Urethral stricture disease, particularly in the anterior urethra, remains a challenging urological condition with significant implications for quality of life and urinary function. While several surgical techniques exist for the management of anterior urethral strictures, buccal mucosal graft (BMG) urethroplasty has emerged as a widely accepted and durable reconstructive option over the last two decades.

The appeal of BMG stems from the histological and anatomical properties of buccal mucosa, which offers a thick, non-keratinized epithelium, high capillary density, and robust resistance to infection and trauma. These qualities contribute to its reliable graft take and long-term patency in urethral reconstruction【1】. Studies have consistently shown favourable outcomes even in complex or redo cases, with acceptable complication profiles【2】.

Despite its increasing global use, recurrence rates after BMG urethroplasty can vary, influenced by factors such as stricture length, prior interventions, graft placement technique (dorsal vs. ventral), and patient comorbidities【3】. The choice of graft source is also subject to ongoing evaluation, with meta-analyses comparing buccal mucosa to lingual mucosa indicating similar success rates but differing donor site morbidity profiles【4】【6】.

Systematic reviews reinforce the versatility of oral mucosal grafts in urethral reconstruction, demonstrating high success rates across various techniques and patient subgroups【5】. In addition, oral mucosa grafts have shown durable results even in patients with prior failed surgeries, further cementing their role in reconstructive urology【7】.

In the Indian context, where long-segment anterior strictures and repeated urethral manipulations are not uncommon, the reproducibility and safety of BMG urethroplasty become particularly relevant. The present study aimed to evaluate the clinical outcomes of BMG urethroplasty in a tertiary care centre in Vijayawada, Andhra Pradesh, over a one-year period, focusing on success rates, complications, and recurrence.

 Objectives

The primary objective of this study was to evaluate the clinical outcomes of buccal mucosal graft (BMG) urethroplasty in patients with anterior urethral strictures over a one-year follow-up period.

Specifically, the study aimed to:

• Assess the success rate of BMG urethroplasty based on symptomatic improvement, uroflowmetry parameters, and radiological findings.
• Determine the rate of stricture recurrence and need for further interventions during the follow-up period.
• Evaluate the perioperative and postoperative complications, including donor site morbidity and graft-related issues.
• Analyze factors potentially associated with treatment failure, such as stricture length, prior interventions, or graft placement technique.

Study Design and Setting

This was a prospective observational study conducted at a tertiary care urology centre in Vijayawada, Andhra Pradesh, over a period of one year. The study included male patients undergoing buccal mucosal graft (BMG) urethroplasty for anterior urethral strictures.

Study Population

A total of 45 male patients were included, all of whom underwent BMG urethroplasty between July 2023 and June 2024. Patients were recruited from the outpatient and inpatient departments of the urology unit.

Inclusion Criteria

• Adult males aged 18 years and above
• Diagnosed with anterior urethral strictures based on history, clinical examination, and imaging (retrograde urethrogram or urethroscopy)
• Fit for surgery and willing to comply with follow-up protocols

Exclusion Criteria

• Posterior urethral strictures
• History of urethral malignancy
• Prior urethroplasty using buccal mucosa
• Severe comorbidities precluding surgery
• Incomplete follow-up data

Surgical Technique

All patients underwent BMG urethroplasty under spinal or general anaesthesia. Buccal mucosa was harvested from the inner cheek after appropriate antiseptic preparation. The graft was defatted and trimmed before being placed as an onlay graft over the strictured segment, either dorsally or ventrally, based on the surgeon’s preference and stricture characteristics. A urethral catheter was left in situ postoperatively for 2 to 3 weeks.

Follow-up Protocol

Patients were followed up at 1, 3, 6, and 12 months postoperatively. Clinical evaluation included:

• Symptom assessment (e.g., weak stream, straining, dribbling)
• Uroflowmetry to measure maximum flow rate (Qmax)
• Post-void residual urine volume measurement
• Retrograde urethrogram (RUG) or urethroscopy when indicated (especially in symptomatic patients or low Qmax)

• Treatment success was defined as absence of symptoms, no requirement for further intervention, and Qmax > 15 mL/sec at last follow-up.

Data Collection and Analysis

Patient demographics, stricture characteristics (site, length, etiology), surgical details, postoperative outcomes, and complications were recorded. Data were analyzed using descriptive statistics (means, medians, percentages). Treatment outcomes were correlated with baseline factors where applicable.

Demographic and Clinical Profile

A total of 45 male patients with anterior urethral strictures were included in the study. The mean age was 44.5 ± 10.2 years, with a range from 20 to 67 years, reflecting a predominance of middle-aged individuals affected by the condition. The mean stricture length was 3.9 ± 1.4 cm, with lengths ranging from 1.5 cm to 6.5 cm.

The etiological distribution revealed that the majority of cases were idiopathic (44%), followed by post-catheterization (27%), trauma-related (18%), and infective causes (11%) (Table 1). In terms of anatomical location, bulbar urethral strictures accounted for the majority (60%), followed by penile strictures (29%) and pan-anterior involvement (11%) (Table 2).

Regarding treatment history, 18 patients (40%) had no prior interventions, whereas 14 (31%) had previously undergone direct visual internal urethrotomy (DVIU), 10 (22%) had a history of dilatation, and 3 (7%) had undergone previous urethroplasty (Table 3). This distribution indicates a substantial proportion of treatment-naïve patients, while also capturing a group with recurrent or persistent disease.

Table 1. Distribution of Urethral Stricture Etiology

Table 2. Stricture Site Distribution

Table 3. Prior Urethral Interventions

Table 4. Summary of Demographic and Stricture Characteristics

 Surgical Details

All 45 patients underwent buccal mucosal graft (BMG) urethroplasty using either a dorsal or ventral onlay technique. The dorsal onlay approach was more frequently employed (71%, n = 32), while the ventral onlay was used in the remaining 29% (n = 13).

Buccal mucosa was harvested from the left cheek in 60% (n = 27) of patients and from the right cheek in 40% (n = 18). No intraoperative complications related to graft harvesting or urethral reconstruction were reported.

The mean operative time was 94.5 ± 13.8 minutes, with a range of 60 to 130 minutes, reflecting the moderate technical demands of the procedure.

A summary of the graft placement technique, harvest laterality, and operative time is provided in Table 5.

Table 5. Surgical Details Summary

 Postoperative Recovery and Follow-Up

Following buccal mucosal graft urethroplasty, patients experienced favorable recovery profiles. The mean duration of urethral catheterization was 20.2 days, and the average time to resume normal oral intake was 3.0 days, indicating rapid resolution of graft site discomfort and minimal impact on oral function.

Regarding donor site morbidity, half of the patients (50%) reported no pain, while 40% experienced mild discomfort and 10% reported moderate pain. No patients experienced severe or persistent donor site symptoms.

Postoperative complications occurred in 20% of patients (n = 9). The most frequent issue was infection (11%), followed by bleeding (7%), and graft loss in one patient (2%), which was managed conservatively. No reoperations were required during the early recovery phase.

A comprehensive overview of postoperative recovery times, donor site morbidity, and complication rates is summarized in Table 8.

Table 8. Postoperative Recovery and Complications Summary

 Functional Outcomes

Functional improvement was assessed using maximum urinary flow rate (Qmax) measured at multiple postoperative intervals. The mean preoperative Qmax was 7.2 mL/sec, indicating moderate to severe flow obstruction.
At 3 months postoperatively, the mean Qmax improved significantly to 16.6 mL/sec, and remained stable over time: 16.2 mL/sec at 6 months and 15.5 mL/sec at 12 months. Although a slight decline was observed over time, the values consistently exceeded preoperative levels, reflecting sustained urethral patency.
These results indicate a clinically meaningful and durable improvement in urinary function following buccal mucosal graft urethroplasty (Table 9; Figure 3).

Table 9. Mean Qmax at Follow-up Intervals

Success Rate and Recurrence

At the end of the 12-month follow-up period, successful treatment outcomes were observed in 25 out of 45 patients (55.6%), defined by sustained symptomatic relief, Qmax > 15 mL/sec, and no need for additional intervention.

However, 20 patients (44.4%) experienced stricture recurrence, as evidenced by declining flow rates, recurrent symptoms, or radiographic findings. Among these, 12 patients (26.7%) required further intervention, which included urethral dilatation or planned redo urethroplasty. The remaining recurrences were managed conservatively or remained under observation due to minimal symptoms.

These results suggest that while buccal mucosal graft urethroplasty yields positive outcomes in a majority, nearly half of patients may face some degree of recurrence, underscoring the importance of long-term surveillance and patient selection.
An overview of treatment outcomes is presented in Table 10.

Table 10. Treatment Outcome Summary

Factors Associated with Outcome

An exploratory analysis was performed to identify potential predictors of stricture recurrence. While none of the parameters reached conventional statistical significance, a few notable trends were observed (Table 11).

Patients with stricture recurrence had a mean stricture length of 4.0 ± 1.5 cm, compared to 3.8 ± 1.3 cm in those without recurrence. Although this difference was not statistically significant (p = 0.533), it reflects a clinically relevant tendency for longer strictures to be associated with poorer outcomes.

Similarly, stricture site showed a near-significant trend (p = 0.083). Notably, pan-anterior strictures accounted for 20% of recurrences but only 4% of non-recurrent cases, suggesting that complex or extensive strictures may carry a higher risk of failure.

No significant association was found between graft placement technique (p = 0.521) or prior interventions (p = 0.668) and recurrence. This suggests that in experienced hands, dorsal and ventral onlay approaches may yield comparable results, and that prior DVIU or dilatation may not independently predict graft failure.

Overall, while this study did not identify statistically significant predictors, the data suggest that stricture length and anatomical complexity (pan-anterior location) may merit close postoperative surveillance. Larger sample sizes may be needed to confirm these associations.

Table 11. Factors Associated with Recurrence

This prospective study evaluated the outcomes of buccal mucosal graft (BMG) urethroplasty for anterior urethral strictures over a one-year follow-up in 45 patients. The success rate was 55.6%, with a recurrence rate of 44.4%, and 26.7% of patients requiring reintervention. These findings align with literature suggesting that outcomes in anterior urethroplasty can vary based on stricture characteristics and surgical approach.

Stricture site plays a pivotal role in treatment outcomes. In our study, pan-anterior strictures showed a disproportionate trend toward recurrence (20% of recurrences, but only 4% of non-recurrent cases). Benson et al. (2020) similarly highlighted that outcomes are significantly influenced by stricture location, with bulbar strictures achieving higher success rates than penile or pan-anterior segments【8】. This underscores the need for tailored surgical strategies in anatomically complex cases.

When evaluating graft site and placement, our study found no statistically significant difference in outcomes between dorsal and ventral onlay grafts (p = 0.521). Soave et al. (2018) compared outcomes by graft site and concluded that while both placements are viable, dorsal onlay may offer slightly improved durability due to its better mechanical support【9】. In our cohort, dorsal placement was used in 71% of cases, supporting its perceived advantage.

Our success rate of 55.6% at 12 months is on the lower end of what Andrich & Mundy (2001) reported for BMG urethroplasty, where success rates often exceeded 80% in high-volume centers with strict patient selection【10】. The discrepancy may be explained by our inclusion of patients with previous interventions (60%) and longer strictures (mean 3.9 cm), which are known to predict poorer outcomes.

We used a dorsal onlay technique in the majority of cases, aligning with the one-sided dorsal approach advocated by Kulkarni et al. (2014), which aims to minimize dissection and preserve vascularity【11】. Our findings reinforce the technique’s feasibility even in resource-limited settings, although the recurrence trends in longer and pan-anterior strictures suggest a need for refined patient stratification.

Donor site morbidity was minimal in our cohort, with 50% of patients reporting no pain, and only 10% experiencing moderate discomfort. These results align with Xu et al. (2020), who reported that non-closure of the buccal donor site may contribute to faster recovery and lower complication rates【12】. In our study, return to oral intake averaged 3 days, reflecting mild and transient morbidity.

From a broader perspective, our recurrence rate (44.4%) falls within the spectrum outlined by Mangera et al. (2011), who reported recurrence rates ranging from 15–40% in augmented urethroplasty, depending on technique and patient factors【13】. Our recurrence trend in patients with longer strictures (mean 4.0 cm vs. 3.8 cm, p = 0.533) mirrors their observation that stricture length significantly affects long-term patency.

Patient satisfaction and quality of life were not formally assessed in this study but remain critical. Barbagli et al. (2008) demonstrated that even with some complications, oral mucosa urethroplasty generally leads to significant improvement in quality of life, a hypothesis supported anecdotally in our patient follow-up【14】.

Regarding donor site complications, Ali et al. (2021) observed that pain, tightness, and numbness are more prevalent with cheek closure techniques, a factor we addressed by leaving sites open when appropriate. Our outcomes — with rapid oral recovery and minimal long-term symptoms — are consistent with that evidence【15】.

Finally, our findings support the conclusion by Andrich & Mundy (2008) and later echoed by Dubey et al. (2005) that the choice of technique must be individualized, and that no single method guarantees universal success【16】【17】. In our experience, the dorsal approach using BMG provided acceptable outcomes in most cases, but close postoperative monitoring is essential, particularly for patients with high-risk anatomical or clinical profiles

 Limitations

This study has several limitations that must be acknowledged. First, the sample size was relatively small (n = 45), limiting the statistical power to detect significant differences in subgroups or associations with recurrence. Second, the single-centre design may restrict the generalizability of our findings, particularly to centres with different surgical volumes or resources.

Third, the follow-up period was limited to 12 months, which, while sufficient to capture early recurrences, may not fully reflect long-term graft durability or late failures. Additionally, patient-reported outcomes and quality-of-life measures were not formally assessed, which could have provided valuable insight into subjective satisfaction and functional outcomes.

Buccal mucosal graft urethroplasty remains a viable and effective option for the management of anterior urethral strictures. In this prospective single-centre study, the procedure resulted in a 55.6% success rate at 12 months, with acceptable donor site morbidity and minimal severe complications.

Although recurrence was observed in 44.4% of patients, the majority were managed conservatively or with minor procedures. Trends toward higher recurrence in patients with longer or pan-anterior strictures suggest that anatomical complexity remains a key factor in surgical planning and prognostication.

Our findings support the use of the dorsal onlay approach as a reproducible technique, even in resource-constrained settings. However, larger multicentric studies with longer follow-up and inclusion of patient-reported outcomes are needed to validate these results and refine patient selection criteria.

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