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Buccal Mucosa Graft Ureteroplasty

Buccal mucosa graft (BMG) ureteroplasty is a tissue-sparing upper-tract reconstruction for complex proximal and mid-ureteral strictures when primary ureteroureterostomy would be under tension and a viable ureteral plate and vascular graft bed permit augmentation. Robotic series have made BMG ureteroplasty a more widely used option in ureteral reconstruction.[1][2][3]

For the hybrid transecting configuration, see Augmented Anastomotic Ureteroureterostomy. For pedicled right-sided flap alternatives, see Appendiceal Onlay / Interposition. For long bowel substitution, see Ileal Ureter Substitution.

Why Buccal Mucosa Works​

Buccal mucosa was adopted from urethral reconstruction as a urinary-tract graft material.[2][4][7]

PropertyReconstructive Value
Panvascular lamina propriaSupports imbibition, inosculation, and neovascularization after placement on a vascular bed
Thick resilient epitheliumTolerates moisture, urine exposure, and mechanical stress better than skin
Non-hair-bearing surfaceAvoids hair, stone, and infection problems seen with skin-bearing grafts
Rapid epithelial healingFamiliar urethroplasty behavior with low scar-contracture tendency compared with skin
Easy harvestInner cheek access, large harvestable surface, and usually acceptable donor morbidity
Long urethroplasty track recordTechnique, harvest, defatting, quilting, and donor-site counseling are mature

BMG is a free graft, which is the main tradeoff. Unlike appendix or ileum, it has no intrinsic pedicle and depends on the recipient bed, omentum, perinephric fat, or other vascular support for graft take.[2][10][14]

Historical Development​

Naude reported five patch graft repairs with omental wrapping and one tubularized buccal graft interposition for ureteric strictures or segmental loss in 1999.[7] Kroepfl et al. later reported open BMG treatment of long ureteric strictures, but the operation remained uncommon until robotic reconstruction made precise intracorporeal graft suturing more reproducible.[17]

Zhao et al. reported robot-assisted ureteral reconstruction with buccal mucosa in 2015, followed by CORRUS multi-institutional series that expanded experience from small feasibility cohorts to a 163-patient 10-year robotic cohort.[8][9][10][11][1]

Indications​

BMG ureteroplasty is best suited to proximal and mid-ureteral strictures in the tissue-sparing middle ground between simple anastomosis and bowel substitution.[1][2][3][18]

IndicationWhy BMG Fits
Proximal or mid-ureteral strictureMost reported location; avoids distal bladder reconstruction
Stricture about 2-8 cmReported range in selected series; configuration depends on obliteration, viable plate and tension-free reach
Failed pyeloplasty / UPJ strictureUseful when redo pyeloplasty or ureterocalicostomy is not the best geometry
Failed endoscopic managementMoves from dilation/incision to tissue reconstruction
Failed prior reconstructionPrior treatment did not independently predict failure in the 163-patient analysis[1]
Left-sided strictureUnlike appendix, BMG is side-independent
Need to avoid bowel substitutionAvoids ileal metabolic, mucus, stone, and bowel-anastomosis morbidity
Patient with usable oral mucosaAllows graft harvest without abdominal bowel work

Distal ureteral strictures usually favor ureteroneocystostomy, psoas hitch, Boari flap, or selective non-transecting side-to-side reimplantation.[6][15] BMG has also been reported for selected pelvic-ureter strictures: 36% of a 39-patient multicenter robotic cohort had pelvic disease, but pelvic-specific outcomes and long-term durability were not established.[29]

Contraindications and Caution Zones​

  • distal ureteral disease where bladder-based reconstruction is simpler and more durable,
  • pan-ureteral or very long strictures where ileal substitution is more realistic,
  • malignant ureteral disease requiring oncologic excision,
  • active oral mucosal disease such as leukoplakia, lichen planus, submucous fibrosis, or severe scarring,
  • inability to provide a vascularized graft bed or wrap,
  • high-risk irradiated tissue without omental or alternative vascular support,
  • oral harvest limitations from prior graft harvest, limited mouth opening, or patient preference.

Radiation-induced ureteral strictures deserve special caution. In the CORRUS radiation-induced stricture cohort, BMG ureteroplasty was used in only 1 of 35 ureteral units; most repairs used reimplantation strategies. When BMG is used in irradiated fields, vascular reinforcement is especially important.[12]

Preoperative Planning​

Planning should define anatomy, function, and graft and bed feasibility.

