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Buccal Mucosa Graft (BMG)

Buccal mucosa is the usual first-choice graft for substitution urethroplasty. Its hair-free, nonkeratinized epithelium, pliability and suitable lamina propria support use in a wet urinary environment. The choice still depends on donor health, recipient vascularity, defect geometry and the patient's priorities. A graft must revascularize after transfer; it is not a vascularized flap.[2][3][19]

See Grafts in GU Reconstruction for tissue selection and The Oral Cavity for harvest anatomy.

Tissue Biology and Selection​

BMG is well suited to reconstruction, but it can scar, contract, become infected or fail. Descriptions of rapid oral healing and a “scarless” biological phenotype are mechanistic observations, not guarantees about a transplanted urethral graft. Saliva and oral flora do not confer proven infection immunity after transplantation.[3][4]

AUA 2023 recommends oral mucosa as the first graft choice and recognizes buccal and lingual mucosa as alternatives. EAU 2026 similarly supports buccal or lingual mucosa when available. Donor-site effects differ: cheek harvest can cause numbness, tightness and swelling; lingual harvest can affect speech and tongue movement. Discuss the trade-offs rather than assuming identical morbidity.[2][19]

Inspect for oral disease, scars, restricted opening and previous harvests. Buccal mucosa is often available, but bilateral or repeat harvest is not automatically appropriate. For LS-associated urethral strictures, avoid genital skin; oral mucosa is generally preferred. This does not make BMG immune to recurrence.[2][19]

Harvest and Preparation​

Exposure and protection​

Coordinate airway access, oral exposure and local anesthesia with the anesthetic team. Identify and protect the parotid duct papilla opposite the upper second molar, oral commissure and relevant sensory structures. Mark the actual graft needed within the patient's available healthy mucosa; a fixed margin does not replace direct identification of the duct.[3][21]

Buccal mucosa graft harvest: Intraoral cheek view

The cheek graft is outlined below the parotid duct papilla and away from the oral commissure. Identify the duct and assess oral capacity before harvesting. This conceptual schematic does not define a universally safe incision margin or graft size.

Elevation and sizing​

Submucosal infiltration can facilitate dissection and hemostasis; the agent, concentration and total dose follow the operative/anesthetic plan. Elevate mucosa with its lamina propria while avoiding unnecessary buccinator injury. Remove excess adherent fat and muscle without perforating or excessively thinning the graft. Secure the prepared graft in close contact with a suitable vascularized recipient bed, avoiding folds, hematoma and shear.[3][6]

Available dimensions vary with oral anatomy, prior harvests and graft design. A defect longer than 7 cm does not automatically mandate bilateral cheek harvest. Plan the total area and configuration needed, and discuss bilateral cheek, lingual or other appropriate donor options when one cheek is insufficient.[1][19]

Close the donor site or leave it open?​

Both are accepted options. Consider hemostasis, defect size, tension, oral mobility and patient preference. A large defect may not permit a comfortable primary closure.[2]

  • Soave's 135-patient RCT found nonclosure noninferior for oral pain intensity and affective quality during follow-up. It did not establish superiority for every oral outcome.[11]
  • Hwang's systematic review based its main analysis on three randomized trials, with two quasi-randomized studies added in sensitivity analysis. Evidence for pain, numbness, salivation, mouth opening and further procedures was low or very low certainty.[20]
  • Güler’s later review included seven studies, four using quasi-random allocation and one involving lingual grafts. It suggested less early pain with nonclosure, but mixed donor sites, sensitivity analyses and imprecise reporting limit a universal recommendation.[21]

The often-quoted pain scores 2.26 versus 3.68 came from Wood's small prospective comparison, separate from Soave's RCT. They should not be presented as a single randomized-trial result.[12]

