula: Bracka 6.8% vs Byars 10.2% (p = 0.63)
Johal 2006[9]62Primary severe hypospadias100% graft take, low complications
Castagnetti 2013[12]18Primary proximal hypospadiasBest parent-reported cosmetic scores among 4 techniques

Outcomes — Adult Urethral Stricture​

SeriesnPopulationSuccessFollow-up
Greenwell 1999[4]34 penile repairs; 26 stagedPenile strictures; all circumferential repairs were stagedAuthors reported better outcomes with staged than one-stage total circumferential penile reconstruction—
Palminteri 2002[14]24Complex bulbar strictures23/24 reported stricture-freeMedian 18 mo
Furr 2021[15]49 included after both stagesStaged anterior urethroplastyLong-term functional success in the follow-up >1-year subset: BMG-only 96.4% vs any STSG 53%Median 57 mo in the included cohort
Figler 2018[6]20 first stage; 12 second stageMixed, including LS and failed hypospadiasSecond-stage fistula 1/12, dehiscence 2/12, meatal stenosis 1/12Median 520 days in the 20-patient series
Palminteri 2022[10]25 followed of 35LS penile strictures (multi-stage)20/25 no further stricture treatment; interval association is observationalMedian 134 mo

Furr reported 96.4% long-term success with BMG-only versus 53% with any STSG, but STSG patients had longer or more often panurethral disease and longer follow-up. Of 85 first-stage patients, 57 completed both stages and 49 entered follow-up analysis; patients lacking at least one year were excluded from the long-term estimate. Late recurrence (median 78 months among failures) supports extended follow-up.[15] For adult penile or graft-substitution urethroplasty, the EAU recommends follow-up for at least one year and a risk-adjusted protocol ; its proposed standard-risk schedule includes uroflowmetry, patient-reported outcomes, and anatomic assessment at 3, 12, and 24 months, then uroflowmetry and patient-reported outcomes at five years with anatomic testing as indicated.[26] Longer follow-up can be considered after penile or substitution repairs.[26]

Complications​

  • Fistula formation occurred in nine of 100 patients in Gill's series and one of 18 flap-covered second-stage repairs in Snodgrass's series. A vascularized barrier layer is commonly used; Gill’s and Snodgrass’s uncontrolled series lack comparative fistula data.[2][3]
  • Wound and glans dehiscence. Partial glans dehiscence occurred in four of 20 patients who had undergone Stage 2 in Snodgrass's series (all four were prepubertal boys with cheek grafts); wound dehiscence occurred in two of 12 second-stage patients in Figler's series. Snodgrass suggested that thinner inner-lip graft may be a better source for the glanular urethra, but no comparative study has tested this.[3][6]
  • Meatal stenosis occurred in 4% of Bracka patients in Wani's trial and in 1/12 (8%) after second-stage urethroplasty in Figler's mixed adult series.[5][6]
  • First-stage graft or outlet problems. Focal graft scar or contracture required patching before tubularization in 3/25 (12%) of Snodgrass’s failed-hypospadias cases. The EAU reports first-stage revision in 0–20% of staged penile-stricture series, usually for contracture; stomal stenosis is another complication in heterogeneous staged anterior cohorts.[3][18]
  • Urethral stricture occurred in about 1% in Wani's randomized comparison.[5]
  • Diverticulum occurred in no Bracka patients and 2% of Byars patients in Wani's randomized comparison.[5]
  • Residual chordee occurred in none of Wani’s 142 randomized patients and in 3/62 (4.8%) in Johal’s primary-repair series; Ziylan’s longer-followed redo cohort reported 6.6% of 122 boys.[5][9][23]

Bracka vs Byars Two-Stage Repair​

A randomized comparative trial (Wani 2020, n = 142, proximal hypospadias with severe chordee) compared Bracka (n = 74) versus Byars (n = 68). Conceptual difference: Bracka uses a free graft placed on the corpora; Byars uses a pedicled dorsal preputial flap transposed ventrally.[5]