QuestionPlanning Tool
Where are the stricture limits?CT urogram, MR urogram, retrograde/antegrade pyelography, ureteroscopy
Is it narrowed or obliterated?Retrograde/antegrade contrast, ureteroscopic passage, guidewire behavior
Is the renal unit salvageable?MAG3/DTPA renography, cortical thickness, symptoms, infection history
Which configuration is needed?Non-transecting onlay for patent lumen; augmented anastomotic for obliterated core
Is oral mucosa suitable?Oral exam, prior harvest history, mouth opening, mucosal disease screen
Can the graft be vascularly supported?Omentum availability, perinephric fat, prior abdominal surgery

When feasible, ureteral rest removes hardware across the stricture while a nephrostomy can maintain drainage. In a retrospective 50-patient robotic reconstruction cohort, 12% of initially narrowed strictures appeared obliterative after a median 11.1 weeks of rest, potentially changing the onlay versus augmented-anastomotic plan.[32] Preoperative stenting may still be needed for drainage, but stent-related edema can obscure stricture length.[10]

Graft Harvest​

BMG harvest is usually performed from the inner cheek, often simultaneously with robotic exposure by a second team.

Steps:

  1. Evert the cheek and mark Stensen's duct.
  2. Mark a graft long enough to cover the ureteral defect, usually about 1 cm wide.
  3. Infiltrate for hemostasis and hydrodissection.
  4. Harvest sharply, avoiding parotid duct injury.
  5. Defat minimally on the back table, preserving lamina propria.
  6. Close the donor site or leave it open depending on surgeon preference.

For longer defects, bilateral cheek grafts or composite grafts may be used.[13] In a 135-patient randomized urethroplasty donor-site trial, nonclosure was noninferior to closure for oral pain; consistent superiority was not shown, and either approach is reasonable.[5]

Robotic Operative Technique​

Buccal graft ureteroplastyOriginal schematic · v2026-09-11 · Clinical review pending

Buccal mucosa graft ureteroplasty. The stricture is opened by a non-transecting longitudinal ureterotomy, then patched with a buccal mucosa onlay graft sewn over a double-J stent to widen the caliber. Because BMG is a free graft with no pedicle, the repair is wrapped in omentum or perinephric fat (cross-section) to supply graft take; the onlay may be placed dorsally or ventrally. (Original WARWIKI schematic)

Exposure and localization​

  • Position similarly to robotic pyeloplasty or upper or mid-ureteral reconstruction.
  • Identify the ureter proximal to the stricture.
  • Preserve periureteral adventitia and blood supply.
  • Use intraoperative flexible ureteroscopy to define the distal stricture extent and transilluminate the ureter.
  • Use ICG/Firefly selectively to assess ureteral perfusion and orientation.[6][13]

Non-transecting onlay​

This is the most common configuration in early robotic series.[10][11]

  1. Incise the ureter longitudinally across the stricture.
  2. Do not transect the ureter.
  3. Extend the ureterotomy until healthy mucosa and lumen are visible at both ends.
  4. Place the BMG as anterior (ventral) or posterior (dorsal) onlay with mucosa facing the lumen.
  5. Suture the graft to ureteral edges using running or interrupted absorbable 4-0 or 5-0 suture.
  6. Place a double-J stent across the reconstruction; insert an antegrade stent before final graft closure when appropriate, or place it retrograde after completing the onlay.[10][28]
  7. Provide a vascular graft bed and cover the free graft with omentum or perinephric fat. A 14-patient open extraperitoneal series used surrounding perirenal or retroperitoneal fat without an omental wrap.[28]

Augmented anastomotic BMG ureteroplasty​

Use this when part of the stricture is obliterated but the remaining segment can be preserved as a plate.

  1. Excise the obliterated segment.
  2. Reanastomose the posterior ureteral wall primarily.
  3. Place BMG as an anterior onlay to complete the circumference.
  4. Stent and wrap as above.

This hybrid operation is covered in more detail in Augmented Anastomotic Ureteroureterostomy.

Omental or fat wrap​

Omental wrap is the main vascular adjunct because BMG has no intrinsic blood supply. In the initial CORRUS series, omentum was used in 95% of cases.[10] The wrap provides vascularity, stabilizes the graft, separates the repair from surrounding scar, and may blunt inflammation.