Applications and Placement​

SettingRole and limitations
Bulbar/anterior strictureDorsal, dorsolateral, ventral and inlay configurations are selected according to the plate, spongiosum and graft support; no placement is universally best
Penile or panurethral strictureOne-sided dissection, multiple grafts or staged reconstruction may be appropriate; donor availability and diseased plate/tissue quality matter
Focal near-obliteration within a longer bulbar strictureSelected double-sided graft or augmented anastomotic techniques; a completely absent plate requires a different reconstruction than simple augmentation
Posterior stenosis after cancer treatmentSelected nonobliterative cases can undergo graft reconstruction; sphincter function, bladder capacity, radiation damage and fistula must be assessed
Distal/fossa navicularis strictureTransurethral ventral inlay is one specialist option; disease extending proximally requires adequate assessment
Complex/failed hypospadiasStaged oral graft reconstruction may be appropriate; later growth, curvature and long-term outcomes require follow-up
Ureteral reconstructionSelected complex strictures may be augmented with BMG; viability, defect configuration and vascularized support determine suitability

These applications have different evidence and operative requirements. EAU advises against a free graft fashioned as a complete tube in a single-stage urethroplasty. Grafting a bed first and tubularizing it after healing in a later stage is a distinct operation.[3][19]

Detailed technique pages: urethral reconstruction, BMG ureteroplasty, and omental support.

Selected outcomes: preserve the population and endpoint​

  • Posterior reconstruction — Doležel 2024: 38 patients with mixed posterior/VUAS pathology and open/endoscopic graft approaches. Three-year freedom from recurrence was 65%; it rose to 81% only when an additional “auxiliary” DVIU was allowed. New incontinence occurred in 2/18 initially continent patients. These are not interchangeable single-operation success rates.[7]
  • Dorsal BMG after prostatectomy plus radiation — Sterling 2024: 45 selected patients with nonobliterative stenosis; seven recurrences, with median 21-month follow-up among those without recurrence. No new SUI was reported, but pre-existing incontinence was common and there was no randomized comparison with excision/transection. The study cannot establish a continence advantage or assess erectile safety in a generally potent population.[8]
  • Distal transurethral ventral inlay — Sterling 2023: 44 patients in a retrospective single-center series, with approximately 95% patency without further intervention at mean 36 months. This is intermediate-term technique evidence, not a result for every distal stricture.[9]
  • Bracka repair — Manasherova 2020: reported complications were 23/112 with buccal versus 33/108 with preputial grafts, but the groups came from different treatment eras. The comparison does not prove BMG superiority for all pediatric reconstructions.[10]

The GURS survey describes respondent preference, not measured clinical efficacy: 134 of 350 invited members responded. BMG was preferred over a penile flap by 95% for circumcised and 84% for uncircumcised patients. Survey-reported success should not be pooled with prospective follow-up.[1]

Donor-Site Morbidity and Counseling​

Discuss pain, bleeding, swelling, sensory change, difficulty opening the mouth, salivary/duct problems and temporary effects on eating or speaking. Some symptoms persist. Published rates depend on the donor site, graft area, closure method, questionnaire and follow-up; they are not one universal complication profile.[11][12][13][14]

EvidenceWhat it contributes
Wood 2004Only 49/110 men returned the morbidity questionnaire, representing 57 harvests. High symptom rates in respondents illustrate possible morbidity but are susceptible to response bias
Barbagli 2014Retrospective 553-person cheek-harvest cohort with closed ovoid defects; reported satisfaction 98.2%. Bilateral harvest predicted dissatisfaction within this cohort, not as the only possible predictor in all patients
Castagnetti 2008Mixed oral-donor/age series of 78 patients; clinical examination found persistent sensory deficits in 28% at median 7.6 years, often with little perceived bother. This is not a BMG-only incidence for every patient
Desai 2025Prospective 40-person series using oral-health questionnaires;80% had at least one daily oral activity affected initially and 3/40 had long-term mouth-opening difficulty. Small size limits generalization
[12][13][14][15]

Provide a plan for analgesia, oral hygiene, diet progression and review of persistent bleeding, swelling, sensory change or restricted opening. The patient's degree of bother and ability to eat/speak matter alongside an event count.

