Operative animation, Bulbar urethroplasty

Bulbar urethroplasty: excision and anastomosis or buccal graft

This animation shows two alternative branches, never a combined repair: selected short, near-obliterative or post-traumatic bulbar strictures may undergo transecting excision and primary anastomosis, while an augmentation branch preserves continuity and opens the urethra longitudinally for a buccal graft.

Selection depends on length, aetiology, obliteration, spongiofibrosis, tissue quality and reconstructive expertise.

Core tier FRCS reconstruction, andrology Interactive 3D
Schematic scene preview: Bulbar urethroplasty
Preparing the 3D anatomy…

UrOops3D · UroRef · © Nity G

Click me next Section 2 of 8 Anatomy The structures this operation works between, and the one it must not cross.

The structures in the scene

Bulbar urethroplasty: how the structures relatePerineal view of the bulbar urethra, with the buccal harvest site. The stricture segment: scar meets healthy spongiosum at the margins Bulbar urethra and spongiosum (danger). The stricture segment: dorsal; the onlay is quilted to their tunica Corpora cavernosa. The stricture segment: divided in the midline to expose the bulb Bulbospongiosus. The stricture segment: excised; tension on the gap is stenosis deferred The anastomotic gap (danger). The stricture segment: opened dorsally and enlarged with the graft Buccal mucosa graft. Buccal mucosa graft: opposite the upper second molar; harvest clear Stensen's duct papilla (danger).The stricture segmentBulbar urethra andspongiosumCorpora cavernosaBulbospongiosus!The anastomotic gapBuccal mucosa graft!Stensen's ductpapillascar meets healthyspongiosum at themarginsdorsal; the onlayis quilted to theirtunicadivided in themidline to exposethe bulbexcised; tension onthe gap is stenosisdeferredopened dorsally andenlarged with thegraftopposite the uppersecond molar; harvestclearTargetDangerLandmarkContext
Perineal view of the bulbar urethra, with the buccal harvest site. Schematic, not to scale; relationships only.
  • In the perineal view the urethra runs horizontally: membranous and bladder posterior, penile anterior, with the bulb and its spongiosum in the middle where the stricture lives.
  • The corpora cavernosa lie dorsal, immediately above the urethra along its whole length, and their fused midline tunica is the fixed bed a dorsal onlay is quilted onto.
  • Bulbospongiosus wraps the bulb ventrally and is the muscle plane the exposure opens.
  • At the other end of the table, the inner cheek offers thin, hairless, tough mucosa, limited anteriorly by Stensen's duct at the papilla opposite the upper second molar and by the lip line.
  • The whole operation is a set of tubes and beds: a tube to reopen or rejoin, and the nearest reliable bed to sew the enlargement to.
  • ›Bulbar urethra + spongiosum - the mobile, well-vascularised mid-urethra; the tissue that makes both anastomosis and grafting possible.
  • ›The stricture segment - fibrotic, narrow, avascular; excised completely in the anastomotic operation, opened dorsally in the substitution one.
  • ›Corpora cavernosa - dorsal to the urethra and fused in the midline; their tunica is the fixed, vascular bed the dorsal onlay is quilted to.
  • ›Bulbospongiosus - divided in the midline and reapproximated at the end; its blood supply contributes to the repair.
  • ›Buccal mucosa + Stensen's duct - the graft of choice and the structure it must avoid: the duct papilla sits opposite the upper second molar.
Click me next Section 3 of 8 Steps The operation in order, with the landmark that guards each move.

