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Augmented Perineal Urethrostomy

Augmented perineal urethrostomy combines a standard perineal urethrostomy (PU) with a dorsal onlay buccal-mucosal graft (BMG) to widen the proximal urethral opening and support perineal-stoma construction in patients with complex anterior urethral stricture disease.[1] The graft lines part of the neomeatus with hairless oral mucosa. Whether augmentation reduces stenosis relative to an otherwise suitable skin-only PU has not been established.[1][7]

Augmented PU is approach-agnostic: the dorsal BMG can be incorporated through either a midline incision (preserving the algorithmic loop or 7-flap framework) or an inverted-U incision (Blandy). It is therefore a graft-augmentation option layered onto a PU, not a distinct incision or flap technique. It is best understood as a PU-shaped first stage of urethroplasty: the patient leaves the operating room with a definitive perineal stoma whose lumen has been augmented with buccal mucosa, with no obligatory second-stage tubularization unless later elected.[1]

For the non-augmented techniques, see Midline Perineal Urethrostomy (loop / 7-flap) and Blandy Perineal Urethrostomy (inverted-U).

Indications​

Augmented PU may be considered for selected complex anterior strictures when the proximal opening or local tissue makes a wide skin-only PU difficult; PU itself is also an option when reconstruction is unsuitable or has failed.[1][2][11]

  • Pananterior (long-segment) anterior urethral strictures. All 44 patients in the DeLong series had pananterior disease.
  • Lichen sclerosus with extensive urethral involvement (approximately 23% of the DeLong cohort).[1]
  • Failed prior hypospadias repairs with depleted local tissue and a hairless requirement.
  • Multiple failed urethroplasties.
  • Fournier's gangrene with urethral destruction; extensive urethral excision for urethral or penile cancer.
  • Older or comorbid patients who are poor candidates for prolonged or staged reconstruction and accept sitting to void.

The AUA 2023 urethral stricture guideline amendment endorses PU as a long-term option, either as an alternative to urethroplasty or for patients at high risk for reconstruction failure ; graft augmentation is a refinement within that framework.[10]

Surgical Technique​

The technique described by DeLong, Jordan, McCammon, and Virasoro layers a dorsal BMG onlay onto a PU.[1]

  1. Positioning and incision. Dorsal lithotomy. A midline or inverted-U perineal incision is made and the bulbospongiosus divided to expose the bulbar urethra.
  2. Urethral exposure and urethrotomy. The bulbar urethra is mobilized and opened; the urethrotomy is extended proximally until healthy, non-strictured urethra is reached. Only the segment needed to establish a patent proximal outlet is opened: a PU bypasses distal disease and does not require opening the entire penile stricture.
  3. Dorsal preparation. Expose the dorsal urethral surface and corporal graft bed with the mobilization required for the chosen reconstruction; preserve remaining spongiosal and lateral vascular attachments where possible. A free graft subsequently relies on a viable recipient bed, not an intact pedicle of its own.[1][8]
  4. BMG harvest. A buccal-mucosal graft is harvested from the inner cheek (one or both cheeks for long strictures), defatted, and tailored. Buccal mucosa was the preferred graft in approximately 99% of the 134 respondents to a GURS survey.[9]
  5. Dorsal onlay graft placement. The BMG is quilted onto the dorsal corporal bed and sutured to the edges of the dorsal urethrotomy with fine absorbable suture (5-0/6-0 polyglactin or polydioxanone). Dorsal placement provides a well-vascularized, mechanically supported bed for graft take.[1][9]
  6. Urethrostomy maturation. The ventral urethral edges are matured to the perineal skin, creating a composite stoma of skin and buccal mucosa in which the graft forms the widened dorsal wall of the neomeatus.
  7. Catheter and closure. A 16–18 Fr catheter is placed through the urethrostomy; the perineal wound is closed in layers and the catheter typically removed at approximately 2–3 weeks.

Gupta described one-stage anterior urethroplasty through a ventral sagittal urethrotomy, not a PU. The 12-patient report illustrates dorsal BMG placement without lateral or dorsal urethral dissection.[8]

Rationale for Dorsal Graft Augmentation​

The dorsal BMG is intended to widen the neomeatus. In separate non-augmented PU cohorts, Joshi reported reintervention in 5/103 men (4.9%) and Myers reported postoperative stenosis in 7/40 (18%); neither result estimates the benefit of graft augmentation.[3][5] Buccal mucosa offers several advantages over perineal or scrotal skin:[1][9]

  • Preferred to genital skin in LS, but not immune to disease-associated recurrence; recurrent LS or stricture in a first-stage BMG was reported in 9/37 patients in one LS series.[7]
  • Thick, resilient epithelium with a thin, highly vascular lamina propria that promotes reliable graft take.
  • Hairless. Avoids intra-stomal hair growth and its sequelae.
  • Can widen an otherwise inadequate proximal urethral segment; comparative durability versus skin-only PU remains uncertain.

