Urethroplasty is surgery to repair or reconstruct the urethra, the tube that carries urine from the bladder out of the body. It’s the most effective treatment for urethral strictures, which are narrowed sections caused by scar tissue buildup. With long-term success rates between 80% and 95%, urethroplasty significantly outperforms less invasive options and is considered the definitive fix when simpler treatments fail or aren’t appropriate.
Why Urethroplasty Is Performed
The most common reason for urethroplasty is a urethral stricture. A stricture develops when inflammation or injury triggers scarring in the urethral lining and the spongy tissue surrounding it. That scar tissue narrows the channel, making it harder to urinate. Symptoms typically include a weak or split urine stream, straining to urinate, frequent urinary tract infections, and the feeling that the bladder doesn’t fully empty.
Strictures can result from several causes: prior medical procedures involving catheters or scopes, pelvic injuries or trauma, a chronic skin condition called lichen sclerosus, or infections. Some strictures develop after childhood surgical repairs for conditions like hypospadias. In many cases, no clear cause is identified.
For short strictures (under 2 cm) in the bulbar urethra (the section behind the scrotum), doctors may first try less invasive approaches like stretching the narrowed area with a dilator or cutting the scar tissue with a small blade passed through a scope. These procedures work 35% to 70% of the time for short strictures and drop to about 20% success for strictures longer than 4 cm. When a stricture recurs after one of these simpler treatments, or when the stricture is 2 cm or longer, urethroplasty is the recommended next step.
How Surgeons Plan the Procedure
Before surgery, imaging is essential to map the stricture’s exact location, length, and severity. The standard tests are retrograde urethrography and voiding cystourethrography, both of which involve injecting contrast dye into the urethra and taking X-ray images. These reveal how narrow the passage has become and how long the affected segment is. Strictures are classified by how much the channel has narrowed: mild (less than 33% reduction), moderate (33% to 50%), or severe (more than 50%).
Ultrasound of the urethra can provide additional detail about the depth of scarring, and MRI is sometimes used for complex cases. The surgeon also typically performs a cystoscopy, passing a thin flexible camera through the urethra, to visually confirm the stricture’s characteristics. All of this information determines which surgical technique will work best.
Types of Urethroplasty
Excision and Reconnection
For short strictures under 2 cm, the most straightforward approach is to cut out the scarred segment entirely and stitch the healthy ends back together. This is called excision and primary anastomosis. The surgeon makes an incision in the perineum (the area between the scrotum and anus), frees the urethra from surrounding tissue, removes the damaged portion, and joins the two healthy ends. The cut edges are widened slightly to prevent re-narrowing at the connection point. This technique has the highest reported long-term success rate, above 85%.
Graft Urethroplasty
When a stricture is too long to simply cut out and reconnect the ends without creating tension, the surgeon uses a tissue graft to widen the narrowed section. The most common graft material is tissue harvested from the inside of the cheek, called buccal mucosa. This tissue is ideal because it’s hairless, thrives in wet environments, has a rich blood supply that helps it heal quickly, and is easy to work with surgically.
To harvest the graft, the surgeon outlines a strip about 2.5 cm wide and as long as needed on the inner cheek, numbs the area, and carefully lifts the tissue away from the underlying muscle. The graft is then placed along the opened urethra, either on top (dorsal) or underneath (ventral), to patch and widen the scarred segment. Studies comparing dorsal and ventral placement show similar success rates, around 88% to 92%. Penile skin grafts or flaps are an alternative, though buccal mucosa grafts perform slightly better overall, with success rates of about 86% compared to 82% for skin grafts.
Staged Procedures
Severe or complex strictures, particularly those in the penile urethra or caused by lichen sclerosus, sometimes require a two-stage approach. In the first surgery, the scarred urethra is opened and a graft is placed to create a new urethral surface. After several months of healing, a second surgery closes the tissue into a tube, completing the reconstruction. This staged technique is especially useful when previous surgeries have left extensive scarring.
What Recovery Looks Like
Urethroplasty is performed under general anesthesia. Most patients go home within 24 hours after a compressive bandage is removed and the surgical site is checked. A catheter remains in place for about two weeks to keep the urethra open while the repair heals. Before the catheter is removed, an imaging test is done to confirm there’s no leakage at the surgical site.
During the catheter period, you’ll need to keep the area clean and avoid strenuous activity. Some discomfort around the perineum is normal, and the cheek donor site (if a graft was used) typically feels sore for several days but heals on its own. Most people return to desk work within two to three weeks and resume full physical activity within six to eight weeks, though your surgeon will set a specific timeline based on the complexity of the repair.
Success Rates by Technique
Urethroplasty is far more durable than repeated dilations or scope-based treatments. Here’s how the main approaches compare:
- Excision and reconnection (short bulbar strictures): greater than 85% long-term success
- Buccal mucosa graft (bulbar strictures): 83% to 89%
- Buccal mucosa graft (penile strictures): approximately 75%
- Penile skin graft or flap: 82% to 84%
- Dilation or internal cutting (for comparison): 35% to 70% for short strictures, dropping to 20% for longer ones
“Success” in these studies generally means the patient doesn’t need another procedure and maintains good urine flow. Failure typically means the stricture recurs, which can happen months or years later. Follow-up appointments with flow tests and occasional imaging are standard for several years after surgery.
Risks and Sexual Function
Like any surgery, urethroplasty carries risks of bleeding, infection, and wound healing problems. The risk that concerns most patients is the potential impact on sexual function.
The overall rate of lasting erectile difficulty after anterior urethroplasty is low, around 1%. After surgery for pelvic fracture-related injuries, which involve a deeper and more complex repair, the rate is closer to 3%. One large study of 200 patients found permanent erectile problems in 5% after excision and reconnection procedures and under 1% after graft procedures. The difference likely reflects the more extensive tissue dissection required when removing a segment of urethra entirely.
Temporary changes in erections are more common, affecting up to 40% of patients in the early weeks after surgery. For men under 40, erectile function typically returns to baseline within six months. Older patients, particularly those over 65, are more likely to notice a lasting change in sexual satisfaction. Some patients also report changes in ejaculation, though many men who had strictures actually report improved sexual function after surgery because the underlying urinary obstruction has been resolved.
Urethroplasty in Women
Though urethral strictures are far less common in women, they do occur. Less invasive treatments tend to perform poorly for female strictures. Current guidelines recommend urethroplasty as the preferred treatment, using the same graft techniques adapted to shorter female urethral anatomy. The specific surgical approach depends on the surgeon’s experience and the characteristics of the individual stricture.