When omentum is difficult to mobilize, perinephric fat wrap is a reported alternative. Jiang et al. retrospectively compared 16 perinephric-fat and 10 omental wraps. They detected no outcome difference and observed earlier passage of flatus with perinephric fat.[14]

Anterior vs Posterior Onlay​

ApproachAdvantagesTradeoffs
Anterior / ventral onlayTechnically straightforward, no ureter rotation, familiar robotic exposureRelies on omentum/fat wrap to provide external vascular support
Posterior / dorsal onlayGraft can rest against psoas or retroperitoneal vascular bedRequires more ureter rotation and posterior exposure

Available reviews have not shown a clear efficacy or complication difference between anterior and posterior onlay, so the choice is usually anatomy- and surgeon-dependent.[3]

Outcomes​

SeriesYearNApproachTypical Stricture LengthSuccess / Key Finding
Naude19996OpenVariableFive patch grafts with omental wrap and one tubularized interposition; all six patent at reported follow-up[7]
Kroepfl et al.20107 strictures (6 patients)OpenLong-segment5/7 (71.4%) recurrence-free at median 18 months[17]
Zhao et al.20154RoboticNot specified100% success at 15.5 months[8]
Lee et al.201712RoboticMedian 3 cm10/12 (83.3%) clinically and radiologically successful at median 13 months[9]
Zhao et al. CORRUS201819RoboticMedian 4 cm17/19 (89%) recurrence-free at median 26 months; 79% onlay and 21% augmented anastomotic[10]
Lee et al. CORRUS update202154 (≥12 months follow-up)RoboticMedian 3 cm47/54 (87.0%) without obstructive pain or imaging obstruction at median 27.5 months; major complications 3/54 (5.6%)[11]
Heijkoop and Kahokehr systematic review202172 proceduresOpen/roboticVariable66/72 (91.6%) reported success; grade ≥3 complications in 3/60 with complication reporting (5%)[16]
Chao et al. 10-year cohort2025163RoboticMedian 3 cm92.0% free from additional intervention at median 29 months[1]

In the 10-year cohort, 169 patients underwent surgery and 163 were eligible for analysis; 150/163 (92.0%) remained free from additional interventions at median 29-month follow-up. Median time to failure was 10.2 months. With only 13 failures, the cohort detected no independent predictors; equivalence across lengths, prior treatments or configurations was not tested.[1]

June 27, 2026 cohort. Puri et al. retrospectively reviewed 40 patients at five centers; 95% met an endpoint combining improved imaging and no additional intervention at median 12.2 months, with 22.5% experiencing a 30-day complication. Inclusion required postoperative imaging. Selection bias, shorter follow-up and a different success definition prevent direct comparison with the 2025 cohort or ileal ureter. This adds support for selected onlay reconstruction without establishing lifelong patency.[27]

Comparison with ileal ureter​

A 2023 meta-analysis pooled 23 single-arm studies, rather than head-to-head trials. Reported success was 94.9% for oral grafting and 85.8% for ileal replacement, but mean stricture length differed substantially (3.73 versus 11.55 cm).[18] Hospital stay and complications also differed between these selected cohorts.[18]

The procedures serve different anatomy. A reconstructable focal stricture may permit graft augmentation; a long defect without usable ureter may require substitution or another salvage option.

Complications​

Recipient site​

ComplicationSignal
Stricture recurrenceMain reported failure mode: 13/163 (8.0%) required additional intervention for recurrent stenosis in the largest cohort at median 29-month follow-up (median time to failure 10.2 months); 7/54 (13.0%) had stricture recurrence in the CORRUS update at median 27.5-month follow-up[1][11]
Urine leak / urinomaUncommon; usually managed with drainage, stent duration, nephrostomy, or intervention
UTI / pyelonephritisVariable, treated with antibiotics and drainage when needed
Clavien-Dindo grade 3 or higher complicationAbout 5-5.6% in systematic review and CORRUS update[11][16]
Graft contracture or failureUsually presents as recurrent obstruction

Oral donor site​

Most donor-site data come from urethroplasty, where the harvest technique is the same and the evidence is larger.[5][19][20][21]

