Two-stage urethroplasty

  • Introduction
  • Lectures
  • Articles
  • F.A.Q.
  • Results
  • Surgical Techniques

The surgical technique of “Two-stage Urethroplasty” is conducted in two operations performed at different times.

Figure 1

Figure 2

Figure 3

Figure 4

During the first operation, the urethra is opened and a perineal urethrostomy (figure 1).
One year later, the perineal urethrostomy is closed (figure 2-3-4) and the patient is again able to void through the external urinary meatus.
The surgical technique of Two-stage urethroplasty is generally suggested in the patients with complex urethral strictures.

Lecture n° 1:

Uretroplastia en dos tiempos ¿cómo y cuándo ?
51 Curso de Urologia Fundació Puigevert
18 – 20 de octubre 2006
Barcelona – Spain

Download PDF

Lecture n° 2:
Penile and bulbar urethroplasty Surgical techniques and results
Hong Kong Urological Association Urethroplasty Workshop Division of Urology – Tuen Mun Hospital
Hong Kong
February 9 – 10, 2009

Download PDF
Article n° 1
Barbagli G, Palminteri E, Bartoletti R, Selli C, Rizzo M.
Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates.
J Urol. 1997 Oct;158(4):1380-2.

Purpose: We analyzed the long-term results of different urethroplasty techniques.
Materials and Methods: We performed a retrospective review of 98 patients who underwent different procedures for anterior (78) and posterior (20) urethral strictures. Mean followup was 53 months. A total of 20 patients underwent end-to-end anastomosis (group 1), 30 underwent 1-stage procedures (group 2), 28 underwent 2-stage procedures (group 3), and 20 underwent bulboprostatic anastomosis (group 4). The results were analyzed using Kaplan-Meier curves and log rank test.
Results: The success rate was 95% for group 1, 93.4% for group 2, 78.6% for group 3, and 70% for group 4. Statistical evaluation of the actuarial success rates failed to show significant differences among the 4 groups.
Conclusions: The stricture recurrences were uniformly distributed over time. Urethroplasty patients must be followed for the rest of their lives.

Article n° 2
Barbagli G, Palminteri E, Lazzeri M, Guazzoni G, Turini D.
Long-term outcome of urethroplasty after failed urethrotomy versus primary repair.
J Urol. 2001 Jun;165(6 Pt 1):1918-9

Purpose: A urethral stricture recurring after repeat urethrotomy challenges even a skilled urologist. To address the question of whether to repeat urethrotomy or perform open reconstructive surgery, we retrospectively review a series of 93 patients comparing those who underwent primary repair versus those who had undergone urethrotomy and underwent secondary treatment.
Materials and Methods: From 1975 to 1998, 93 males between age 13 and 78 years (mean 39) underwent surgical treatment for bulbar urethral stricture. In 46 (49%) of the patients urethroplasty was performed as primary repair, and in 47 (51%) after previously failed urethrotomy. The strictures were localized in the bulbous urethra without involvement of penile or membranous tracts. The etiology was ischemic in 37 patients, traumatic in 23, unknown in 17 and inflammatory in 16. To simplify evaluation of the results, the clinical outcome was considered either a success or a failure at the time any postoperative procedure was needed, including dilation.
Results: In our 93 patients primary urethroplasty had a final success rate of 85%, and after failed urethrotomy 87%. Previously failed urethrotomy did not influence the long-term outcome of urethroplasty. The long-term results of different urethroplasty techniques had a final success rate ranging from 77% to 96%.
Conclusions: We conclude that failed urethrotomy does not condition the long-term result of surgical repair. With extended followup, the success rate of urethroplasty decreases with time but it is in fact still higher than that of urethrotomy.

Article n° 3
Palminteri E, Lazzeri M, Guazzoni G, Turini D, Barbagli G.
New 2-stage buccal mucosal graft urethroplasty.
J Urol. 2002 Jan;167(1):130-2

Purpose: Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty.
Materials and Methods: A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure.
Results: A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25).
Conclusions: Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.

Article n° 4
Barbagli G., Guazzoni G., Lazzeri M.
One-Stage bulbar urethroplasty: Retrospective analisys of the results in 375 patients
Eur Urol 2008; 53:828 – 33

Objective: To review the outcome of bulbar urethroplasty using one-stage surgical techniques.
Methods: Of 375 patients, who underwent one-stage bulbar urethroplasties, 165 patients (44%) underwent anastomotic repair (AR), 40 (10.7%) underwent augmented anastomotic repair (AAR) using penile skin grafts (PSGs) or oral mucosal grafts (OMGs), and 170 (45.3%) underwent onlay grafting techniques (OGTs) using PSGs or OMGs. Clinical outcome was considered a failure when any postoperative instrumentation was needed. The chi(2) and Fisher’s exact test for categorical data were used. The sample size of 375 patients provides a statistical power (1-beta) of 99% at alpha=0.05; p<0.05 was set as significant.
Results: The average follow-up was 53 mo. Of 375 cases, 313 (83.5%) were successful and 62 (16.5%) failures. Of 165 ARs, 150 (90.9%) were successful and 15 (9.1%) failures. Of 40 AARs, 24 (60%) were successful and 16 (40%) failures. Of 170 OGTs, 139 (81.8%) were successful and 31 (18.2%) failures. The AR showed statistically significant higher success rate compared to OGT (p=0.023) and AAR (p=0.0001). Of 47 PSGs, 28 (59.6%) were successful and 19 (40.4%) failures. Of 163 OMGs, 135 (82.8%) were successful and 28 (17.2%) failures. This difference was statistically significant (p=0.002).
Conclusions: One-stage bulbar urethroplasties showed an overall 83.5% success rate. The AR showed the higher success rate compared to the OGT or AAR. OMGs (82.8% success rate) perform statistically better than PSGs (59.6% success rate).
1. Question: What kind of anesthesia is used for this surgery?
Answer: General anesthesia with nasal or oro-tracheal intubation.

2. Question: How many hours does the surgery take?
Answer: About 2 hours for the first operation and one hour for the second operation.

3. Question: Are there any risks concerning erection, fertility and urinary incontinence after the surgery?
Answer: No, there aren’t.

4. Question: How many days of hospital recovery are expected following the surgery?
Answer: In general, from 5 to 7 days for both operations.

5. Question: How long will I have to use a catheter after the surgery?
Answer: The urethral catheter must stay in place for two weeks following the first operation, and for four weeks following the second operation, when the first post-operative voiding urethrography is done.

6. Question: Are there any particular recommendations during convalescence?
Answer: During convalescence, the use antibiotics until the catheter is removed is suggested. Avoiding long car trips, as well as heavy labor and sexual and sports activities are also suggested.

7. Question: When will I be able to resume my working, sexual and sports activities?
Answer: All these activities can be gradually resumed about 30 days after the removal of the catheter.

8. Question: Can I ride a bike or a motorcycle immediately after the surgery?
Answer: It is not recommended to ride bikes, motorcycles or horses after the surgery.

9. Question: What kinds of foods and drinks should be avoided after the surgery?
Answer: Beer and sparkling wines should be avoided, as well as large quantities of chocolate, cocoa, nuts and shellfish.