Skip to main content

Turner-Warwick Two-Stage Scrotal Inlay Urethroplasty

The Turner-Warwick urethroplasty is a two-stage scrotal inlay technique for bulbomembranous urethral strictures, named after Richard Turner-Warwick (1925–2020) of The Middlesex Hospital and the Institute of Urology, London. Stage 1 marsupializes the strictured urethra to scrotal skin; Stage 2 tubularizes the matured plate approximately 4–6 months later. In Reid's selected 60-patient historical series, the reported overall success was approximately 90%; the abstract does not define success or specify follow-up.[1] Modern two-stage BMG urethroplasty has largely replaced the technique because of the limitations of hair-bearing scrotal skin. Turner-Warwick's broader contributions remain in use: the staged-reconstruction approach, transpubic posterior urethroplasty and the principles of vascularized tissue transfer.[1][2][3][4]

For the related Cecil / Culp / Pierce / Johanson scrotal-based two-stage lineage, see Cecil-Culp Procedure. For the longitudinal ventral penile skin flap (often mistakenly attributed to Turner-Warwick), see Orandi Flap. For modern BMG-based staged repair, see Buccal Mucosa Graft.

Nomenclature note. A "Turner-Warwick longitudinal ventral penile flap" is not a recognized technique in the reconstructive urology literature. The longitudinal ventral penile skin flap is Ahmad Orandi's 1968 contribution.[12] Turner-Warwick's principal eponymous urethroplasty technique is the two-stage scrotal inlay described here.

Richard Turner-Warwick — The Man and His Contributions​

Richard Turner-Warwick (1925–2020) was a British urological surgeon based at The Middlesex Hospital and the Institute of Urology, London, widely regarded as one of the founding fathers of modern urethral reconstructive surgery. His major contributions:[1][2][4]

  1. Two-stage scrotal inlay urethroplasty ("the Turner-Warwick urethroplasty"), a staged technique for complex bulbomembranous strictures.
  2. Transpubic approach for posterior urethral distraction injuries.
  3. Classification systems for urethral stricture disease.
  4. Principles of urethral reconstruction. Tissue transfer, the importance of vascularized tissue, the role of staged procedures.
  5. Training and mentorship. Turner-Warwick trained a generation of reconstructive urologists, including Anthony Mundy, who succeeded him at the Institute of Urology and continued to refine the techniques.

For biographical dates, see the ICS tribute. For the surgeon profile, see Richard Turner-Warwick.

The Two-Stage Scrotal Inlay Technique​

Stage 1 — marsupialization and scrotal inlay​

  • The strictured urethra is opened along its ventral surface (ventral urethrotomy) through the full length of the stricture.
  • The opened urethral edges are sutured to the surrounding scrotal or perineal skin, creating a marsupialized urethral trough, in which the urethra is laid open and the patient voids through a perineal opening.
  • This allows the strictured segment to heal in an open configuration, with the scrotal skin providing a vascularized bed for epithelialization.
  • The patient voids through the perineal opening for typically 4–6 months while the tissue matures.

Stage 2 — tubularization (closure)​

  • After tissue maturation and once the urethral bed is healthy, the marsupialized trough is tubularized: the scrotal skin edges are rolled inward and sutured together to recreate a tubular urethra.
  • A urethral catheter is placed, and follow-up assesses stricture recurrence and continence. For bulbomembranous reconstruction after prior surgery for benign prostatic obstruction, the EAU 2026 guideline recommends counseling about de novo urinary incontinence .[19]

Reid 1975 outcomes (60 patients)[1]​

  • Overall success approximately 90%[1]
  • Restenosis of the proximal or distal stoma after Stage 1 was an early difficulty; the report describes nitrofurazone-hydrocortisone urethral suppositories as practically eliminating it.[1]
  • Modifications included placement of urethral sutures prior to scrotal mobilization and abandonment of suprapubic cystotomy at Stage 2.
  • Reid reported urinary-control problems when stricture surgery followed prostatectomy; he did not report the same problem when prostatectomy followed Stage 1.[1]

Ashken’s 1974 Turner-Warwick series included 37 patients, of whom 25 had reached closure when reported; a few reported slight postvoid dribbling or impaired ejaculation.[21]