EndpointBrackaByarsp
Fistula6.8%10.2%0.63
Meatal stenosis4%3%NS
Stricture1%1%NS
Diverticulum0%2%NS

No statistically significant difference was detected. Choice also depends on anatomy, donor tissue and experience.[5]

Bracka vs Classic Johanson​

FeatureClassic JohansonBracka Two-Stage
Stage 1 conceptMarsupialization (urethra opened to skin)Free graft placement on corpora
Graft at Stage 1No (originally)Yes (preputial skin or BMG)
Urethral plate qualityRelies on native tissueCreates new plate from graft
Suitability for LSLimited (native skin diseased)Oral mucosa preferred; LS-related recurrence remains possible
Need for additional stagesDepends on plate qualityMay require regrafting or delayed closure; counsel before starting
Primary applicationAdult urethral stricturesHypospadias + strictures

Modern Modifications and Hybrid Approaches​

  • Mitsukawa modification. Combines a modified Bracka method (oral-mucosal graft) with a modified Byars flap of the dorsal foreskin for severe proximal hypospadias requiring urethral plate resection.[16]
  • Palminteri 2-stage BMG urethroplasty. Adapts the Bracka concept to adult bulbar strictures with a 2 × 6 cm BMG sutured to the urethral mucosal plate margin: 23/24 reported stricture-free success.[14]
  • Johanson-Bracka hybrid. In contemporary stricture surgery, the first stage often combines Johanson marsupialization with Bracka-type BMG grafting. If a Johanson-only first stage is performed without grafting, a three-stage approach may be needed (marsupialization, then grafting, then tubularization).[10]
  • Tunica vaginalis as alternative free graft. Rosito’s rabbit model showed good graft uptake with minimal retraction, stratified non-keratinized epithelium development (metaplasia), and good vascularization.[17]
  • Tunica vaginalis graft bed. When penile dartos is insufficient to support a graft plane, mobilizing tunica vaginalis from one testis through a scrotal window and fixing it over the corpora before placing the free graft has been described as a salvage graft bed, distinct from using tunica vaginalis as the graft material itself (above); no case series or outcome data are reported.[21]

Key Takeaways​

Staged oral-graft reconstruction is used when tissue quality makes a single-stage repair unsuitable. The EAU 2026 guideline advises offering staged urethroplasty to men with complex anterior stricture who are not suitable for a single stage and are fit for reconstruction , and advises against staged bulbar urethroplasty for LS when a single stage is possible .[18] It also advises warning patients that staging may take more than two operations; up to 45.5% of men elect not to proceed to second-stage tubularization after a successful first stage.[18] The AUA guideline lets surgeons choose one-stage or multi-stage techniques for long multi-segment strictures .[13]

Videos​

Staged BMG Urethroplasty After Failed Hypospadias Surgery
Jeremy Myers, TURNS
Staged Urethroplasty for Lichen Sclerosus and Failed Hypospadias Strictures
Brad Figler, UNC Urology

References​

1. Hadidi AT. History of hypospadias: lost in translation. J Pediatr Surg. 2017;52(2):211-217. doi:10.1016/j.jpedsurg.2016.11.004.

2. Gill NA, Hameed A. Management of hypospadias cripples with two-staged Bracka's technique. J Plast Reconstr Aesthet Surg. 2011;64(1):91-96. doi:10.1016/j.bjps.2010.02.033.

3. Snodgrass W, Elmore J. Initial experience with staged buccal graft (Bracka) hypospadias reoperations. J Urol. 2004;172(4 Pt 2):1720-1724. doi:10.1097/01.ju.0000139954.92414.7d.

4. 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.

5. Wani SA, Baba AA, Mufti GN, et al. Bracka versus Byar's two-stage repair in proximal hypospadias associated with severe chordee: a randomized comparative study. Pediatr Surg Int. 2020;36(8):965-970. doi:10.1007/s00383-020-04697-x.

6. 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.

