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Penile / Preputial Skin Graft

A free penile/preputial skin graft is detached from its donor circulation and placed on a vascularized recipient bed. Select healthy, non-hair-bearing skin, usually inner prepuce or appropriate distal shaft skin. Graft survival depends on tissue preparation, contact with the recipient bed and revascularization. A pedicled penile-skin flap retains a vascular pedicle and is a different tissue transfer.[1][2]

Current role: oral mucosa remains the usual graft choice. EAU 2026 gives a Weak recommendation to use penile skin when buccal or lingual mucosa is unavailable, unsuitable or declined, and a Strong recommendation against genital skin grafts in lichen sclerosus.[2] The randomized graft comparisons found no significant success difference in selected patients.[3][4]

Historical Context​

Preputial skin was the routine graft for urethral reconstruction before oral mucosa was adopted. Devine, Horton and colleagues reported full-thickness skin grafts for repair of urethral strictures in 1963.[17] Barbagli's 1998 series described one-stage nontubularized dorsal onlay grafting with preputial skin, or with buccal mucosa when local skin was scarce.[6] In a tertiary-center review of 403 complex anterior strictures treated in 2007–2017, buccal graft use stayed stable, penile skin flap use declined, and perineal urethrostomy rose from 4.3% of case volume in 2008 to 38.7% in 2017.[16] Skill with penile skin techniques remains relevant for men in whom oral mucosa is unsuitable.[6][16]

Tissue Selection and Harvest​

Inner preputial skin is thin, pliable and normally hair-free. It remains a skin graft, even when described as mucosa-like. Inspect the actual donor site for hair, scarring, inflammation and available surface area. Tyagi et al. describe inner-preputial skin as familiar to urologists and available in the same operative field, avoiding an oral graft harvest.[1] In LS-associated strictures, genital skin grafts have poor observed patency; EAU recommends against their use .[2]

  1. Assess both donor and recipient. Confirm healthy skin, enough tissue for reconstruction and closure, and a recipient bed that can support a graft.
  2. Plan the skin harvest and donor closure. Circumcision may remove the inner-preputial option, but suitable distal shaft skin can sometimes provide a free graft.[5]
  3. Harvest above the dartos. Preserve the graft dermis while removing excess subepithelial tissue and adherent dartos fibers. Avoid both a bulky graft and excessive thinning/perforation.
  4. Prepare and secure the graft. Tailor it to the opened stricture and fix it against a vascularized bed with close tissue contact and appropriate quilting, avoiding folding, hematoma and shearing. 5.[1][3][4] Use the chosen reconstruction's drainage and follow-up plan.[1][3][4]

EAU 2026 gives a Strong recommendation against using a free graft as a complete tube in a single-stage reconstruction. A graft that first heals on a vascular bed and is tubularized in a later stage is a different procedure.[2]

Adult Anterior Urethroplasty: Evidence​

Randomized graft-versus-graft studies​

StudyPopulation and assessmentResultInterpretation
PeeBuSt — Tyagi 2022100 randomized; 47 penile/preputial and 48 buccal graft recipients analyzed at 18 months; LS, unhealthy donor tissue, fistula and scarred perineum excludedStudy-defined composite success at 18 months was 42/47 (89.3%) with penile skin versus 44/48 (91.7%) with buccal mucosa, p=0.70; it could be met by Qmax >15 mL/s, passage of a 16 Fr calibration catheter, or passage of a 17 Fr cystoscope. Median follow-up was 22 monthsSupplement confirms power to detect a 24-percentage-point difference, not equivalence or noninferiority. Anatomical testing was conditional on flow results; any further intervention counted as failure[3]
Alrefaey 2025Single-center superiority trial; 98 randomized, 92 analyzed after six were lost to follow-up (44 penile, 48 buccal); LS, fistula, diverticulum and unsalvageable plates excludedSuccess 41/44 (93.2%) versus 47/48 (97.9%) at 12 months, p=0.346; median follow-up 20 monthsThe authors defined success as no voiding LUTS or further intervention with RGU-confirmed patency after 12 months, yet their follow-up protocol reserved RGU/cystoscopy for unfavorable outcomes, symptoms or Qmax of 14 mL/s or less. Small sample, short follow-up and baseline site/etiology differences limit inference; no evidence of equivalence.[4]

Neither trial establishes a universal donor-site morbidity advantage. PeeBuSt describes oral symptoms in the BMG arm and preputial edema, including one later circumcision, in the skin-graft arm. Functional comparisons rely on selected follow-up populations.[3][4]

Longer-term and pooled evidence​

Tyagi 2021 DOIG series: In this retrospective series, 69/80 patients (86.3%; the paper reports 87%) met the study's success definition of stable Qmax >14 mL/s or passage of a 16 Fr Foley after dorsolateral inner-preputial grafting, at median follow-up 48 months (range 30–66). Mean IIEF and MSHQ-EJD scores showed no statistically significant change over follow-up in this single-arm series. Failure included subsequent instrumentation; 11 patients required treatment for recurrence.[1] This was a single-arm retrospective analysis of a maintained database.[1]

