Buccal mucosal graft ureteroplasty uses a strip of inner-cheek lining to widen a long scarred segment of ureter rather than replacing the whole ureter. It is an increasingly used option for selected complex proximal or mid-ureter strictures when healthy ureteric tissue remains but a tension-free excision-and-rejoin repair is not possible. The ureter is opened along the stricture and the oral graft is sutured as an onlay or tailored configuration, usually with well-vascularised tissue such as omentum supporting it. It can avoid bowel substitution in suitable patients.

Why use buccal mucosa?

Oral mucosa is robust in a wet environment and has long experience in urethral reconstruction. In the ureter, it provides additional width while preserving native continuity and blood supply.

Who may be suitable?

• Long proximal or mid-ureteric stricture.
• Redo stricture after previous repair.
• Stricture where excision would create excessive tension.
• Selected patients in whom avoiding an ileal ureter is desirable.
• Adequate renal function and reconstructable surrounding tissue.

Who may not be ideal?

• Complete loss of a very long segment with no usable ureteric plate.
• Severely unhealthy or radiated tissue without reliable vascular support.
• Poor oral donor tissue or significant oral disease.
• A poorly functioning kidney where reconstruction offers little benefit.

How is it performed?

• The stricture is exposed and length confirmed.
• The ureter is opened longitudinally through the narrowing.
• A buccal graft is harvested from the cheek.
• The graft is sutured to widen the ureter rather than forcing a tight excision-and-anastomosis.
• Vascularised tissue, commonly omentum, is positioned around the graft when appropriate.
• A DJ stent provides internal drainage during healing.

Benefits

• Can bridge longer strictures than simple uretero-ureterostomy.
• Preserves native ureteric continuity.
• May avoid bowel interposition and its metabolic or mucus-related issues.
• Can be used in selected redo reconstruction.

Limitations

This is specialised reconstruction with less long-term evidence than traditional reimplantation or pyeloplasty. Very extensive defects may still require ileal ureter or another solution.

Mouth recovery

The cheek donor site can be sore or tight initially. Most patients progress from soft foods to normal diet as comfort improves. Persistent numbness, major bleeding or severe mouth-opening difficulty should be reviewed.

Risks and follow-up

• Urine leak.
• Recurrent stricture.
• UTI.
• Stent symptoms.
• Mouth donor-site pain or numbness.
• Need for further endoscopic or reconstructive treatment.

Where buccal mucosal graft ureteroplasty fits in modern reconstruction

Buccal mucosal graft (BMG) ureteroplasty augments a narrowed ureter instead of replacing a long segment completely. The strictured ureter is opened longitudinally and oral mucosa is sutured as an onlay patch, often with omentum or another vascularised tissue wrapped around it. In some techniques the graft is used with an augmented anastomosis after excising the worst scar.

This approach is particularly attractive for complex proximal or mid-ureteric strictures that are too long for a tension-free uretero-ureterostomy but where preserving the native ureter can avoid bowel interposition or renal autotransplantation. Contemporary multi-institutional series and systematic reviews report success around 90%, but evidence is still mainly observational and expertise is concentrated in reconstructive centres.

Patient selection matters. Active malignancy in the segment, severely unhealthy tissue, very extensive ureteric loss, poor renal function or lack of a suitable vascular bed may favour another strategy. The operation can be open, laparoscopic or robotic; the reconstructive principle is more important than the platform. Patients should also understand the separate oral donor-site recovery.

How the graft is supported and why vascularity matters

Buccal mucosa is a free graft, so it must acquire blood supply from the tissue onto which it is placed. The reconstructed ureter is therefore commonly wrapped or covered with well-vascularised omentum, perirenal fat or another local tissue. A heavily radiated or devascularised bed may be less suitable.

The surgeon can use an onlay graft to widen a longitudinally opened stricture or an augmented anastomosis in which the worst segment is partly excised and the remaining defect is patched. A temporary DJ stent keeps the lumen drained while healing occurs.

Follow-up is important because early technical success does not prove lifelong patency. Symptoms, creatinine and imaging are monitored; if hydronephrosis persists, functional testing may distinguish residual dilatation from recurrent obstruction.

