Anatomical and Functional Outcome of Penile Skin Graft Versus Buccal Mucosal Graft for Urethral Substitution in Long Segment Anterior Urethral Strictures
Phase: NA
Conditions: Anterior Urethral Stricture, Male
Sponsor: Al-Azhar University

Al Azhar Faculty of Medicine
 
Urology department
 
 
Anatomical and Functional Outcome of Penile Skin Graft 
versus Buccal Mucosal Graft for Urethral Substitution in Long 
segment Anterior Urethral Strictures: A Prospective 
randomized Study
 
 
A thesis proposal submitted for partial fulfillment of MD degree 
in Urology
 
BY
 
Mohamed Ahmed Mohamed Anwar
 
Assistant Lecturer of Urology, Faculty of medicine, Al Azhar University
 
 
Under the supervision of
 
Prof Dr. Mostafa Ezzeldeen Abdelmagid
 
Emeritus Professor of Urology, Faculty of medicine, Al Azhar University
 
Prof Dr. Ahmed Fahim Abdelrahim
 
Professor of Urology, Faculty of medicine, Al Azhar University
 
Dr. Ahmed Abdullah Abdelhamid Alrefaey
 
Lecturer of urology, Faculty of medicine, Al Azhar University
 
Date: 30/06/2022
 

Introduction 
Urethral stricture disease is a common problem faced by urologists worldwide.  
The treatment of urethral strictures varies from urethral dilation to urethroplasty. 
It depends significantly on urethral stricture length and location, degree of 
spongiofibrosis, and underlying etiology. 
Urethroplasty is classified into excision with primary anastomosis or augmentation 
urethroplasty. The direct anastomosis technique is suitable for short segment 
stricture (≤ 2 cm), while lengthy stricture requires substitution.[1] 
Grafts or local skin flaps can be used to substitute the urethra. Although local skin 
flaps might yield equivalent results to those of grafts, flaps are associated with 
more complications like penile torsion, shrinkage and tissue necrosis. Moreover, 
harvesting a flap is technically more challenging. Therefore, grafts are preferred in 
substitution urethral reconstruction (UR) whenever possible.[2] 
Numerous grafts have been described in UR: genital and extragenital skin, tunica 
vaginalis, bladder mucosa, colonic mucosa, buccal mucosa, lingual mucosa, and 
tissue-engineered grafts.  
Currently, penile skin graft (PSG) and buccal mucosal graft (BMG) are the most 
widely used materials for substitution.[3] 
BMG is the current gold standard for substitution urethroplasty, as it is a readily 
available, strong neurovascular tissue that resists infection.  However, BMG harvest 
may be associated with donor site scarring, perioral sensory defect, and jaw 
opening impairment. Also, BMG harvest is contraindicated in patients with oral 
morbidity 
(e.g., 
oral 
leucoplakia, 
poor 
oral 
hygiene, 
heavy 
tobacco 

smoking/chewing, previous irradiation, or previous BMG), and in those at high risk 
for general anesthesia.[4, 5] The possible advantages of PSG over BMG include: 
same operative field, shorter operation time, more familiar place for urologists, can 
be done with regional anesthesia, and can be used when longer grafts are 
needed.[6] 
The substitution urethroplasty approach can be ventral, dorsal, lateral, or 
dorsolateral. Barbagli and Kulkarni have proposed unilateral mobilization of the 
urethra to one side with sparing of central tendon of perineum and dorsolateral 
placement of the BMG in order to preserve the blood supply to the urethra and 
maintain the neuro-vascular integrity of the bulbospongiosus muscle.[7, 8] 
Moreover, through the perineal wound the pendulous urethra is accessed by penile 
eversion through the wound and no incision is made on the penis except for 
meatotomy, this minimizes chances of wound infection and fistula formation.[9, 10] 
Several studies were conducted to compare functional and anatomic outcomes 
after substitution urethroplasty with PSG and BMG for anterior urethral stricture 
disease. Most studies reported superior outcomes with BMG over PSG. 
However, most previous studies were: 
► Retrospective and very few were prospective randomized studies   
► Some studies were done on lichen sclerosis cases that have an adverse effect 
on the PSG outcome. 
► The follow-up duration was longer for PSG patients. 
► Stricture length was usually longer for PSG cases.[11] 

Study problem and hypothesis: 
This study aims to compare the PSG and BMG for substitution of long anterior 
urethral strictures using one-sided dorsal perineal approach. 
▪ We hypothesize that: 
❶ 
Conducting a well-designed prospective, randomized study can help 
identify which technique is better than the other.  
❷ 
Using the one-side dorsal approach can improve the outcomes of both 
techniques and identify their advantages and disadvantages. 
 
