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Cecil-Culp Procedure

The Cecil-Culp procedure is a historical staged reconstructive technique in which the penis is temporarily embedded in the scrotum. The embedded tissue provides vascularized coverage for urethral reconstruction or penile-skin replacement, and the penis is separated at a later stage, with urethral reconstruction or skin coverage according to the variant.[1][2][3] It was originally described for severe hypospadias repair, and the concept has been adapted for urethral stricture disease, urethrocutaneous fistula repair, and penile trauma reconstruction.

Note on terminology. The Turner-Warwick "scrotal drop back" procedure brings scrotal skin to a perineal urethrostomy; it is distinct from later penile separation in Cecil-Culp reconstruction.[24] Cecil-Culp penile embedding, Johanson staged urethroplasty, Pierce perineal-scrotal flaps, and Turner-Warwick scrotal drop-back share some staged-reconstruction concepts but are not interchangeable operations. Their tissue arrangement, purpose, and stage sequence differ.[3][23][24]

Part I: Historical origins​

Arthur Bond Cecil (1885–1967), an American urologist, first described his eponymous technique in the 1930s–1940s for repair of severe proximal hypospadias. The original Cecil procedure:

  1. Cecil reconstructed the urethra from the urethral plate and adjacent penile skin before scrotal embedding.[26]
  2. Embedded the repaired ventral penile surface in the scrotum for vascularized coverage of the urethral repair.[3]
  3. Separated the penis from the scrotum at a second stage after tissue maturation.

Ormond Skinner Culp (1910–1977), a Mayo Clinic urologist, subsequently modified and popularized the technique, refining the scrotal-inlay approach and extending its applications. The combined "Cecil-Culp" designation reflects Culp's modifications, particularly in adapting the procedure for more complex hypospadias variants and urethral stricture disease.[1][4] Kelalis, Benson, and Culp (1977) reported 198 children operated upon between 1970–1975, with the modified two-stage Cecil urethroplasty one of three primary techniques used.[4]

Part II: The core concept — tissue transfer by temporary embedding​

The fundamental principle is a biological tissue-transfer concept:

  1. The scrotum (or perineum) serves as a vascularized tissue bed. Its rich blood supply from the inferior external pudendal arteries and perineal arteries provides a reliable source of well-vascularized tissue for urethral reconstruction or skin coverage.[5]
  2. Temporary embedding allows neovascularization. Burying the penis into the scrotum lets scrotal tissue develop a vascular connection to the penile structures over weeks to months.
  3. Staged separation preserves the new vascular supply. At the second stage, the penis is separated from the scrotum, and the newly vascularized tissue is tubularized or used as coverage.

This resembles a delayed tissue-transfer approach: the penis is temporarily embedded in vascularized tissue before later separation and reconstruction.[2]

Part III: Indications​

A. Severe proximal hypospadias (original indication)​

  • Perineal or penoscrotal hypospadias where the urethral groove fails to develop adequately and the scrotal folds have failed to rotate caudally.[1]
  • In Marshall's single 234-patient operative cohort, about 8% presented the severe proximal reconstructive problem described here.[1]

B. Recurrent urethrocutaneous fistula after hypospadias repair​

Ehle, Cooper, et al. (2001) applied the modified Cecil-Culp technique specifically for recurrent urethrocutaneous fistulas in boys who had failed previous fistula repairs and/or had deficient penile skin:[3]

  • Fifteen boys with hypospadias fistula underwent modified two-stage Cecil repair between 1994 and 1999.
  • The average age at the first stage was 3.5 years (range 1.8 to 6.0).
  • Five, four and two patients had undergone one, two and three previous fistula repairs, respectively.
  • Four boys had deficient penile skin at the time of repair.
  • No fistula recurred at an average follow-up of 21 months (range 1 to 62 months).
  • The authors concluded that the technique "takes advantage of penile mobility to place it in a scrotal location, ensuring excellent vascularized tissue coverage."[3]

C. Penile trauma with skin loss​

Weiss, Canning, et al. (2017) described a modified Cecil-Culp concept applied to a devastating penile trauma case:[2]

