Male Urethroplasty — Incisions & Approaches
For male urethroplasty, the surgeon's first decisions are how to incise the skin and how to access the urethra. This reference page organizes the choices by skin incision, penile-stricture exposure, anterior urethrotomy approach, posterior approach, graft / tissue placement, flap-based technique, and one-stage vs staged. Outcomes for individual named techniques live on their own pages, cross-linked below.
For decision principles (graft selection, tension, spongiofibrosis), see Principles of Urethral Reconstruction. For the Master Decision Framework.
1. Perineal Skin Incisions
Three principal perineal skin incisions are described for bulbar and posterior urethroplasty:
| Incision | Description | Reported endpoint | Notes |
|---|---|---|---|
| Midline perineal vertical | Longitudinal incision in the perineal raphe | SSI 1.9% in bulbar and 3.1% in posterior repairs | Lin: matched retrospective urethroplasty cohort, not a PU comparison; lower infection rates than inverted-U in that cohort[1] |
| Inverted-U (curvilinear) | U-shaped incision curving around the perineum | SSI 18.6% in bulbar and 16.4% in posterior repairs | Lin: corresponding inverted-U groups; cadaveric incisions crossed more nerves and vessels[1] |
| Lambda perineal incision (LPI) | Inverted-Y / lambda shape extending laterally from midline | Minor wound complications 23.3% (vs 11.9% midline), not SSI alone | Bascom 2016 (n = 540 bulbar urethroplasties): independently associated with increased 90-day wound complications, primarily superficial wound-edge separation (10.7% vs 0%); no urethroplasty-success advantage[2] |
Midline, inverted-U and lambda incisions illustrate different ways to obtain perineal exposure. Choice depends on exposure, prior scars, patient anatomy and reconstruction. (Original WARWIKI schematic; see the figure source record and review limits.)
A midline vertical incision is a useful option for bulbar perineal access and permits the loop / 7-flap decision after exposure. Incision choice remains individualized; retrospective urethroplasty wound data do not establish superiority of one PU reconstruction.[1][2][24]
For penile urethral strictures, the three penile-skin incisions are described in the next section.
2. Penile-Stricture Exposure — Three Approaches
For penile urethral strictures specifically, three exposure strategies dominate contemporary practice. The Abramowitz multi-institutional review found no significant difference in outcomes by incision approach for penile urethroplasty — choice is driven by stricture characteristics and surgeon experience.[3]
2a. Degloving / circumcising incision
Subcoronal circumferential incision (identical to a circumcision incision); penile skin retracted proximally to "deglove" the shaft, exposing the entire penile urethra from glans to penoscrotal junction.[4]
- Advantages: excellent circumferential exposure; standard for penile-skin-flap harvest (Orandi, Quartey, Q-flap, McAninch circular) and for staged urethroplasty; allows simultaneous fasciocutaneous flap harvest.
- Disadvantages: disrupts dartos blood supply circumferentially; risk of penile edema / skin necrosis (especially in redo cases); preputial preservation depends on the incision and reconstruction.
- Best for: isolated penile strictures, staged repair, cases requiring fasciocutaneous flap harvest, selected cases requiring wide penile exposure; LS alone does not require complete plate excision.
2b. Kulkarni penile invagination (perineal-only)
Standard perineal midline incision with the penis invaginated (telescoped) into the perineal wound — no penile incision. One-sided urethral mobilization preserves the contralateral neurovascular bundle and central perineal tendon attachments. The graft is placed as a dorsolateral onlay.[3][5]
- Advantages: avoids a separate penile skin incision and permits long-segment oral-graft reconstruction with one-sided urethral mobilization. Functional outcomes and recurrence remain important counseling points; the technique does not guarantee preservation of erectile function. See the technique page for study-specific results.[3][5]
- Limitations: distal access can be difficult, and meatal or fossa-navicularis disease may require an additional distal maneuver. LS involving the meatus is not by itself a categorical exclusion; tissue quality determines the reconstruction.[24]
- Best for: long-segment and panurethral strictures (especially > 8 cm), peno-bulbar strictures, and cases where penile-skin preservation is a priority.
