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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 supports penile skin when buccal/lingual mucosa is unavailable, unsuitable or not accepted, and advises against genital skin in lichen sclerosus. The randomized graft comparisons found no significant success difference in selected patients; they did not prove equivalence.[2][3][4]

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; do not assume that all penile skin is hairless or biologically interchangeable with oral mucosa. Inspect the actual donor site for hair, scarring, inflammation and available surface area.[1][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. Oral donor suitability, prior harvests and patient preference also matter.
  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. This is an availability question rather than an automatic contraindication to every penile-skin graft.
  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. Use the chosen reconstruction's drainage and follow-up plan. A study's catheter duration or antibiotic regimen is not automatically a general protocol.[1][3][4]

EAU advises against a free graft used 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 excludedSuccess 42/47 (89.3%) versus 44/48 (91.7%), p=0.70; median follow-up 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 monthsSmall sample, short follow-up and appreciable baseline differences in stricture site/etiology 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. A nonsignificant difference is not proof that either operation never affects sexual function.[3][4]

Longer-term and pooled evidence​

Tyagi 2021 DOIG series: 69/80 patients had success (approximately 86%; published rounded value 87%) after dorsolateral inner-preputial grafting, with median follow-up 48 months. Failure included subsequent instrumentation; 11 patients required treatment for recurrence. This was a single-arm retrospective analysis of a maintained database, not a comparison showing equivalence to BMG.[1]

Sharma 2020 systematic review: 16 nonrandomized studies, 1,406 patients, favored BMG in pooled success (83.7% versus 76.1%). 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]

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. It is not an isolated long-term preputial-graft success rate.[6]

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.[7][8]

A GURS survey of 134 respondents supports the current preference for oral mucosa, but surgeon preference is separate from comparative efficacy. Its circumcision questions compared BMG with flaps; they do not quantify free skin-graft availability or failure.[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, one early recurrence treated by dilation and six patients with at least one complication at approximately one year. This is a tissue-supply option in selected patients, not evidence that it replaces all staged repairs or guarantees durable panurethral success.[10]

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][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]

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. The association between greater graft width and fewer complications is observational and does not establish a universal width prescription. 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. Oral grafts are generally preferred, but are not biologically immune to recurrence or subsequent disease.[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

A 12–18-month success percentage does not establish long-term durability. 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.

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. Current reconstruction and follow-up guidance.

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