  • A 12-year-old boy sustained a close-range shotgun wound with buckshot to the penis and lower abdomen.
  • The proximal two-thirds of the corpora cavernosa was obliterated; the distal third was thrombosed; all dorsal penile skin was lost; the urethra remained intact.
  • After multiple debridements, the penis was marsupialized onto the suprapubic area (modification of the traditional scrotal embedding).
  • The penis remained embedded for 8 months.
  • A graft-delaying procedure was performed, followed by graft harvest 2 months later and penoplasty tubularization.
  • One trauma case describes an adaptation of staged embedding beyond hypospadias.[2]

D. Complex urethral stricture disease​

The scrotal-inlay concept was historically used for:

  • Posterior urethral strictures. In a 1977 series of 20 patients with severe posterior urethral injury after pelvic fracture, Coffield and Weems reported no stricture, incontinence or impotence in the 11 who had delayed scrotal-inlay urethroplasty after initial cystostomy. The 9 who had primary repair had a 77% stricture rate, 22% incontinence and 33% impotence.[6]
  • Complex anterior urethral strictures. As a salvage technique when local tissue is insufficient for single-stage repair.[7][8]
  • However, Koraitim (1995) found that urethroscrotal inlay procedures were "doomed to failure in 57% of cases" for posterior urethral strictures, and recommended restricting them, with other substitution procedures, to strictures involving extensive segments of the posterior and/or anterior urethra. In that series of 145 strictures, anastomotic urethroplasty succeeded in 95% (perineal) and 97% (transpubic) of cases.[8]

Part IV: Surgical technique — step by step​

Fistula coverage, urethral substitution, and skin replacement require different reconstructions; not every variant uses scrotal skin as a urethral wall or includes urethral tubularization. Exact stage timing, drainage, and closure must follow the selected technique and patient anatomy.

Stage 1 — urethral reconstruction and penile embedding​

  1. Curvature assessment and correction. After degloving and release of ventral tethering, assess residual curvature with an intraoperative erection test. Severe plate hinging may require plate transection; for persistent corporeal curvature, weigh dorsal plication against ventral lengthening and its avoidance of penile shortening.[28]
  2. Urethral plate preparation. The ventral penile surface is opened and the strictured or absent urethra is addressed:
    • Hypospadias: urethral groove opened from existing meatus to the desired endpoint (typically the glans).
    • Fistula repair: fistula tract excised and urethra repaired.
    • Stricture: strictured segment opened ventrally (marsupialized).
  3. Scrotal inlay. The ventral penile surface (with the open urethral plate or repaired urethra) is buried into the scrotum:
    • An incision is made in the anterior scrotal wall.
    • The ventral penile surface is sutured to the edges of the scrotal incision, embedding the penis into the scrotum.
    • Scrotal skin may form a ventral urethral wall in a substitution variant; in a modified fistula repair it instead provides vascularized coverage of the repaired urethra.
    • Scrotal tissue provides a rich vascular bed that promotes healing and neovascularization.
  4. Catheter placement. Urethral catheter or suprapubic tube for urinary drainage.
  5. Maturation period. Interval before separation varies by operation and healing. The 8-month embedding in Weiss et al. was a single unusual trauma case.[1][2][3]

Stage 2 — separation and tubularization​

  1. Timing. After tissue healing and adequate vascularized coverage, according to the selected historical variant and clinical findings.
  2. Incision. Scrotal skin surrounding the embedded penis is incised, freeing the penis from the scrotum.
  3. Urethral step, if indicated. Scrotal skin may be tubularized to create a neourethra in a substitution variant; a fistula-coverage or skin-resurfacing variant does not automatically require this step.
  4. Skin closure. Scrotal defect is closed primarily; the penile shaft is covered with remaining scrotal skin or local tissue.
  5. Catheter management. Urinary drainage type and duration, including any 10–14-day course, depend on the urethral repair and surgeon's protocol.

Marshall modification (1979)​

Marshall et al. modified the Cecil procedure by adding concurrent scrotoplasty, rotating the scrotum caudally from its high location (common in penoscrotal hypospadias) during Stage 1. This modification:[1]

  • In their reported modification, tension and acute angulation associated with earlier attempts were avoided.[1]
  • Extended the urethra from behind the penoscrotal junction to the glans at Stage 2.
  • Produced satisfactory results in their 13-year series.

