Bracka Two-Stage Urethroplasty
The Bracka two-stage urethroplasty is a landmark reconstructive technique originally described by Arul Bracka in 1995 for the repair of complex hypospadias and subsequently widely 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 simply 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 (originally inner preputial skin, now preferably buccal mucosa) is placed onto the corpora cavernosa at Stage 1, allowed to mature and revascularize, then tubularized into a neourethra at Stage 2. This produces a wider, well-vascularized urethral plate than the Johanson marsupialization, which relies on native (often scarred or diseased) urethral tissue.[2][3][4]
Surgical Technique
Stage 1 — Chordee correction, scar excision, and graft placement
| Step | Detail |
|---|---|
| 1. Degloving | Circumcoronal or ventral midline incision; degloving; full exposure of the strictured / scarred urethral segment |
| 2. Chordee correction | Ventral curvature corrected. In hypospadias cases, may require urethral plate transection and dorsal plication. In stricture cases, all fibrotic spongiosal tissue is excised[2][5] |
| 3. Scar excision | All visibly scarred / fibrotic / LS-affected tissue excised until healthy, well-vascularized tissue is reached[3][6] |
| 4. Proximal urethrostomy | Cutaneous urethrostomy created proximally for voiding during the maturation period[3] |
| 5. Graft harvest | Originally inner preputial skin; modern practice: buccal mucosa from the inner cheek (or inner lip for glanular reconstruction)[3][7] |
| 6. Graft inset | Defat and quilt the graft (multiple interrupted fixation sutures) onto the ventral surface of the corpora cavernosa, creating a flat neourethral plate from the proximal urethrostomy to the glans tip[3][8] |
| 7. Glans split (hypospadias) | In hypospadias cases, glans is split ventrally to allow the graft to extend to the tip — enabling creation of a terminal slit-like meatus at Stage 2[9] |
| 8. Bolster dressing | Tie-over or compressive bolster over the graft to ensure contact with the corporal bed and promote imbibition / inosculation[8] |
Maturation interval
Minimum 6 months to allow complete graft maturation and revascularization.[2][3][9] Palminteri found that an interval < 12 months between first and last stages is an independent predictor of failure.[10]
Stage 2 — Tubularization
| Step | Detail |
|---|---|
| 1. Graft assessment | Inspect matured graft. Complete take in ~ 88% of cases; focal scar / contracture can be patched with additional graft before proceeding[3] |
| 2. Tubularization | Tubularize the graft plate over a catheter (8–10 Fr in children, 14–16 Fr in adults) with running or interrupted absorbable suture (e.g., 6-0 polyglactin) |
| 3. Waterproofing layer | Mobilize a dartos fascia or tunica vaginalis flap as a second layer over the suture line. Snodgrass: fistula rate 5% with a barrier layer[3] |
| 4. Glansplasty | Close glans wings over the neourethra to create a conical glans with a vertical slit neomeatus[3][9] |
| 5. Closure | Close penile skin; catheter for ~ 7–14 days (children) or up to 3 weeks (adults) |
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) — genital skin diseased, oral mucosa mandatory.[6][11]
- 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. Modern practice has shifted decisively to buccal mucosa:[7][8]
| Feature | Inner Preputial Skin | Buccal Mucosa |
|---|---|---|
| Complication rate (Bracka hypospadias) | 31% | 20% |
| Cosmetic result (HOPE scale) | Good | Superior |
| Susceptibility to LS | Yes (skin) | No (mucosa) |
| Graft take | Good | Excellent (100% at 5 days) |
| Histology after maturation | Keratinization possible | Minimal keratinization, good vascularity |
| Availability | Requires intact prepuce | Always available (both cheeks) |
| Thickness for glanular urethra | May be too thick | Inner-lip mucosa thinner; preferred for glans |
Manasherova compared 108 patients with preputial grafts to 112 with BMG in Bracka hypospadias repair: 20% vs 31% complication rate and superior cosmetic outcomes with BMG.[7] Mokhless demonstrated that BMG shows excellent uptake within 5 days, develops good vascularization, and undergoes only mild focal keratinization after prolonged air exposure.[8]
The AUA 2023 urethral stricture guideline amendment recommends oral mucosa as the first-choice graft material, with buccal and lingual mucosa equivalent alternatives. Genital skin should be avoided in lichen sclerosus due to high long-term failure.[13]
Outcomes — Hypospadias Repair
| Series | n | Population | Outcome |
|---|---|---|---|
| Gill / Hameed 2011[2] | 100 | Hypospadias cripples (3–16 prior surgeries) | Meatal tip 94%, straightening 96%, fistula 9% |
| Snodgrass / Elmore 2004[3] | 25 | Failed hypospadias (avg 4.4 prior surgeries) | Graft take 88%, fistula 5%, no stricture / stenosis |
| Manasherova 2020[7] | 220 | Proximal hypospadias (preputial vs BMG) | Complications: preputial 31% vs BMG 20% |
| Wani 2020 RCT[5] | 142 | Bracka vs Byars (proximal hypospadias) | Fistula: Bracka 6.8% vs Byars 10.2% (p = 0.63) |
| Johal 2006[9] | 62 | Primary severe hypospadias | 100% graft take, low complications |
| Castagnetti 2013[12] | 18 | Primary proximal hypospadias | Best cosmetic results among 4 techniques |
Outcomes — Adult Urethral Stricture
| Series | n | Population | Success | Follow-up |
|---|---|---|---|---|
| Greenwell 1999[4] | 26 | Penile strictures (circumferential) | Two-stage much better than one-stage | — |
| Palminteri 2002[14] | 24 | Complex bulbar strictures | 92.8% | Median 18 mo |
| Furr 2021[15] | 49 | Staged anterior urethroplasty | BMG-only 96.4% vs STSG 53% | Median 57 mo |
| Figler 2018[6] | 20 | LS + failed hypospadias | Fistula 8%, dehiscence 17%, stenosis 8% | Median 520 days |
| Palminteri 2022[10] | 25 | LS penile strictures (multi-stage) | 80% (interval < 12 mo predicts failure) | Long-term |
A critical finding from Furr 2021: long-term success is 96.4% with BMG-only but only 53% when STSG is incorporated. All recurrences occurred after the initial 4-month cystoscopy with a median time to recurrence of 78 months — underscoring the need for prolonged follow-up.[15]
Complications
- Fistula formation — most common, 5–9%; reduced by use of a dartos / tunica vaginalis barrier flap.[2][3]
- Wound / glans dehiscence — partial glans dehiscence ~ 6–17%, particularly in prepubertal boys when thicker cheek BMG is used for the glanular urethra; inner-lip graft preferable for this location.[3][6]
- Meatal stenosis — 3–8%.[5][6]
- Graft contracture / scar — ~ 12% may have focal scar or contracture requiring patching before tubularization.[3]
- Urethral stricture — ~ 1% in hypospadias series.[5]
- Diverticulum — rare, 0–2%.[5]
- Residual chordee — 0–5%.[5][9]
Bracka vs Byars Two-Stage Repair
The only randomized comparative trial (Wani 2020, n = 142, proximal hypospadias with severe chordee) compared Bracka (n = 74) vs Byars (n = 68). Key conceptual difference: Bracka uses a free graft placed on the corpora; Byars uses a pedicled dorsal preputial flap transposed ventrally.[5]
| Endpoint | Bracka | Byars | p |
|---|---|---|---|
| Fistula | 6.8% | 10.2% | 0.63 |
| Meatal stenosis | 4% | 3% | NS |
| Stricture | 1% | 1% | NS |
| Diverticulum | 0% | 2% | NS |
No statistically significant differences. Choice depends on surgeon preference and experience.[5]
Bracka vs Classic Johanson
| Feature | Classic Johanson | Bracka Two-Stage |
|---|---|---|
| Stage 1 concept | Marsupialization (urethra opened to skin) | Free graft placement on corpora |
| Graft at Stage 1 | No (originally) | Yes (preputial skin or BMG) |
| Urethral plate quality | Relies on native tissue | Creates new plate from graft |
| Suitability for LS | Limited (native skin diseased) | Yes (BMG resistant to LS) |
| Need for third stage | Sometimes (if plate inadequate) | Rarely |
| Primary application | Adult urethral strictures | Hypospadias + 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: 92.8% 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 → grafting → tubularization).[10]
- Tunica vaginalis as alternative free graft — Rosito rabbit-model work shows good graft uptake with minimal retraction, stratified non-keratinized epithelium development (metaplasia), and good vascularization — a possible alternative when oral mucosa is unavailable.[17]
Key Takeaways
The Bracka technique is versatile, reproducible, and applicable to the most challenging reconstructive scenarios. It is described as "relatively easy to learn" and applicable in difficult salvage cases.[2] The shift from preputial skin to buccal mucosa has further improved outcomes. The technique remains the gold standard for staged urethral reconstruction when one-stage repair is not feasible, supported by the AUA 2023 amendment's endorsement of multi-stage techniques with oral mucosal grafts for complex and long-segment strictures.[13]
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.
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.