Skip to main content

Dorsal Onlay Buccal Mucosal Graft Urethroplasty for Posterior Stenosis

Dorsal BMG augmentation is an option for selected refractory posterior stenoses with a usable urethral plate and viable recipient bed. It aims to widen the lumen without circumferential transection. Nontransection does not guarantee sphincter preservation or prove less incontinence than another repair. Bladder-neck stenosis, post-prostatectomy VUAS and bulbomembranous stenosis are different anatomical populations.[1][2][3]

See BNC, VUAS, and subtrigonal inlay for the distinct transvesical graft technique.

Selection​

Assess stenosis location, length and caliber, prior radiation/operations, baseline continence, fistula or necrosis, bladder function and future drainage needs. The Sterling cohort excluded obliterative disruptions requiring excisional reconstruction and did not represent severely contracted, fistulizing or necrotic bladders. Its results should not be applied to those cases.[2]

EAU recommends individualized posterior reconstruction in experienced centers. Complete obliteration is not suitable for endoluminal treatment; open or robotic reconstruction, chronic drainage and diversion are different options depending on tissue and bladder status. No guideline establishes dorsal BMG as the universal technique of choice for radiated or nonradiated VUAS.[1]

Shahrour perineal technique​

The original four-patient VUAS report describes:[4]

  1. Perineal exposure and bulbar dissection, with dorsal access beneath the pubic bone toward the anastomosis.
  2. Dorsal opening through the stenosis to the bladder neck, preserving viable tissue and protecting the sphincter and rectum.
  3. Buccal graft fixation proximally at 11, 12 and 1 o'clock; a ski/J-hook needle can assist deep suturing.
  4. Interrupted graft quilting to pubic periosteum and continuous fixation to the urethral edges with 4-0 polyglactin.
  5. Catheter drainage followed by urethrogram and a voiding trial at 3 weeks in that report.

The recipient bed is technique-specific. Pubic periosteal quilting is described in Shahrour's operation; other dorsal BMG approaches fix to periurethral tissue, corpora or intercrural tissues. Do not describe every posterior graft as lying on a pubic periosteal bed. A perineal approach can avoid abdominal access in selected anatomy but does not eliminate rectal injury or the possible need for a combined approach.[4][2][3]

Outcomes with correct populations​

StudyPopulationOutcome and limitation
Shahrour 20194 post-prostatectomy VUAS patients, 3 radiatedAll patent at 3 months. All were incontinent before and after surgery, so the series cannot measure new incontinence risk in initially continent patients.[4]
Sterling 202445 post-prostatectomy plus radiation patients: 21 anastomotic and 24 bulbomembranous stenoses7 recurrences; median follow-up 21 months among patients without recurrence. No new SUI reported, but baseline/postoperative continence counts differ between sections of the publication; do not interpret this as a demonstrated 0/45 at-risk rate.[2]
Angulo 2021107 membranous/bulbomembranous stenoses after benign prostate surgery; BNC excluded10 recurrences at mean 59.3 months. One new SUI case among 87 patients known continent before surgery; the paper's 0.9% uses all 107 as denominator. This is not a BNC success cohort.[3]
Doležel 202438 mixed posterior cases, 27 perineal and 11 endourethroplastyThree-year recurrence-free survival 65% overall, 81% when auxiliary DVIU is included; new incontinence 2/18 initially continent patients across both approaches. Neither endpoint belongs solely to dorsal perineal BMG.[5]

These uncontrolled cohorts cannot establish superiority over excision/reanastomosis or Y-V plasty. Satisfaction scores also require the responding-patient denominator; they should not be reported as though every enrolled patient supplied a questionnaire.

Recurrence, complications and follow-up​

Radiation, prior interventions and postoperative complications were associated with recurrence in Angulo's small-event analysis. The article gives differing adjusted estimates for prior dilation between abstract and main results; a precise universal risk multiplier or “strongest predictor” is not justified.[3]

Discuss recurrence, oral donor-site morbidity, urinary leakage, infection, fistula, sexual effects and new or worsened SUI. Reassess symptoms, flow, residual and patency after healing. A short recurrence may be amenable to a further procedure, which should be recorded as additional treatment rather than hidden within primary success.[5][1]

For persistent SUI, assess bladder function and establish stable patency before considering an AUS. Prior radiation and urethral reconstruction can complicate later device surgery; nontransection alone does not establish AUS safety.[1]

Videos​

Dorsal Onlay BMG for VUAS — Operative Technique
Includes ski / J-hook needle use beginning at 3:07
Dorsal Onlay BMG Urethroplasty for VUAS
Operative video demonstration

References​

1. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.

2. Sterling J, Simhan J, Flynn BJ, et al. "Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis." The Journal of Urology. 2024;211(4):596-604. doi:10.1097/JU.0000000000003848

3. Angulo JC, Dorado JF, Policastro CG, et al. "Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra After Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes." Journal of Clinical Medicine. 2021;10(17):3969. doi:10.3390/jcm10173969

4. Shahrour W, Hodhod A, Kotb A, Prowse O, Elmansy H. "Dorsal Buccal Mucosal Graft Urethroplasty for Vesico-Urethral Anastomotic Stricture Postradical Prostatectomy." Urology. 2019;130:210. doi:10.1016/j.urology.2019.04.022

5. Doležel J, Hrabec R, Uher M, et al. "Substitution Urethroplasty With Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-Institution Long-Term Experience With Perineal Approach and Endourethroplasty." Urology. 2024;192:126-132. doi:10.1016/j.urology.2024.05.034