Urethroplasty Techniques: Ventral, Dorsal and Graft Repair Methods

“Surgery was recommended, but I didn't understand exactly what to do” — this is one of the most common sentences said by our patients who were recommended urethroplasty (surgery to repair the urinary tract) due to urethral stricture. Urethroplasty is not actually a single surgery; it is the common name of several different techniques that vary depending on the location, length and cause of the stenosis. In this article, we explain these techniques - such as end-to-end anastomosis, ventral (lower surface) and dorsal (upper surface) graft (tissue patch) methods, use of oral mucosal tissue - in plain language and explain which method is preferred for which patient, based on current scientific sources.

What is Urethroplasty? Is it necessary for every patient with a stricture?

Urethroplasty is a surgery to surgically repair a narrowed section of the urethra. The aim is not to open the narrow area by force; is to permanently expand this area or replace it with healthy tissue. However, not every patient with a stricture requires direct surgery. In some first-time, short strictures, non-surgical methods (dilatation, endoscopic incision) can be tried first. Which path to follow? The length of the stricture, its location, how many times it has recurred before and your preference are decided together with your urologist.

What is the Difference Between Dilatation, Internal Urethrotomy and Urethroplasty?

The purpose of these three methods is the same: to ensure that urine flows easily. But their paths are different:

• Dilatation: It is the physical expansion of a narrow area with special tools. The effect is usually not permanent and needs to be repeated frequently.

• Internal urethrotomy (endoscopic procedure, briefly DVIU): It is entered with a camera (endoscope) and the narrow area is cut open from the inside. In the first attempt, it is more successful in cases of short strictures (less than 2 cm) and in the area between the bladder and the penis (bulbar region). However, if the stenosis recurs, it is no longer recommended to perform the same procedure again; because the chance of permanent success drops significantly after the second attempt.

• Urethroplasty: Removing the stenotic section or repairing it with healthy tissue. It is a larger surgery than the methods performed with a camera, but it gives much more permanent results in cases of recurrent or long stenosis.

How to Choose a Surgery Technique? End-to-End Anastomosis or Grafted (Patched) Repair?

End-to-End Anastomosis (Anastomosis) Techniques

In the end-to-end anastomosis method, the narrow section is completely removed, and the remaining two healthy ends are stitched together without creating tension. This method is especially preferred in narrow cases that are short (usually less than 2 cm), contain hard scar tissue, and develop due to perineal trauma. The long-term success rate of this method has been reported in a wide range in scientific studies, between approximately 85-95%; however, this rate varies depending on the length and location of the stenosis and how long the patient is followed. In some centers, the stenotic tissue is not completely removed, only the narrowing scar tissue is opened and stitched without creating tension. The purpose of this “non-excision” method is to further protect the vessels and nerves around the urethra.

Repair with Graft (Tissue Patch): Ventral, Dorsal and Dorsolateral Techniques

If the stenosis is longer than 2 cm or in cases where end-to-end anastomosis would create tension, the stenosis area is not removed; instead, a tissue patch (graft) is added over it. The main point where the techniques differ from each other is on which surface of the urinary tract this patch is placed (lower surface: ventral, upper surface: dorsal, or side-upper: dorsolateral):

• Ventral (bottom surface) patch: The tissue patch is placed on the bottom surface of the urinary tract. Since the blood circulation of this area is generally strong, it is relatively easier to apply.

• Dorsal (upper surface) patch: The tissue patch is placed on the upper surface of the urinary tract. In this technique, the patch contacts the spongy and vascular tissue around the urethra more tightly; this may help the patch adhere.

• Dorsolateral (side-upper) patch: It is an intermediate method that aims to combine some of the advantages of dorsal and ventral techniques without the need to completely circumvent the urinary tract.

There is no consensus in the scientific literature that one of these three methods is definitively superior to the others.

Repair and Combined Techniques with Oral Mucosal Tissue (Buccal Mucosa)

The most commonly used tissue worldwide in surgeries requiring grafts (patches) is the intraoral cheek tissue (buccal mucosa). The main reasons for this are:

• It can be easily removed and does not leave a permanent, visible mark where it is removed.

