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Quilting Stitch

The quilting stitch tacks an overlying flap, skin graft, or mucosal graft to the underlying tissue bed at multiple points — like the stitching of a quilt — to eliminate dead space, spread and fix the graft against its bed, and prevent contraction and folding. In reconstructive urology it has two distinct workhorse applications: flap fixation (scrotal/perineal reconstruction, phalloplasty) and graft fixation in urethroplasty (buccal mucosa, skin graft).[1][2][3][4]

Principles of Graft Survival​

Free grafts (buccal mucosa, split-thickness skin) survive through a predictable sequence:[5][6]

  1. Plasmatic imbibition (0–48 h) — graft absorbs plasma from recipient bed
  2. Inosculation (48–72 h) — graft vessels align with recipient bed vessels
  3. Neovascularization (days 4–7) — capillary ingrowth from recipient bed
  4. Maturation (weeks to months) — graft remodeling and epithelialization

Why quilting matters:[2][4][7]

  • Eliminates dead space → prevents seroma/hematoma between graft and bed
  • Maximizes graft–bed contact → essential for imbibition and vascular ingrowth
  • Prevents graft contraction and folding ("hanging" the graft)[7]
  • Distributes tension evenly, reducing edge failure

Suture Quilting in Urethroplasty​

The dominant application of graft quilting in reconstructive urology. Several named techniques define how the graft is placed and fixed.

Standard technique​

  1. Graft preparation — trim to size, remove excess submucosa to improve imbibition
  2. Apex fixation — secure proximal and distal apices first
  3. Edge suturing — continuous or interrupted sutures along lateral margins
  4. Quilting sutures — multiple interrupted sutures through graft center into the underlying bed (tunica albuginea, periosteum, or urethral margins)

Suture selection​

MaterialSizeApplicationAdvantages
Polyglactin (Vicryl)4-0 to 5-0Edge and quiltingBraided; good handling; predictable absorption
Polydioxanone (PDS)5-0 to 6-0Spread fixationMonofilament; longer tensile-strength retention
Poliglecaprone (Monocryl)5-0 to 6-0Delicate quiltingMonofilament; minimal tissue reaction

Dorsal onlay — Barbagli technique​

Urethra mobilized from the corpora cavernosa, opened dorsally, graft quilted to the tunica albuginea.[8][9]

  • Quilting sutures pass through graft → tunica albuginea → back through graft
  • Urethra rotated back to cover the graft
  • Success rate: ~88% at 42 months[9][10]

Dorsal inlay — Asopa technique​

Urethra opened ventrally, then incised dorsally through the stricture without mobilization; graft quilted into the dorsal defect through the ventral approach.[11][12]

  • No urethral mobilization
  • Shorter operative time (128 vs 205 min)[12]
  • Less blood loss (105 vs 228 mL)[12]
  • Success rate: 86–87% — equivalent to dorsal onlay[12]

Ventral onlay​

Urethra opened ventrally, graft quilted to the ventral bed with spongiosal coverage.[13][14][15]

  • Spongioplasty — corpus spongiosum advanced and closed over the graft
  • Pseudospongioplasty — when spongiosum is inadequate distally, periurethral tissue flaps are mobilized over the graft[16]
  • Success rate equivalent to dorsal onlay (80–84%)[16]
  • May have lower transient post-op erectile dysfunction (5% vs 25%)[15]

Double graft — Palminteri technique​

For tight/obliterative bulbar strictures, both dorsal inlay and ventral onlay grafts are used.[4][17]

  1. Urethra opened ventrally
  2. Dorsal urethra incised in midline to create raw area on tunica albuginea
  3. First graft quilted dorsally (dorsal inlay) to corpora
  4. Second graft quilted ventrally (ventral onlay) to urethral margins
  5. Spongiosum closed over ventral graft

Success rate: 88–90% at 22–49 months[4][17]

Transurethral quilting — fossa navicularis​

A minimally invasive approach for distal strictures.[1][18]

  1. Transurethral ventral urethrotomy to excise cicatrix
  2. Double-arm 6-0 PDS delivers triangular BMG to the proximal urethrotomy
  3. Graft secured to meatus with 5-0 polyglactin
  4. Additional 6-0 double-arm PDS sutures quilt the graft for spread fixation
  5. 16 Fr silicone catheter

