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Penile / Preputial Skin Graft

The penile / preputial skin graft is non-glabrous penile-shaft or preputial skin used as a free graft (without a dartos vascular pedicle), placed on a vascularized recipient bed (typically the corpus spongiosum or tunica albuginea) and dependent on imbibition and inosculation for survival. It is the historical predecessor of buccal mucosa as the workhorse substitute for urethroplasty,[1] and remains a viable alternative when oral mucosa is unavailable or unsuitable.[2][3]

See the overview article for graft-selection principles: Grafts in GU Reconstruction. For pedicled (dartos-based) configurations — Quartey / Duckett transverse preputial island, Orandi dorsal onlay, McAninch circular fasciocutaneous, etc. — see the dedicated pedicled penile / preputial skin flap page.

Graft vs flap — the distinction matters

WARWIKI separates free penile-skin grafts from pedicled penile-skin flaps because they have different vascular requirements, configurations, and outcome profiles:

  • Free graft (this page) — harvested as a defatted full-thickness skin graft and placed on a vascularized bed. Survival depends on the recipient bed. Used in Bracka staged hypospadias, dorsal-onlay onlay graft urethroplasty, dorsolateral inner-preputial graft (DOIG), and the Kulkarni spiral preputial graft.
  • Pedicled flap — maintains its dartos blood supply, allowing transfer to scarred or poorly vascularized recipient sites. Used in Quartey-Duckett TPIF, Orandi dorsal onlay flap, McAninch circular flap, and other named techniques on the flap page.[4]

Historical Context​

Through the 1990s, penile / preputial skin was the standard substitute for urethral reconstruction. Barbagli 1998 reported 92% success with dorsal-onlay preputial skin grafts for bulbar strictures, anchoring the dorsal-onlay-graft paradigm that has since transferred essentially intact to buccal mucosa.[5] The late 1990s and 2000s saw a gradual shift toward buccal mucosa; current GURS practice surveys show that 99% of reconstructive urologists prefer buccal mucosa as the primary graft material, and 95% prefer BMG over fasciocutaneous flaps for penile urethroplasty regardless of circumcision status.[3] At a major US tertiary center, penile-skin-flap utilization fell as perineal urethrostomy rose (4.3% in 2008 → 38.7% in 2017) while BMG use remained stable.[1] Despite the shift, expertise in penile-skin-graft techniques remains essential for managing complex strictures and patients in whom oral mucosa is unsuitable.

Tissue Properties​

Inner preputial skin offers several qualities desirable for urethral reconstruction:[6][2]

  • Hairless (inner preputial skin specifically) — avoids the urethral-calculus, recurrent-UTI, and obstruction risks associated with hair-bearing skin in the urethra[6]
  • Thin, pliable, and elastic
  • Local availability — same operative field, no second surgical site
  • Familiar to most urologists; harvestable under regional anesthesia
  • Non-keratinizing to mildly keratinizing when non-hair-bearing

Compared with buccal mucosa, preputial skin lacks the wet-epithelium / urinary-milieu compatibility, the rapid neovascularization of mucosal lamina propria, and the intrinsic resistance to lichen sclerosus that have driven BMG adoption.[2]

Harvest Technique​

The graft is harvested as a defatted full-thickness skin graft:

  1. Site selection — inner preputial skin is preferred for its hairlessness. In circumcised patients, ventral or lateral non-hair-bearing penile-shaft skin can sometimes be used, but options are limited; consider circumpenile shaft skin (flap variant) or shifting to oral mucosa.
  2. Marking and incision — outline the graft on the inner prepuce sized to the urethral defect plus margin; circumcise carefully to preserve the desired skin.
  3. Defatting — place the harvested skin epithelium-down on a wet sponge and meticulously remove all subcutaneous tissue and dartos using sharp scissors. Inadequate defatting is the most common preventable cause of graft loss.
  4. Spiral configuration (Kulkarni 2023) — for panurethral strictures, a helicoidal harvest from a 5-cm-wide preputial cuff can yield grafts up to 20 cm in length. At 12-month follow-up, only 1 of 20 patients had recurrence.[7]
  5. Recipient bed preparation — quilt the graft to a vascularized recipient bed (corpus spongiosum or tunica albuginea) using interrupted absorbable sutures to ensure intimate apposition and prevent shearing.