Operative steps

  1. Exaggerated lithotomy The legs are raised into the exaggerated lithotomy position that gives the perineal exposure, with padded supports at the fibular heads and nothing pressing across the calves. The position is checked before draping: contact points, calves and hips compared side to side, because a subtle asymmetry loads one leg for hours. The time in position is recorded and the calves are reassessed at closure. The exposure and the nerve injury come from the same position, so positioning is treated as part of the operation rather than as preparation for it.
    where it bites: the common peroneal nerve on the fibular head and the calf compartments are the two casualties of a long case in an unbalanced position.
  2. Perineal exposure A midline perineal incision is made over the bulb and the subcutaneous tissues opened until the fibres of bulbospongiosus present in the midline. The muscle is divided exactly on that midline seam, where the two halves meet, and reflected off the bulb to expose the corpus spongiosum carrying the strictured segment. The seam is the safe plane: dissection swept laterally off it meets the corpora and their neurovascular supply. A self-retaining retractor holds the exposure for the rest of the case.
    where it bites: lateral dissection off the midline wanders toward the corpus cavernosum and its neurovascular supply.
  3. Assess + calibrate Calibration, imaging and direct assessment define length, site, calibre, aetiology, degree of obliteration and spongiofibrosis. Those findings, tissue quality, prior treatment, patient priorities and reconstructive expertise select the repair. The animation therefore branches after this step; it does not imply that length alone makes the decision.
    where it bites: choosing a repair from length alone ignores aetiology, obliteration and tissue quality.
  4. Branch A: selected transecting EPA For an appropriate short, near-obliterative or post-traumatic bulbar pattern, the diseased segment is transected and excised to healthy ends. Other short non-traumatic strictures may be treated with non-transecting anastomotic or graft techniques; this branch is deliberately labelled rather than presented as universal.
    where it bites: excision that creates a gap which cannot close without tension is the wrong branch.
  5. Branch A: tension-free anastomosis The healthy ends are spatulated and joined mucosa to mucosa without tension. The repair is abandoned or revised if the ends do not lie together comfortably; the scene does not teach increasingly aggressive mobilisation as a licence to force a long gap closed.
    where it bites: a visibly tensioned join risks ischaemia and recurrence.
  6. Branch B (field reset): buccal augmentation The animation now resets to the untransected stricture to demonstrate an alternative repair. A longitudinal dorsal urethrotomy opens the narrowed segment and buccal mucosa, harvested clear of Stensen's duct, is oriented along the urethral axis, quilted to its bed and sutured to the urethral margins. Dorsal and ventral graft positions both have acceptable outcomes; choice follows stricture features and surgeon experience. The harvest itself is shown: the lips held apart on commissure stays, the mucosa hydrodissected with lidocaine and adrenaline, a 2 cm wide ellipse incised with a No. 15 blade and lifted off buccinator with fine scissors from one end, the bed treated with diathermy and packed to heal by secondary intention (primary closure with absorbable sutures is the alternative), and the graft defatted on a board and kept in saline before it is tailored to the measured defect.
    where it bites: never interpret the replay as a graft laid on top of a completed excision-and-anastomosis repair.
  7. Closure + catheter Bulbospongiosus is reapproximated over the repair on its midline seam to rebuild the muscle layer, and the perineum is closed in layers over a drain that exits laterally, away from the repair. A catheter is left across the reconstruction to splint the anastomosis or onlay while it heals, and the intended duration is written down before the patient leaves theatre. The pericatheter study is planned before removal, so the repair is shown sealed rather than assumed. Drain output, calf status and foot movement are checked once the patient is down from lithotomy.
    where it bites: the catheter is a stent across the repair, not a safety net for a poor one, and it comes out on a schedule, not on a whim.
Click me next Section 4 of 8 Danger zones Where this operation bites, and why it bites there.
Critical relationship

Danger zones

The spatial relationships the animation is built to make automatic. Before you read each one, ask yourself: at this point in the operation, what is about to go wrong, and what is my first move? The save for each sits in the Complications tab.

  • RiskThe excision margins - the junction of scar and healthy spongiosum at each end; the commonest address of recurrence.
  • RiskThe anastomotic gap - the distance the mobilised ends must close; tension here is stenosis deferred by a few months.
  • RiskStensen's duct papilla - opposite the upper second molar; a graft harvest over it obstructs the duct and swells the cheek with every meal.
Practise it Take me into the scene Opens the animation at a danger moment and asks you to predict the mechanism and your first move before it reveals.
Click me next Section 5 of 8 Complications The save for each one: the first move, the escalation trigger, the op-note line.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

Recurrent stricture

  • the repair narrows again, months to years out, from scar left at the excision margins, a tensioned or ischaemic anastomosis, or a graft that failed to take.
The save
  1. Recognise the pattern: a stream that improved after catheter removal, then slows again with straining over the following months. first move
  2. Assess with flow rate, calibrated endoscopy and contrast studies; define whether the recurrence is at the anastomosis, the onlay, or a new segment.
  3. Short, web-like recurrences at the anastomosis respond to endoscopic incision or dilation in selected patients, accepting that repeat instrumentation alone rarely cures.
  4. Longer or dense recurrences are re-operated: revision urethroplasty, often with substitution where primary anastomosis has already been used.
  5. Complex or panurethral recurrence → specialist reconstructive centre for staged repair rather than serial dilation. escalation trigger
  6. Note: original technique, site of recurrence, and the objective flow data before and after each intervention. document

Oral donor-site morbidity

  • bleeding, tightness, numbness or pain at the cheek harvest; the specific injury is Stensen's duct obstruction when the harvest crosses the papilla.
The save
  1. Prevent: identify the papilla opposite the upper second molar before marking, stay posterior and clear of it, and size the graft to what is needed. first move
  2. Recognise duct injury early: cheek and gland swelling that worsens with meals after harvest.
  3. Most harvests are managed by leaving the donor site open to heal by secondary intention; haemostasis is achieved before closure of the mouth, not after.
  4. Duct obstruction is assessed clinically, and a sialendoscopic or radiological pathway used where it does not settle.
  5. Persistent duct obstruction, fistula or continuing pain → maxillofacial referral for duct reconstruction. escalation trigger
  6. Note: harvest site relative to the papilla, size of graft, and any oral complication and its course. document