 

Patients and Methods: 
Study type: a prospective randomized interventional study. 
Sampling: hospital-based sample. 
Allocation: Patients will be randomly allocated into one of 2 groups. 
Intervention Model: The 1st group: PSG cases, the 2nd group: BMG cases. 
Patients in the PSG group will be compared with BMG group patients. 
Randomization: Block randomization will be utilized, with a block size of 2. 
Estimated Enrollment: 60 participants (30 cases in each group). 
Masking: Open-label 
Study Location: Al-Hussein and Sayed Galal, Al-Azhar University Hospitals, Cairo, 
Egypt. 
 
Study Population 
Inclusion criteria 
➢ The study will include patients with long segment anterior urethral 
stricture (>2 cm). 
Exclusion criteria  
➢ Urethro-cutaneous fistula, urethral abscess or diverticulum. 
➢ A scarred and unsalvageable urethral plate or scarred perineum. 
➢ Lichen sclerosis (Balanitis xerotica obliterans). 
➢ Unhealthy/unavailable buccal mucosa.  
 
 
 

Pretreatment evaluation: 
 Medical and surgical history including age, cause of stricture, presence of 
medical diseases like diabetes mellitus, and history of previous urethral 
procedures. 
 The following questionnaires will be used for assessment of LUTS, sexual 
function and satisfaction, and oral health: 
➢ IPSS (international prostate symptom score).[12] 
➢ IIEF-5 Score (international index of erectile function).[13] 
➢ MSHQEJD (male sexual health and ejaculatory dysfunction 
questionnaire).[14] 
➢ BMG questionnaire for brief oral health status examination 
(BOHSE).[15] 
 
 Physical examination including BMI, oral, abdominal and penile examination 
and presence of supra-pubic catheter. 
 Laboratory investigations (urine analysis, urine culture and sensitivity, 
complete blood count, bleeding profile and serum creatinine levels). 
 Uroflowmetry (UFM) if feasible. 
 Radiologic investigations:  
# Retrograde urethrography (RGU) and micturating cystourethrography 
(MCU).  
# Renal and bladder ultrasound with estimation of pre and post voiding 
residual urine. 
An informed consent will be signed by each patient. 
surgical technique: 
The patient will be put in lithotomy position then a midline perineal incision will be 
made and a distal penile skin or buccal mucosal graft will be harvested.  
Buccal graft harvest Using a marking pen, the graft well be outlined 2.5 cm wide 
and as long as is required. Bupivacaine 0.5% with epinephrine will be injected 
underneath the graft for good analgesia and intraoperative hemostasis. The graft 

will be then incised and dissected off of the buccinator muscle, while avoiding 
Stensen's duct. The defect will be left open to close by secondary intention, as it is 
less painful. The graft will be pinned out and defatted/thinned on the back table. It 
will be kept in saline until the time of implantation. [16] 
Penile skin graft harvesting: PSG will be obtained by a circumferential distal penile 
incision and harvesting the graft from the lateral distal penile shaft in a transverse 
or longitudinal direction subcoronally. The subepithelial tissue of graft will be 
thinned to the level of the dermis and tailored as necessary.[17] 
The pendulous urethra will be accessed by penile eversion through the perineal 
wound. The urethra will not be separated from the corporal bodies on one side and 
will only be mobilized from the midline on the ventral aspect to beyond the midline 
on the dorsal aspect (Figure 1A). The anterior urethra will be opened on the 
dorsolateral aspect (Figure 1B). The free graft will be sutured to the opened 
urethral edge and graft will be quilted on the ventral tunica of the corporal bodies 
(Figure 1C). Thereafter, the free edges of graft and opened urethra will be closed 
over a 14 Fr silicone catheter (Figure 1D). A surgical drain will be put if needed. [18, 
19] 
 
Figure 1: (A) Mobilization of urethra beyond midline dorsally, (B) Dorsal uethrotomy, (C) Graft 
sutured to medial urethral margin, (D) Free margin of the graft sutured to lateral urethral 
margin.[19] 
The complications will be graded using the modified Clavien-Dindo classification 
system.[20] 

FOLLOW UP:   The follow up period will be at least 6 months 
The patients will be treated with broad spectrum IV antibiotics for 48–72 h, which 
will be followed by oral antibiotics until catheter removal. The patients will be 
also treated with analgesics, bladder antispasmodics, stool softener, and 
diazepam to help prevent erections. 
The patients will be discharged after the drain is removed, if it was put, usually 
within 2–3 days after surgery.  
They will be followed up at the clinic after 1 week for wound assessment. Another 
visit will be scheduled 30 days after surgery where the urethral catheter will be 
removed and a voiding urethrogram will be taken.  
A 3 monthly follow-up visits thereafter will be scheduled for assessment of LUTS 
with performing simple uroflowmetry, treatment satisfaction and sexual function. 
The follow-up will rely mainly on patient symptoms (subjective diminished force-
of-stream, UTI, urinary retention, etc.), while diagnostic procedures such as 
urethroscopy and/or retrograde urethrogram will be done selectively. 
 