MorbidityTypical Course
Oral painCommon early, usually improves over weeks
Perioral numbness / sensory changeCan persist in a minority; often not bothersome
Mouth tightness or reduced openingUsually improves, occasionally persistent
Eating/drinking difficultyMost prominent in first days to weeks
Speech changesUsually transient
BleedingUncommon but possible immediately post-harvest

Prospective donor-site data suggest overall oral health usually recovers. In a randomized urethroplasty donor-site trial, nonclosure was noninferior to closure for oral pain; superiority was not established.[5][19]

Adjuncts​

AdjunctRole
Flexible ureteroscopyDefines stricture edge and can transilluminate the target ureter
ICG near-infrared fluorescenceIntravenous administration can assess perfusion; intraluminal administration outlines the ureter and does not itself establish perfusion[6]. If intraluminal ICG spills after ureterotomy, field staining can prevent later IV perfusion assessment; select the route before incision.[10]
Omental wrapMost established vascular support for the free graft[10]
Perinephric fat wrapAlternative vascularized support when omentum is difficult[14]
Double-J stentMaintains luminal alignment during healing; reported series removed it at 3–4 or 6 weeks and used upper-tract imaging after removal to assess recurrent obstruction[10][28]
DrainDetects or controls early leak

Buccal vs Lingual Mucosa​

Lingual mucosa graft (LMG) is an alternative oral graft source. A 10-patient series described posteriorly augmented anastomotic LMG ureteroplasty for long proximal strictures.[23] A later 61-patient multicenter series reported 61/61 as surgically successful at median 32 months, using symptom and imaging assessments for success and reporting complications separately; one patient nevertheless had poor antegrade patency, and no BMG comparison was made.[30] Urethroplasty donor-site comparisons show broadly similar success but different morbidity patterns: LMG may produce more early speech, eating, and taste disturbance, while BMG may produce more early mouth tightness.[22]

BMG is the oral graft most familiar to many reconstructive teams, with the largest harvestable surface area and the most urethroplasty experience. LMG is an alternative when buccal harvest is limited, exhausted, or undesirable.

Special Settings​

Radiation-induced ureteral stricture​

Radiation strictures are ischemic, fibrotic, and less forgiving. BMG can be considered selectively, but graft take is only as good as the vascular bed. CORRUS radiation data show reconstructive feasibility overall, but BMG was used rarely in that cohort.[12] For BMG in an irradiated field, assess recipient-bed viability and plan well-vascularized coverage when needed; the radiation cohort contained only one BMG repair.[12]

Failed prior reconstruction​

Prior reconstruction does not preclude BMG ureteroplasty. In the largest cohort, nearly half of patients had prior stricture treatment, and prior treatment was not an independent predictor of failure.[1]

Salvage BMG pyeloplasty at the UPJ​

The same onlay and augmented-anastomotic configurations apply when the disease is at the ureteropelvic junction rather than the mid-ureter. Recurrent UPJO after failed pyeloplasty is a reported indication, and BMG-augmented salvage pyeloplasty has been described both in adults after two prior failed repairs and endoscopic management, and in children undergoing robot-assisted redo pyeloplasty with a buccal onlay.[25][26] The choice between BMG-augmented redo pyeloplasty and ureterocalicostomy turns on pelvic accessibility (an inaccessible intrarenal pelvis favors ureterocalicostomy, while a usable pelvis and proximal ureteral plate favor a BMG onlay). A crossing vessel or other extrinsic compression may require dismembered redo pyeloplasty instead of a nontransecting BMG onlay.[31] See Pyeloplasty for the redo decision framework.

Left-sided strictures​

BMG is side-independent. Appendiceal flap may be unavailable because of laterality, prior appendectomy, or competing Mitrofanoff or MACE needs.

Emerging Alternatives​

Vesical mucosal graft​

Robot-assisted vesical mucosal graft ureteroplasty has been reported as a fully intracorporeal option that avoids oral harvest. Early 2025 data describe 14 patients with no stenosis recurrence at 21.3 months of follow-up and no Clavien-Dindo grade 3 or higher complications, but experience is still very limited.[24]

Tissue-engineered grafts​

Small-intestinal submucosa, scaffold-based repairs, extracellular vesicles, organoid systems, and cell-seeded constructs remain investigational.[3][4]

Decision Framework​

BMG ureteroplasty is favored when:

  1. the stricture is proximal or mid ureter,
  2. the length is roughly 2-8 cm,
  3. primary ureteroureterostomy would be tight or ischemic,
  4. distal reimplantation is not the right geometry,
  5. appendix is unavailable, left-sided, too short, or needed elsewhere,
  6. the kidney is worth preserving,
  7. omental or fat support can be provided.