- Canonical technique page: Kulkarni One-Sided Dorsolateral BMG.
2c. Midline ventral penile incision
Direct longitudinal incision along the ventral raphe — preserves lateral dartos pedicles and avoids circumferential degloving. Used for modified Orandi dorsal-skin-flap repair, penile fracture repair, and penoscrotal-junction strictures.[3][4]
- Advantages: preserves lateral penile-skin vascularity; avoids circumcision; can be combined with perineal invagination for penoscrotal-junction strictures.
- Disadvantages: limited exposure for long penile strictures; visible ventral scar; the incision must accommodate any planned flap and preserve its dartos pedicle.
- Best for: focal / short penile strictures, modified Orandi dorsal-skin-flap repairs, penoscrotal-junction strictures, penile-fracture repair.
3. Anterior Urethrotomy Approaches
How the urethra itself is opened once exposed — the choice drives graft placement, blood-supply preservation, and operative time.
| Approach | Description | Implication |
|---|---|---|
| Ventral urethrotomy | Urethra opened on its ventral surface | Traditional approach; supports ventral onlay BMG and the Asopa dorsal inlay (dorsal wall incised through the ventral opening). Less urethral mobilization required[6][7] |
| Dorsal urethrotomy (Barbagli) | Urethra mobilized circumferentially and rotated 180° to expose the dorsal surface | More extensive dissection; supports dorsal onlay BMG (Barbagli)[6][8] |
| Dorsolateral (Kulkarni) | One-sided urethral dissection; contralateral blood supply preserved | Minimizes urethral devascularization; particularly useful for long penile strictures; the basis of the Kulkarni one-sided dorsolateral BMG technique[6] |
| Non-transecting | Corpus spongiosum is not fully transected — antegrade blood flow preserved | Cotter 2019 multi-institutional data: + 430% increase in non-transecting excisional repairs over a 7-year period. Includes Jordan vessel-sparing EPA, non-transecting bulbar, and the entire ANTA / MsANTA / MANTA / ntAAU family[9] |
4. Posterior Urethroplasty Approaches
For posterior urethral distraction defects (PFUI) and post-prostatectomy / post-radiation membranous-urethral / VUAS strictures:
| Approach | Used in | Indication |
|---|---|---|
| Perineal anastomotic | Usual reconstructive access for PFUI | Obtain healthy ends and a tension-free anastomosis; required maneuvers depend on fibrosis, displacement and urethral elasticity rather than a universal gap-length cutoff[10][11][24] |
| Elaborated perineal (Webster steps 1–4) | Webster step framework | Bulbar mobilization → corporal splitting → inferior pubectomy → supracrural rerouting. Pubectomy used in ~ 10% of cases; corporal splitting ~ 17%[11][12] |
| Supracrural rerouting (step 4) | Rare adjunct | Mobilized urethra routed around a crus when other maneuvers do not provide reach. Kizer reported recurrence in 3/4 rerouted cases; this very small selected subgroup cannot establish comparative inferiority to an abdominal approach[11] |
| Transpubic (abdominoperineal) | Selected complex defects | Consider when adequate exposure or a tension-free repair cannot be obtained perineally, including selected fistulas or cavities. Defect length alone is insufficient. See Abdominoperineal Urethroplasty[12][13][14][24] |
| Modified perineal (Quartey 1988) | Niche | Standard perineal-prostatectomy incision with division of the urogenital diaphragm in the midline; improved membranous-urethra exposure without pubectomy[15] |
| Robotic transabdominal | Contemporary alternative for VUAS / BNC | AUA 2023 Conditional Grade C. ~ 39% require combined robotic + open perineal. See Robotic Posterior Urethroplasty[16] |