What the operation can look like in practice

The strictured ureter is exposed and opened longitudinally through the narrowed segment. If the lumen is still present, a buccal graft can be sewn as an onlay patch to widen it. When a short central portion is nearly obliterated, the worst tissue may be excised and the remaining gap augmented with mucosa rather than replacing a long length of ureter.

The graft has no independent blood supply when harvested. It survives by inosculating with the vascular bed underneath and is often covered with omentum or healthy peri-ureteric tissue. This vascular support is one reason severe radiation fibrosis or gross devascularisation can limit suitability.

Robotic surgery has expanded use of this technique because intracorporeal suturing allows precise graft placement, but open or laparoscopic principles are the same. Current evidence is encouraging, with contemporary multi-institutional series and systematic reviews reporting high patency, but it remains a specialised reconstruction with less long-term evidence than traditional distal reimplantation.

What patients should know about the evidence

Buccal-mucosal graft ureteroplasty has moved from isolated reports to multi-institutional series, particularly with robotic reconstruction. Recent systematic reviews report high short- and intermediate-term success, around nine in ten patients in pooled series, but the evidence is largely observational and follow-up is shorter than for traditional reimplantation or pyeloplasty.

That makes it a valuable specialised option rather than a universal replacement for established repairs. It is most attractive when a diseased ureteric segment is too long for a tension-free native anastomosis but enough ureter remains to preserve as a graft bed.

Patients should ask not only whether the operation is technically possible but what alternative would be used if the tissue encountered at surgery is unsuitable for grafting.

Onlay grafting versus excision: why the ureter must still have a lumen

Buccal mucosal graft ureteroplasty is most useful when a narrowed ureter can be opened longitudinally and widened over a healthy vascular bed. A completely obliterated segment cannot simply be patched because there is no usable ureteral plate to augment. In that setting, excision-anastomosis or another replacement strategy may be more appropriate.

The quality of the ureter is as important as its length. An impacted stone, radiation or previous surgery may leave tissue that is narrow but also ischemic; reconstructive planning must identify whether that wall is healthy enough to support an onlay graft.

Why current results are encouraging but still need perspective

Recent multi-institutional series and meta-analyses report high short- to intermediate-term success for oral mucosal graft ureteroplasty, particularly for complex strictures that would otherwise require more invasive substitution. Robotic surgery has helped make the technique more accessible in specialised centres.

However, the evidence is still dominated by retrospective series from experienced reconstructive teams. Long-term durability, ideal stricture length and the best graft configuration are less established than for traditional ureteric reimplantation or pyeloplasty. Patients should view BMG ureteroplasty as an important modern option, not as a universal replacement for every ureteric reconstruction.

What to bring for consultation

• Ultrasound, CT urography/CT abdomen or MR urography reports and images if available.
• Renogram report (DTPA/MAG3) if performed.
• Serum creatinine and recent kidney-function reports.
• Urine routine and culture reports.
• Previous operative notes, discharge summaries and pathology reports if the problem followed surgery.
• Details of any DJ stent or nephrostomy: side, date placed and last change.
• A list of current medicines and any history of radiation, stones, endoscopy or pelvic surgery.

FAQs

Related reading

• Ureteric Stricture: Symptoms and Treatment
• Uretero-Ureterostomy Explained
• Boari Flap Surgery Explained
• Ileal Ureter Replacement for Long Ureteric Stricture
• Buccal Mucosa Graft: What Happens to the Mouth After Urethroplasty?
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urological Trauma, 2026 https://uroweb.org/guidelines/urological-trauma
• Lo Re M, Bucca B, Cocci A; EAU Young Academic Urologists Trauma/Reconstructive Urology Working Party. Oral mucosa graft ureteroplasty: defining its role in complex ureteral reconstruction. Curr Opin Urol. 2026;36:374-380. PMID: 41936128 https://pubmed.ncbi.nlm.nih.gov/41936128/
• Zeng X, et al. Ureteroplasty for the Repair of Ureteral Stricture Using Lingual Mucosa and Buccal Mucosa Grafts: A Meta-Analysis. Urol Int. 2025;109:533-545. PMID: 40064149 https://pubmed.ncbi.nlm.nih.gov/40064149/
• Chao BW, et al. Robotic Buccal Mucosa Graft Ureteroplasty: A Decade of Experience From a Multi-institutional Cohort. Urology. 2025;197:174-179. PMID: 39622442 https://pubmed.ncbi.nlm.nih.gov/39622442/