Alexander 1977 reviewed 59 cases of urethral stricture treated at Charity Hospital of Louisiana from 1965 to 1975. Five procedures were used (internal urethrotomy, Johanson-Leadbetter, patch-graft, Turner-Warwick and dismembered techniques). Results of internal urethrotomy were poor, and the other procedures together had an overall success of 72%. Turner-Warwick outcomes were not reported separately.[6]

Turner-Warwick vs. Johanson — The Two Staged Techniques​

The Turner-Warwick two-stage urethroplasty is closely related to the Johanson 1953 staged urethroplasty. Both involve marsupialization followed by tubularization. The differences are:[1][2][7][8]

FeatureJohanson (1953)Turner-Warwick
Primary indicationAnterior (penile / bulbar) stricturesBulbomembranous strictures
Stage 1Ventral urethrotomy + marsupialization to penile / perineal skinVentral urethrotomy + scrotal inlay
Stage 2Tubularization of the marsupialized troughTubularization with scrotal mobilization
Tissue sourceLocal penile / perineal skinScrotal skin
Key advantageSimpler; applicable to anterior stricturesReaches bulbomembranous junction; more tissue available
Key limitationLimited reach for posterior stricturesHair-bearing scrotal skin; diverticula; urine-induced dermatitis

Olsson and Krane 1978 compared their and others' single-stage repair experience with published reports of staged Johanson, Leadbetter-Johanson and Turner-Warwick repairs. Across those reports, they found no advantage in initial or final success rates and described greater hospitalization, time away from work and exposure to multiple anesthetics with staged repair.[2]

Limitations of the Scrotal Inlay Approach​

The scrotal inlay technique has well-documented limitations that led to its decline:[5][9][10][11]

  1. Hair-bearing scrotal skin. Scrotal skin is typically hair-bearing; intraurethral hair growth, hair-ball formation, and stone formation are characteristic complications. In a separate one-stage scrotal island-flap series, Provet et al. emphasized hairless skin and flap tailoring to limit diverticulum, hair ball and stone formation.[10]
  2. Diverticula formation. Diverticula have been reported after scrotal inlay and scrotal island-flap urethroplasty.[9][10] Jordan argued that properly prepared scrotal or perineal skin islands are no more likely to form diverticula than other genital skin islands.[11]
  3. Urine-induced dermatitis. Prolonged contact of urine with scrotal skin during the marsupialized phase can cause chronic dermatitis, compromising tissue quality for Stage 2 closure.[9]
  4. Two-stage morbidity. Two separate operations with months of perineal voiding between stages impose a quality-of-life burden.[2]
  5. Stomal restenosis. Restenosis at the proximal or distal stoma after Stage 1 was a frequent early problem in Reid's series.[1]

Jordan 2002 argued that scrotal and perineal flaps have been "unfairly maligned" for poor waterproofing, diverticula and hair importation. Hairless scrotal areas can be mobilized as skin islands, and the skin overlying the perineal artery is non-hirsute or nearly non-hirsute in many individuals.[11]

Distinguishing Turner-Warwick from the Orandi Flap​

The longitudinal ventral penile skin flap is the Orandi flap (1968), which is not a Turner-Warwick technique:

FeatureTurner-Warwick UrethroplastyOrandi Flap
Year1960s–1970s[1][2]1968[12]
StagesTwo-stage (marsupialization → tubularization)Single-stage (pedicled island flap)
Tissue sourceScrotal / perineal skinVentral penile shaft skin
PedicleBroad local attachment supplies the scrotal skin inlayDartos fascia pedicle (vascularized island flap)
Primary indicationBulbomembranous stricturesPenile urethral strictures
Hair-bearingYes (scrotal skin)No (distal penile skin is hairless)
Current statusLargely replaced by modern BMG staged urethroplastyStill used (Barbagli dorsal modification 2019)

Turner-Warwick's Broader Legacy​

The scrotal inlay technique has largely been superseded, but Turner-Warwick's broader contributions remain in use:[4][5][13]

