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Johanson Two-Stage Urethroplasty

The Johanson two-stage urethroplasty is a classic reconstructive technique for complex anterior urethral strictures, originally described by Bengt Johanson in 1953 for the management of penile urethral strictures.[1][2] It is used mainly when single-stage repair is not feasible.

For the BMG / oral-mucosa graft material, see Buccal Mucosa Graft. For the related panurethral one-sided BMG approach, see Kulkarni One-Sided Dorsolateral BMG. For the variant with active graft placement at Stage 1 (used for hypospadias reoperations and for LS strictures unsuitable for a single stage), see Bracka Two-Stage Urethroplasty. For permanent first-stage-only solutions, see Blandy Perineal Urethrostomy and Midline Perineal Urethrostomy.

Historical Background​

Johanson originally described the procedure (see the History of Urethral Surgery) as a marsupialization-and-closure technique for penile urethral strictures.[1] The concept was later modified by Leadbetter (the "Johanson-Leadbetter" technique) and by Fernandes and Draper for bulbomembranous strictures without splitting the scrotum.[3][4] The technique has evolved to incorporate modern graft materials, particularly buccal mucosal grafts (BMG), replacing the original reliance on local genital skin.[5][6] Older reconstructions that used scrotal skin could leave hair within the urethra; a 2006 historical review describes calcification caused by retained scrotal hair as one of the disadvantages of this practice, one reason hair-bearing tissue was abandoned in favor of oral mucosa.[20]

Surgical Technique​

Before reconstruction, the EAU 2026 guidelines strongly recommend retrograde urethrography to map stricture location and length, combined with voiding cystourethrography for a nearly obliterative segment.[24] After urethral manipulation, allow urethral rest before urethroplasty; EAU lists a minimum of three months as a level-3 evidence statement, while noting that the optimal duration is unknown.[16] Reconstruction is planned in two stages separated by a maturation interval, but graft revision may require another stage.[17]

Stage 1 — Marsupialization​

StepDetail
1Strictured segment exposed via ventral midline incision along the penile shaft (or perineum for bulbar strictures)
2Open the stricture ventrally from the meatus or its distal extent and continue proximally into healthy, patent urethra. If distal urethra is absent or unusable, split the glans or excise diseased distal plate as required for graft reconstruction.[22]
3Release the stricture and preserve useful native plate and vascular support; excise tissue that is unusable or hair-bearing
4Marsupialization: urethral edges are sutured to surrounding penile skin, creating a flat open urethral plate (essentially a hypospadiac-type urethrostomy)
5In modern practice, a buccal mucosa graft may be quilted onto the opened urethral bed to augment the plate when native tissue is insufficient or diseased[6][7]
6Drain through the first-stage outlet as appropriate.[17] EAU 2026 notes that after perineostomy or a first stage the catheter can be removed after 3 to 5 days without urethrography.[16] For a fresh graft or wound concern, tailor the drainage plan; in Furr's series the graft bolster remained for five days and the urethral stent was removed approximately 10–14 days after surgery.[15]

A proximal-shaft first-stage neomeatus can give an inadequate standing stream with dribbling and soiling. For selected patients, creating a temporary perineal urethrostomy at the first-stage operation and closing it during Stage 2 has been described as an option; in one author's experience, most patients did not choose it.[18]

Maturation interval​

Healing, plate width and disease activity are assessed before closure, together with first-stage outlet and proximal urethral patency. Furr's staged-repair cohort used flexible cystoscopy at four months to verify the outlet and proximal segment before tubularization.[15] For penile strictures, EAU 2026 offers an interval of at least four to six months before the second stage when the first stage outcome is satisfactory .[15][17] Among 25 patients with follow-up in Palminteri’s LS cohort, a first-to-last-stage interval under 12 months was associated with failure (adjusted OR 27; 95% CI 1.36–537.55).[9] Al-Ali performed the second stage 2–3 months after the first in a mainly war-injury salvage series.[8]

Stage 2 — Tubularization​

StepDetail
1Matured urethral plate (with or without incorporated graft) tubularized over a 14–16 Fr catheter
2Plate edges mobilized and closed in a tension-free, watertight fashion with absorbable suture
3When available, interpose a vascularized dartos or spongiosal layer over the suture line to reinforce closure, with the aim of reducing fistula risk; preserve penile-skin blood supply. If dartos is deficient after failed hypospadias repair, a tunica vaginalis flap has been described.[22][17]
4Urethral stent and/or suprapubic drainage according to the reconstruction; in Furr's series, the urethral stenting catheter was removed at three weeks with a voiding cystourethrogram.[15] EAU 2026 notes that an indwelling catheter is commonly left for two to three weeks, strongly recommends validated urethrography before removal, and weakly recommends considering a first study at 7 to 10 days after uncomplicated repair. For persistent significant extravasation, maintain or reinsert the catheter and repeat imaging after one week.[16]

One approach marks the matured plate to a width of 28 mm with calipers before incising and closing it in the midline.[18]

