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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​

Palminteri's rationale is that a single dorsal or ventral graft may not provide an adequate lumen in a very narrow (tight) urethral stricture.[1][2] He also notes that anastomotic techniques (EPA and AAU) create wide lumens but may cause sexual complications after urethral transection and mobilization.[1] The double-face technique does not transect the urethra, preserves the urethral plate and augments the urethra from both sides in one operation.[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]
  • Bulbar strictures 2–10 cm long in the original series (mean 3.3–3.65 cm).[1][2]
  • An alternative to augmented anastomotic urethroplasty for tight or near-obliterative segments. The technique depends on a salvageable, if narrow, urethral plate.[1][3] For short, nearly obliterative bulbar segments treated with free-graft urethroplasty, the EAU 2026 guideline also gives a weak recommendation for augmented non-transecting anastomotic repair.[19]
  • 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] In the original technique, identify the narrow lumen with a guidewire and methylene blue, and extend the incision 1 cm into healthy urethra at both ends; after the dorsal incision in step 3, partially excise fibrotic margins while preserving the remaining plate.[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 one lateral urethral plate margin as a ventral onlay, insert the catheter, then rotate and suture it to the opposite margin. This completes two-sided augmentation while retaining native lateral plate strips.[1][2]
6. Ventral graft quilting and closureFix the spongiosum to the ventral graft with a few quilting stitches.[2] Then close the spongiosal adventitia over the graft for vascular support and mechanical protection.[1][2]
7. CatheterKeep the urethral catheter for approximately 3 weeks in the original protocol.[2] The EAU 2026 guideline strongly recommends validated urethrography to check for extravasation before removal.[18]

Graft Material​

  • Buccal mucosa is the graft material in the original series. The AUA 2023 guideline names oral mucosa as the first-choice graft .[1][5] Two graft segments are needed, but the original series split one wide cheek graft in 43/48 patients; 5/48 required bilateral harvest.[2] In a 2022 survey of Society of Genitourinary Reconstructive Surgeons members (134 respondents), 56% preferred both cheeks when harvesting long grafts.[6]
  • Chen / Santucci combined ventral BMG with dorsal full-thickness skin graft in 15 patients, compared retrospectively with 115 ventral BMG repairs. Overall failure was 21% versus 17%; a subgroup of strictures ≥6 cm favored double grafting (0% versus 24%).[7]

Outcomes​

SeriesnPopulationMean follow-upMean strictureSuccessRe-stricture
Palminteri 2008[2]48Bulbar22 mo3.65 cm89.6%10.4%
Palminteri 2011[1]73 analyzed of 105 operatedBulbar48.9 mo3.3 cm88%12%
Palminteri 2023[16]216; overlaps earlier Palminteri cohortsBulbar, single surgeonMedian 98 mo (IQR 41–131)—188/216 (87%) without postoperative instrumentation28/216 (13%)
Schardein 2020[4]8 followed of 9 operatedPost-phalloplasty31 mo—75%25%

A 2025 retrospective series of 52 patients used double-sided BMG for near-obliterated (< 6 Fr) long anterior strictures (> 2 cm; 40 bulbar, 12 bulbo-penile), with dorsal inlay plus ventral onlay in 30 and ventral inlay plus dorsal onlay in 22. Recurrence occurred in 4 (7.7%) at median 24 months, all in patients with prior failed urethroplasty and longer strictures, and IIEF scores were preserved or improved in most.[14]

In the retrospective 216-patient Palminteri series, stricture length <1.5 cm and no previous stricture treatment were associated with success in multivariable analysis.[16]

A 2011 systematic review reported 90.1% success for the Palminteri technique in 53 patients at mean 21.9 months, versus 86.7% for Asopa in 89 patients; these were separate series.[8] A 2026 synthesis of ten single-arm double-face series (511 patients) estimated 89% success (95% CI 86–92%). It pooled both dorsal-inlay/ventral-onlay and ventral-inlay/dorsal-onlay variants, with differing success definitions and moderate risk of bias; only one series had more than five years of follow-up.[17]

In the long-term series, 49 sexually active men reported no postoperative erectile impairment.[1]