  1. Principles of tissue transfer. Turner-Warwick is credited with early articulation of the principle of using vascularized tissue for urethral reconstruction (well-vascularized tissue heals better and resists stricture recurrence).
  2. Staged-approach philosophy. Recognition that some strictures are too complex for single-stage repair.[5] Secrest 2002 listed indications including chronic inflammation, fistula, false passage, urethral stones, diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures, and long strictures.[5]
  3. Transpubic approach for posterior urethral distraction injuries provided excellent exposure and visualization of the involved anatomy. Brock and Kaplan 1981 used this approach in 5 children, 2 of whom had concomitant closure of a failed first-stage Turner-Warwick scrotal inlay.[3]
  4. Training the next generation. Turner-Warwick's trainees, particularly Anthony Mundy at the Institute of Urology, continued to advance the field. Greenwell, Venn, and Mundy 1999 documented the transition from one-stage flap to two-stage free-graft procedures. They concluded that buccal mucosal free grafts are the material of choice for patch urethroplasty of an uncomplicated bulbar stricture, that the Orandi procedure remains the "gold standard" for patch urethroplasty of an uncomplicated penile stricture, and that two-stage free-graft repairs give better results than one-stage flap repairs for circumferential reconstruction of the penile urethra.[4]

Modern Evolution — From Scrotal Inlay to BMG Staged Urethroplasty​

The Turner-Warwick scrotal inlay concept has been modernized by replacing scrotal skin with buccal mucosal grafts (BMG) or split-thickness skin grafts (mesh grafts) in the staged approach.[5][9][14]

Mesh graft urethroplasty (Schreiter / Noll 1989; Carr / MacDiarmid / Webster 1997)[9][14]​

  • Scrotal skin replaced with meshed split-thickness skin graft from the thigh or full-thickness foreskin.
  • Advantages over scrotal inlay: non-hair-bearing, easier to size, seemingly less permeable to urine penetration.
  • Carr 1997: 20 men with complex strictures, most after failed urethroplasty, received 17 thigh split-thickness grafts and 3 foreskin grafts. Success by urethrography and history was 12/15 (80%) after closure at median 38 months; 6/20 needed revision before closure, and 5/20 had not undergone closure (2 refused, 3 grafts were not ready).[9]
  • Schreiter and Noll 1989: 96 patients (meshed foreskin or split-thickness skin) with excellent anatomical and functional results in all but 1 patient.

Modern two-stage BMG urethroplasty​

The current standard for staged urethroplasty uses BMG rather than scrotal skin or mesh grafts:[4][5][15]

  • Stage 1. Strictured urethra opened; BMG quilted to the corpora cavernosa or urethral bed to create a new urethral plate.
  • Stage 2 (after adequate maturation, commonly at least 4–6 months; timing individualized): the matured BMG plate may be tubularized to recreate the urethra. Counsel that revision can be needed before closure and that some patients elect to continue voiding through the perineal opening; the EAU 2026 guideline advises warning that staged repair may require more than two operations .[19]
  • BMG avoids importing hair-bearing skin and supplies a mucosal surface. Staged oral graft repair remains an option for complex penile strictures, failed prior repair or unfavorable local tissue; for LS-related penile strictures without adverse local conditions, the EAU 2026 guideline recommends single-stage oral graft repair .[19] In a nonrandomized nine-center cohort of 231 men with LS-induced penile strictures that excluded short meatal, bulbar and panurethral disease, five-year stricture-free estimates were 82% after single-stage oral graft repair, 76% after staged repair and 75% after perineal urethrostomy, with no detectable recurrence difference (P = .6).[19][20]

The evolution from Turner-Warwick-era techniques to modern practice is substantial:[4][16][17]

  • Greenwell 1999. Documented the shift at the Institute of Urology (79 anterior urethroplasties, 1992 to 1996) from one-stage flap to two-stage free-graft procedures. Of 45 one-stage bulbar patch urethroplasties, 37 used BMG rather than flaps. Of 34 penile urethroplasties, 26 were two-stage procedures.[4]
  • Cotter 2019. Multi-institutional analysis of 2,098 anterior urethroplasties (2010–2017): fasciocutaneous flap use in the penile urethra declined (-86%) while single-stage dorsal repairs increased (+280%).[17]
  • Fuchs 2018. In a retrospective single-center review of 403 complex anterior strictures (2007 to 2017), penile skin flap use declined while perineal urethrostomy use increased from 4.3% of case volume in 2008 to 38.7% in 2017.[16]

Guideline Context​

The AUA Urethral Stricture Disease Guideline (2023 amendment) makes these recommendations relevant to staged urethroplasty:[18]

  • Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination .[18]
  • Surgeons should use oral mucosa as the first choice when using grafts .[18]
  • In lichen sclerosus-proven stricture, surgeons should not use genital skin for reconstruction .[18]
  • Surgeons should not use hair-bearing skin for substitution urethroplasty .[18] This addresses the main limitation of the scrotal inlay technique.