Part V: Comparison with the Johanson urethroplasty​

Cecil-Culp fistula-coverage variants embed a repaired penile urethra in scrotal tissue, whereas Johanson stricture repair marsupializes the strictured urethra for later tubularization. These operations differ as follows:[3][9]

FeatureCecil-CulpJohanson
Original indicationSevere proximal hypospadiasUrethral stricture disease
Stage 1 conceptPenile embedding into scrotumMarsupialization of strictured urethra to perineal / scrotal skin
Tissue sourcePenile skin or urethral plate for the repair; scrotal tissue for temporary coveragePerineal / scrotal skin as urethral plate
Later stagePenile separation after healing; urethral reconstruction depends on the Cecil-Culp variantTubularization of marsupialized urethral plate
Inter-stage interval6 weeks to months2–3 months typically
Reported stricture outcomesHistorical posterior-injury/inlay cohorts vary substantiallyLater long-segment stricture cohorts have different case mix and techniques
Modern roleFistula repair, trauma, salvageSalvage for complex / panurethral strictures
[1][3][4][9][10]

Fernandes and Draper (1975) reported a 12-year experience with 200 patients undergoing two-stage Johanson urethroplasty (including modifications for bulbomembranous strictures without splitting the scrotum), with no patient requiring urethral dilation after urethroplasty.[9]

Warner et al. (2015), the largest multi-institutional series of long-segment strictures (466 patients), found that second-stage Johanson urethroplasty had a higher recurrence rate than single-stage BMG urethroplasty (35.7% vs. 17.5%, p < 0.01), and it was the only technique with an increased odds ratio of recurrence on regression (2.82, 95% CI 1.41 to 5.86). The cohort comprised strictures of 8 cm or longer at 8 centers, with a mean follow-up of 20 months.[10]

Part VI: Advantages and disadvantages​

Advantages

  • Vascularized tissue coverage. The scrotum is supplied by the inferior external pudendal arteries and perineal arteries.[5][11]
  • Versatility. Applicable to hypospadias, fistula, stricture, and trauma.[1][2][3]
  • Zero fistula recurrence in the Ehle et al. series for recurrent fistulas.[3]
  • Technically straightforward. Does not require microsurgical expertise or free tissue transfer.
  • No distant graft-harvest site is required for the scrotal-tissue variant, although scrotal donor-site and inter-stage morbidity remain possible.

Disadvantages

  • Two-stage procedure. At least two operations separated by weeks to months, with associated increased hospitalization, time away from work or school, and anesthetic exposure.[12]
  • Cosmetic concerns. Temporary penile embedding in the scrotum creates an abnormal appearance during the inter-stage period.
  • Hair-bearing skin. Scrotal skin is typically hirsute, and if hair-bearing skin is incorporated into the neourethra, complications include hair-ball formation, stone formation, diverticula, and recurrent UTI.[7][13]
    • Select a hairless scrotal area when skin will enter the urethra. Gil-Vernet et al. described selective epilation of the planned neourethral skin three months before surgery.[11][14]
    • Jordan (2002) argued that scrotal and perineal flaps have been "unfairly maligned"; hairless scrotal areas can be mobilized, and the skin overlying the perineal artery is non-hirsute in many individuals.[11]
  • Stricture recurrence. In a historical posterior-injury series, urethroscrotal inlay failed in 57% of cases, whereas perineal and transpubic anastomotic repairs succeeded in 95% and 97%, respectively.[8] In a separate long-segment anterior-stricture cohort, second-stage Johanson repair had more recurrence than one-stage BMG repair (35.7% versus 17.5%; mean follow-up 20 months).[10]
  • Diverticulum formation. Scrotal skin may be more compliant than urethral tissue, leading to pseudodiverticulum and post-void dribbling.[7][13]
  • Urine-induced dermatitis. Prolonged urine contact with scrotal skin during the marsupialization phase can cause skin changes.[7]

Part VII: Modern context — where does Cecil-Culp fit today?​

The shift away from scrotal skin​

Contemporary substitution urethroplasty uses oral mucosal grafts and selected skin flaps. The AUA guideline recommends oral mucosa as the first-choice graft and advises against genital skin for LS-proven stricture ; one-center data document declining penile-flap use with stable BMG use:[15][16][17][18][25]