5. Graft / Tissue Placement Configurations
For substitution urethroplasty, the graft (most commonly buccal mucosa — AUA 2023 first-choice[16]) can be placed in several configurations:
| Configuration | Eponym | Vascular bed | Indication |
|---|---|---|---|
| Dorsal onlay | Barbagli | Tunica albuginea | Bulbar strictures, ~ 88% success[17][18] |
| Ventral onlay | Morey / McAninch | Corpus spongiosum | Bulbar strictures, ~ 89%; lower transient ED for proximal bulbar[19][20][17] |
| Dorsal inlay | Asopa | Tunica albuginea exposed by incising the dorsal plate through a ventral urethrotomy | Shorter OR / less EBL than dorsal onlay; ~ 87% success[7][8] |
| Dorsolateral onlay | Kulkarni | Corporal bed, with contralateral urethral attachments retained | Long penile / panurethral; preserves contralateral NVB[6] |
| Two-sided dorsal + ventral | Palminteri double-face | Tunica + spongiosum | Tight / near-obliterative bulbar strictures; reported 89% patency in 73 evaluated patients; no postoperative ED reported among the 49 sexually active patients assessed. See Palminteri Double-Face[21][17] |
| Augmented anastomotic | Guralnick / Webster | Hybrid — excise + onlay | Selected focal obliteration within a longer bulbar stricture; avoid unnecessary transection. See the dedicated augmented-anastomotic pages for comparative evidence and tissue-preserving alternatives[6][24] |
For combined graft-and-flap configurations, see Combined Dorsal BMG + Ventral Fasciocutaneous Flap (Erickson) and Ventral BMG + Gracilis Muscle Flap (Vanni / Zinman).
6. Flap-Based Techniques — Declining Role
Penile fasciocutaneous flaps (Orandi, Quartey, Q-flap, McAninch circular) historically dominated long penile and panurethral reconstruction. Cotter 2019 multi-institutional data:[9]
- Fasciocutaneous-flap use declined ~ 86% over 7 years.
- Dorsal-graft repairs increased ~ 280% over the same period.
Among respondents to the 2024 GURS survey, approximately 90% preferred multiple BMGs over combined graft / flap for panurethral strictures.[22] Flap-based techniques remain valuable in specific scenarios:
- Compromised graft bed (radiation, severe spongiofibrosis) — flap brings its own blood supply.
- Depleted oral mucosa — preputial / penile flap or preputial spiral graft.
- Resource-limited settings — no specialized graft material required.
7. One-Stage vs Staged
| Setting | Preferred |
|---|---|
| Most bulbar strictures | One-stage dorsal / ventral / dorsolateral onlay BMG (~ 88%) |
| Distal / primary penile strictures | One-stage |
| Complex penile strictures with extensive spongiofibrosis | Staged (Bracka or Johanson) |
| Lichen sclerosus | Oral mucosa; single-stage reconstruction if local tissue is suitable, staged repair when adverse local conditions preclude it. Avoid genital skin[24] |
| Failed hypospadias repair | Individualize single-stage versus staged reconstruction to plate, skin, scarring and chordee; refer complex cases to an experienced center[24] |
| Panurethral with healthy plate | One-stage Kulkarni dorsolateral BMG |
| Panurethral, plate destroyed | Combined graft + flap (Erickson) or staged |
Mangera 2011 reported pooled success of 90.5% for staged versus 75.7% for one-stage penile repairs across heterogeneous series. These are not randomized comparative estimates and should not dictate staging for an individual patient.[17][23]
Contemporary Trends — Summary
Multi-institutional data demonstrate clear shifts:[1][2][9]
- Dorsal graft placement ↑ 280%; fasciocutaneous flap use ↓ 86%.
- Non-transecting bulbar excisional repair ↑ 430%.
- Midline perineal incision preferred over lambda or inverted-U for lower wound complications.
- Buccal mucosa is the AUA-2023-anchored first-choice graft.