Key Advantages​

  • Additional augmentation. Two grafts can provide adequate caliber when one graft would not, while retaining usable native plate.[1][2]
  • Preservation of the urethral plate. This supports graft take and preserves urethral blood supply.[1][3]
  • Non-transecting. The technique preserves urethral continuity. A comparative reduction in sexual dysfunction has not been established for this technique.[1]
  • Single-stage. Reconstruction is completed in one operation in suitable patients; comparative morbidity has not been established.[1][2]

Complications​

  • Re-stricture. This is the primary failure mode, approximately 10–12% in the bulbar urethra and up to 25% in the post-phalloplasty setting.[1][2][4]
  • Fistula on voiding cystourethrography. At catheter removal 3 weeks after surgery, 3 of 48 patients (6.3%) in the initial series had a fistula on the study, and all resolved with prolonged catheterization.[2]
  • Semen sequestration. Three of 48 patients (6%) in the original series reported this symptom despite no urethrocele on imaging or endoscopy.[2]
  • Contrast leakage and hematoma. In a 2025 mixed-technique series, 6/52 had contrast leakage after catheter removal and received two more weeks of catheterization; 1/52 had a perineal hematoma requiring re-exploration.[14]
  • Postvoid dribbling. The 2026 review describes reported rates of 17–25% among double-face series; the review includes different graft-placement configurations.[17]
  • BMG donor-site morbidity. In a prospective single-surgeon cohort of 40 patients (mixed stricture sites), donor-site pain peaked at 1 week in 28/40 and 35/40 were pain-free by 3 months. Eating, speaking and cleaning teeth were the most affected activities. Long-term difficulty with mouth opening occurred in 3/40 (7.5%).[9]
  • Erectile dysfunction. None was reported by the 49 sexually active respondents in Palminteri 2011.[1]

Where It Fits​

For typical bulbar strictures, dorsal and ventral onlay BMG urethroplasty have similar success in a meta-analysis (8 studies, 655 patients; RR 1.00) and in a systematic review of mostly case series; transient erectile dysfunction was lower with ventral onlay in the meta-analysis.[10][11][12] The double-face technique is used when a single graft would be insufficient, namely in tight or near-obliterative strictures.[3]

A single-center retrospective cohort (221 augmented anastomotic repairs and 286 dorsal onlays) associated augmented anastomotic repair with more recurrence than pure dorsal onlay (adjusted HR 4.8, p = 0.002).[13]

Post-Phalloplasty Application​

The technique has been adapted for neophallus anastomotic strictures after radial forearm flap phalloplasty. The EAU 2026 guideline strongly recommends against urethroplasty within six months after neophalloplasty.[15] 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 6 of 8 evaluable patients without recurrence at mean 31 months; 7 of 8 could void standing, and all eight reported improvement in their condition. Mean postoperative IPSS was 3.1.[4] The two recurrences were treated with perineal urethrostomy and staged urethroplasty.[4] The EAU 2026 guideline reports patency of 56–100% for graft augmentation of neophallic anastomotic strictures; length >2 cm is one reason it lists graft augmentation when excision and primary anastomosis is not feasible. It advises supporting the graft with a local fasciocutaneous flap when ventral tissue is insufficient and lists staged repair as an alternative, especially after a previous repair has failed.[15]

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.

14. Mahmoud O, Reyad AM, AbdelRazek M, et al. Evaluating intermediate-term functional outcomes of double-sided buccal mucosal graft urethroplasty for anterior urethral stricture. Int Urol Nephrol. 2025;57(12):4027-4035. doi:10.1007/s11255-025-04579-y.

15. EAU Guidelines on Urethral Strictures, 2026 limited update: disease management in transgender patients. https://uroweb.org/guidelines/urethral-strictures. Accessed September 26, 2026.

16. Palminteri E, Preto M, Clementi MC, et al. "Long-term follow-up of two-sided dorsal plus ventral oral graft bulbar urethroplasty: single center experience on 216 patients." Minerva Urol Nephrol. 2023;75(1):99-105. doi:10.23736/S2724-6051.21.04258-0

17. Li X, Guo Q, Fan L, et al. "Efficacy and safety of double-face buccal mucosa graft urethroplasty for obliterative or near-obliterative anterior urethral stricture: a systematic review and single-arm meta-analysis." Adv Urol. 2026;2026:5608421. doi:10.1155/aiu/5608421

18. European Association of Urology. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery." 2026. https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery

19. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males." EAU Guidelines. 2026. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males