Indications​

Staged reconstruction is considered when local tissue quality or associated pathology makes a suitable single-stage repair impractical.[1][2][10]

  • Complex penile urethral strictures. Particularly circumferential strictures requiring complete urethral plate reconstruction.
  • Lichen sclerosus (BXO). Genital skin can be affected by LS; for LS-proven urethral stricture, the AUA recommends against using genital skin for reconstruction . If urethral cancer is suspected, biopsy must be performed .[13] For men with LS-related urethral strictures, the EAU 2026 guideline recommends single-stage oral mucosa graft urethroplasty when there are no adverse local conditions , and advises against staged repair for bulbar LS when a single-stage repair is possible .[7][9][17][21] In a nine-center retrospective cohort of selected LS penile strictures, 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 (P = .6).[7][9][17][21]
  • Failed hypospadias repair. Local tissue is scarred and unhealthy.[7][11]
  • Long-segment, multifocal, or panurethral disease when the plate or surrounding tissue cannot support a suitable single-stage repair.[8][12][17]
  • Salvage after multiple failed prior urethroplasties or endoscopic treatments.[8][11]
  • Unhealthy local tissue. Fistulae and scarring occurred in Al-Ali's war-injury salvage cohort. EAU 2026 also lists radiotherapy-induced bulbar strictures among circumstances in which staging may be considered.[8][17]
  • Patient preference. The EAU guideline suggests considering a staged procedure in patients unsure between perineal urethrostomy and reconstruction . Medical comorbidities require assessment of fitness for reconstruction; for men unfit for formal reconstruction, EAU suggests perineal urethrostomy .[17]

The AUA urethral stricture guideline (amended 2023) states that surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination . It states that surgeons should use oral mucosa as the first choice when using grafts .[13]

Outcomes​

OutcomeResultSource
Composite success: cystourethroscopy passes without resistance and the patient voids without further intervention (mixed staged-repair cohort)89/100 at median 53 moMinami 2025[14]
Long-term success — BMG-only staged repair96.4% in the long-term subset; median follow-up 45 mo in the BMG groupFurr 2021[15]
Long-term functional success — staged repair with any STSG (including BMG plus STSG)53% (9/17) in the long-term subset; median follow-up 79 mo in the any-STSG groupFurr 2021[15]
Penile graft-augmentation urethroplasty (pooled techniques, not Johanson-specific)Staged: 90.5% of 129 at mean 22.2 mo; one-stage: 75.7% of 432 at mean 32.8 moMangera 2011[10]
Salvage cohort, improved urine flow94% (mean Qmax 17.4 mL/s)Al-Ali 2001[8]
Patient satisfaction (PRO)93.5% of questionnaire respondents satisfied / very satisfiedMinami 2025[14]

In a retrospective multi-institutional cohort of 466 men with strictures at least 8 cm long, recurrence was 35.7% among 56 second-stage Johanson repairs versus 17.5% among 223 one-stage dorsal-onlay BMG repairs (P < .01); overall mean follow-up was 20 months.[12] Selection and tissue quality differ between groups, limiting inference about staging.

Furr’s BMG-only 96.4% versus any-STSG 53% figures describe long-term functional success, assessed by symptoms and questionnaires or repeat cystoscopy when symptoms, elevated residual, or UTI prompted it. STSG patients had longer or more panurethral disease and longer follow-up (median 79 versus 45 months), so this comparison is observational.[15] Of 85 first-stage patients, 57 completed both stages and 49 were eligible for follow-up analysis; the long-term estimate excluded patients followed less than one year.[15]

Complications​

  • Fistula occurred in 1 of 12 second-stage patients in Figler; Al-Ali reported revision for fistula or recurrence in 4 of 68 (6%).[7][8]
  • Wound dehiscence occurred in 2 of 12 patients who completed stage 2 in Figler, from 20 who underwent stage 1.[7]
  • Meatal stenosis occurred in 1 of 12 second-stage patients in Figler.[7]
  • Postoperative UTI occurred in about 9% in Al-Ali.[8]
  • First-stage revision before tubularization was required in 17–19% (Minami 17%, Kozinn 18.7%).[11][14]
  • Late recurrence and follow-up. Furr observed a median 78 months to recurrence among nine failures.[15] EAU 2026 recommends at least one year of routine follow-up , flexible cystoscopy at three months , and a risk-adjusted protocol . Its proposed schedule follows penile or graft/flap substitution repairs to five years, with longer follow-up considered.[23]
  • Abandoned second stage. In the EAU 2026 summary of evidence, up to 45.5% of men elect not to proceed to second-stage tubularization after a successful first stage.[17]
  • Erectile function. SHIM scores showed no significant change after surgery in Minami's series.[14]
  • Cosmetic concerns. Aesthetic appearance was the most affected patient-reported dimension in Palminteri's LS cohort.[9]
  • Other functional sequelae. In retrospective staged-urethroplasty series with mixed stricture locations summarized in the EAU 2026 bulbar-stricture section, post-micturition dribble occurred in 14–18%, stress incontinence in up to 16%, penile curvature in up to 9%, and erectile dysfunction in up to 4% after second-stage surgery.[17]

