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Endoscopic Urethroplasty

Endoscopic urethroplasty describes endoluminal buccal mucosa graft (BMG) placement for selected posterior stenoses: Warner's method uses an RD 180 suturing device, whereas Doležel's uses a catheter-mounted tubular graft.[1][2] Small cohorts describe endoscopic graft augmentation without an external incision but lack durability comparisons with established reconstruction. Two named approaches are detailed here: the Warner technique, first reported in one membranous-stricture case in 2023, and the Doležel endourethroplasty, reported in an 11-patient subgroup with PUS or VUAS in 2024.[1][2]

For the broader VUAS / posterior-urethral-stenosis decision framework, see Bladder Neck Reconstruction & VUAS. For the open perineal benchmark, see Dorsal Onlay BMG Urethroplasty. For the standalone graft material, see Buccal Mucosa Graft. For the related transmeatal anterior-urethral application, see Transmeatal OMG Ventral Inlay.

Why Endoscopic Posterior BMG​

Endoscopic treatment outcomes for posterior stenosis vary substantially with etiology, luminal patency, radiation exposure and prior treatment. Established reconstruction may use excision and anastomosis, a flap, or graft augmentation, with different morbidity and continence risks.[3][6] Endoscopic BMG urethroplasty was developed to deliver the augmentation principle through the lumen, sparing the perineum.

Warner Technique — Membranous Urethral Stricture (Ungerer 2023)​

Index case. Male with prostate-cancer-related radiation therapy and an 8 mm flow-limiting membranous urethral stricture, a population where open repair carries higher recurrence and morbidity.[1]

Step-by-step.[1]

StepDetail
1. Stricture dilationMembranous stricture dilated to allow resectoscope passage; defines proximal / distal extent
2. Graft-bed preparationIn the reported case, a resectoscope removed a 1 cm-wide strip of superficial mucosa from the bladder neck across the strictured segment, creating a vascularized recipient bed for graft imbibition and inosculation. Keep this resection superficial; for DVIU in VUAS or radiation-induced bulbomembranous stenosis, EAU strongly advises against deep six- and 12-o’clock incisions because of rectal injury and urosymphyseal fistula risk.[1][6]
3. BMG harvestStandard inner-cheek BMG; defatted and trimmed on the back table
4. Pulley deliveryWith graft outside the urethra, the RD 180 endoscopic suturing device is passed transurethrally; a suture is placed through the proximal graft, then through the bladder neck, then back through the graft. Pulling the suture advances the graft into the correct intraluminal position
5. AnchoringGraft anchored against the prepared bed with SecureStrap fixation, separate from the RD 180 suturing device[1][8]
6. CatheterCatheter holds the graft flat against the bed during healing; removed at 4 weeks

Outcome (n = 1).[1]

MetricResult
Operative time2.5 hours
EBL50 mL
DischargeSame day
CatheterRemoved POD 28
Cystoscopy at 10 wkGood graft viability
Qmax4 → 20 mL/s
6-month follow-upNo recurrence; no complications

Potential advantages. Entirely transurethral delivery and same-day discharge were feasible in this case. Comparative efficacy and safety, including in irradiated tissue, remain unestablished.

Limitations. Evidence is one case report with 6-month follow-up and one single-surgeon retrospective series of 28 men with a median follow-up of 8 months, both from the originating center; requires the RD 180 suturing device and endoscopic-suturing skill; the graft is held by RD 180-placed stay sutures, a few SecureStrap tacks and catheter compression rather than the quilting sutures of the Nikolavsky ventral inlay.[1][8]

Instrumentation. The RD 180 endoscopic suturing device is the enabling technology; its pulley mechanism allows graft delivery into the confined posterior-urethral space without an external incision. The same device is also used in TUITMR mucosal-realignment techniques.[1][3]

Doležel Endourethroplasty — PUS / VUAS (2024)​

Series. Single Czech institution, 1999–2022, 38 consecutive patients with posterior urethral stenosis (PUS) or vesicourethral-anastomotic stenosis (VUAS). Twenty-six of 38 (68%) had prior failed procedures (25 endoscopic, one open); 12 of 38 (32%) underwent primary reconstruction.[2] Twenty-seven patients (71%) had a perineal approach; 11 patients (29%) had endourethroplasty (EUP). Etiologies included post-radical-prostatectomy VUAS and post-TURP or post-radiation membranous stenosis; only 2 of 11 EUP patients had received pelvic radiotherapy, limiting inference for irradiated stenosis.[2]