Erectile effects / shortening

  • after long excision and extensive mobilisation the penis shortens slightly and erections may be affected, most often transiently; de novo sexual dysfunction should be consented honestly.
The save
  1. Prevent at selection: where the stricture is long, substitution is chosen partly to avoid the shortening of a wide excision and mobilisation. first move
  2. Counsel before surgery that transient erectile change can occur and that most recover within months.
  3. Assess persisting dysfunction on history, examination and validated scores; distinguish loss of erection from pain or curvature.
  4. Conservative first: time, review of contributing medication, and psychosexual input where appropriate.
  5. Persistent dysfunction beyond the expected recovery window → andrological assessment and treatment of erectile dysfunction on standard pathways. escalation trigger
  6. Note: consent about sexual function, the degree of excision, and dysfunction reported at follow-up. document
Click me next Section 6 of 8 Troubleshooting When the case turns: the problem, then the next move.

Intra-operative troubleshooting

When the case turns: the problem, then the next move.

  • ActionThe stricture is longer on the table than on imaging - convert the plan: excision and anastomosis for what is truly short, substitution for what is not; never bridge a long gap under tension.
  • ActionThe ends will not meet without tension - mobilise the proximal urethra further, resect less if scar truly allows, and if tension persists, abandon anastomosis for substitution.
  • ActionThe graft bed looks poor after opening dorsally - quilt the graft to the best available fixed vascular surface, and consider a staged approach rather than a single-stage repair on a bad bed.
  • ActionNumbness or foot drop noted after lithotomy - document timing, relieve pressure immediately, involve neurology and physiotherapy early, and review the positioning protocol.
Click me next Section 7 of 8 FRCS viva Say it out loud, then mark yourself against the model answer.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

QWalk me through your decision ladder: excision and anastomosis versus substitution.reveal answer
  • Length matters, but it is not the whole decision.
  • I first define site, aetiology, calibre and obliteration, the extent of spongiofibrosis, prior treatment, tissue quality and patient priorities.
  • The EAU guideline particularly supports transecting excision and primary anastomosis for short post-traumatic bulbar strictures with near-complete obliteration and full-thickness spongiofibrosis.
  • For other short non-traumatic bulbar strictures, non-transecting anastomotic repair or graft urethroplasty may preserve vascular and spongiosal continuity.
  • Longer or complex disease usually needs augmentation or substitution, and lichen sclerosus or a hostile bed changes graft and staging choices.
  • Whatever branch is selected, the endpoints are healthy tissue, adequate calibre, secure vascularity and no tension.
  • The animation makes that logic visible by resetting the field before the graft branch rather than performing both repairs sequentially.
Strong pass

Naming tension and shortening as the two specific failures that force the move from anastomosis to substitution, and measuring length on the table rather than on imaging.

QDorsal or ventral onlay, and why?reveal answer
  • Both dorsal and ventral oral-mucosa graft positions are established options for bulbar urethroplasty, and current EAU evidence does not show a clear patency advantage for one position.
  • I choose according to stricture site and tissue quality, the exposure achieved, previous surgery and the technique in which the reconstructive surgeon is experienced.
  • A dorsal onlay provides a fixed corporal bed and allows quilting; a ventral onlay can offer direct access through robust spongiosum and may be technically appropriate in selected proximal bulbar disease.
  • The viva answer should explain the chosen geometry and vascular bed without claiming that one orientation is universally superior.
  • In this animation dorsal placement is an explicit example branch, not a rule for every bulbar graft.
Strong pass

Say all three

  • Framing the whole question around graft take and the quality of the bed
  • With the corporal tunica as the answer
  • Rather than as a preference between two incisions
Examiner note
Framing the whole question around graft take and the quality of the bed, with the corporal tunica as the answer, rather than as a preference between two incisions.
QHow long do you catheterise, and how do you image afterwards?reveal answer
  • The catheter is a stent across the healing repair and its duration follows the repair type and the unit protocol rather than habit.
  • After a straightforward excision and anastomosis, the catheter typically stays for a period of a few weeks; after substitution with a graft, commonly a little longer, because the graft needs time to take and stabilise.
  • What matters more than any single number is what happens at removal: the anastomosis is tested before the catheter comes out, traditionally with a pericatheter study, a contrast study alongside the catheter that shows extravasation or a sealed repair, and the catheter is removed only when the repair is shown dry.
  • After removal, symptoms and flow are assessed objectively, because the patient's sense of the stream is a poor instrument for a gradual recurrence.
  • A flow rate at review, with calibrated endoscopy or contrast imaging where the flow drops or symptoms return, is the follow-up standard, at intervals that are front-loaded in the first years when recurrence clusters.
  • I would add one discipline: the follow-up is where most recurrences are caught, and it is scheduled before discharge, with the imaging pathway written into the plan, because a repair without follow-up is a repair without a result.
Strong pass

