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Palminteri Double-Face (Two-Sided) BMG Urethroplasty

The Palminteri double-face urethroplasty is a single-stage urethral-reconstruction technique that uses two buccal mucosal grafts (BMGs) placed on both the dorsal and ventral surfaces of the urethra to augment tight or near-obliterative bulbar strictures while preserving the native urethral plate.[1][2]

For the single-sided alternatives, see Dorsal Onlay BMG (Barbagli) and Ventral Onlay BMG. For the dorsal-inlay variant on which the dorsal half of the double-face technique is built, see Asopa Dorsal Inlay BMG. For the obliterative-bulbar transecting alternative, see Augmented Anastomotic Urethroplasty. For the canonical graft material, see Buccal Mucosa Graft.

Concept and Rationale​

The technique addresses a key limitation of single-sided graft urethroplasties: in very narrow (tight) urethral strictures, a single dorsal or ventral graft alone may not provide an adequate urethral lumen.[1][2] Anastomotic techniques (EPA / AAU) achieve wide lumens but carry sexual-complication risk from urethral transection and mobilization.[1] The double-face technique avoids transection, preserves the urethral plate, and augments the urethra from both sides simultaneously.[1][2][3]

Indications​

  • Tight or near-obliterative bulbar urethral strictures where a single-sided graft would be insufficient to create an adequate lumen.[1][2]
  • Strictures typically ≥ 2 cm in length (mean stricture length 3.3–3.65 cm, range 2–10 cm in the Palminteri series).[1][2]
  • An alternative to augmented anastomotic urethroplasty for obliterative segments — avoids urethral transection.[3]
  • Adapted for post-phalloplasty anastomotic strictures in transgender patients, where excisional techniques have high failure rates due to poor neourethral vascularization.[4]

Surgical Technique​

StepDetail
1. PositioningLithotomy; perineal incision to expose the bulbar urethra[2]
2. Ventral urethrotomyOpen the stenotic urethral segment along its ventral surface through the spongiosum, exposing the lumen and the dorsal urethral wall[1][2]
3. Dorsal Asopa-type incisionIncise the exposed dorsal urethra in the midline from the luminal side, creating an elliptical raw area directly over the tunica albuginea of the corpora cavernosa[1][2]
4. Dorsal inlay BMGPlace the first BMG into the dorsal incision as a dorsal inlay; quilt to the underlying tunica albuginea / corpora cavernosa to augment the dorsal urethral plate[1][2]
5. Ventral onlay BMGSuture a second BMG to the lateral urethral margins as a ventral onlay, completing circumferential augmentation[1][2]
6. Spongiosal closureClose the corpus spongiosum over the ventral graft for vascular support and mechanical protection[1][2]
7. CatheterUrethral catheter for ~ 3 weeks[2]

Graft Material​

  • Buccal mucosa is the standard graft material — consistent with AUA 2023 first-choice oral-mucosa recommendation. Two grafts are needed, so harvesting from both cheeks is often required.[5][6]
  • A variation by Chen / Santucci using a ventral BMG onlay combined with a dorsal full-thickness skin graft (FTSG) inlay has also been described, with particular benefit for strictures ≥ 6 cm: 0% failure vs 24% for single BMG alone in their cohort.[7]

Outcomes​

SeriesnPopulationMean follow-upMean strictureSuccessRe-stricture
Palminteri 2008[2]48Bulbar22 mo3.65 cm89.6%10.4%
Palminteri 2011[1]73Bulbar48.9 mo3.3 cm88%12%
Schardein 2020[4]8Post-phalloplasty31 mo—75%25%

A systematic review reported a pooled success of 90.1% for the Palminteri technique across 53 patients at mean follow-up 21.9 mo.[8]

In Palminteri's long-term series, no patients reported postoperative erectile impairment — a notable advantage over transecting approaches.[1]

Key Advantages​

  • Maximal urethral augmentation — grafting both surfaces achieves a wider lumen than single-sided approaches, critical for tight strictures.[1][2]
  • Preservation of the urethral plate — supports graft take and preserves urethral blood supply.[1][3]
  • Non-transecting — associated with lower rates of postoperative sexual dysfunction.[1]
  • Single-stage — avoids the morbidity of staged reconstruction.[1][2]

Complications​

  • Re-stricture — primary failure mode, ~ 10–12% in the bulbar urethra; up to 25% in the post-phalloplasty setting.[1][2][4]
  • Urethrocutaneous fistula — 3 / 48 (6.3%) in the initial series, all resolved with prolonged catheterization.[2]
  • Bilateral BMG donor-site morbidity — transient oral pain peaking at 1 wk and resolving by 3 mo in most; temporary difficulty with eating / speaking; occasional long-term oral numbness or restricted mouth opening (~ 7.5%).[9]
  • Erectile dysfunction — not reported in the available literature, a notable advantage over transecting approaches.[1]

Where It Fits​

Single-sided dorsal and ventral BMG urethroplasties have equivalent success rates (~ 88%) for typical bulbar strictures.[10][11][12] The double-face technique is reserved for cases where a single graft would be insufficient — namely tight, near-obliterative, or longer strictures.[3]

The non-transecting nature is particularly valuable given the Redmond / Rourke 2020 multicenter signal that augmented anastomotic urethroplasty (AAU) is independently associated with failure (HR 4.8, p = 0.002) compared with non-transecting dorsal onlay for long bulbar strictures.[13]

Post-Phalloplasty Application​

The technique has been adapted for neophallus anastomotic strictures following gender-affirming phalloplasty. The pars fixa is exposed through a perineal dissection, and surrounding tissue analogous to a Martius flap is rotated to support the ventral graft. Schardein 2020 reported 75% success at mean 31 mo with high satisfaction (mean IPSS 3.1 postoperatively).[4]

Videos​

Palminteri Double-Face BMG Urethroplasty
Operative technique

References​

1. Palminteri E, Berdondini E, Shokeir AA, et al. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. J Urol. 2011;185(5):1766-1771. doi:10.1016/j.juro.2010.12.103.

2. Palminteri E, Manzoni G, Berdondini E, et al. Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol. 2008;53(1):81-89. doi:10.1016/j.eururo.2007.05.033.

3. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493-503. doi:10.1111/iju.13356.

4. Schardein J, Beamer M, Hughes M, Nikolavsky D. Single-stage double-face buccal mucosal graft urethroplasty for neophallus anastomotic strictures. Urology. 2020;143:257. doi:10.1016/j.urology.2020.06.010.

5. 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.

6. 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.

7. Chen ML, Odom BD, Johnson LJ, Santucci RA. Combining ventral buccal mucosal graft onlay and dorsal full-thickness skin graft inlay decreases failure rates in long bulbar strictures (≥ 6 cm). Urology. 2013;81(4):899-902. doi:10.1016/j.urology.2012.11.055.

8. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011;59(5):797-814. doi:10.1016/j.eururo.2011.02.010.

9. Desai D, Joshi S, Ravichandran K, et al. Donor-site morbidity and impact on oral health following buccal mucosal graft harvesting for urethroplasty: a prospective study. World J Urol. 2025;43(1):531. doi:10.1007/s00345-025-05898-6.

10. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.

11. Barratt R, Chan G, La Rocca R, et al. Free graft augmentation urethroplasty for bulbar urethral strictures: which technique is best? A systematic review. Eur Urol. 2021;80(1):57-68. doi:10.1016/j.eururo.2021.03.026.

12. Shalkamy O, Elatreisy A, Salih E, et al. Erectile and voiding function outcomes after buccal mucosa graft urethroplasty for long-segment bulbar urethral stricture: ventral versus dorsal onlay technique. World J Urol. 2023;41(1):205-210. doi:10.1007/s00345-022-04220-y.

13. Redmond EJ, Hoare DT, Rourke KF. Augmented anastomotic urethroplasty is independently associated with failure after reconstruction for long bulbar urethral strictures. J Urol. 2020;204(5):989-995. doi:10.1097/JU.0000000000001177.