Key Takeaways​

The Turner-Warwick urethroplasty is a two-stage scrotal inlay technique for bulbomembranous strictures, and not a longitudinal ventral penile flap, which is the Orandi 1968 technique. Reid 1975 reported approximately 90% success in 60 patients.[1] Modern two-stage BMG urethroplasty has largely replaced the technique and avoids importing hair-bearing scrotal skin.[5][9][14] Turner-Warwick's broader legacy includes the staged-reconstruction approach, the transpubic approach, the principles of vascularized tissue transfer and the training of Anthony Mundy and a generation of reconstructive urologists.[2][3][4][5]

References​

  1. Reid RE. Turner-Warwick urethroplasty and urethral stricture: results in 60 patients. Urology. 1975;6(6):711-5. doi:10.1016/0090-4295(75)90802-x.

  2. Olsson CA, Krane RJ. The controversy of single versus multistaged urethroplasty. J Urol. 1978;120(4):414-7. doi:10.1016/s0022-5347(17)57205-5.

  3. Brock WA, Kaplan GW. Use of the transpubic approach for urethroplasty in children. J Urol. 1981;125(4):496-501. doi:10.1016/s0022-5347(17)55085-5.

  4. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. 1999;83(6):631-5. doi:10.1046/j.1464-410x.1999.00010.x.

  5. Secrest CL. Staged urethroplasty: indications and techniques. Urol Clin North Am. 2002;29(2):467-75, viii-ix. doi:10.1016/s0094-0143(02)00040-x.

  6. Alexander RM, Spadaro JJ, Stripling JR, et al. Surgical treatment of urethral stricture. South Med J. 1977;70(12):1405-6. doi:10.1097/00007611-197712000-00007.

  7. Fernandes M, Draper JW. Two-stage urethroplasty: improved method for treating bulbomembranous strictures. Urology. 1975;6(5):568-75. doi:10.1016/0090-4295(75)90504-x.

  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):268-71. doi:10.1159/000052451.

  9. Carr LK, MacDiarmid SA, Webster GD. Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty. J Urol. 1997;157(1):104-8. doi:10.1016/s0022-5347(01)65298-4

  10. Provet JA, Surya BV, Grunberger I, Johanson KE, Brown J. Scrotal island flap urethroplasty in the management of bulbar urethral strictures. J Urol. 1989;142(6):1455-7; discussion 1457-8. doi:10.1016/s0022-5347(17)39124-3.

  11. Jordan GH. Scrotal and perineal flaps for anterior urethral reconstruction. Urol Clin North Am. 2002;29(2):411-6, viii. doi:10.1016/s0094-0143(02)00030-7.

  12. Orandi A. One-stage urethroplasty. Br J Urol. 1968;40(6):717-9. doi:10.1111/j.1464-410x.1968.tb11872.x. PMID: 4883846.

  13. Joshi PM, Bandini M, Kulkarni SB. Common flaps in genitourinary reconstruction. Urol Clin North Am. 2022;49(3):361-369. doi:10.1016/j.ucl.2022.04.001.

  14. Schreiter F, Noll F. Mesh graft urethroplasty using split thickness skin graft or foreskin. J Urol. 1989;142(5):1223-6. doi:10.1016/s0022-5347(17)39036-5.

  15. Naud E, Rourke K. Recent trends and advances in anterior urethroplasty. Urol Clin North Am. 2022;49(3):371-382. doi:10.1016/j.ucl.2022.04.002.

  16. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169-173. doi:10.1016/j.urology.2018.08.009.

  17. 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.

  18. 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.

  19. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males. EAU Guidelines Office; 2026. Guideline chapter.

  20. 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

  21. Ashken MH. "A personal experience with 37 Turner-Warwick scrotal inlay urethroplasties." Br J Urol. 1974;46(3):313-324. doi:10.1111/j.1464-410X.1974.tb03833.x