Urethral Stricture Repair


Potential complications

Buccal mucosal graft harvest

  1. Give cefoxitin and gentamicin for antibiotic prophylaxis
  2. Place u-drape with opening towards genitals
  3. Place mouth retractor and lip retractor, secure together with Penrose and allis clamp
  4. Place lip stitch X3 3-0 silk pops, place stitch within mouth and come out right at vermillion border
  5. Delineate stensen duct (do not include within graft) and measure out graft, usually adding 1cm length and using ~2-3cm width
  6. Use lidocaine 1% w epi to hydrodissect under graft, starting proximal and moving distal
  7. Cut with #15 scalpel, push deep to maintain smooth incision
  8. Place silk traction stitch at distal tip of graft, either x2 or figure of 8 for traction
  9. Use curved metzenbaum scissors to dissect off underlying layers, trying to leave as much muscle behind as possible
  10. Obtain minimal hemostasis (avoid cautery injury), then place tonsil balls X3 (tie tails together) soaked in residual lido/epi for compression

Urethral access

  1. Place patient in dorsal lithotomy, prep/drape, give antibiotics (cefazolin/cefoxitin +/- gentamicin)
  2. Perform cystoscopy, place double floppy wire if stricture not obliterated
  3. Make midline perineal incision with scalpel, divide underlying layers
  4. Place lone star retractor, place hooks to retract skin, larger rakes for scrotal retraction
  5. Divide bulbospongiosus with metzenbaum scissors (do not use cautery), identify urethra

Excision and Primary Anastomosis

  1. Circumferentially free urethra proximally and distally to allow for adequate mobilization
  2. Place cystoscope to identify stricture and mark site with cautery on outside of urethra
  3. Place 3 clamps - two at distal stricture site, then 3rd clamp very proximal to control sponge bleeding
  4. Cut urethra with heavy scissors
  5. Continue to remove strictured urethra until it accommodates 22-26Fr bougie, send urethra for pathology
  6. Spatulate urethra - distal dorsally, proximal perineally
  7. Start placing 4-0 vicryl anastomotic stitches, starting at 12 on proximal urethra and moving counterclockwise, with tails out outside
  8. Tip: place catheter after 6 o'clock stitch, ensuring it does not tangle the already-placed sutures and that the new sutures don't tag the catheter
  9. Tip: place dorsal stitches full thickness (9 to 3), place ventral stitches only through mucosa and not the spongiosum (8 to 4)
  10. After all stitches placed, tie down starting with 12 o'clock and moving counterclockwise, tying in order, confirm catheter is still mobile
  11. Close ventral spongiosum with 5-0 PDS running stitch

Dorsal onlay buccal mucosa graft

  1. Choose one side of urethra and divide urethra from surrounding tissue until dorsal portion is accessible
  2. Place 22Fr Bougie through meatus to level of distal stricture, mark urethra and start dorsal incision 1cm distal
  3. Incise further proximal until able to pass 22-28Fr Bougie, then perform cystoscopy to confirm no bladder abnormalities, can retract urethra with 4-0 vicryl retracting stitches through urethral edge
  4. Take fenestrated graft and suture (with 4-0 vicryl) at 5, 6, and 7 o'clock at proximal portion of graft, suture graft directly to urethra, then suture distal apex to hold in place
  5. Place 4-0 vicryl interrupted sutures on both edges - on side with native urethra, suture urethral edge + corpus underneath + graft edge
  6. Place 6-0 monocryl on TF needle in running fashion to quilt graft and hold it onto corpus, be careful not to wrinkle or tug on graft
  7. Place running 5-0 PDS on urethral edge, include corpus underneath
  8. Place catheter and run 5-0 PDS x2 from top and bottom to close urethra completely

Ventral onlay graft

  1. Place 24Fr bougie and incise directly over widest part with #15 scalpel to avoid underestimating stricture, use fingers to push urethra onto bougie, place traction stitch with 4-0 vicryl pop (but do not tie) to provide hemostasis (ensure mucosa included in stitch), place mosquito snap and hang traction stitches on lone star
  2. Continue cutting proximally sharply with Metzenbaum scissors until stricture accommodates 24Fr bougie, make sure to see/feel the wire within the urethral lumen to make sure false passages aren't created
  3. Place graft with mucosal side inwards, anchor proximally with 4-0 vicryl at 5, 6, and 7 o'clock (place all stitches into urethra first, then graft, then tie)
  4. Tip: place stitches into mucosa and portion of spongiosus, but leave tunica for separate closure
  5. Run 5-0 PDS 80% up one side and 20% up the other side, cutting out traction stitches as they become less helpful for retraction, then place 16Fr catheter
  6. Continue running PDS until 80% on both sides
  7. Repeat 4-0 vicryl x3 stitches on distal portion of grat
  8. Close remaining opening with running 5-0 PDS or interrupted 4-0 vicryl to avoid redundant graft (trim as needed)
  9. Close spongiosus over graft with 4-0 PDS


  1. Close bulbospongiosus and colles with 2-0 vicryl running
  2. Close skin with 4-0 monocryl horizontal mattress interrupted
  3. Place bacitracin, telfa, and compressive dressing

Follow-up plan