One-stage urethroplasty using oral mucosal graft

  • Introduction
  • Lectures
  • Articles
  • F.A.Q.
  • Results
  • Surgical Techniques
The surgical technique of “One-stage penile urethroplasty with skin or oral mucosal graft” is made by opening the urethra at the level of the stricture site and widening the urethral lumen by applying a skin or oral graft. There are three basic types of One-stage penile urethroplasty:

  • One-stage penile urethroplasty using skin flap. Using this technique, the urethral plate is augmented using a skin penile flap (figure 1).
  • One-stage penile urethroplasty with oral mucosal graft. Using this technique, the urethral plate is augmented by a transplant of an oral graft (figure 2).
  • One-stage penile urethroplasty with skin graft. Using this technique, the urethral plate is augmented by a transplant of a skin graft (figure 2).

The surgical technique of One-stage penile urethroplasty with skin or oral mucosal graft is generally suggested in the following cases:

  • patients no-obliterative penile urethral strictures, more than 2 cm in length (figure 3).

Figure 1

Figure 2

Figure 3

Lecture n° 1:

Which type of urethroplasty – a critical overview of results and complications
22nd Annual EAU Congress
March 21-24, 2007
Berlin – Germany

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Lecture n° 2:
Which type of urethroplasty. A critical overview of results and complications
23rd Annual EAU Congress
ESU Course 8
March 26-29, 2008
Milan – Italy
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Lecture n° 3:
Penile Urethroplasty
III Simposio Internacional de Cirurgia Urologica Reconstrutora
April 11-12, 2008
Rio de Janeiro-Brazil
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Lecture n° 4:
Urethral Reconstructive Surgery: Current Trends
Portuguese Andrological Association National Meeting
June 21 – 23, 2008
Porto – Portugal
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Lecture n° 5:
Penile and bulbar urethroplasty Surgical techniques and results
Hong Kong Urological Association Urethroplasty Workshop Division of Urology – Tuen Mun Hospital
Hong Kong
February 9 – 10, 2009
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Article n° 1
Barbagli G, Selli C, Tosto A, Palminteri E.
Dorsal free graft urethroplasty.
J Urol. 1996 Jan;155(1):123-6.

Purpose: Dorsal free graft urethroplasty was performed to reduce the incidence of urethrocele.
Materials and Methods: We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 patients with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a patch graft.
Results: Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good in 2. No signs of graft weakening, such as post-void dribbling or diminished ejaculation, were apparent.
Conclusions: The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.

Article n° 2
Barbagli G, Palminteri E, Lazzeri M.
Dorsal onlay techniques for urethroplasty.
Urol Clin North Am. 2002 May;29(2):389-95.

Dorsal onlay graft urethroplasty is a versatile procedure which may be combined with various substitute materials such as preputial skin, buccal mucosa grafts or pedicled flaps. Others substitute materials such as human urethral mucosa from corpses or collagen matrix will be possible in future. The long-term results of a wide series of patients showed a final success rate from 92% to 97%. Any kind of substitution urethroplasty deteriorate over time, and in our series of patients with an extended follow-up from 21.5 to 43 months the success rate of dorsal onlay graft urethroplasty decreased from 92% to 85%. With regard to substitute material concerns (buccal mucosa versus preputial skin) a long-term follow-up is mandatory to establish if buccal mucosa is superior to foreskin as urethral substitute material. At present, the authors currently use both according to patient preference, status of the genital tissues or strictures characteristics.

Article n° 3
Barbagli G, Palminteri E, Balò S, Picinotti A, Lazzeri M,
Dorsal onlay graft urethroplasty. Current technique step-by-step.
Contemporary Urology, 2002: 14(5), 18-32

The ideal surgical procedure for long bulbourethral strictures would be simple, reliable, effective over the long term, and reproducible in the hands of any surgeon. The Barbagli procedure – based on sound atomic, historic, and surgical principles – fulfils these criteria.

Article n° 4
Barbagli G, Palminteri E, Lazzeri M, Guazzoni G.
Anterior urethral strictures.
BJU Int. 2003 Sep;92(5):497-505.

The surgical treatment of adult anterior urethral strictures has developed continuously. Recently considerable changes have been introduced, involving the cause of the urethral disease and surgical techniques. The criteria for selecting the reconstructive surgical technique are presented according to the cause and a new classification of urethral strictures. The main surgical procedures are presented and fully illustrated, with an updated and comprehensive review of recent publications.

Article n° 5
Barbagli G, Palminteri E, Bracka A, Caparros Sariol J.
Penile urethral reconstruction: concepts and concerns.
Arch Esp Urol. 2003 Jun;56(5):549-56.

