Staged urethroplasty reconstructs a complex urethral stricture over more than one operation. In the first stage, severely scarred urethral tissue is opened and unhealthy tissue may be replaced or augmented with oral mucosa. The graft is allowed to heal as an open urethral plate. Months later, if the tissue is healthy and wide enough, it is tubularised to create a new urethra. Staging is commonly used for failed hypospadias, severe penile scarring, fistula or other adverse local tissue conditions. “Two-stage” surgery can sometimes require additional revision before final closure.

Why would a surgeon choose staged rather than one-stage repair?

A one-stage operation assumes that the existing urethral plate and surrounding tissue can support a durable reconstruction immediately. In heavily scarred tissue, trying to force a one-stage repair can increase recurrence or fistula risk. Staging allows the surgeon to first create a healthy, stable graft bed and only tubularise after it has matured.

Common reasons for staged urethroplasty

• Failed hypospadias with a scarred or narrow urethral plate.
• Complex penile urethral stricture with poor local tissue.
• Multiple fistulae or false passages.
• Severe spongiofibrosis.
• Previous failed complex urethroplasty.
• Selected lichen sclerosus or radiation cases when one-stage reconstruction is not suitable.

What happens in the first stage?

The diseased urethra is opened longitudinally. Scarred tissue may be excised, and oral mucosa is quilted onto a healthy vascular bed to create a wide urethral plate. The urinary opening is temporarily brought to the reconstructed surface. After healing, the patient urinates through this open plate/meatus.

How long between stages?

An interval of at least four to six months is commonly used when healing is satisfactory. More time may be needed if the graft contracts, there is lichen sclerosus, infection or revision is required. The second stage should not be rushed simply to meet a calendar date.

What happens in the second stage?

Once the graft is supple, wide and free of troublesome scar, the plate is rolled/tubularised into a urethra and closed with well-vascularised tissue coverage. A catheter remains while the repair heals and urethrography is used before removal.

Why can it become three stages?

Graft contraction, fistula, residual scar or insufficient width may require revision before tubularisation. EAU guidance specifically advises patients that staged urethroplasty may comprise more than two operations. This is not necessarily a failure; it is part of protecting a complex reconstruction from being closed over poor tissue.

Can a patient choose to remain after the first stage?

Yes. Some men void comfortably through the first-stage opening and decide that the functional result is acceptable. In published series, a meaningful proportion do not proceed to tubularisation. This choice should be discussed rather than assumed.

Benefits and limitations

Recovery

After the first stage, the catheter can often be removed much earlier than after tubularisation because the urethral plate is left open. After the final tubularisation, catheterisation is longer and a leak study is commonly performed before removal. Sexual activity and strenuous activity are restricted according to each stage.

What to bring for consultation

• RGU and MCU/VCUG images or films, not only the written report.
• Uroflowmetry report and post-void residual if already done.
• Urine routine and urine culture reports.
• Serum creatinine and other relevant blood tests.
• Previous catheter, VIU/dilatation or urethroplasty discharge summaries.
• Details of any pelvic injury, prostate surgery, hypospadias surgery, radiation or recurrent infections.
• Current medicines, including blood thinners, and any history of self-dilatation.

What happens between the stages

After the first stage, the grafted urethral plate is deliberately left open. This allows the surgeon and patient to see how the tissue heals before it is converted into a tube. During the healing interval, graft take, scar contraction, local skin disease and the width/suppleness of the plate are assessed.

An interval of at least four to six months is commonly recommended before the next stage when healing is satisfactory. Some patients need revision or additional grafting if part of the plate contracts. This is why the term “two-stage urethroplasty” can be misleading: the reconstructive pathway is staged according to tissue biology, not according to a promise that exactly two operations will always be enough.

At the later stage, the plate is tubularised to recreate the urethra. Fistula, wound breakdown or recurrent narrowing can occur, particularly in heavily scarred failed-hypospadias or lichen-sclerosus cases. Patients should plan for the entire pathway – dressings, change in urinary stream after stage one, the healing interval and the possibility of revision – rather than viewing stage one as an incomplete version of a one-stage repair.

Living with the first stage

After stage one, the urinary opening is intentionally located along the grafted urethral plate rather than at the tip. Most men void sitting or carefully directing the stream while the plate matures. Dressings and local hygiene are important early, and the graft changes appearance as swelling settles and it becomes integrated.

Sexual activity is resumed only after the wound has healed according to surgeon advice. Erections do not mean the operation has failed, but significant curvature or graft contracture should be reported at follow-up. The surgeon assesses whether the plate is wide, supple and free of active disease before scheduling tubularisation.

At stage two, the mature plate is rolled into a tube and covered with healthy tissue layers to reduce fistula risk. Another catheter period follows. Patients should plan time away from work for both operations and understand that long-term surveillance is still needed after completion.

Why stage two may be postponed or changed

The interval between stages is not merely waiting for a calendar date. The surgeon is waiting for a soft, well-vascularised and adequately wide urethral plate. If the graft contracts, lichen sclerosus remains active or part of the plate scars, revision of the first stage may be safer than tubularising poor tissue.

Some patients decide after stage one that they are comfortable voiding through the perineal or penile opening and do not want the second operation. In selected adults, leaving a functional first-stage opening is a legitimate endpoint rather than a surgical failure.

If stage two proceeds, the plate must close without tension and be covered by vascular tissue. Fistula, wound breakdown and recurrent narrowing are the main reasons careful tissue selection and adequate maturation matter.

FAQs

Related reading

• One-Stage vs Two-Stage Urethroplasty
• Adult Failed Hypospadias: Reconstructive Options
• Urethral Stricture After Hypospadias Surgery
• Buccal Mucosal Graft Urethroplasty
• Perineal Urethrostomy Explained
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males
• European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/tissue-transfer
• European Association of Urology. EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery
• European Association of Urology. EAU Guidelines on Urethral Strictures: Follow-up, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/followup
• European Association of Urology. EAU Guidelines on Urethral Strictures, 2026 https://uroweb.org/guidelines/urethral-strictures
• American Urological Association. Urethral Stricture Guideline (2023 amendment) https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline