Buccal mucosal graft urethroplasty uses lining from the inner cheek to widen or reconstruct a scarred urethra. Buccal mucosa is hairless, resilient, accustomed to a wet environment and can take well on a healthy vascular bed. It is widely used for longer bulbar, penile and panurethral strictures and for lichen sclerosus-related disease. The graft is not a tube taken from the mouth; it is usually a flat strip sewn into the opened urethra. The urethral catheter commonly stays about two to three weeks, and mouth soreness usually improves over days to weeks.

What is buccal mucosa?

Buccal mucosa is the smooth lining on the inside of the cheek. It has a thick epithelium and relatively thin, vascular connective-tissue layer, which make it a useful free graft for urinary reconstruction.

Why is it used for urethral stricture?

• It is hairless.
• It survives well in a moist urinary environment.
• It can be harvested in useful lengths.
• The mouth usually heals quickly.
• It avoids relying on scarred genital skin.
• It is particularly useful in lichen sclerosus, where genital skin should generally not be used for augmentation.

Which strictures commonly use a buccal graft?

• Longer bulbar urethral strictures.
• Penile urethral strictures.
• Panurethral strictures.
• Lichen sclerosus-related urethral disease.
• Redo strictures when local tissue is limited.
• Staged failed-hypospadias reconstruction.

How is the graft harvested?

The surgeon marks a strip on the inner cheek away from the salivary duct opening, injects local solution to assist dissection and removes a thin mucosal graft. Excess fat or muscle is trimmed from the back of the graft before it is transferred to the urethra. The donor site may be left open or closed; current evidence does not show a clear long-term superiority of one approach.

How is the graft placed on the urethra?

The scarred urethra is opened along its length and the graft is sutured as an onlay to widen it. Depending on location and technique, the graft may be placed dorsally, dorsolaterally or ventrally. The choice is less important than selecting an appropriate well-vascularised graft bed and preserving healthy tissue.

Does the graft grow inside the urethra?

The graft survives by initially absorbing nutrients from the recipient bed and then developing new blood supply. Over time it becomes integrated into the reconstructed urethral wall. The mouth grows a new lining over the donor area.

What happens to the mouth afterwards?

• Pain or burning when eating spicy/acidic foods for several days.
• Temporary cheek tightness.
• Mild swelling.
• Numbness or altered sensation that usually improves.
• Reduced mouth opening for a short period in some patients.

Long-term significant donor-site problems are uncommon, but can include persistent numbness, tightness or salivary-duct symptoms in a minority of patients. The risk increases with larger or repeated harvests.

What patients often misunderstand about the graft

The buccal mucosal graft is not a rigid patch placed over a hole. During urethroplasty it is spread flat onto a well-vascularised bed and carefully sutured to augment the opened urethral plate. The graft initially survives by diffusion from the recipient bed and then develops a new blood supply. Good contact, a healthy bed and avoidance of haematoma are therefore important technical principles.

The graft can be positioned dorsally, dorsolaterally or ventrally depending on urethral segment, spongiosum quality and surgeon preference. Current evidence does not support a single orientation as universally superior for every bulbar stricture. What matters more is appropriate patient/stricture selection and sound graft handling.

Oral mucosa is particularly useful because it is hairless, accustomed to a moist environment and relatively robust. It is also valuable in lichen sclerosus because genital skin may be involved by the same inflammatory disease. The cheek donor site heals independently from the urethral repair; eating does not “pull” on the graft inside the perineum.

How much buccal mucosa can be used?

The required graft length follows the urethral defect. A short bulbar augmentation may need tissue from one cheek, while a long penile or panurethral repair may require both cheeks and occasionally additional oral mucosa. The surgeon avoids the parotid duct opening and plans the width so the donor site can heal without excessive tightness.

There is no visible facial scar because tissue is harvested from inside the mouth. The donor bed may be left open or partly or completely closed depending on surgeon preference and graft size; evidence has not established one closure method as best for every harvest.