Reconstruction of the penile urethra is a challenging exercise, and for many surgeons an ungratifying experience. The past three decades have seen us move from predominantly 2-staged surgery, through foreskin grafts, and then single stage flap reconstructions, and now in the 3rd millennium, for some situations 2-stage repair has again become the favoured option. Satisfying short-term solutions have sometimes resulted in poor long-term outcomes when reviewed 10 years later. Clearly there are still problems to be resolved, hence the need for continuing evolution in our surgical management. Lessons have been learned from the treatment of Lichen Sclerosus, from strictures following hypospadias repair, and strictures associated with severe spongiofibrosis. Management of these problems has traditionally been associated with not only a high incidence of restricture and fistula formation, but also with poor cosmetic results, something that men today find increasingly difficult to accept. Several considerations are fundamental to achieving the best functional and aesthetic results. These include the presence or absence of Lichen Sclerosus, the extent of urethral disease and its grade (i.e. mucosal disease or with accompanying spongiofibrosis); furthermore the use of non-genital grafts for urethral reconstruction when the local penile tissues are deficient or unhealthy. In arriving at our present strategy, a collaborative approach that integrates established urological practice with the different perspectives of a plastic surgeon (A.B.) has proved constructive and beneficial.

Article n° 6
Barbagli G, Palminteri E, Lazzeri M, Bracka A.
Penile and bulbar urethroplasty using dorsal onlay techniques.
Atlas Urol Clin., 2003: 11, 29-41

The surgical treatment of adult anterior urethral strictures has been a constantly evolving process. Recently, considerable changes have been introduced: the wider use of the buccal mucosa graft and the use of the dorsal onlay approach, also named the Barbagli procedure. Moreover, in penile urethra, the dorsal placement of the graft is now combined by the incision of the urethral plate, as suggested by Snodgrass for childhood hypospadias surgery and its augmentation, as suggested by Bracka, Asopa and Hayes.
Three different techniques are presented:

  • Penile one-stage urethroplasty with urethral plate incision and augmentation using a dorsal buccal mucosa graft;
  • Bulbar one-stage urethroplasty with urethral plate augmentation using a dorsal buccal mucosa graft;
  • Bulbar one-stage urethroplasty with urethral place replacement using a dorsal buccal mucosa graft.

Article n° 7
Guido Barbagli, Enzo Palminteri, Stefano De Stefani and Massimo Lazzeri
Penile urethroplasty: theniques and outcomes using buccal mucosa grafts.
Contemporary Urology. March 2006, 25-33

Penile urethroplasty may represents a simple problem in patients with urethral stricture in which the penis is normal, but may represents a difficult challenge in patients with urethral stricture associated with failed hypospadias repair or Lichen sclerosus (LS), in which the penis is fully involved in the disease. In our experience, failed hypospadias repair and Lichen sclerosus are the most frequent cause (62%) of penile urethral strictures (data submitted for publication). Basically, the surgical procedure for the repair of penile urethral stricture is selected according to etiology of disease. In patients with normal penis, the penile skin, the urethral plate, the corpus spongiosum and dartos fascia are available for urethral reconstruction and one-stage urethroplasty is worldwide the solution of choice. In patients with failed hypospadias repair when the penile skin, the urethral plate and dartos fascia are unavailable for urethral reconstruction a multi-stage urethroplasty could be advisable. Moreover, in patients with LS the use of buccal mucosa as substitute material is mandatory, because LS is a skin disease, thus any skin used for the repair may also become diseased and usually is diseased in course.
The selection of surgical technique for penile urethra reconstruction may have a great respect for the status of the all penile tissue and components: glans, penile skin, urethral plate, corpus spongiosum, dartos fascia, and the urethroplasty would be based on the proper anatomical characteristics that everyone of these penile tissues provide in order to ensure flap or graft taking and survival. Certainly, sexual function can be placed at risk by any surgery on the genitalia and dissection must avoid interference with neurovascular supply to the penis, and the use of flaps or grafts should not compromise penile length, should not cause penile chordee and certainly should not untowardly affect penile appearance.
1. Question: Can the surgical procedure be performed with full coverage by the National Health Care System?
Answer: Yes.


2. Question: What kind of anesthesia is used for this surgery?
Answer: General anesthesia with nasal tube.


3. Question: How many hours does the surgery take?
Answer: About 2 hours.


4. Question: Are there any risks concerning erection, fertility and urinary incontinence after the surgery?
Answer: No, there aren’t.


5. Question: How many days of hospital recovery are expected following the surgery?
Answer: In general, from 5 to 7 days.


6. Question: How long will I have to use a catheter after the surgery? Is it painful to use the catheter?
Answer: The catheter must stay in place for two or three weeks after the surgery. The catheter is well tolerated because of its small diameter.


7. Question: Are there any particular recommendations during convalescence?
Answer: During convalescence, the use antibiotics until the catheter is removed is suggested. Avoiding long car trips, as well as heavy labor and sexual and sports activities are also suggested.


8. Question: When will I be able to resume my working, sexual and sports activities?
Answer: All these activities can be gradually resumed about 30 days after the removal of the catheter.


9. Question: Can I ride a bike or a motorcycle immediately after the surgery?
Answer: Yes.


10. Question: What kinds of foods and drinks should be avoided after the surgery?
Answer: Beer and sparkling wines should be avoided, as well as large quantities of chocolate, cocoa, nuts and shellfish.

Surgical Technique: step by step


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