7. Manasherova D, Kozyrev G, Nikolaev V, et al. Bracka's method of proximal hypospadias repair: preputial skin or buccal mucosa? Urology. 2020;138:138-143. doi:10.1016/j.urology.2019.12.027.

8. Mokhless IA, Kader MA, Fahmy N, Youssef M. The multistage use of buccal mucosa grafts for complex hypospadias: histological changes. J Urol. 2007;177(4):1496-1499. doi:10.1016/j.juro.2006.11.079.

9. Johal NS, Nitkunan T, O'Malley K, Cuckow PM. The two-stage repair for severe primary hypospadias. Eur Urol. 2006;50(2):366-371. doi:10.1016/j.eururo.2006.01.002.

10. 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.

11. Chung ASJ, Suarez OA. Current treatment of lichen sclerosus and stricture. World J Urol. 2020;38(12):3061-3067. doi:10.1007/s00345-019-03030-z.

12. Castagnetti M, Zhapa E, Rigamonti W. Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs. J Urol. 2013;189(4):1508-1513. doi:10.1016/j.juro.2012.11.013.

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. Palminteri E, Lazzeri M, Guazzoni G, Turini D, Barbagli G. New 2-stage buccal mucosal graft urethroplasty. J Urol. 2002;167(1):130-132. doi:10.1016/s0022-5347(05)65397-9. PMID 11743290.

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.

16. Mitsukawa N, Saiga A, Akita S, et al. Two-stage repair for severe proximal hypospadias using oral mucosal grafts: combination of a modified Bracka method and a modified Byars flap method. Ann Plast Surg. 2015;74(2):220-222. doi:10.1097/SAP.0b013e318292099d.

17. Rosito TE, Pires JA, Delcelo R, Ortiz V, Macedo A. Macroscopic and histological evaluation of tunica vaginalis dorsal grafting in the first stage of Bracka's urethroplasty: an experimental study in rabbits. BJU Int. 2011;108(2 Pt 2):E17-22. doi:10.1111/j.1464-410X.2010.09708.x.

18. EAU Guidelines on Urethral Strictures, limited update 2026: staged augmentation urethroplasty, penile and bulbar strictures, and lichen sclerosus. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.

19. Andrich DE, Mundy AR. The use of free grafts for urethroplasty. In: Schreiter F, Jordan GH, eds. Urethral Reconstructive Surgery. Springer; 2006:175-179. doi:10.1007/3-540-29385-X_21

20. Andrich DE, Mundy AR. Staged urethroplasty. In: Montague DK, Gill IS, Angermeier KW, Ross JH, eds. Textbook of Reconstructive Urologic Surgery. Informa Healthcare; 2008:483-486.

21. McClung C, Wessells H. Staged Urethroplasty. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:289-303. doi:10.1007/978-1-4614-7708-2_20

22. Hengel R, Vanni A, Erickson B, et al. "Multi-Institutional Analysis of Surgery for Lichen Sclerosus-Induced Penile Urethral Stricture: Establishing Single-Stage Urethroplasty as a Primary Treatment Option." J Urol. 2025;213(5):628-637. doi:10.1097/JU.0000000000004434.

23. Ziylan O, Selvi I, Dönmez Mİ, Aydın AB, Oktar T. "Two-Stage Repair for re-do Hypospadias: Results of Over 5-Year Follow-Up." Int J Urol. 2025;32(8):1045-1053. doi:10.1111/iju.70098.

24. European Association of Urology. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery." EAU Guidelines. 2026. Guideline chapter.

25. Zhang Y, Wang X, Wu Y, et al. "Grafts vs. flaps: a comparative study of Bracka repair and staged transverse preputial island flap urethroplasty for proximal hypospadias with severe ventral curvature." Front Pediatr. 2023;11:1214464. doi:10.3389/fped.2023.1214464

26. European Association of Urology. "EAU Guidelines on Urethral Strictures: Follow Up." EAU Guidelines. 2026. Guideline chapter.

27. European Association of Urology. "EAU Guidelines on Paediatric Urology: Hypospadias." EAU Guidelines. 2026. Guideline chapter.