Sharma 2020 systematic review: 16 nonrandomized studies, 1,406 patients, favored BMG in pooled success (83.7% versus 76.1%).[5] However, skin-graft groups had different stricture lengths and substantially longer follow-up, techniques varied, and the review did not formally assess risk of bias. It predates the two randomized reports. These limitations prevent a simple universal ranking.[5] A 2026 meta-analysis of 11 studies (n = 1,018) instead reported higher pooled success with penile skin grafts (OR 0.52; p = 0.0004), but inconsistent success definitions, follow-up and methods limit its interpretation.[18] EAU 2026 still weakly recommends buccal or lingual mucosa when available.[2]

Barbagli 1998: the reported 92% success was 34/37 across a mixed cohort of 31 preputial and six buccal graft recipients, at mean follow-up 21.5 months.[6] A later, partly overlapping retrospective Barbagli series of 38 dorsal-onlay bulbar skin grafts (26 preputial, 12 ventral penile) found 25/38 (65.8%) required no postoperative instrumentation, including dilation, at mean follow-up 111 months (range 80–149); it was not a comparison with oral mucosa.[20]

Interpreting comparative studies​

The Dubey 2007 randomized comparison used a pedicled penile-skin flap, not a free penile-skin graft. Its 224-versus-162-minute operating times, penile necrosis/torsion and dribbling figures cannot be used as the expected outcomes of the graft on this page. Likewise, Mathur's 2014 flap risk ratios are not validated predictors for free skin-graft urethroplasty. In that 58-patient preputial flap series (overall success 81%, median follow-up 42 months), diabetes (relative risk 5.21) and smoking (4.19) were the strongest predictors of failure, followed by stricture length above 70 mm (3.25), panurethral stricture (2.73), previous urethroplasty (2.4), severe periurethral fibrosis (2.37) and postinfective etiology (2.19).[7][8]

A GURS survey of 134 respondents supports the current preference for oral mucosa, but surgeon preference is separate from comparative efficacy.[9] Ninety-five percent favored BMG over a fasciocutaneous flap for penile urethroplasty in circumcised men and 84% in uncircumcised men.[9]

Specific Applications​

Spiral preputial graft​

Kulkarni's 2023 technique creates a long graft by harvesting a 5-cm-wide preputial cuff in a spiral; a graft up to 20 cm was described. The initial consecutive series included 20 patients. Among 20 patients, six had at least one complication within 30 days and one had an early recurrence treated by dilation after catheter removal. Median Qmax was 6.5 mL/s preoperatively, 16 mL/s postoperatively, and 15.1 mL/s at one year; median follow-up was 12 months.[10] This remains a tissue-supply option for selected patients with intact prepuce.[10] A subsequent prospective five-center series (114 men; 91 at the original center) reported VCUG-confirmed recurrence in 11/114 (9.6%) and 30-day complications in 26/114 (22.8%) at median follow-up 16 months (IQR 7–24).[19] EAU recommends against genital skin grafts in LS-associated stricture .[2]

Bracka staged hypospadias repair​

In staged reconstruction, the graft first heals on the ventral penile bed and is subsequently tubularized once tissue conditions are suitable. Timing and any need for revision depend on graft take, contraction, curvature and the operative plan.[11] EAU 2026 describes two-stage or multistage repair as increasingly preferred when the urethral plate cannot be preserved, because ventral curvature recurs less often than after TIP in proximal hypospadias.[12]

Manasherova compared successive historical cohorts, not randomized contemporaneous groups: 108 preputial-graft patients treated in 2001–2013 and 112 buccal-graft patients treated in 2013–2016. Reported complications were 33/108 (31%) and 23/112 (20%), and assessed cosmetic results favored BMG. Differences in era and follow-up preclude declaring one graft universally superior in children.[11]

Dorsal inlay in prior hypospadias repair​

When reviewing an adult’s prior repair, an inner-preputial or buccal dorsal inlay graft may have augmented a deeply incised urethral plate during childhood TIP repair; EAU 2026 says this may be considered to reduce stenosis in primary repairs.[12] See Hypospadias & Epispadias for childhood technique selection and Redo Hypospadias Repair in Adolescents and Adults for interpreting prior repairs.

Onlay graft for hypospadias​

Cambareri's retrospective 62-patient series reported complications in 22/62 (35.5%), including fistula in 21/62 (33.9%); complication types could overlap. Mean follow-up was 47.4 months. In this retrospective series, wider grafts were associated with fewer complications; no width threshold was established. Late presentation supports continued follow-up.[13]

Combined tissue transfers​

Some complex repairs combine a graft with a vascularized flap. Identify which tissue provides each component. For example, a buccal graft plus penile flap is not a combined free penile-skin graft technique. See the flap companion for these constructions.[2]