OUTCOME 
Anatomic (Objective): Urethral patency will be evaluated by  
✓ Uroflowmetry, and 
✓ Urethrography. 
Functional (Subjective): LUTS, sexual function, and satisfaction. Through: 
✓ IPSS (international prostate symptom score).[12] 
✓ IIEF-5 Score (international index of erectile function).[13] 
✓ MSHQEJD 
(male 
sexual 
health 
and 
ejaculatory 
dysfunction 
questionnaire).[14] 
✓ USS-PROM (patient reported outcome for urethral stricture surgery).[21] 

References 
 
[1] Andrich DE, Mundy AR. (2008). What is the best technique for urethroplasty? Eur Urol 
2008; 54:1031–1041.
 
[2] Dubey D, Vijjan V, Kapoor R, et al. (2007). Dorsal onlay buccal mucosa versus penile skin 
flap urethroplasty for anterior urethral strictures: results from a randomized prospective 
trial. J Urol 2007; 178:2466–2469.
 
[3] Levy ME and Elliott SP. (2017). Graft use in bulbar urethroplasty. Urol Clin North Am 2017; 
44:39-47.
 
[4] Ahmed ABS et al (2021). Substitution Urethroplasty in the Management of Anterior Urethral 
Stricture Disease - a Study of 50 Cases. Saudi J Med. 2020; 6(6): 169-175.
 
[5] Sharma G, Sharma S, Parmar K. (2020). Buccal mucosa or penile skin for substitution 
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[6] Alsikafi NF, Eisenberg M, McAninch JW. (2005). Long-term outcomes of penile skin graft 
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73:87.
 
[7] Barbagli G, De Stefani S, Annino F, De Carne C, Bianchi G. (2008). Muscle- and nerve-
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[8] Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. (2009). One-sided anterior urethroplasty: a 
new dorsal onlay graft technique. BJU Int. 2009; 104:1150-5.
 
[9] Chaudhary R, Jain N, Singh K, Bisoniya HS, Chaudhary R, Biswas R. (2011). Dorsolateral 
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approach. BMJ Case Reports 2011;10.1136/bcr.10.2010.3409.
 
[10] Prabha V, Devaraju S, Vernekar R, Hiremath M. (2016). Single stage: dorsolateral onlay 
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[11] Lumen N, Oosterlinck W, Hoebeke P. (2012). Urethral reconstruction using buccal mucosa 
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[12] Cockett, A. T. K. (1992). The International Consultation on Benign Prostatic Hyperplasia. 
1991: Paris, France: World Health Organization. ISBN 2905744111. 
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International journal of impotence research vol. 11(6): 319-26. 
[14] Rosen, Raymond C et al. (2007). Development and validation of four-item version of Male 
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[15] Kayser-Jones J, Bird W, Paul S, et al. (1995). An instrument to assess the oral health status 
of nursing home residents. The Gerontologist, 35(6), 814-24. Figure 2, p. 823. 
[16] Zimmerman WB, Santucci RA. (2011). Buccal mucosa urethroplasty for adult urethral 
strictures. Indian J Urol. 2011 Jul;27(3):364-70. 
[17] Hudak SJ, Hudson TC, Morey AF. (2012). 'Minipatch' penile skin graft urethroplasty in the 
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[18] Kartal I, Cimen S, Kokurcan A, et al. (2020). Comparison between dorsal onlay and one-
sided dorsolateral onlay buccal mucosal graft urethroplasty in long anterior urethral strictures. 
IJU: official journal of the Japanese Urological Association. 2020; 27(9): 719-724.
 
[19] Islam Mf, Haque M, Islam M, et al. (2012). Dorsolateral Onlay OMG Urethroplasty through 
Unilateral Urethral Mobilization in Anterior Urethral Stricture - Our Experience in Dhaka 
Medical College Hospital and Salam Urology & Transplantation Foundation of Bangladesh 
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240:205–213.
 
[21] Jackson, Matthew J et al. (2011). Defining a patient-reported outcome measure for 
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