Durability and Recurrence​

Assess success using freedom from reintervention, symptoms/flow, appropriate anatomical testing and patient-reported function. Short follow-up, survivor-only questionnaires and inconsistent definitions can make percentages look more favorable than durable single-operation success.[2][5][6]

Previous repair: Vetterlein's 534-person retrospective series reported 87.4% initial,87.5% repeat-BMG and 70.6% secondary-after-other-repair success at median 33 months. These groups describe selected patients at a specialist center, not guaranteed outcomes for the next patient.[16]

LS: the historical 50%-versus 80% single/staged comparison involved only eight versus five LS patients. It does not determine the operation for every LS stricture. Current guidance allows single-stage oral grafting when local conditions are favorable; extensive scarring or an unsuitable plate may require staging or another approach.[17][19]

Comorbidity and length: a 2025 systematic review found associations with diabetes, penile/penobulbar location and longer strictures, but the evidence was observational with variable definitions and follow-up. The 7-cm subgroup result came from only two studies; it is not a validated threshold for accepting or refusing BMG.[22]

Blood loss is not a graft-quality target. Meyer's selected 517-person retrospective analysis associated a larger hemoglobin drop with fewer recurrences. It did not prove better perfusion, justify additional bleeding or show that cardiometabolic risk is irrelevant. Preserve vascularity and use careful hemostasis; optimize the patient's actual risk factors.[18]

Discuss possible changes in erections, ejaculation, sensation, penile shape and dribbling. Improvement in average urinary scores or unchanged sexual scores in a small selected group does not exclude individual harm.[5][6][8]

Comparison With Penile Skin Grafts​

PeeBuSt and Alrefaey 2025 found no significant success difference in selected anterior-stricture patients. BMG success was 44/48 at 18 months and 47/48 at 12 months, respectively. These were not equivalence trials; short follow-up, sample size and selection limit the inference. See the penile/preputial graft page for denominators, trial design and donor-site trade-offs.[5][6]

Oral mucosa remains the guideline-preferred graft when appropriate. A healthy penile-skin graft can be considered when oral tissue is unavailable, unsuitable or declined, outside LS-related reconstruction.[2][19]

Investigational Alternatives​

Tissue-engineered mucosa, extracellular-vesicle approaches and organoid systems remain areas of research. Manufacturing, effectiveness, safety and durable clinical outcomes must be established; they are not routine substitutes for a standard autograft. EAU advises use of autologous tissue-engineered oral mucosa within clinical trials.[4][19]

Videos​

Buccal Mucosa Graft Harvest
Operative technique

References​

1. Berg C, Singh A, Hu P, et al. "Current Trends in the Use of Buccal Grafts During Urethroplasty Among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019

2. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." J Urol. 2023;210(1):64–71. doi:10.1097/JU.0000000000003482

3. Horiguchi A. "Substitution Urethroplasty Using Oral Mucosa Graft for Male Anterior Urethral Stricture Disease: Current Topics and Reviews." Int J Urol. 2017;24(7):493–503. doi:10.1111/iju.13356

4. Sterling J, Hecksher D, Hayden C, et al. "Buccal Mucosa a Narrative Review: How Does It Work, How Is It Used, What Is Coming Next." Urology. 2026:S0090-4295(26)00169-X. doi:10.1016/j.urology.2026.03.015

5. Alrefaey A, Anwar MA, Abdelmagid ME, et al. "Comparative Outcomes of Penile Skin Grafts Versus Buccal Mucosal Grafts in Urethroplasty for the Treatment of Extensive Anterior Urethral Strictures." Sci Rep. 2025;15(1):29508. doi:10.1038/s41598-025-14191-w

6. Tyagi S, Parmar KM, Singh SK, et al. "'Pee'BuSt Trial: A Single-Centre Prospective Randomized Study Comparing Functional and Anatomic Outcomes After Augmentation Urethroplasty With Penile Skin Graft Versus Buccal Mucosa Graft for Anterior Urethral Stricture Disease." World J Urol. 2022;40(2):475–481. doi:10.1007/s00345-021-03843-x

7. Doležel J, Hrabec R, Uher M, et al. "Substitution Urethroplasty With Buccal Mucosal Graft in the Management of Stricture of Vesicourethral Anastomosis or Membranous Urethra: Single-Institution Long-Term Experience With Perineal Approach and Endourethroplasty." Urology. 2024;192:126–132. doi:10.1016/j.urology.2024.05.034

8. Sterling J, Simhan J, Flynn BJ, et al. "Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis." J Urol. 2024;211(4):596–604. doi:10.1097/JU.0000000000003848