An appendiceal flap is favored when a right-sided moderate stricture has a healthy appendix and a pedicled flap is preferred. Ileal ureter is favored when disease length exceeds graft or flap reconstruction. Renal autotransplantation or TUU is considered alongside other salvage options when anatomy, renal function, tissue quality and patient goals favor them; no fixed mandatory sequence applies.

Operative Pearls​

  • BMG ureteroplasty can avoid an unnecessary ileal ureter; pan-ureteral disease usually needs substitution.
  • Define the distal stricture edge with ureteroscopy whenever possible.
  • Incise until healthy ureteral mucosa is seen at both ends.
  • Do not over-defat the graft; preserve the lamina propria.
  • Make the graft broad enough; narrow grafts become narrow repairs.
  • Plan a viable vascular graft bed or coverage using omentum, suitable perinephric fat or another appropriate local tissue.
  • Counsel about oral morbidity; most symptoms improve.
  • In a 163-patient retrospective series, 13 required reintervention for recurrent stenosis at a median 10.2 months (median cohort follow-up, 29 months); longer surveillance remains prudent.[1]

Videos​

Buccal Mucosa Graft Ureteroplasty for Complex Upper and Mid Ureteral Strictures
Grand Rounds in Urology (2025)
Laparoscopic Right BMG Ureteroplasty
AINU Surgical Videos (2025)
BMG Ureteroplasty and Non-Transecting Ureteroneocystostomy for Multiple Strictures
Abalajon MJ, et al. Urology Video Journal 2023 (CC BY 4.0)
Open source videoRead the article
Robotic BMG Ureteroplasty and Reimplantation (Carina System)
Han W, et al. Int Braz J Urol 2026 (CC BY 4.0)
Open source videoRead the article

References​

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2. Bello D, Van Shufflin M, Hofer MD. Expanding the armamentarium: perspectives on buccal mucosal grafts and appendiceal flaps in ureteral reconstructive surgery. J Clin Med. 2025;14(21):7681. doi:10.3390/jcm14217681.

3. Xiong S, Wang J, Zhu W, et al. Onlay repair technique for the management of ureteral strictures: a comprehensive review. Biomed Res Int. 2020;2020:6178286. doi:10.1155/2020/6178286.

4. Sterling J, Hecksher D, Hayden C, et al. Buccal mucosa a narrative review: how does it work, how is it used, what is coming next. Urology. 2026. doi:10.1016/j.urology.2026.03.015.

5. Soave A, Dahlem R, Pinnschmidt HO, et al. Substitution urethroplasty with closure versus nonclosure of the buccal mucosa graft harvest site: a randomized controlled trial with a detailed analysis of oral pain and morbidity. Eur Urol. 2018;73(6):910-922. doi:10.1016/j.eururo.2017.11.014.

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19. 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.

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21. Wood DN, Allen SE, Andrich DE, Greenwell TJ, Mundy AR. The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol. 2004;172(2):580-583. doi:10.1097/01.ju.0000132846.01144.9f.

22. Lumen N, Vierstraete-Verlinde S, Oosterlinck W, et al. Buccal versus lingual mucosa graft in anterior urethroplasty: a prospective comparison of surgical outcome and donor site morbidity. J Urol. 2016;195(1):112-117. doi:10.1016/j.juro.2015.07.098.

23. Fan S, Yin L, Yang K, et al. Posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures: 10 cases of experience. J Endourol. 2021;35(2):192-199. doi:10.1089/end.2020.0686.

24. Morra I, Busacca G, Ornaghi PI, et al. Vesical mucosal graft for the treatment of ureteral strictures with a total robot-assisted approach. Eur Urol. 2025. doi:10.1016/j.eururo.2025.04.016.

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31. Lee M, Nagoda E, Strauss D, Loecher M, Stifelman M, Zhao L. "Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure." Asian J Urol. 2024;11(3):373-376. doi:10.1016/j.ajur.2023.09.001

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