If buccal mucosa from the inner cheek cannot be used, urethroplasty is still possible in many patients. The first alternatives are often another oral site such as lingual mucosa from the tongue, or penile skin in carefully selected men when the skin is healthy and there is no lichen sclerosus. In complex redo surgery, reconstructive surgeons may use combinations of tissues or less common graft sources. The correct substitute depends on why buccal mucosa is unavailable, how much tissue is needed and whether the disease itself affects genital skin.

Why buccal mucosa is used so often

The inner cheek provides a hairless, resilient mucosal graft that tolerates contact with urine and is familiar to reconstructive urologists. It is especially useful for augmentation of bulbar, penile and long anterior strictures. However, the urethra can be reconstructed with other tissues when cheek mucosa is insufficient, previously harvested or unsuitable.

Why might cheek mucosa not be suitable?

• Previous large buccal mucosa harvest from one or both cheeks.
• Poor oral mucosal quality from chronic tobacco or betel/areca nut exposure.
• Significant oral scarring, disease or previous oral surgery.
• A very long stricture requiring more graft than safely available from the cheeks alone.
• Patient preference after discussion of oral donor-site symptoms.

Option 1: lingual mucosa from the tongue

Lingual mucosa is harvested from the side or underside of the tongue and has urethral patency outcomes broadly comparable with buccal mucosa in available studies. The donor-site symptoms are different: tongue discomfort, altered sensation or temporary speech/eating difficulty may occur. For some long strictures, cheek and tongue grafts can be combined.

Option 2: healthy penile skin

Penile skin can be used as a graft or flap in selected men, particularly when oral mucosa is unavailable. It must be hairless and healthy. Foreskin can provide useful tissue in uncircumcised men. This option is not appropriate when lichen sclerosus affects the genital skin because using diseased skin carries a high risk of recurrent scarring.

What about scrotal or hair-bearing skin?

Hair-bearing perineal or scrotal skin is generally avoided because hair inside the reconstructed urethra can lead to infection, hairballs, stones and later revision. Modern reconstructive planning prefers hairless mucosa or skin whenever possible.

Less common grafts for difficult redo reconstruction

When oral mucosa and healthy penile skin are unavailable, specialised centres have described postauricular skin, abdominal or inguinal skin, split-thickness skin and even colonic mucosa. These should be understood as rescue options rather than interchangeable substitutes for buccal or lingual mucosa. Evidence is much smaller, donor-site trade-offs differ and some grafts are suitable only in very selected anatomy. The aim is not simply to find any tissue long enough to patch the urethra, but to choose tissue likely to remain healthy in that particular disease.

Does “no buccal mucosa” mean a staged urethroplasty?

Not automatically. A one-stage reconstruction may still be possible using another suitable graft or a flap if the urethral plate is healthy. A staged repair is considered when the local urethral plate and skin are severely scarred, when lichen sclerosus is extensive, after failed hypospadias surgery, or when there is insufficient healthy tissue for a reliable one-stage operation.

Can oral mucosa be harvested again?

Sometimes. The surgeon examines both cheeks and tongue to determine what has already been taken and how the donor sites healed. A previous cheek graft does not always eliminate all future oral graft options, but repeated harvest must be planned carefully to avoid excessive donor-site morbidity.

How the graft decision is made

• Length and location of the urethral stricture.
• Cause of the stricture, especially lichen sclerosus or failed hypospadias repair.
• Quality of the remaining urethral plate and penile skin.
• Previous graft harvest and prior urethroplasty technique.
• Amount of graft required.
• Oral examination and tobacco/areca exposure.
• Patient preference regarding oral, penile or staged reconstruction.

What to bring for consultation

• Previous urethroplasty operation notes stating which graft was harvested.
• RGU/VCUG images.
• Details of oral surgery, oral disease or previous graft donor-site problems.
• History of tobacco, gutkha, betel/areca nut or other chronic oral exposure.
• Current uroflow/PVR and urine culture.
• Photographs/records of genital skin disease if lichen sclerosus has been diagnosed.

What if only one cheek has already been used?

Previous harvest does not automatically mean all oral tissue is unavailable. The opposite cheek, lateral tongue or a combination may still provide enough graft, depending on previous scar and oral health. The mouth should be examined before surgery rather than assuming from memory that no graft remains. In a very long reconstruction, using multiple oral sites may be preferable to taking an excessively wide graft from one donor area.

Why graft choice depends on the disease, not just availability

A graft must remain healthy for years in the environment where it is placed. In lichen sclerosus, genital skin is a poor substitute even if it is easy to harvest, because the inflammatory disease can involve that skin. In a patient without lichen sclerosus, healthy penile skin may be a reasonable alternative. The same tissue can therefore be appropriate for one patient and a poor choice for another.

Donor-site counselling matters

Cheek and tongue harvest can cause short-term pain, tightness, altered sensation, difficulty opening the mouth or tongue discomfort. Most symptoms improve, but the pattern differs by donor site. Patients with oral tobacco exposure, prior oral surgery or limited mouth opening should mention this before the operation. The best graft is not only the one that reconstructs the urethra; the donor site should also be safe and acceptable.

FAQs

Related reading

• How Does the Urologist Decide Which Urethroplasty You Need?
• Can a Long Urethral Stricture Be Repaired in One Surgery?
• What If Urethroplasty Fails?
• Lichen Sclerosus and Urethral Stricture
• Urethroplasty Surgery Explained
• Buccal Mucosa Graft: What Happens to the Mouth After Urethroplasty?
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urethral Strictures: Tissue Transfer, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/tissue-transfer
• American Urological Association. Urethral Stricture Guideline (2023 amendment) https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline
• Abrate A, Gregori A, Simonato A. Lingual mucosal graft urethroplasty 12 years later: Systematic review and meta-analysis. Asian J Urol. 2019;6(3):230-241. doi:10.1016/j.ajur.2019.01.001.
• Wang A, Chua M, Talla V, et al. Lingual versus buccal mucosal graft for augmentation urethroplasty: a meta-analysis of surgical outcomes and patient-reported donor site morbidity. Int Urol Nephrol. 2021;53(5):907-918. doi:10.1007/s11255-020-02720-7.