Success rate: 95% at 36 months[1]

Quilting to periosteum — VUAS repair​

For vesicourethral anastomotic stricture after radical prostatectomy, the graft can be quilted to the pubic bone periosteum.[3]

  • Dorsal BMG sutured to bladder neck at 11, 12, and 1 o'clock
  • Interrupted dorsal quilting through periosteum over pubic bone using 4-0 Vicryl
  • Graft sutured to urethra in continuous fashion
  • Small-series success rate: 100% at 3 months[3]

Fibrin Glue Fixation​

Fibrin sealants combine fibrinogen and thrombin to form an adherent clot — mimicking the final stage of coagulation — and can replace or supplement suture quilting.[19][20][21]

Advantages over pure suture fixation: faster application, uniform graft–bed contact, no suture-related trauma, promotes angiogenesis.

Dorsal onlay BMG with fibrin glue (Barbagli)​

  1. Urethra mobilized and opened dorsally
  2. 2 mL fibrin glue applied to corpora cavernosa (recipient bed)
  3. BMG placed on glue bed
  4. Only 2 interrupted 5-0 polyglactin sutures fix graft apices to tunica albuginea
  5. Additional fibrin glue injected over urethra after rotation

Mean operative time 100 min; no restrictures at 12–24 months.[19]

One-stage penile urethroplasty with glue​

Oral graft "pasted" with fibrin glue to the recipient bed:[22]

  • Median operative time: 60 min
  • Success rate: 85.7% (12/14) at 16 months
  • No fistula or sacculation on VCUG
  • No chordee or sexual dysfunction

Experimental — fibrin glue + MSCs​

Fibrin glue combined with autogenic bone marrow mesenchymal stem cells improves neovascularization, enhances smooth muscle formation, and prevents urethral fistula in rabbit injury models.[23]

Barbed Sutures​

Unidirectional or bidirectional barbs grip tissue, eliminating knot tying and maintaining uniform tension.[24][25][26]

Vesicourethral anastomosis​

The most validated urologic application. Meta-analysis of 786 patients:[25]

  • Anastomosis time reduced by 3.98 min (p = 0.0001)
  • Operative time reduced by 10.06 min (p = 0.0003)
  • Leakage rate unchanged
  • Continence rates equivalent at 4–6 weeks, 3 months, and 6–12 months

RCT (Zorn):[24] barbed 13.1 min vs monofilament 20.8 min; need to readjust tension 6% vs 24% (p = 0.03); cost $48 vs $70 per case. Additional comparative data confirm equivalent stenosis rates and cost advantage,[27][28] with bidirectional barbed configurations showing similar continence outcomes to poliglecaprone with rhabdosphincter reconstruction.[29]

Barbed sutures for graft quilting​

Early but promising. Self-anchoring suture provides equivalent approximation strength to standard tied suture (13.2 vs 14.1 N) with watertight closure.[26] Theoretical advantages: continuous quilting without knot tying, uniform spread fixation, reduced operative time. Caveat: may induce more local fibrosis.

Staged Urethroplasty​

First stage — graft inlay and maturation​

Graft quilted to recipient bed and left to mature before tubularization.[30][31][32][33]

  1. Stricture excised or urethra opened ventrally
  2. Graft quilted to urethral bed / corporal bodies
  3. Lateral edges sutured to skin margins (marsupialization)
  4. Maturation: 4–6 months (BMG) or 8–12 weeks (mesh graft)[30][31]

Triangular extension technique at proximal/distal stoma prevents stomal stenosis between stages — reduces revision-surgery rate (0% vs 20%) and improves post-op Qmax (21.5 vs 15.8 mL/s).[34]

Second stage — tubularization​

  1. Urethral plate mobilized from surrounding skin
  2. Plate rolled into tube over catheter
  3. Multi-layer closure (mucosa, dartos, skin)
  4. Additional graft inlay if needed

Long-term outcomes:[33] BMG-only staged repairs — 96.4% success. STSG-containing repairs — 53% success. Median time to recurrence: 78 months (late failures common).

