Oral Mucosa Graft Urethroplasty
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Direct answer
When a urethral stricture is too long or the diseased plate too poor for excision and end-to-end anastomosis, the stricture is patched with a graft, and oral (buccal) mucosa is the contemporary gold standard. It is hairless, thickly epithelialised, lamina-rich and takes well on the vascular tunica of the corpora, resisting both infection and the lichen sclerosus that defeats genital skin. Harvested from the inner cheek as an ellipse avoiding Stensen's duct, it is applied most often as a dorsal onlay graft (Barbagli technique) on the urethral back wall, with success rates commonly quoted around 85-90 per cent at five years in experienced hands.
What you must remember
- Indication: anterior strictures too long for anastomotic repair (beyond roughly 2 cm bulbar, earlier in the penile urethra), recurrent strictures, and strictures after lichen sclerosus.
- Why buccal mucosa displaced skin: hairless, panlaminar vascular plexus for imbibition and inosculation, tough lamina propria, easy harvest with low morbidity; genital skin recurs under lichen sclerosus, which is why scrotal skin flaps were abandoned.
- Harvest: inner cheek ellipse (commonly 4-6 cm long), staying clear of Stensen's duct (opposite the upper second molar), the papilla and the gumline; the defect is left open or closed loosely.
- Donor complications: temporary cheek numbness and tightness of mouth opening in a minority; most resolve within weeks.
- Dorsal onlay (Barbagli) is preferred over ventral for better mechanical support and graft blood supply on the corporal bodies; ventral (Asopa) and double-face techniques exist.
- Graft survival needs a well-vascularised, immobile bed and a water-tight, tension-free anastomosis; a stent catheter is typically retained two to three weeks.
- Two-stage repairs (graft laid, tubularised months later) are reserved for severely diseased plates — BXO, failed single-stage surgery, long panurethral strictures.
- Success means stricture-free voiding at a year, but follow-up continues — flow rates and symptom review for at least five years, since recurrence can be late.
Where students slip
The historical answer "scrotal skin flap urethroplasty" still surfaces in exams; scrotal and penile skin grafts were abandoned because of hair-bearing epithelium, diverticulum formation and devastating recurrence in lichen sclerosus — knowing why, not just that, is the viva point. The second slip is injuring Stensen's duct at harvest or forgetting to warn about cheek numbness; consent covers the mouth too. The third is choosing excision-anastomosis for a long stricture because "it has the best success rates": true for 1-2 cm bulbar strictures, false as a general rule, since tension destroys the advantage.
Frequently asked questions
Why is buccal mucosa preferred over skin for urethral reconstruction?
It is hairless, thick, richly vascularised and resistant to lichen sclerosus, with low donor morbidity — whereas genital skin carries hair, forms diverticula and recurs under BXO.
What is the Barbagli technique?
Dorsal onlay graft urethroplasty — the strictured dorsal urethra is opened and the oral mucosa graft is quilted onto the corporal bodies, giving the graft a reliable vascular bed and mechanical support.
What donor-site complications follow buccal mucosa harvest?
Temporary cheek numbness, tightness or restricted mouth opening, usually settling within weeks; injury to Stensen's duct is avoided by harvesting away from the duct opening opposite the upper second molar.
When is a staged urethroplasty chosen?
For severely diseased or lichen sclerosus strictures and failed single-stage repairs — the graft is laid flat first and tubularised at a second operation months later.
What is the approximate success rate of single-stage buccal mucosa urethroplasty?
Around 85-90 per cent stricture-free at five years in experienced centres, with follow-up flow rates and symptom review continuing thereafter.