Technique. The EUP subgroup received a tubularized BMG mounted on a catheter and delivered retrograde to the incised stenosis; onlay grafting was used in the perineal approach:[2]

  1. Endoscopic assessment of stenosis length, location, and degree of obliteration.
  2. The reported EUP used a 24 Fr cold-knife urethrotome; tight stenoses were first dilated to 10–12 Fr. For VUAS, the authors made a deep ventral six-o'clock incision through adjacent muscle into prerectal tissue. EAU 2026 strongly recommends against deep six-o'clock DVIU for VUAS or radiation-induced bulbomembranous stenosis because of rectal injury risk.[2][6]
  3. Standard inner-cheek BMG harvest.
  4. A tubularized BMG was fixed to a 20 Fr Tiemann catheter with absorbable 4-0 sutures, then inserted retrograde through the urethra to the incised stenosis; the perineal approach used an onlay graft.[2]
  5. After balloon seating at the bladder neck, a transcutaneous mattress stitch secured the urethral catheter at the penoscrotal angle. The urethral and safety suprapubic catheters remained for 3–4 weeks.[2]

Auxiliary cold-knife DVIU. In the Doležel protocol, a short PUS or VUAS recurrence within the first 12 months is transected by a single cold-knife DVIU. The report presents both recurrence-free survival and survival allowing this additional treatment. An auxiliary DVIU remains a reintervention and must be counted when comparing treatment burden. One patient died on postoperative day two from sepsis-associated multiorgan failure after auxiliary DVIU for complete VUAS reobliteration three months after perineal repair; the authors noted prior salvage radiotherapy and possible urinary extravasation as risk factors.[2] EAU 2026 gives a strong recommendation against endoluminal treatment of completely obliterated VUAS.[6]

Outcomes.[2]

Cohort3-yr stricture-recurrence-free survival
Endourethroplasty (n = 11)73%
Perineal approach (n = 27)63%
Whole cohort65%
Whole cohort with permitted auxiliary DVIU81%

De novo incontinence occurred in 2 of 18 preoperatively continent patients across both groups. Both events followed perineal repair, with none reported after EUP in this small series; separate robotic series provide no direct continence comparison.[2]

What the series adds. It reports a three-year recurrence endpoint and documents technical feasibility.

Limitations. Small, heterogeneous cohort (n = 11 EUP); single-center retrospective design; the published endourethroplasty technique fixes a tubularized graft to a 20 Fr Tiemann catheter with absorbable sutures before retrograde insertion; the auxiliary-DVIU protocol complicates comparison with techniques that count any reintervention as failure.[2]

Published Technique Comparison​

FeatureWarner (Ungerer 2023)Doležel Endourethroplasty (2024)
Target anatomyMembranous urethral stricturePUS / VUAS (membranous + bladder neck)
Graft configurationOnlay (on resected mucosal bed)Tubularized BMG mounted on a 20 Fr catheter[2]
Graft-bed preparationResectoscope mucosal-strip resection (1 cm wide)Cold-knife incision; for VUAS, Doležel reports a deep ventral six-o'clock cut, while EAU 2026 strongly recommends against that incision in VUAS[2][6]
Graft deliveryRD 180 suturing device + pulley techniqueEndourological (device not specified)
Graft fixationSecureStrap anchors and catheter compression[1][8]Absorbable 4-0 sutures attach the graft to the catheter; a transcutaneous mattress stitch secures the catheter[2]
Catheter duration4 weeksUrethral and suprapubic catheters for 3–4 weeks[2]
Sample size1 (case report)11 (institutional series)
Follow-up6 monthsThree-year SRFS endpoint; median follow-up was 89 months for the full n = 38 cohort, with no EUP-specific median reported[2]
Reported outcomeNo recurrence reported at 6 months (1 patient)[1]EUP three-year SRFS was 73% before and 77% with auxiliary DVIU; 81% with auxiliary DVIU applies to all 38 patients[2]
De novo incontinenceNot separately reported in the single-patient case[1]2 / 18 preoperatively continent patients in the combined cohort; both events followed perineal repair[2]
Auxiliary DVIUNone usedPermitted within 12 months as protocol
Primary etiologyPost-radiationMixed (post-prostatectomy, post-TURP, post-radiation)
Technical-detail publishedHigh (step-by-step + device specifics)Moderate