Skin Graft Fixation​

Tie-over bolster​

Traditional method for irregular surfaces.[35][36][37][38]

  1. Graft sutured to wound edges with long suture tails
  2. Bolster material (gauze, foam, proflavine-soaked gauze) placed over graft
  3. Suture tails tied over the bolster to compress graft to bed

TODGA (Tie-Over Dressing for Graft Application, penectomy/glans resurfacing): proflavine-soaked gauze bolster left 10 days, immediate patient mobilization, 97% graft uptake across 29 operations.[38] Modified extra-wound fixation variants reduce graft-edge trauma during dressing take-down.[39]

Negative pressure wound therapy (NPWT)​

Superior to tie-over bolster for irregular, high-mobility areas.[35][36] RCT:[36]

  • Overall graft take: 97.2% (NPWT) vs 90.2% (tie-over) — p = 0.005
  • Irregular/high-mobility areas: 97.6% vs 81.7% — p < 0.001

Eggcrate foam bolster — penile/genital reconstruction​

A structured alternative for high-risk genital reconstruction:[40]

  1. Bacitracin on nonadherent dressing
  2. Saline-moistened silver dressing
  3. Gauze layer
  4. Eggcrate foam (spikes toward wound)
  5. Penis extended; cylindrical bolster placed and stapled

21 patients: median graft take 100% through POD 14; 95% at days 15–30; 95% had impaired wound-healing factors.[40]

Flap Quilting — Scrotal and Perineal Reconstruction​

Distinct from graft quilting but uses the same mechanical principle: the flap is tacked to the underlying fascia at multiple points to eliminate dead space and prevent seroma.

Technique — after the flap is inset on the skin edges, place multiple interrupted or running sutures from the underside of the flap to underlying fascia or tissue bed. Grid pattern, typically 2–3 cm apart. Absorbable 3-0 or 4-0 Vicryl is standard.

Key uses:

  • Scrotal reconstruction after Fournier's gangrene — quilting the advancement or STSG to cord structures
  • Perineal reconstruction with local advancement flaps
  • Phalloplasty skin closure — reducing fluid collection beneath mobilized skin
  • Abdominal wall reconstruction adjacent to complex urologic cases
  • Groin / inguinal skin reconstruction where dead-space seroma is a known complication

Benefits: reduced seroma (primary), reduced flap ischemia from fluid collection, tension distribution across the flap–bed interface, often eliminates drain need.

Technical Pearls​

Graft preparation:[2][4][7]

  • Trim excess submucosa to improve imbibition
  • Fenestrate graft if seroma risk is high
  • Keep graft moist during preparation

Recipient bed:[16][19]

  • Ensure adequate hemostasis
  • Create a well-vascularized bed
  • Remove all scar tissue

Suture placement:[1][2][7]

  • "Hanging" sutures — anchor graft to surrounding tissue to prevent folding/retraction[7]
  • Spread fixation — multiple quilting sutures distribute graft evenly[1]
  • Avoid excessive tension — prevents graft ischemia
  • Mattress sutures provide better tissue approximation than simple interrupted
  • Mechanical "sewing-machine" devices — a handheld battery-powered suturing tool has been described to accelerate BMG quilting in deep, narrow fields (dorsal-onlay membranous urethroplasty, robotic subtrigonal inlay for BNC, augmented perineal urethrostomy) where conventional needle-driver quilting is slow and ergonomically unfavorable.[41]

Postoperative:[1][38]

  • Catheter drainage 1–3 weeks depending on procedure
  • Avoid pressure on graft site
  • Monitor for hematoma/seroma

Summary — method selection​

MethodBest applicationsNotes
Suture quiltingAll urethroplasty (Barbagli, Asopa, Palminteri); flap fixationGold standard; precise control
Fibrin glueDorsal onlay BMG; one-stage penile urethroplastyFaster; uniform contact; can pair with minimal suture
Barbed sutureRobotic VUA; emerging for graft quiltingKnotless; fast; watch fibrosis
Tie-over bolster (incl. TODGA)Penile skin grafts; glans resurfacingSimple; lower take in mobile areas
NPWTComplex wounds; irregular surfacesBest take in high-mobility areas
Eggcrate foamPenile/genital reconstruction, high-riskStructured NPWT alternative

See Also​

References​

1. 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

2. Gelman J, Siegel JA. "Ventral and Dorsal Buccal Grafting for 1-Stage Repair of Complex Anterior Urethral Strictures." Urology. 2014;83(6):1418-22. doi:10.1016/j.urology.2014.01.024

3. Shahrour W, Hodhod A, Kotb A, Prowse O, Elmansy H. "Dorsal Buccal Mucosal Graft Urethroplasty for Vesico-Urethral Anastomotic Stricture Postradical Prostatectomy." Urology. 2019;130:210. doi:10.1016/j.urology.2019.04.022

4. Palminteri E, Manzoni G, Berdondini E, et al. "Combined Dorsal Plus Ventral Double Buccal Mucosa Graft in Bulbar Urethral Reconstruction." Eur Urol. 2008;53(1):81-9. doi:10.1016/j.eururo.2007.05.033

5. Fukui A, Maeda M, Tamai S, Inada Y. "Proof of Plasmatic Imbibition in Rat Musculocutaneous Grafts: Enzymatic Proof Using Peroxidase." Plast Reconstr Surg. 1992;89(3):530-4. doi:10.1097/00006534-199203000-00022

6. El-Sherbiny MT, Abol-Enein H, Dawaba MS, Ghoneim MA. "Treatment of Urethral Defects: Skin, Buccal or Bladder Mucosa, Tube or Patch? An Experimental Study in Dogs." J Urol. 2002;167(5):2225-8.

7. Djordjevic ML, Kojovic V, Bizic M, et al. "'Hanging' of the Buccal Mucosal Graft for Urethral Stricture Repair After Failed Hypospadias." J Urol. 2011;185(6 Suppl):2479-82. doi:10.1016/j.juro.2011.01.036

8. 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.

9. Barratt R, Chan G, La Rocca R, et al. "Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which Technique Is Best? A Systematic Review." Eur Urol. 2021;80(1):57-68. doi:10.1016/j.eururo.2021.03.026

10. Mangera A, Patterson JM, Chapple CR. "A Systematic Review of Graft Augmentation Urethroplasty Techniques for the Treatment of Anterior Urethral Strictures." Eur Urol. 2011;59(5):797-814. doi:10.1016/j.eururo.2011.02.010

11. Pisapati VL, Paturi S, Bethu S, et al. "Dorsal Buccal Mucosal Graft Urethroplasty for Anterior Urethral Stricture by Asopa Technique." Eur Urol. 2009;56(1):201-5. doi:10.1016/j.eururo.2008.06.002

12. Aldaqadossi H, El Gamal S, El-Nadey M, et al. "Dorsal Onlay (Barbagli Technique) Versus Dorsal Inlay (Asopa Technique) Buccal Mucosal Graft Urethroplasty for Anterior Urethral Stricture: A Prospective Randomized Study." Int J Urol. 2014;21(2):185-8. doi:10.1111/iju.12235

13. Hassan AA, Soliman AM, Shouman HA, et al. "Dorsal- Vs Ventral-Onlay Buccal Mucosal Graft Urethroplasty for Urethral Strictures: A Meta-Analysis." BJU Int. 2025. doi:10.1111/bju.16811

14. Vasudeva P, Nanda B, Kumar A, et al. "Dorsal Versus Ventral Onlay Buccal Mucosal Graft Urethroplasty for Long-Segment Bulbar Urethral Stricture: A Prospective Randomized Study." Int J Urol. 2015;22(10):967-71. doi:10.1111/iju.12859

15. Mousa A, Eissa A, Raheem AA, Zoeir A. "Ventral Versus Dorsal Onlay Buccal Mucosal Graft Urethroplasty for Non-Traumatic Proximal Bulbar Urethral Strictures in Sexually Active Men: Erectile and Urinary Functions." World J Urol. 2025;43(1):87. doi:10.1007/s00345-025-05441-7

16. Cordon BH, Zhao LC, Scott JF, Armenakas NA, Morey AF. "Pseudospongioplasty Using Periurethral Vascularized Tissue to Support Ventral Buccal Mucosa Grafts in the Distal Urethra." J Urol. 2014;192(3):804-7. doi:10.1016/j.juro.2014.03.003