Say both

  • Testing the repair before catheter removal with a pericatheter study
  • Following outcomes with objective flow measurement rather than the patient's impression
Examiner note
Testing the repair before catheter removal with a pericatheter study, and following outcomes with objective flow measurement rather than the patient's impression.
QWhat do you tell a man about sexual function after urethroplasty, and what about the lithotomy position itself?reveal answer
  • Two honest conversations.
  • The first is about position.
  • The exaggerated lithotomy that gives the perineal exposure puts the common peroneal nerve against the fibular head and the calf compartments under load for the duration of a long operation, so I consent for transient, occasionally persisting, numbness or foot drop, and I describe the mitigations: padding, checked position, documented time, and calf observation afterwards.
  • Nerve injury in this operation is a positioning injury, and saying so makes the prevention obvious.
  • The second is about sexual function.
  • After excision and anastomosis, particularly a long excision with extensive mobilisation, the penis can shorten slightly and some men notice discomfort or curvature at erection;
  • de novo erectile dysfunction can occur, is usually transient, and most men recover within months.
  • After substitution the shortening issue is smaller.
  • Ejaculation can be affected by disruption or stenosis at the level of the repair, and painful ejaculation is mentioned where relevant.
  • I frame the risk honestly against the alternative, because a recurrent stricture with retention and serial instrumentation damages quality of life at least as much as the reconstruction does.
  • Psychosexual input is offered where wanted.
  • The purpose of the consent is that the man who wakes with a numb foot or a modest change in function is not surprised by it.
Strong pass

Say both

  • Calling the nerve injury a positioning injury with named mitigations
  • Quantifying the trade against uncorrected stricture disease rather than against a perfect outcome
Examiner note
Calling the nerve injury a positioning injury with named mitigations, and quantifying the trade against uncorrected stricture disease rather than against a perfect outcome.
Click me next Section 8 of 8 Evidence The guidance each of these answers is built on.

Evidence and guidance

EAU Guidelines
Urethral strictures: disease management in males
Canonical selection guidance for transecting and non-transecting anastomotic repair, graft urethroplasty, graft position and staged reconstruction.
Open guideline
EAU Guidelines
Urethral strictures: tissue transfer and oral mucosa graft harvest (section to be confirmed)
Graft choice, oral mucosa harvest and donor-site management for augmentation urethroplasty; the guideline source for the harvest sequence in step 6. The exact section of the tissue-transfer chapter is to be confirmed against the current edition.
Open guideline
BAUS
British Association of Urological Surgeons
UK information on urethroplasty, buccal graft harvest and catheter care for patients and surgeons.
Open guideline
EAU Guidelines
Penile cancer
Management of lichen sclerosus-related and malignant urethral disease bordering stricture reconstruction.
Open guideline
Two minutes

Close the lap: recall it before you leave.

Say it aloud, then reveal. Reading is not remembering.

  1. 01 The relationship Say the critical spatial relationship out loud, then reveal. reveal
    Memory frame

    In the perineal view the urethra runs horizontally

    Why?
    In the perineal view the urethra runs horizontally: membranous and bladder posterior, penile anterior, with the bulb and its spongiosum in the middle where the stricture lives. The corpora cavernosa lie dorsal, immediately above the urethra along its whole length, and their fused midline tunica is the fixed bed a dorsal onlay is quilted onto. Bulbospongiosus wraps the bulb ventrally and is the muscle plane the exposure opens. At the other end of the table, the inner cheek offers thin, hairless, tough mucosa, limited anteriorly by Stensen's duct at the papilla opposite the upper second molar and by the lip line. The whole operation is a set of tubes and beds: a tube to reopen or rejoin, and the nearest reliable bed to sew the enlargement to.
  2. 02 The first move Recurrent stricture. Your first move? reveal
    First move

    Recognise the pattern: a stream that improved after catheter removal, then slows again with straining over the following months.

  3. 03 The escalation trigger Recurrent stricture. What makes you call for help? reveal
    Escalate when

    Complex or panurethral recurrence → specialist reconstructive centre for staged repair rather than serial dilation.

  4. 04 The discriminator What turns a pass into a strong pass? reveal
    Strong pass

    Naming tension and shortening as the two specific failures that force the move from anastomosis to substitution, and measuring length on the table rather than on imaging.

  5. 05 The pitfall Where does this operation bite first? reveal
    Pitfall

    The excision margins

    Why?
    the junction of scar and healthy spongiosum at each end; the commonest address of recurrence.

Revision practice with self-marked answers, not an assessment of clinical competence. Kept in this browser only; it does not sync between devices.