For referring physicians
Anterior urethral stricture: how I choose the operation
Bulbar, penile and panurethral strictures, first time and redo, in men and in women. The questions I ask, in order, with a video for each operation. The posterior urethra and the bladder neck have their own pages.
Length, segment, cause
Three facts decide most of the operation, and they are the three axes of the staging system we built and validated in TURNS: how long the stricture is, which segment it sits in, and what caused it. A short bulbar stricture after a straddle injury and a long penile stricture from lichen sclerosus are different diseases with the same name. A retrograde urethrogram and a cystoscopy give me the first two facts; the history and the skin give me the third. Lichen sclerosus and a failed hypospadias repair change the plan before I have seen the urethrogram.
What dilation can and cannot do
Dilation and internal urethrotomy give most men temporary relief and not a durable one. The man who ends up on intermittent self-dilation is the man the success rates hide: when we surveyed him across four institutions he rated his quality of life as poor, and in the VA population men on repeated scheduled endoscopic treatments had more emergent procedures than men taken to urethroplasty after the first failure. In the posterior urethra and the ureter I give endoscopic treatment one attempt and then repair. Whether a short first-time bulbar stricture earns more than that is a question I have deliberately left open.
The drug-coated balloon changed the arithmetic for some patients. In the TURNS real-world series, one-year functional recurrence-free survival after Optilume was 78 percent for anterior strictures, with a lower anatomic figure on cystoscopy. It is a reasonable choice for the man who wants to avoid an incision and understands what the number counts, and it is not a urethroplasty. The patient video below is how I put that choice to him.
Excise it or graft it
A short bulbar stricture with a traumatic or idiopathic cause is excised and the healthy ends joined, which is the operation with the best long-term record. Longer strictures, penile strictures and anything from lichen sclerosus get substitution, and the substitute is buccal mucosa, placed dorsally where the corporal bed feeds it. Where the distal urethra has no spongiosum to cover a ventral graft, the periurethral tissue can be brought over it, the pseudospongioplasty we described. Excision in the penile urethra shortens the penis, and the AUA guideline I helped write recommends against it there.
The redo field
In redo surgery the field, not the technique, is the dominant variable. Scar, ischemia, radiation and infection make a bed a graft will not take in, and the move is to recognize that bed early and bring vascularized tissue to it. The bailout is declared before the incision: if a tension-free closure is impossible after full mobilization, the case converts to a two-stage repair, and that decision is documented as a plan rather than discovered as a failure.
Donor tissue runs out. Contralateral buccal comes first, lingual second with more donor morbidity, and when oral mucosa is exhausted a rectal mucosa graft harvested transanally has reconstructed panurethral strictures with a median length of 13 cm in the TURNS series. For the man who has been through several repairs, a perineal urethrostomy is an operation that gets him voiding without a catheter, and when it stenoses it can be revised with a posterior thigh propeller flap rather than another attempt at the same scar.
When nothing local is left
A free flap brings in tissue with its own blood supply. With NYU plastic surgery I use a free ileal flap or a radial forearm flap for the urethra that has no local option, most often after radiation, and the radiated posterior urethra has its own page. The videos show the harvest and the inset.
Female urethral stricture and diverticulum
The female urethral stricture is repaired with a dorsal onlay oral mucosa graft, which we reported with the Rennes group. A urethral diverticulum that has taken the urethra with it is excised with the SP robot, and the urethra is rebuilt with bladder mucosa in the same sitting (video below).
After the repair
In TURNS we look at every urethroplasty with a flexible cystoscope at about three to four months. A normal lumen at that scope predicted a low rate of later intervention, and a narrowing that would not pass a 17 Fr scope predicted the opposite: 64 percent of those men needed a second operation. Success has to be defined before it is counted: the same cohort gives different success rates depending on whether you count retreatment, cystoscopy, flow rate or the patient's own report, which is why I ask what the patient is doing on the day a paper counts him as a success.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Buccal mucosa graft urethroplasty
Endoscopic treatment
When local tissue is used up: free flaps
Papers
- Male urethral stricture: American Urological Association guideline. J Urol. 2016. PubMed 27497791
- Development and validation of the Length, Segment, and Etiology anterior urethral stricture disease staging system using longitudinal urethroplasty outcomes data from TURNS. J Urol. 2024. PubMed 39652884
- Development and validation of a male anterior urethral stricture classification system. Urology. 2020. PubMed 32580016
- Defining success after anterior urethroplasty: an argument for a universal definition and surveillance protocol. J Urol. 2022. PubMed 35239415
- Early real-world experience with Optilume drug-coated balloon for anterior urethral strictures and posterior urethral stenoses. Urology. 2025. PubMed 41109561
- Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol. 2013. PubMed 23820057
- Burden of disease for urethral stricture managed by repeat endoscopic treatment vs single endoscopic treatment or urethroplasty in the Veterans Affairs population. Urol Pract. 2017. PubMed 37312311
- Urethroscopic findings following urethroplasty predict the need for secondary intervention in the long term: a multi-institutional study from TURNS. J Urol. 2021. PubMed 34854754
- Clinical significance of cystoscopic urethral stricture recurrence after anterior urethroplasty: a multi-institution analysis from TURNS. World J Urol. 2019. PubMed 30712091
- Reconstruction of traumatic and reoperative anterior urethral strictures via excisional techniques. Urol Clin North Am. 2013. PubMed 23905938
- Pseudospongioplasty using periurethral vascularized tissue to support ventral buccal mucosa grafts in the distal urethra. J Urol. 2014. PubMed 24631104
- Multi-institutional outcomes of minimally invasive harvest of rectal mucosa graft for anterior urethral reconstruction. J Urol. 2019. PubMed 30864909
- Propeller flap perineal urethrostomy revision. Urology. 2020. PubMed 33309704
- Understanding the relationship between chronic systemic disease and lichen sclerosus urethral strictures. J Urol. 2016. PubMed 26343349
- The impact of social deprivation on anterior urethral stricture recurrence after urethroplasty: a TURNS analysis. J Urol. 2024. PubMed 39088547
- Dorsal onlay oral mucosa graft urethroplasty for female urethral stricture. Urology. 2021. PubMed 34537197
- Free ileal flap: an alternative approach to urethral reconstruction. J Urol Surg. 2022. DOI 10.4274/jus.galenos.2022.2021.0116