Contraindications and Practical Limits​

  • LS-associated urethral stricture: avoid genital skin grafts and flaps.[2] Oral grafts are generally preferred.[2]
  • Hair-bearing, inflamed or scarred donor skin: unsuitable intraluminal material. Prior surgery and circumcision require inspection of the remaining tissue rather than an assumption of availability.[14][2]
  • Poorly vascularized recipient bed: a free graft may not be the right transfer; consider the reconstruction's staging or vascularized alternatives.[2]
  • Oral donor pathology or prior harvest: may favor a suitable nonoral graft. Assess the actual lesion and alternative oral sites; tobacco use alone is not a blanket prohibition on all oral grafting.[3][15]

Counseling and Follow-up​

DecisionWhat to explain
Penile/preputial graftAvoids an oral harvest, but donor closure, edema, scarring and tissue availability matter
Buccal/lingual graftBroad clinical experience and suitability for LS-related reconstruction; donor discomfort, numbness, tightness or other oral morbidity can occur
Both are technically suitableConsider the complete evidence, patient preference and surgeon experience; current guidance generally favors oral mucosa
Assessment of successRecord freedom from reintervention, symptoms and flow, appropriate anatomical evaluation, sexual function and patient satisfaction

Explain the possibility of recurrence and further procedures, and provide a route back to care for deteriorating stream, infections or other new symptoms. Pediatric follow-up also needs to address later growth, curvature and patient-reported outcomes.[1][3][4][12]

See Also​

References​

1. Tyagi S, Parmar K, Sharma A, et al. Dorsolateral inner preputial graft urethroplasty for anterior urethral strictures: long-term outcomes from a single tertiary care centre. World J Urol. 2021;39(9):3549–54. doi:10.1007/s00345-021-03613-9

2. EAU. Urethral Strictures: Tissue Transfer. 2026; sections 9.1–9.3.

3. Tyagi S, Parmar KM, Singh SK, et al. 'Pee'BuSt trial: a single-centre prospective randomized study comparing functional and anatomic outcomes after augmentation urethroplasty with penile skin graft versus buccal mucosa graft for anterior urethral stricture disease. World J Urol. 2022;40(2):475–81. doi:10.1007/s00345-021-03843-x

4. Alrefaey A, Anwar MA, Abdelmagid ME, et al. Comparative outcomes of penile skin grafts versus buccal mucosal grafts in urethroplasty for the treatment of extensive anterior urethral strictures. Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w

5. Sharma G, Sharma S, Parmar K. Buccal mucosa or penile skin for substitution urethroplasty: a systematic review and meta-analysis. Indian J Urol. 2020;36:81–88. doi:10.4103/iju.IJU_298_19.

6. Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol. 1998;160(4):1307–9. PubMed. doi:10.1016/s0022-5347(01)62522-9

7. Dubey D, Vijjan V, Kapoor R, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007;178(6):2466–9. doi:10.1016/j.juro.2007.08.010

8. Mathur RK, Nagar M, Mathur R, et al. Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: evaluation and determinants of success. BJU Int. 2014;113(1):120–6. doi:10.1111/bju.12361

9. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139–43. doi:10.1016/j.urology.2024.06.019

10. Kulkarni SB, Joshi PM, Basile G, Bandini M. Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique. World J Urol. 2023;41(9):2459–63. doi:10.1007/s00345-023-04514-9

11. Manasherova D, Kozyrev G, Nikolaev V, et al. Bracka's method of proximal hypospadias repair: preputial skin or buccal mucosa? Urology. 2020;138:138–43. doi:10.1016/j.urology.2019.12.027

12. EAU. Paediatric Urology: Hypospadias. Section 9.5.5 (urethral reconstruction) and 9.6.1 (outcomes), 2026 limited update.

13. Cambareri GM, Yap M, Kaplan GW. Hypospadias repair with onlay preputial graft: a 25-year experience with long-term follow-up. BJU Int. 2016;118(3):451–7. doi:10.1111/bju.13419

14. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

15. Gn M, Sterling J, Sinkin J, Cancian M, Elsamra S. The expanding use of buccal mucosal grafts in urologic surgery. Urology. 2021;156:e58–65. doi:10.1016/j.urology.2021.05.039

16. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169–73. doi:10.1016/j.urology.2018.08.009

17. Devine PC, Horton CE, Devine CJ Sr, Devine CJ Jr, Crawford HH, Adamson JE. Use of full thickness skin grafts in repair of urethral strictures. J Urol. 1963;90(1):67–71. doi:10.1016/S0022-5347(17)64362-3

18. Abbas SM, Farhan M, Khan A, et al. "Penile skin graft versus buccal mucosal graft for anterior urethral strictures in adult urethroplasty- a systematic review and meta-analysis." Int Urol Nephrol. 2026;58(6):1895–1910. doi:10.1007/s11255-025-04955-8

19. Bandini M, Joshi P, Bafna S, Yepes C, Alrefaey A, Longoni M, Montorsi F, Kulkarni SB. "Establishing the role of single-stage preputial spiral graft urethroplasty for panurethral stricture." BJU Int. 2025;136(4):640–646. doi:10.1111/bju.16796

20. Barbagli G, Morgia G, Lazzeri M. "Dorsal onlay skin graft bulbar urethroplasty: long-term follow-up." Eur Urol. 2008;53(3):628–633. doi:10.1016/j.eururo.2007.08.019