  • BMG is non-hair-bearing, resistant to urine-induced dermatitis, and has good graft-take characteristics.
  • The AUA Urethral Stricture Disease Guideline (2023) recommends that surgeons should not use genital skin for reconstruction in lichen-sclerosus-proven urethral stricture . Oral mucosal grafts have been reported to succeed in 83% to 100% of LS-related strictures.[17]
  • Fuchs et al. (2018) documented the trend at one tertiary center over 2007 to 2017 among 403 complex strictures: BMG was used in 61.3%, penile skin flaps in 21.6% and perineal urethrostomy in 19.1% overall. BMG use remained stable, penile skin flap use declined, and perineal urethrostomy rose from 4.3% of case volume in 2008 to 38.7% in 2017.[18]

Remaining niche indications for Cecil-Culp​

A two-center retrospective series of 39 selected pediatric modified Cecil-Culp repairs reported perioperative complications in 4/39 and later hypospadias-repair complications in 8/37 at a mean 22.3 months of follow-up.[27] Mean embedding-to-release intervals were 345 days for hypospadias cases and 473 days for other indications.[27] Reported indications include:

  1. Hypospadias-associated urethrocutaneous fistula, including recurrent cases or deficient penile skin; Ehle et al. reported no postoperative fistula recurrence among 15 boys at mean 21 months. Eleven had prior fistula repairs and four had deficient penile skin.[3]
  2. Penile trauma with extensive skin loss; the Weiss case demonstrated adaptability of the concept to non-urethral indications.[2]
  3. Repeat penile reconstruction. Modified Cecil-Culp coverage has been described after recurrent fistula repair or with deficient ventral penile skin, and with buccal mucosal grafts for scarred redo penile surgery.[3][26]
  4. Resource-limited settings where BMG-harvest expertise or staged BMG techniques are unavailable.
  5. Salvage situations where other reconstructive options have been exhausted.

The staged BMG urethroplasty — the modern successor​

Staged buccal mucosal graft urethroplasty is a contemporary option when staged reconstruction is needed.[16][19][20] For males with LS-related strictures and no adverse local conditions, the 2026 EAU guideline gives a Weak recommendation for single-stage oral mucosa graft urethroplasty; it gives a Strong recommendation against genital skin in augmentation penile urethroplasty for LS-related strictures.[25]

  • Stage 1. Strictured urethra is opened; BMG is placed as a dorsal or ventral inlay graft on the opened urethral plate (or on the tunica albuginea if the plate is absent).
  • Stage 2. After graft maturation, the grafted plate is tubularized. Reported intervals include a minimum of 6 months in the Meeks series and a median of 277 days in the Figler series.[19][20]
  • Meeks et al. (2009): 13/15 men (86%) had no clinical stricture recurrence, fistula, or wound dehiscence after staged reconstruction for long-segment strictures (mean 8 cm) following childhood hypospadias repair, at median 22-month follow-up after closure. Buccal mucosa was used in 12 cases; other graft tissues were also used.[20]
  • Figler et al. (2018): staged penile urethroplasty in 20 patients (45% LS, 40% failed hypospadias repair). Sixty percent (12 patients) had second-stage closure at a median of 277 days, and second-stage complications included wound dehiscence (17%), fistula (8%) and meatal stenosis (8%).[19]
  • Horiguchi et al. (2022): 26/29 adults (89.7%) needed no additional procedure at a median of 31 months after reconstruction for hypospadias-related strictures. The mixed cohort included 22 staged urethroplasties, three one-stage onlays and four perineal urethrostomies; 23/25 respondents (92%) reported satisfaction.[21]

Part VIII: Scrotal and perineal flap vascular anatomy​

Carrera et al. (2009) performed a microvascular study of scrotal skin in 15 cryopreserved cadavers that is relevant to any Cecil-Culp or scrotal-flap procedure:[5]

  • Two main vascular systems. Inferior external pudendal arteries (lateral) and perineal arteries (posterior or central).
  • Three cutaneous territories. Two lateral and one central, which are widely inter-anastomosed.
  • Each lateral territory receives an inferior external pudendal artery at the midpoint of the scrotal root, fanning out to cover the entire hemiscrotum.
  • The central territory is vascularized by branches of the main scrotal arteries (continuations of the perineal arteries), running deeply on both sides of the septum.
  • The authors conclude that this anatomy permits longitudinal median island scrotal flaps with axial vascularization for panurethral stenosis.[5] Flap lengths of up to 20 cm have been reported with the biaxial design below.[14]