Previous buccal harvest does not automatically rule out another oral graft. Examination determines whether adequate healthy mucosa remains. In complex redo reconstruction, lingual mucosa or other tissues may also be considered, but oral mucosa remains the most established free graft in contemporary urethroplasty.

How graft position is chosen

Buccal mucosa can be placed dorsally, ventrally or laterally depending on stricture location, spongiosum quality and surgical approach. In bulbar urethroplasty, both dorsal and ventral onlay techniques can provide good outcomes when well performed; the choice often reflects anatomy and surgeon experience rather than a universal winner.

A dorsal graft is supported against the corporal bodies, while a ventral graft is supported by the vascular corpus spongiosum. In the penile urethra, dorsal placement and other graft configurations are used to maintain a supple channel without excessive shortening. Long strictures may require extended or double-surface augmentation in selected cases.

The important patient-facing point is that the cheek graft is not simply sewn in as a tube. It is laid onto a well-vascularised bed and becomes incorporated into the reconstructed urethral wall over time.

Catheter and recovery

After one-stage graft urethroplasty, a catheter commonly remains for two to three weeks. A urethrogram is used before removal to assess for significant extravasation. Patients gradually increase walking while avoiding heavy straining, cycling and perineal pressure during early healing.

Success and recurrence

Buccal graft urethroplasty has high patency in well-selected anterior strictures, but outcome varies by location, length, lichen sclerosus, radiation, previous surgery and follow-up duration. A recurrence can occur at either graft junction or within the reconstructed segment, so symptoms and flow should be followed.

Risks

• Recurrent stricture.
• Urine leak/fistula.
• Wound or urinary infection.
• Bleeding/haematoma.
• Post-void dribbling.
• Temporary perineal or penile sensory changes.
• Oral pain, numbness or tightness.

Dorsal versus ventral graft: why there is no universal winner

Patients sometimes hear that a buccal graft must be placed on a particular surface of the urethra. In reality, dorsal, dorsolateral and ventral graft placement can all be effective in appropriately selected bulbar strictures. The choice depends on stricture location, spongiosal quality, surgical exposure and the reconstructive technique being used.

The important principles are a well-vascularised graft bed, accurate quilting or fixation where required, a wide urethral plate and a tension-free closure. A technically fashionable graft position is less important than matching the operation to the scar.

What the graft does after surgery

The buccal mucosa is transferred without its own blood supply. During early healing it receives nutrients from the graft bed and then develops new vascular connections. That is why graft contact with healthy tissue, avoidance of haematoma and careful handling matter.

The graft does not remain a loose patch inside the urethra. It becomes incorporated into the reconstructed wall. Long-term success still depends on the underlying disease: recurrent lichen sclerosus, poor tissue quality or further instrumentation can affect a repair even when the graft initially heals well.

What to bring for consultation

• RGU and MCU/VCUG images or films, not only the written report.
• Uroflowmetry report and post-void residual if already done.
• Urine routine and urine culture reports.
• Serum creatinine and other relevant blood tests.
• Previous catheter, VIU/dilatation or urethroplasty discharge summaries.
• Details of any pelvic injury, prostate surgery, hypospadias surgery, radiation or recurrent infections.
• Current medicines, including blood thinners, and any history of self-dilatation.

FAQs

Related reading

• Buccal Mucosa Graft: What Happens to the Mouth After Urethroplasty?
• Urethroplasty Surgery Explained
• Panurethral Stricture Explained
• Lichen Sclerosus and Urethral Stricture
• Recovery 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
• European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males
• European Association of Urology. EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery
• European Association of Urology. EAU Guidelines on Urethral Strictures: Follow-up, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/followup
• European Association of Urology. EAU Guidelines on Urethral Strictures, 2026 https://uroweb.org/guidelines/urethral-strictures
• American Urological Association. Urethral Stricture Guideline (2023 amendment) https://www.auanet.org/guidelines-and-quality/guidelines/urethral-stricture-guideline