When and how to use buccal mucosa grafts in penile and bulbar urethroplasty.

The surgical treatment of adult anterior urethral strictures has been a constantly evolving process, and renewed controversy exists over the best means of reconstructing the anterior urethra. Recently, considerable changes have been introduced: the wider use of buccal mucosa graft versus the use of genital or extragenital skin, and the use of dorsal onlay urethroplasties, also named Barbagli procedures. Moreover, in the penile urethra the dorsal placement of the graft is now combined with the incision and the augmentation of the urethral plate, as suggested for childhood hypospadias surgery. In adult male patients, the urethral strictures involving the penile and bulbar urethra are due to failed hypospadias repair, ischemia, lichen sclerosus, congenital anomalies of the mucosal membrane, traumatic scar after blunt perineal trauma. Buccal mucosa is receiving increased attention in the urological literature for penile and bulbar urethroplasty. We present here, step by step, 4 different surgical techniques for penile and bulbar urethroplasty, using buccal mucosa grafts. The surgical procedures are selected according to the current and updated literature and to the new classification of anterior urethral diseases. The ideal surgical technique should be simple, safe, reliable and reproducible in the hands of any surgeon, as well as being based on sound anatomical principles. We believe the technique we present here fulfil all these criteria.