Gil-Vernet et al. (1997) used this biaxial vascularization for a perineum-based scrotal flap in 37 men with complex urethral stenosis. The whole anterior urethra was reconstructed with a scrotal patch in 10 men, with later penile separation. Two failures required perineal urethrostomy, one after epilation-related dermoepidermal sclerosis and one after deep vascular injury during penile release; three men required Z-plasty for bending during erection.[14] Across all 37 men treated with three scrotal-flap variants, 86% had a good result (no clinical or radiographic stricture and maximum urinary flow >15 mL/s) at a mean follow-up of 39.5 months.[14]

Part IX: Complications and management​

ComplicationMechanismPrevention / management
Urethrocutaneous fistulaInadequate tissue coverage; tension on suture linesAdequate vascularized tissue interposition, which the Cecil-Culp concept was designed to provide
Hair growth in neourethraIncorporation of hair-bearing scrotal skinUse hairless scrotal areas; pre- or post-operative epilation (electrolysis / laser)
Stone / hair-ball formationHair and debris serve as nidus for calculusEpilation; endoscopic removal if symptomatic
Diverticulum formationExcessive compliance of scrotal skin; inadequate tailoringAggressive flap tailoring; avoid excess tissue
Stricture recurrenceScarring at anastomotic sites; ischemiaTension-free anastomosis; adequate blood supply; consider BMG instead for long strictures
ChordeeInadequate release at Stage 1; tethering by scrotal tissueComplete orthoplasty before embedding; adequate mobilization at Stage 2
Meatal stenosisScarring at distal anastomosisMeatoplasty at Stage 2; adequate caliber at closure
Urine-induced dermatitis / stenosisUrine exposure of scrotal skin incorporated into a neourethra in historical inlay repairRecognize the skin-related stricture risk and assess for stenosis during follow-up
[1][2][3][7][8][10][13][22]

Summary — key principles of the Cecil-Culp procedure​

  1. Core concept. Temporary embedding of the penis into the scrotum for vascularized urethral coverage or skin replacement, followed by staged separation; tubularization applies only to variants constructing a neourethra.[1][2]
  2. Original indication. Severe proximal (penoscrotal or perineal) hypospadias where the urethral groove is absent and scrotal folds have failed to rotate caudally.[1]
  3. Expanded indications.[2][3] Selected hypospadias-associated urethrocutaneous fistulas (no postoperative recurrence among 15 boys in Ehle et al. at mean 21 months; 11 had prior fistula repairs and four had deficient penile skin), individual trauma adaptations, and salvage reconstruction.[2][3]
  4. Stage sequence. Culp's chordee-first modification added a straightening operation before two-stage Cecil repair, whereas the modified fistula-coverage operation used two stages. Penile separation follows healing, and urethral tubularization depends on the selected variant.[1][2][3][4]
  5. Advantages. Vascularized local tissue coverage without a distant donor site; the favorable fistula result comes from one small selected cohort.[3][11]
  6. Disadvantages. Staged operations, hair-bearing skin complications when scrotal skin enters the urethra, and altered appearance between stages.[7][8][10] Historical posterior-injury urethroscrotal inlay failed in 57% of cases.[7][8]
  7. Modern context. Oral mucosal graft urethroplasty may be single-stage or staged for urethral substitution according to the stricture and local tissue.[16][18][19][25] Cecil-Culp coverage variants remain described for selected recurrent fistulas and traumatic skin loss.[2][3]
  8. Vascular basis. The scrotum is supplied by the inferior external pudendal and perineal arteries, which are widely inter-anastomosed.[5][14]

See Also​

References​

1. Marshall M, Johnson SH, Price SE, Barnhouse DH. "Cecil urethroplasty with concurrent scrotoplasty for repair of hypospadias." J Urol. 1979;121(3):335–338. doi:10.1016/s0022-5347(17)56777-4

2. Weiss DA, Smith ZL, Taylor JA, Canning DA. "Old tools, old problems, new solution: the use of a modified Cecil-Culp concept in the trauma setting." Urology. 2017;106:196–199. doi:10.1016/j.urology.2017.04.023

