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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. Bladder-neck stenosis, post-prostatectomy VUAS and bulbomembranous stenosis are different anatomical populations.[1][2][3]

Related pages: BNC, VUAS, and subtrigonal inlay (the transvesical graft technique).

Selection​

Assess stenosis location, length and caliber, prior radiation or operations, baseline continence, fistula or necrosis, bladder function and future drainage needs. Sterling’s post-prostatectomy/post-radiation series treated only nonobliterative stenoses traversable by guidewire; patients with obliterative stenosis or anastomotic disruption underwent excision and primary anastomosis, and patients with bladder capacity <100 mL, fistula or radionecrosis would not be offered the graft repair.[2] EAU 2026 recommends urinary diversion in recurrent or complex cases with loss of bladder capacity and/or incapacitating local symptoms .[1]

EAU 2026 advises that VUAS reconstruction be performed in experienced high-volume centers, particularly after radiotherapy. It gives a strong recommendation against endoluminal treatment of VUAS, bulbomembranous or bladder neck stenosis with complete obliteration, and a weak recommendation for redo vesicourethral anastomosis (VUA) in obliterative VUAS or VUAS refractory to endoluminal treatment, in non-irradiated patients and irradiated patients with adequate bladder function (§6.3.5.a). The choice of reconstruction depends on stenosis length, location and caliber, continence, bladder function, prior radiotherapy, patient preference and surgeon expertise. For radiation-induced bulbomembranous stenosis refractory to endoscopy, EAU 2026 recommends either excision and primary anastomosis or augmentation for short (<2.5 cm) stenoses , and augmentation for long (>2.5 cm) stenoses .[1] For treatment-refractory bladder neck stenosis after surgery for benign prostatic obstruction, EAU 2026 recommends Y-V or T-plasty . It describes robot-assisted subtrigonal buccal mucosa inlay only as a case report requiring further investigation and does not include dorsal BMG in that recommendation.[1]

Shahrour perineal technique​

The original four-patient VUAS report describes these steps:[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 later posterior substitution-urethroplasty report describes a ski/J-hook needle for deep apical sutures.[8]
  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 depends on the technique. Pubic periosteal quilting is described in Shahrour's operation. In Sterling’s one-sided dorsolateral approach, the urethrotomy extends about 1.5 cm into healthy tissue at each end; a shallow scar wedge is excised at 11–1 o’clock without cautery near the membranous urethra or cavernous nerves, and the graft is quilted to proximal periurethral tissue and distal corpora cavernosa.[2] A perineal approach can avoid abdominal access in selected anatomy but does not remove the risk of 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 radiatedThe report described 100% success at 3 months. All were incontinent before and after surgery.[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 de novo SUI was reported, but 17/45 men (38%) subsequently received an AUS for postoperative incontinence. Baseline and postoperative continence counts differ between sections of the publication, so a 0/45 at-risk rate cannot be derived.[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.[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 is specific to dorsal perineal BMG.[5]
Policastro 202179 men with post-radiation posterior urethral stenosis (median stenosis 3.0 cm; EBRT, brachytherapy or both, with or without prior prostatectomy)82.3% stenosis-free at median 21-month follow-up (14/79 recurrence); de novo SUI in 3/37 (8.1%) preoperatively continent patients. The cohort did not include a BNC population.[6]

These uncontrolled cohorts have no comparison with excision and reanastomosis or Y-V plasty. In a separate two-center retrospective study of 212 men with radiation-induced bulbomembranous stenosis, BMG onlay (n = 49) was associated with more cystoscopically defined recurrence (lumen <16 Fr) than anastomotic repair (n = 163; adjusted HR 3.43, 95% CI 1.03–11.47); median follow-up among men without recurrence was 97 months. Reported incontinence was 18% in each group.[7]

Recurrence, complications and follow-up​

In Angulo's analysis, which had few events (10), radiation, two or more prior dilations and postoperative complications were associated with recurrence.[3]

Discuss recurrence, oral donor-site morbidity, urinary leakage, infection, fistula, sexual effects and new or worsened SUI. EAU 2026 recommends warning patients about de novo incontinence after reconstruction of BNS or bulbomembranous stenosis following surgery for benign prostatic obstruction, and about de novo incontinence and new erectile dysfunction after radiation-induced bulbomembranous repair .[1] For the separate transperineal redo VUA operation, it recommends warning that incontinence is inevitable and staged anti-incontinence surgery may be needed after at least 3–6 months .[1] Sterling's 45-patient cohort also reported one venous thrombotic event requiring anticoagulation.[2] Reassess symptoms, flow, residual and patency after healing. In Sterling's cohort, voiding cystourethrogram/retrograde urethrogram preceded catheter removal at 3 weeks; suspected extravasation prompted another week of drainage. Recurrence in that study meant any subsequent intervention.[2] A short recurrence may be amenable to a further procedure, and Doležel counted this as auxiliary treatment separate from primary success.[5][1]

For persistent SUI, assess bladder function and establish stable patency before considering an AUS. In Sterling's cohort, cystoscopy before implantation ruled out recurrent stenosis.[2] Prior radiation and urethral reconstruction can complicate later device surgery.[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
Robotic Double-Faced Buccal Graft Bladder Neck Reconstruction
Related robotic double-faced graft for complete post-TURP bladder-neck obliteration; distinct from perineal dorsal onlay (Desai et al., 2023; CC BY-NC-ND 4.0)
Open source videoRead the article

References​

1. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, section 6.3.5.a. 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

6. Policastro CG, Simhan J, Martins FE, et al. "A Multi-Institutional Critical Assessment of Dorsal Onlay Urethroplasty for Post-Radiation Urethral Stenosis." World Journal of Urology. 2021;39(7):2669-2675. doi:10.1007/s00345-020-03446-y

7. Rourke K, Gelman J. "Anastomotic Urethroplasty Is Associated With a Lower Risk of Stricture Recurrence Compared With Buccal Mucosa Graft Onlay After Reconstruction for Radiation-Induced Bulbomembranous Urethral Stenosis." J Urol. Published online August 26, 2026. doi:10.1097/JU.0000000000005279

8. Kaldany A, Cedars B, Nikolavsky D. "Substitution urethroplasty for posterior urethral stenosis." Transl Androl Urol. 2025;14(12):3962-3974. doi:10.21037/tau-2025-566