• It has a durable and flexible tissue structure

• Resistant to the urinary environment

• High retention rate of the patch thanks to strong blood circulation

In very long strictures (especially in "panurethral" strictures that cover most or all of the urinary tract), a single piece of oral mucosal tissue may not be sufficient. In this case, combined techniques such as taking tissue from both cheeks, combining it with the inner lip tissue, or a two-stage surgery plan can be considered. These approaches are especially preferred in recurrent or very long strictures that develop due to a chronic skin-mucosa disease called lichen sclerosus; the decision is made individually for the patient based on the surgeon's experience.

What Determines Your Technique Selection?

When deciding which technique to apply, your urologist evaluates the following factors together:

• Location of the stricture: Location covering the penis, bulbar region (between the bladder and the penis) or almost the entire urinary tract requires different techniques.

• Length of the stenosis: End-to-end stitching is preferred for short stenoses, and grafted (patched) techniques come to the fore for long stenoses.

• Reason: Graft is generally preferred for stenoses due to lichen sclerosus (a chronic skin-mucosa disease); End-to-end stitching is more suitable for short stenoses due to impact.

• The degree of hardening in the surrounding tissue: How much the tissue around the stenosis hardens (scars) affects whether the decision to graft or remove the tissue is made.

• Previous treatments: Previous dilatation, endoscopic incision, or unsuccessful urethroplasty attempts may change tissue quality and options.

The statement “Urethroplasty is the gold standard” is true, but it is important where it applies: this statement is valid when looking for a permanent solution in cases of recurrent or long strictures, where camera-based methods have a low chance of success. In cases of short stricture occurring for the first time, it may not always be necessary to recommend direct urethroplasty as the first treatment.

What to Expect for Patients After Surgery?

Although the process after urethroplasty varies depending on the technique, it generally includes the following:

• Hospital stay for a few days after surgery

• Follow-up with a urethral catheter (catheter) for several weeks; Duration varies depending on technique and recovery status.

• Follow-up with uroflowmetry (urine flow measurement) at 3, 6 and 12 month controls

• If a slowdown in urine flow rate is noticed, re-evaluation is performed early.

Possible risks include recurrence of stenosis, rare urinary incontinence, and temporary changes in sexual function. How often these risks will occur; it varies depending on the technique applied, the cause of the stenosis (the risk is slightly higher, especially in cases caused by impact) and your personal characteristics. These issues should be discussed in detail with your physician before surgery.

When to Consult a Doctor?

Situations requiring urgent evaluation in the post-urethroplasty period:

• Signs of infection such as fever and chills

• No urine draining through or around the catheter

• Heavy bleeding

• Severe, uncontrolled pain

There are also situations that are not urgent but require control: such as a gradual decrease in urine flow or a persistent complaint of slight dripping. In these cases, it is important not to miss your follow-up appointments — because an early decrease in flow may be the first sign that the stenosis has recurred.

Frequently Asked Questions

Does every urethral stricture patient require urethroplasty?

No. In short stenoses detected for the first time, endoscopic methods can be tried first. Urethroplasty stands out as a permanent solution, especially for recurrent or long strictures.

Which of the dorsal and ventral graft techniques is better?

Scientific studies show that both have similar success and side effect rates. Which one to choose; it is determined according to the location of the stenosis, tissue characteristics and your surgeon's experience.

Does buccal mucosa graft cause permanent damage to the mouth?

The area where buccal mucosa is removed usually heals in a short time; no permanent effect on speech and chewing functions is expected. There may be temporary sensitivity.

Can stricture recur after urethroplasty?

Yes, all surgical techniques have a certain risk of recurrence. Therefore, regular uroflowmetry checks are important; Recurrence detected early can be more easily managed.

How long does the catheter remain after surgery?

Duration varies depending on the technique and healing process; usually within a few weeks. The exact duration is determined by the physician performing the surgery.

Does urethroplasty affect erectile function?

Transient erectile changes have been reported in some patients; Permanent effects are seen at a relatively lower rate. The risk varies depending on the cause of the stenosis and the technique used.

Why are success rates described differently from patient to patient?

Because success rates; it varies depending on the location of the stenosis, its length, the technique applied and the follow-up period. Instead of a general percentage, it would be better to get the rate specific to your situation from your doctor.

Conclusion

Urethroplasty is not a single surgery; it is a set of techniques adapted to the characteristics of your stenosis. The choice between end-to-end suturing, ventral/dorsal graft repair, and combined techniques is a decision that you and your urologist will make together. This article is for general information purposes; Surgery decision and technique selection can only be made specifically for you after a comprehensive examination and imaging.