Dr. Sean Elliott, MD
Reconstructive Urologist
Two Stage Urethroplasty
What is a Two-stage urethroplasty?
A 2-stage urethroplasty means that there are 2 surgeries done to repair the stricture -- a "set-up" surgery and a "completion" surgery.
Why would we want to split a urethroplasty out into 2 different surgeries?
We use this technique in the most challenging strictures because it is the most conservative (or safest) way to fix strictures. It is conservative because by breaking the surgery into 2 stages, we can make sure that the first portion worked before proceeding with the second portion.
How much time do I have to wait between the first surgery and the second?
6 months.
In the first stage we move tissue around and this can disrupt the blood supply to these tissues. It takes about 6 months for new blood vessels to grow into the tissue. We want the tissue to have the best blood supply possible before we do the second stage operation. We are performing these surgeries in high risk situations so it is important that we optimize things before the second stage.
How do I pee in between the first and second stage surgeries?
In the first surgery, the opening of the urethra is moved lower on the shaft of the penis. In the second stage, we move the opening back to where is should be. So, during the time between the first and second stage, the urine will come out of a hole set further back on the penis. This might require you to sit down while you pee until the second stage is done.
First-Stage Surgery
What is done in the First-Stage Surgery?
The urethra is "unzipped" until we find an area of healthy urethra. Depending on how long the stricture is, this might mean the urethra is unzipped <1 inch to even several inches. The illustration below shows a situation where the scar tissue is in the middle of the penis. So only the middle of the penis urethra is opened up (or unzipped). If the stricture also extends into the head of the penis then that part would need to be opened up as well.
Figure 1a:
Open the skin. Here, the urethra is seen through the skin as a dotted black line and the area of the stricture is shown through the skin as a dotted white line. The incision in the skin is shown as a dotted yellow line.
Figure 1b:
Spread the skin away so the you can see the urethra underneath. The outside of the urethra is shown as a light yellow tube. Open the urethra along the dotted line in the middle.
Figure 1c:
After the urethra is opened over the scar tissue area, the stricture is shown in green. Healthy inside of the urethra is shown in light pink and the edges of that healthy urethra in red.
Figure 1d:
We then place skin grafts on either side of the stricture urethra. These grafts are shown in dark gold / tan. The skin grafts are usually take from the inside of the cheek (called "buccal mucosa" grafts). In rare cases, there is enough penis skin available and we don't have to add the skin grafts.
The grafts are sewn onto the shaft of the penis so that blood vessels will grow into the graft from the penis. The graft is also sewn to the urethra in the center and to the penis skin on the sides.
Figure 1a
Figure 1b
Figure 1c
Figure 1d
Second-Stage Surgery
What is done in the Second Stage Surgery?
Basically, we make a tube out of the open urethra section plus the previously placed grafts.
Figure 2a:
Make a skin incision along the edges of the skin in the shape of an ellipse.
Figure 2b:
Mobilize the edges of the previously placed graft so that we we can roll the edges of the graft into a tube. "Mobilizing" the edges means cutting some attachments between the grafts and the shaft of the penis. These attachments formed when the graft healed onto the shaft after the first stage.
Figure 2c:
Sew the graft closed in the shaft of a tube. We will usually also move some healthy tissue from the scrotum onto the shaft of the penis to wrap over the urethra to help with healing.
Figure 2d:
Close the skin
Figure 2a
Figure 2b
Figure 2c
Figure 2d