3. Ehle JJ, Cooper CS, Peche WJ, Hawtrey CE. "Application of the Cecil-Culp repair for treatment of urethrocutaneous fistulas after hypospadias surgery." Urology. 2001;57(2):347–350. doi:10.1016/s0090-4295(00)00997-3

4. Kelalis PP, Benson RC, Culp OS. "Complications of single and multistage operations for hypospadias: a comparative review." J Urol. 1977;118(4):657–658. doi:10.1016/s0022-5347(17)58141-0

5. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps." BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x

6. Coffield KS, Weems WL. "Experience with management of posterior urethral injury associated with pelvic fracture." J Urol. 1977;117(6):722–724. doi:10.1016/s0022-5347(17)58601-2

7. Carr LK, MacDiarmid SA, Webster GD. "Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty." J Urol. 1997;157(1):104–108. doi:10.1016/s0022-5347(01)65298-4

8. Koraitim MM. "The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years." J Urol. 1995;153(1):63–66. doi:10.1097/00005392-199501000-00024

9. 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

10. 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

11. Jordan GH. "Scrotal and perineal flaps for anterior urethral reconstruction." Urol Clin North Am. 2002;29(2):411–416. doi:10.1016/s0094-0143(02)00030-7

12. Olsson CA, Krane RJ. "The controversy of single versus multistaged urethroplasty." J Urol. 1978;120(4):414–417. doi:10.1016/s0022-5347(17)57205-5

13. 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):1455–1458. doi:10.1016/s0022-5347(17)39124-3

14. Gil-Vernet J, Arango O, Gil-Vernet A, Gil-Vernet J, Gelabert-Mas A. "A new biaxial epilated scrotal flap for reconstructive urethral surgery." J Urol. 1997;158(2):412–420. doi:10.1016/s0022-5347(01)64491-4

15. Dugi DD, Simhan J, Morey AF. "Urethroplasty for stricture disease: contemporary techniques and outcomes." Urology. 2016;89:12–18. doi:10.1016/j.urology.2015.12.012

16. Andrich DE, Mundy AR. "What is the best technique for urethroplasty?" Eur Urol. 2008;54(5):1031–1041. doi:10.1016/j.eururo.2008.07.052

17. 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

18. 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

19. 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

20. Meeks JJ, Erickson BA, Gonzalez CM. "Staged reconstruction of long-segment urethral strictures in men with previous pediatric hypospadias repair." J Urol. 2009;181(2):685–689. doi:10.1016/j.juro.2008.10.013

21. Horiguchi A, Asanuma H, Shinchi M, et al. "Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults." Int J Urol. 2022;29(12):1470–1475. doi:10.1111/iju.15015

22. Snodgrass WT, Bush NC. "Management of urethral strictures after hypospadias repair." Urol Clin North Am. 2017;44(1):105–111. doi:10.1016/j.ucl.2016.08.014

23. Pierce JM. "Posterior urethral stricture repair." J Urol. 1979;121(6):739–742. doi:10.1016/s0022-5347(17)56975-x. — two-stage perineal-scrotal flap exteriorization, an early "scrotal dropback" precursor recommended when EPA is not feasible due to long stricture or severe scarring.

24. Boddepalli Y, Kota M, Banavath A. "Turner-Warwick scrotal drop back procedure as a revision perineal urethrostomy." Indian J Urol. 2019;35(2):159–160. doi:10.4103/iju.iju_345_18. PMID: 31000923.

25. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males," section 6.3.1.e. In: EAU Guidelines, 2026 ed. Arnhem: EAU Guidelines Office; 2026. Guideline.

26. Weiss DA, Canning DA. "The Cecil-Culp technique." In: Hadidi AT, ed. Hypospadias Surgery. Cham: Springer; 2022:593–601. doi:10.1007/978-3-030-94248-9_41

27. Weiss DA, Long CJ, Frazier JR, et al. "Back to the future: The Cecil-Culp technique for salvage penile reconstructive procedures." J Pediatr Urol. 2018;14(4):328.e1–328.e7. doi:10.1016/j.jpurol.2018.04.026

28. European Association of Urology. "Hypospadias." EAU Guidelines on Paediatric Urology. Accessed 2026-10-07. Guideline.