References
1. Lin Y, Luo D, Liao B, et al. Perineal midline vertical incision versus inverted-U incision in urethroplasty: which is better? World J Urol. 2018;36(8):1267-1274. doi:10.1007/s00345-018-2267-x.
2. Bascom A, Ghosh S, Fairey AS, Rourke KF. Assessment of wound complications after bulbar urethroplasty: the impact of a lambda perineal incision. Urology. 2016;90:184-188. doi:10.1016/j.urology.2015.12.047.
3. Abramowitz D, Sam AP, Pachorek M, et al. Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes. Int J Urol. 2022;29(5):376-382. doi:10.1111/iju.14786.
4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.
5. Takekawa K, Horiguchi A, Shinchi M, et al. One-sided dorsal onlay urethroplasty with penile invagination (Kulkarni urethroplasty) for complex anterior urethral strictures: a single-center experience. Int J Urol. 2025;32(6):749-755. doi:10.1111/iju.70048.
6. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493-503. doi:10.1111/iju.13356.
7. Pisapati VL, Paturi S, Bethu S, et al. Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. Eur Urol. 2009;56(1):201-205. doi:10.1016/j.eururo.2008.06.002.
8. Aldaqadossi H, El Gamal S, El-Nadey M, et al. Dorsal onlay (Barbagli technique) versus dorsal inlay (Asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: a prospective randomized study. Int J Urol. 2014;21(2):185-188. doi:10.1111/iju.12235.
9. Cotter KJ, Hahn AE, Voelzke BB, et al. Trends in urethral stricture disease etiology and urethroplasty technique from a multi-institutional surgical outcomes research group. Urology. 2019;130:167-174. doi:10.1016/j.urology.2019.01.046.
10. Koraitim MM. On the art of anastomotic posterior urethroplasty: a 27-year experience. J Urol. 2005;173(1):135-139. doi:10.1097/01.ju.0000146683.31101.ff.
11. Kizer WS, Armenakas NA, Brandes SB, et al. Simplified reconstruction of posterior urethral disruption defects: limited role of supracrural rerouting. J Urol. 2007;177(4):1378-1381. doi:10.1016/j.juro.2006.11.036.
12. Koraitim MM. Transpubic urethroplasty revisited: total, superior, or inferior pubectomy? Urology. 2010;75(3):691-694. doi:10.1016/j.urology.2009.09.026.
13. Pratap A, Agrawal CS, Tiwari A, et al. Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty. J Urol. 2006;175(5):1751-1754. doi:10.1016/S0022-5347(05)00974-2.
14. Koraitim MM. The lessons of 145 post-traumatic posterior urethral strictures treated in 17 years. J Urol. 1995;153(1):63-66. doi:10.1097/00005392-199501000-00024.
15. Quartey JK. A modified perineal approach to reconstruction of membranous urethra for stricture. J Urol. 1988;139(4):780-783. doi:10.1016/s0022-5347(17)42635-8.
16. 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.
17. 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.
18. Barratt R, Chan G, La Rocca R, et al. Free graft augmentation urethroplasty for bulbar urethral strictures: which technique is best? A systematic review. Eur Urol. 2021;80(1):57-68. doi:10.1016/j.eururo.2021.03.026.
19. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.
20. Mousa A, Eissa A, Raheem AA, Zoeir A. Ventral versus dorsal onlay buccal mucosal graft urethroplasty for non-traumatic proximal bulbar urethral strictures in sexually active men: erectile and urinary functions. World J Urol. 2025;43(1):87. doi:10.1007/s00345-025-05441-7.
21. Palminteri E, Berdondini E, Shokeir AA, et al. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. J Urol. 2011;185(5):1766-1771. doi:10.1016/j.juro.2010.12.103.
22. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139-143. doi:10.1016/j.urology.2024.06.019.
23. Campos-Juanatey F, Bugeja S, Dragova M, et al. Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures. Asian J Androl. 2020;22(2):134-139. doi:10.4103/aja.aja_78_19.
24. EAU Guidelines on Urethral Strictures: disease management in males. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.