Applications in Urology and Urogynecology​

1. Anterior urethral stricture — dorsal-onlay graft urethroplasty​

The original and most studied application. Barbagli 1998 reported 92% success for bulbar strictures with dorsal-onlay preputial skin grafts at long-term follow-up.[5] Contemporary head-to-head data:

Trial / seriesConfigurationComparisonSuccess rate (penile / preputial skin graft)Comparator successSignificance
Tyagi 2021 (DOIG)[8]Dorsolateral inner preputial graftSingle-arm86.7–93.3% at long-term FU——
Tyagi 2022 (PeeBuSt RCT)[9]Augmentation urethroplastyPenile skin graft vs BMG89%BMG 91%NS
Alrefaey 2025 RCT[10]Augmentation urethroplasty (extensive anterior strictures)Penile skin graft vs BMG93.2%BMG 97.9%NS
Dubey 2007 RCT[11]Dorsal-onlay BMG vs penile-skin flapFlap (not free graft)85.6%BMG 89.9%NS for success; flap had higher morbidity (skin necrosis, penile torsion) and lower patient preference

Synthesis. The two graft-vs-graft RCTs (PeeBuSt, Alrefaey 2025) confirm statistical equivalence in success rates between penile / preputial skin grafts and BMG. The Dubey 2007 RCT — comparing BMG to a penile-skin flap — found similar success but higher technical complexity and morbidity for the flap arm. Despite the equivalence, contemporary practice favors BMG because of its broader indication profile, faster operative time, lower donor-site morbidity, and applicability in lichen sclerosus.[3][2]

2. Panurethral stricture — Kulkarni spiral preputial graft​

For panurethral disease, Kulkarni 2023 described a single-stage spiral preputial graft technique: a 5-cm-wide preputial skin cuff is harvested helicoidally and reconfigured into a graft up to 20 cm in length, sufficient for the entire anterior urethra. At 12-month follow-up, only 1 of 20 patients had recurrence.[7]

3. Bracka staged hypospadias repair​

The Bracka technique uses inner preputial skin (or BMG) as a free graft on the ventral penile shaft in stage 1, with tubularization in stage 2 at 6 months. Manasherova 2020 compared preputial skin graft vs BMG in Bracka's method for proximal hypospadias:[12]

  • Preputial-skin-graft complication rate 31% vs BMG 20%
  • BMG yielded superior cosmetic results
  • Both grafts viable; BMG marginally preferred for cosmetic outcome

4. Onlay preputial graft for hypospadias​

Cambareri 2016 — 25-year experience with onlay preputial graft hypospadias repair:[13]

  • 62 patients
  • Overall complication rate 35.5% (fistula most common at 33.9%)
  • Wider grafts associated with fewer complications — a recurrent technical principle in preputial-graft urethroplasty

5. Combined graft–flap techniques​

In complex urethral strictures with damaged urethral plates, free penile-skin grafts can be combined with pedicled flaps or with BMG to reconstruct extensive defects in a single stage.[14]

Predictors of Failure​

The strongest data on failure predictors come from Mathur 2014 (single-stage preputial-skin flap urethroplasty for long-segment strictures) — the same risk-factor pattern broadly applies to free preputial grafts:[15]

Risk factorRelative risk
Diabetes mellitus5.21 (p = 0.003)
Smoking4.19 (p = 0.01)
Stricture length > 70 mm3.25
Panurethral stricture2.73
Previous urethroplasty2.40
Severe periurethral fibrosis2.37
Post-infective etiology2.19

The metabolic and tissue-quality factors (diabetes, smoking, fibrosis) dominate, consistent with the graft's dependence on a healthy vascularized recipient bed.

Contraindications​

  • Lichen sclerosus — genital skin is affected by the disease process; all penile / preputial skin substitutes (graft or flap) should be avoided in LS-associated urethral strictures. Kulkarni 2009 anchors this rule with a 215-patient multicenter LS series; the AUA 2023 guideline explicitly recommends oral mucosa for LS strictures.[6][16] For glans resurfacing in LS, split-thickness skin grafts from extragenital sites are the standard.[17]
  • Prior circumcision — eliminates the inner preputial donor site. Circumpenile non-hair-bearing shaft skin can sometimes substitute as a pedicled flap, but free graft options become very limited.
  • Hair-bearing skin — the AUA 2023 guideline explicitly prohibits hair-bearing skin in the urethra (calculus, recurrent UTI, obstruction risk).[6]
  • Diseased or scarred penile skin — prior surgery, radiation, or infection compromising tissue quality.
  • Oral dyskeratosis from tobacco / betel nut — paradoxically a relative indication for penile / preputial skin graft, since BMG is contraindicated when the buccal mucosa shows submucous fibrosis or leukoplakia.[18]

Comparison — Penile / Preputial Skin Graft vs BMG​

ParameterPenile / preputial skin graftBuccal mucosa graft
Success rate (anterior stricture)85–93%89–98%
Operative timeLonger (~224 min)Shorter (~162 min)
Post-void dribbling~34%~15%
Donor-site morbidityPenile skin necrosis, torsion (with flap)Oral numbness, tightness (transient)
Patient preference (Dubey 2007)65% would recommend89% would recommend
Availability in circumcised patientsLimitedUniversal
Use in lichen sclerosusContraindicatedPreferred
Use with oral dyskeratosisPreferred alternativeContraindicated
GURS 2024 surgeon preference (penile urethroplasty)5%95%