Complications​

The EAU guideline summarizes complications across heterogeneous PU series in 2.5–11.4% of patients, including superficial wound dehiscence, scrotal abscess, UTI or urosepsis, bleeding, and transient scrotal pain or numbness. At medium-term follow-up, 22.2–30.8% of men with PU reported post-micturition dribble. These estimates are for PU broadly and are not specific to graft-augmented PU.[11]

Outcomes​

SeriesnCohortFUSuccess
DeLong 2017 (augmented PU)[1]44Pananterior; 23% LS; mean age 6045 mo35/44 (80%) primary; four successful revisions among nine recurrences
Joshi 2024 (standard midline PU)[3]103Mixed midline algorithmic61 mo at survey in 49 respondents98/103 (95.1%)
Fuchs 2018 (standard PU)[4]77Mixed50.7 mo median, whole 403-patient reconstruction cohort94.8%

These are separate retrospective cohorts with different case mix, definitions and follow-up; they cannot rank augmented versus non-augmented PU. In Joshi, 49/103 men were reached by telephone at a median of 61 months, with some survey questions unanswered: 42/49 were satisfied and 12/49 reported de novo ED; 31/41 answering the sitting-to-void question were unbothered.[3] The EAU guideline summarizes PU patency as 51.5-100% in retrospective, heterogeneous series with mean or median follow-up of 13-62 months; series with longer follow-up reported lower patency.[11]

Selection and Lichen Sclerosus​

Consider augmentation when a healthy, adequately wide proximal opening cannot be fashioned with local tissue alone, particularly with proximal bulbar extension or a stenosed prior PU. The EAU guideline describes the Gil-Vernet-Blandy PU with a dorsal or ventral free oral-mucosa graft ("augmented Blandy") for strictures after radiotherapy or from LS, and for PU stenosis or stricture extending into the proximal bulbar or membranous urethra. It describes the 7-flap PU for very obese men or for men of any BMI with proximal extension. It gives a weak recommendation to consider augmented Gil-Vernet-Blandy or 7-flap PU for proximal bulbar or membranous disease. Little data determine the best PU technique, and augmentation is not required for every LS case.[11]

Prior radiation was associated with PU stenosis in the small Myers cohort (OR 11.2; 95% CI 1.4–87.2).[5] In Patel's LS series, 13/14 PU patients and 15/20 single-stage BMG patients met the study success definition; selection and small numbers prevent a comparative superiority claim.[7] LS-related recurrence can occur in BMG and at a PU, so continuing follow-up is necessary.[7][11] A pooled analysis of one-stage BMG urethroplasty for LS (21 studies, 625 patients) found 10% recurrence overall and 18% in studies with follow-up of 24 months or more.[12]

PU can be discussed as a primary long-term choice, alongside reconstruction, when the patient accepts a perineal outlet. A healthy, tension-free non-augmented stoma avoids oral donor morbidity. For graft biology and donor counseling, see Buccal Mucosa Graft.

Augmented PU in the Family of PU Techniques​

TechniqueIncisionKey featureBest suited for
BlandyInverted-UPosteriorly based inverted-U flap; apex parachuted to opened urethraStandard PU with adequate perineal skin
JohansonMidline or inverted-USimple marsupialization of opened urethra to skin (no formal flap)Historical / staged-urethroplasty first stage
7-flapMidlineLaterally based "7" skin flap advanced into the depth of the woundLong urethra-to-skin distance; obesity; proximal transection
LoopMidlineDorsal plate preserved; urethra matured directly to skin, no flapDistal strictures; low BMI
Augmented (this page)Midline or inverted-UDorsal onlay BMG + skin maturation → composite stomaSelected complex anterior strictures, including LS or failed hypospadias, when a sufficiently wide skin-only stoma cannot be formed; proximal extension or stenosed prior PU[1][11]
Propeller flapRevisionPosterior-thigh perforator flap rotated into a scarred perineumComplex PU revision when local tissue is depleted

Revision Setting​

Kamat described buccal-mucosa revision of a stenotic perineal urethrostomy to create a composite skin-and-mucosa stoma in four patients, particularly in the setting of balanitis xerotica obliterans.[6] When local perineal tissue is wholly depleted (radiated, multiply operated), salvage escalates to a posterior-thigh propeller flap.

See Also​

References​

1. DeLong J, McCammon K, Capiel L, et al. Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study. World J Urol. 2017;35(8):1285-1290. doi:10.1007/s00345-017-2002-z.

2. Verla W, Oosterlinck W, Waterloos M, Spinoit AF, Lumen N. Perineal urethrostomy for complicated anterior urethral strictures: indications and patient's choice. An analysis at a single institution. Urology. 2020;138:160-165. doi:10.1016/j.urology.2019.11.064.

3. Joshi EG, VanDyke ME, Langford BT, Franzen BP, Morey AF. Algorithmic midline approach to perineal urethrostomy is associated with long-term success and high patient satisfaction. Urology. 2024;190:133-139. doi:10.1016/j.urology.2024.03.016.

4. 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;122:169-173. doi:10.1016/j.urology.2018.08.009.

5. Myers JB, Porten SP, McAninch JW. The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply. Urology. 2011;77(5):1223-1227. doi:10.1016/j.urology.2010.10.041.

6. Kamat N. Perineal urethrostomy stenosis repair with buccal mucosa: description of technique and report of four cases. Urology. 2008;72(5):1153-1155. doi:10.1016/j.urology.2008.06.072.

7. Patel CK, Buckley JC, Zinman LN, Vanni AJ. Outcomes for management of lichen sclerosus urethral strictures by 3 different techniques. Urology. 2016;91:215-221. doi:10.1016/j.urology.2015.11.057.

8. Gupta NP, Ansari MS, Dogra PN, Tandon S. Dorsal buccal mucosal graft urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal approach for anterior urethral stricture. BJU Int. 2004;93(9):1287-1290. doi:10.1111/j.1464-410X.2004.04822.x.

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;191:139-143. doi:10.1016/j.urology.2024.06.019.

10. 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.

11. EAU Guidelines on Urethral Strictures: perineal urethrostomy. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.

12. Kurtzman JT, Blum R, Brandes SB. One-stage buccal mucosal graft urethroplasty for lichen sclerosus-related urethral stricture disease: a systematic review and pooled proportional meta-analysis. J Urol. 2021;206(4):840-853. doi:10.1097/JU.0000000000001870.