9. Sterling J, Daneshvar M, Nikolavsky D. "Transurethral Ventral Inlay Buccal Mucosa Graft Urethroplasty: Technique and Intermediate Outcomes." BJU Int. 2023;132(1):109–111. doi:10.1111/bju.16007

10. Manasherova D, Kozyrev G, Nikolaev V, et al. "Bracka's Method of Proximal Hypospadias Repair: Preputial Skin or Buccal Mucosa?" Urology. 2020;138:138–143. doi:10.1016/j.urology.2019.12.027

11. Soave A, Dahlem R, Pinnschmidt HO, et al. "Substitution Urethroplasty With Closure Versus Nonclosure of the Buccal Mucosa Graft Harvest Site: A Randomized Controlled Trial With a Detailed Analysis of Oral Pain and Morbidity." Eur Urol. 2018;73(6):910–922. doi:10.1016/j.eururo.2017.11.014

12. Wood DN, Allen SE, Andrich DE, Greenwell TJ, Mundy AR. "The Morbidity of Buccal Mucosal Graft Harvest for Urethroplasty and the Effect of Nonclosure of the Graft Harvest Site on Postoperative Pain." J Urol. 2004;172(2):580–583. doi:10.1097/01.ju.0000132846.01144.9f

13. Barbagli G, Fossati N, Sansalone S, et al. "Prediction of Early and Late Complications After Oral Mucosal Graft Harvesting: Multivariable Analysis From a Cohort of 553 Consecutive Patients." J Urol. 2014;191(3):688–693. doi:10.1016/j.juro.2013.09.006

14. Desai D, Joshi S, Ravichandran K, et al. "Donor Site Morbidity and Impact on Oral Health Following Buccal Mucosal Graft Harvesting for Urethroplasty: A Prospective Study." World J Urol. 2025;43(1):531. doi:10.1007/s00345-025-05898-6

15. Castagnetti M, Ghirardo V, Capizzi A, Andretta M, Rigamonti W. "Donor Site Outcome After Oral Mucosa Harvest for Urethroplasty in Children and Adults." J Urol. 2008;180(6):2624–2628. doi:10.1016/j.juro.2008.08.053

16. Vetterlein MW, Stahlberg J, Zumstein V, et al. "The Impact of Surgical Sequence on Stricture Recurrence After Anterior 1-Stage Buccal Mucosal Graft Urethroplasty: Comparative Effectiveness of Initial, Repeat and Secondary Procedures." J Urol. 2018;200(6):1308–1314. doi:10.1016/j.juro.2018.06.067

17. Levine LA, Strom KH, Lux MM. "Buccal Mucosa Graft Urethroplasty for Anterior Urethral Stricture Repair: Evaluation of the Impact of Stricture Location and Lichen Sclerosus on Surgical Outcome." J Urol. 2007;178(5):2011–2015. doi:10.1016/j.juro.2007.07.034

18. Meyer CP, Lamp J, Vetterlein MW, et al. "Impact of Cardiovascular and Metabolic Risk Factors on Stricture Recurrence After Anterior One-Stage Buccal Mucosal Graft Urethroplasty." Urology. 2020;146:253–259. doi:10.1016/j.urology.2020.07.073

19. EAU. Urethral Strictures: Tissue Transfer and Disease Management in Males. 2026; tissue-transfer and LS reconstruction guidance.

20. Hwang EC, de Fazio A, Hamilton K, et al. A systematic review of randomized controlled trials comparing buccal mucosal graft harvest site non-closure versus closure in patients undergoing urethral reconstruction. World J Mens Health. 2022;40(1):116. doi:10.5534/wjmh.200175.

21. Güler Y. Comparison of closure versus non-closure of the intraoral buccal mucosa graft site in urethroplasties: a systematic review and meta-analysis. Arab J Urol. 2023;21(1):18. doi:10.1080/2090598X.2022.2097613.

22. Yoshikawa GB, Gomar GG, Gadens GC, et al. Re-stricture after buccal mucosal graft urethroplasty: a systematic review and meta-analysis. Acta Cir Bras. 2025;40:e403525. doi:10.1590/acb403525.