References: Wessells 2023,[6] Berg 2024,[3] Sterling 2026,[2] Tyagi 2022 PeeBuSt,[9] Alrefaey 2025,[10] Dubey 2007,[11] Kulkarni 2009,[16] Fuchs 2018.[1]

When to Choose Penile / Preputial Skin Graft​

ScenarioRationale
Oral mucosa unsuitable (submucous fibrosis, leukoplakia, limited oral opening)Penile / preputial skin is the natural alternative[18]
Bracka staged hypospadias repairLong track record; comparable outcome to BMG with marginally inferior cosmesis[12]
Panurethral strictureKulkarni spiral graft can yield up to 20 cm of single-stage graft[7]
Combined long-segment defect requiring graft + flapSingle-stage harvest of both graft and flap from the same operative field[14]
Resource-limited settingFamiliar local tissue; no second surgical site[18]

When to avoid​

  • Lichen sclerosus — disease-process recurrence in the graft.[16]
  • Circumcised patients — donor tissue unavailable.[3]
  • Diseased or scarred penile skin — graft take compromised.
  • Hair-bearing skin — explicitly prohibited by AUA 2023.[6]

Key Takeaways​

Penile / preputial skin grafts remain a viable and effective option in reconstructive urology, with success rates statistically equivalent to buccal mucosa (PeeBuSt 89% vs 91%; Alrefaey 2025 93.2% vs 97.9%) in appropriately selected patients.[9][10] Their primary advantages are proximity to the operative field, hairlessness (inner prepuce), and availability when oral mucosa is unsuitable (oral dyskeratosis, limited oral opening, prior multiple buccal harvests). Their main limitations are longer operative time, higher post-void dribbling, contraindication in lichen sclerosus, unavailability in circumcised patients, and the AUA-mandated exclusion of hair-bearing skin from the urethra.[6] Contemporary GURS practice favors BMG as first-line, with penile / preputial skin reserved for the specific scenarios above.[3] Expertise in preputial-graft techniques — particularly the Kulkarni spiral graft for panurethral disease and the Bracka staged technique for proximal hypospadias — remains essential for the contemporary reconstructive urologist.[7][12]

See Also​

References​

1. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169–73. doi:10.1016/j.urology.2018.08.009

2. 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;published online. doi:10.1016/j.urology.2026.03.015

3. 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;191:139–43. doi:10.1016/j.urology.2024.06.019

4. Joshi PM, Bandini M, Kulkarni SB. Common flaps in genitourinary reconstruction. Urol Clin North Am. 2022;49(3):361–9. doi:10.1016/j.ucl.2022.04.001

5. Barbagli G, Palminteri E, Rizzo M. Dorsal onlay graft urethroplasty using penile skin or buccal mucosa in adult bulbourethral strictures. J Urol. 1998;160(4):1307–9.

6. 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

7. Kulkarni SB, Joshi PM, Basile G, Bandini M. Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique. World J Urol. 2023;41(9):2459–63. doi:10.1007/s00345-023-04514-9

8. Tyagi S, Parmar K, Sharma A, et al. Dorsolateral inner preputial graft urethroplasty for anterior urethral strictures: long-term outcomes from a single tertiary care centre. World J Urol. 2021;39(9):3549–54. doi:10.1007/s00345-021-03613-9

9. 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):475–81. doi:10.1007/s00345-021-03843-x

10. 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

11. Dubey D, Vijjan V, Kapoor R, et al. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007;178(6):2466–9. doi:10.1016/j.juro.2007.08.010

12. Manasherova D, Kozyrev G, Nikolaev V, et al. Bracka's method of proximal hypospadias repair: preputial skin or buccal mucosa? Urology. 2020;138:138–43. doi:10.1016/j.urology.2019.12.027

13. Cambareri GM, Yap M, Kaplan GW. Hypospadias repair with onlay preputial graft: a 25-year experience with long-term follow-up. BJU Int. 2016;118(3):451–7. doi:10.1111/bju.13419

14. Anadani A, Obaidin A, Badawi B, Lutfi MY. One-stage urethroplasty using a combination of buccal mucosa graft and Q penile skin flap for a complicated urethral stricture: a challenging case report. Medicine (Baltimore). 2025;104(12):e41888. doi:10.1097/MD.0000000000041888

15. Mathur RK, Nagar M, Mathur R, et al. Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: evaluation and determinants of success. BJU Int. 2014;113(1):120–6. doi:10.1111/bju.12361

16. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol. 2009;55(4):945–54. doi:10.1016/j.eururo.2008.07.046

17. Garaffa G, Shabbir M, Christopher N, Minhas S, Ralph DJ. The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature. J Sex Med. 2011;8(4):1246–53. doi:10.1111/j.1743-6109.2010.02165.x

18. Gn M, Sterling J, Sinkin J, Cancian M, Elsamra S. The expanding use of buccal mucosal grafts in urologic surgery. Urology. 2021;156:e58–65. doi:10.1016/j.urology.2021.05.039