Open Perineal D-BMGU as Benchmark​

For context, these observational series describe open perineal dorsal onlay BMG urethroplasty (D-BMGU) in selected posterior stenosis populations:

  • Angulo 2021 (multi-institutional, n = 107, membranous / bulbomembranous after endoscopic prostate procedures): mean follow-up 59.3 months; 9.35% recurrence; 0.9% de novo SUI. Independent recurrence predictors: postoperative complications (OR 12.5), prior radiation (OR 8.3), and ≥ 2 prior dilations (OR 7.2).[4]
  • Sterling 2024 (multi-institutional, n = 45, after both prostatectomy and radiation, with VUAS or bulbomembranous stenosis): 7 recurrences (median follow-up 21 months in men without recurrence); no de novo SUI reported (28 men were incontinent before and after repair); 23/27 (85%) reported GRA ≥ +2.[5]

Where It Fits​

Endoscopic posterior BMG urethroplasty remains an emerging technique with limited clinical evidence. Published applications include:

  • Post-radiation membranous stricture in patients unfit for or declining open / robotic perineal reconstruction.
  • Post-prostatectomy VUAS where the bladder-neck stenosis is short and amenable to endoluminal graft placement.
  • Centers with expertise and equipment for the selected graft-delivery and fixation method; RD 180 is specific to the Warner method.[1][2]

Selection requires reconstructive assessment of stenosis location, obliteration, tissue quality, radiation injury, bladder function and continence goals. In a single-surgeon retrospective series of 28 men with membranous stricture, 23/28 (82%) passed a 17 Fr cystoscope at four months; median follow-up was eight months. Sixteen later received an artificial urinary sphincter, and three required cystectomy for radiation-related bladder disease, including one delayed urosymphyseal fistula. Four of 28 patients (14%) lost part or all of the graft, and two experienced clot retention requiring operative evacuation.[8] The authors recommend cystectomy over urethral repair when there is significant necrosis or calcification at the stenosis, fistula, wide bladder neck separation, osteitis pubis or bladder capacity below 200 mL; all five obliterative strictures in the series were patent at four-month cystoscopy.[8] Do not treat complete posterior obliteration endoluminally: EAU 2026 gives a strong recommendation against endoluminal treatment of vesicourethral anastomotic stenosis, bulbomembranous stenosis or bladder neck stenosis with complete obliteration (§6.3.5.a) and against endoscopic treatment of an obliterative post-traumatic stenosis (§6.3.5.b).[6] AUA advises against single-stage tubularized graft urethroplasty .[7] See BNC / VUAS for the broader treatment pathway.

Videos​

Posterior Endoscopic Urethroplasty with Graft
Li O, et al. Urology Video Journal 2024 (CC BY 4.0)
Open source videoRead the article

References​

1. Ungerer G, Kemble J, Sischka M, Balzano FL, Warner JN. Endoscopic urethroplasty using buccal graft for male membranous urethral stricture. Urology. 2023;181:e200-e203. doi:10.1016/j.urology.2023.05.059.

2. Doležel J, Hrabec R, Uher M, et al. Substitution urethroplasty with buccal mucosal graft in the management of stricture of vesicourethral anastomosis or membranous urethra: single-institution long-term experience with perineal approach and endourethroplasty. Urology. 2024;192:126-132. doi:10.1016/j.urology.2024.05.034.

3. Hudson CN, Damm T, Monn MF. Minimally invasive treatments for posterior urethral stenosis. J Endourol. 2025. doi:10.1177/08927790251371037.

4. Angulo JC, Dorado JF, Policastro CG, et al. Multi-institutional study of dorsal onlay urethroplasty of the membranous urethra after endoscopic prostate procedures: operative results, continence, erectile function and patient-reported outcomes. J Clin Med. 2021;10(17):3969. doi:10.3390/jcm10173969.

5. Sterling J, Simhan J, Flynn BJ, et al. Multi-institutional outcomes of dorsal onlay buccal mucosal graft urethroplasty in patients with post-prostatectomy, post-radiation anastomotic stenosis. J Urol. 2024;211(4):596-604. doi:10.1097/JU.0000000000003848.

6. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. 2026. Guideline.

7. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210:64-71. doi:10.1097/JU.0000000000003482.

8. Ungerer GN, Pence ST, Findlay BL, et al. "Endoscopic buccal urethroplasty for membranous stricture disease." Transl Androl Urol. 2025;14(8):2383-2390. doi:10.21037/tau-24-430