Modern Modifications and Graft Choice​

The original Johanson concept used local tissue; modern variants incorporate oral grafts when native plate is inadequate. AUA guidance favors oral mucosa for graft urethroplasty and avoidance of genital skin in LS. Oral mucosa can nevertheless develop disease-associated recurrence; its relatively thin lamina propria supports graft take, but neither material nor technique guarantees durability.[5][6][13][17]

Some patients require a three-stage approach. When the first-stage Johanson alone does not provide an adequate urethral plate, an additional grafting stage is performed before final tubularization.[9]

For panurethral disease, exposing the anterior urethra through penile, scrotal and perineal incisions, excising the full fibrotic segment, and replacing it with a fenestrated oral mucosal graft left to mature before closure has been described as a staged panurethral variant, distinct from preserving usable native plate for less extensive disease.[19]

Comparison With Alternatives​

  • Penile strictures. The Mangera pooled series reported 90.5% staged versus 75.7% one-stage success; heterogeneity, selection and follow-up prevent a causal comparison.[10]
  • Bulbar strictures. One-stage dorsal or ventral onlay BMG can avoid a planned second operation in suitable cases. Mangera's broader graft-augmentation review reported 88.4% success for 934 dorsal onlays at mean 42.2 months and 88.8% for 563 ventral onlays at mean 34.4 months; these pooled estimates were not BMG-only.[10]
  • Permanent perineal urethrostomy. EAU 2026 recommends offering PU as a management option to men with complex anterior urethral stricture disease .[17] It may be selected before staged reconstruction; a perineal first-stage outlet can also be retained when a patient cannot or elects not to proceed to tubularization.[13][17] Johanson, Blandy and 7-flap PUs have distinct operative designs.[17]

Videos​

Stage 1 Johanson Urethroplasty
Dr Nitesh Jain (2025)

References​

1. Zimmerman WB, Santucci RA. A simplified and unified approach to anterior urethroplasty. Nat Rev Urol. 2010;7(7):386-391. doi:10.1038/nrurol.2010.79.

2. Chapple C, Andrich D, Atala A, et al. SIU/ICUD consultation on urethral strictures: the management of anterior urethral stricture disease using substitution urethroplasty. Urology. 2014;83(3 Suppl):S31-S47. doi:10.1016/j.urology.2013.09.012.

3. 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.

4. Alexander RM, Spadaro JJ, Stripling JR, et al. Surgical treatment of urethral stricture. South Med J. 1977;70(12):1405-1406. doi:10.1097/00007611-197712000-00007.

5. 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.

6. 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

7. 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.

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):268-271. doi:10.1159/000052451.

9. 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.

10. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011;59(5):797-814. doi:10.1016/j.eururo.2011.02.010.

11. Kozinn SI, Harty NJ, Zinman L, Buckley JC. Management of complex anterior urethral strictures with multistage buccal mucosa graft reconstruction. Urology. 2013;82(3):718-722. doi:10.1016/j.urology.2013.03.081.

12. 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.

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. Minami T, Horiguchi A, Shinchi M, et al. Surgical and patient-reported outcomes of staged urethroplasty for anterior urethral strictures: a comprehensive analysis. Int J Urol. 2025;32(4):441-446. doi:10.1111/iju.15679.

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. EAU Guidelines on Urethral Strictures: perioperative care. https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery. Accessed September 12, 2026.

17. EAU Guidelines on Urethral Strictures: LS and staged reconstruction. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.

18. Elliott SP. Reconstruction of strictures of the penile urethra. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:716-729.

19. Martins FE, Holm HV. Staged approaches to panurethral strictures. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:143-149. doi:10.1007/978-981-97-5196-9_18

20. Bandhauer K. Historical highlights in the development of urethral surgery. In: Schreiter F, Jordan GH, eds. Urethral Reconstructive Surgery. Springer; 2006:5-10. doi:10.1007/3-540-29385-x_2

21. 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.

22. Mori RL, Angermeier KW. "Staged urethroplasty in the management of complex anterior urethral stricture disease." Transl Androl Urol. 2015;4(1):29-34. doi:10.3978/j.issn.2223-4683.2015.01.10

23. Lumen N, Campos-Juanatey F, Dimitropoulos K, et al. EAU Guidelines on Urethral Strictures. EAU Guidelines Office; Arnhem, the Netherlands; 2026. Chapter 11, Follow Up. ISBN 978-94-92761-32-5. Guideline chapter. Accessed October 4, 2026.

24. Lumen N, Campos-Juanatey F, Dimitropoulos K, et al. EAU Guidelines on Urethral Strictures. EAU Guidelines Office; Arnhem, the Netherlands; 2026. Chapter 5, Diagnostic Evaluation. ISBN 978-94-92761-32-5. Guideline chapter.