17. Palminteri E, Berdondini E, Shokeir AA, et al. "Two-Sided Bulbar Urethroplasty Using Dorsal Plus Ventral Oral Graft: Urinary and Sexual Outcomes of a New Technique." J Urol. 2011;185(5):1766-71. doi:10.1016/j.juro.2010.12.103

18. Farrell MR, Campbell JG, Zhang L, Nowicki S, Vanni AJ. "Transurethral Reconstruction of Fossa Navicularis Strictures With Dorsal Inlay Buccal Mucosa Graft Urethroplasty." World J Urol. 2022;40(6):1523-1528. doi:10.1007/s00345-022-03994-5

19. Barbagli G, De Stefani S, Sighinolfi MC, et al. "Bulbar Urethroplasty With Dorsal Onlay Buccal Mucosal Graft and Fibrin Glue." Eur Urol. 2006;50(3):467-74. doi:10.1016/j.eururo.2006.05.018

20. Barbagli G, De Stefani S, Sighinolfi MC, et al. "Experience With Fibrin Glue in Bulbar Urethral Reconstruction Using Dorsal Buccal Mucosa Graft." Urology. 2006;67(4):830-2. doi:10.1016/j.urology.2005.10.033

21. Evans LA, Morey AF. "Hemostatic Agents and Tissue Glues in Urologic Injuries and Wound Healing." Urol Clin North Am. 2006;33(1):1-12, v. doi:10.1016/j.ucl.2005.10.004

22. Barbagli G, Pellegrini G, Corradini F, et al. "One-Stage Penile Urethroplasty Using Oral Mucosal Graft and Glue." Eur Urol. 2016;70(6):1069-1075. doi:10.1016/j.eururo.2016.04.025

23. Wang K, Guan Y, Liu Y, et al. "Fibrin Glue With Autogenic Bone Marrow Mesenchymal Stem Cells for Urethral Injury Repair in Rabbit Model." Tissue Eng Part A. 2012;18(23-24):2507-17. doi:10.1089/ten.TEA.2011.0359

24. Zorn KC, Trinh QD, Jeldres C, et al. "Prospective Randomized Trial of Barbed Polyglyconate Suture to Facilitate Vesico-Urethral Anastomosis During Robot-Assisted Radical Prostatectomy: Time Reduction and Cost Benefit." BJU Int. 2012;109(10):1526-32. doi:10.1111/j.1464-410X.2011.10763.x

25. Li H, Liu C, Zhang H, et al. "The Use of Unidirectional Barbed Suture for Urethrovesical Anastomosis During Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis of Efficacy and Safety." PLoS One. 2015;10(7):e0131167. doi:10.1371/journal.pone.0131167

26. Weld KJ, Ames CD, Hruby G, Humphrey PA, Landman J. "Evaluation of a Novel Knotless Self-Anchoring Suture Material for Urinary Tract Reconstruction." Urology. 2006;67(6):1133-7. doi:10.1016/j.urology.2005.12.022

27. Massoud W, Thanigasalam R, El Hajj A, et al. "Does the Use of a Barbed Polyglyconate Absorbable Suture Have an Impact on Urethral Anastomosis Time, Urethral Stenosis Rates, and Cost Effectiveness During Robot-Assisted Radical Prostatectomy?" Urology. 2013;82(1):90-4. doi:10.1016/j.urology.2013.02.002

28. Sammon J, Kim TK, Trinh QD, et al. "Anastomosis During Robot-Assisted Radical Prostatectomy: Randomized Controlled Trial Comparing Barbed and Standard Monofilament Suture." Urology. 2011;78(3):572-9. doi:10.1016/j.urology.2011.03.069

29. Cakici OU, Canda AE. "Bidirectional Barbed Only vs Poliglecaprone Suture With Rhabdosphincter Reconstruction for Urethrovesical Anastomosis During Robotic Radical Prostatectomy: Does It Make Any Difference?" J Endourol. 2018;32(10):944-949. doi:10.1089/end.2018.0386

30. Reichert M, Aragona M, Soukkar A, Olianas R. "Mesh Graft Urethroplasty—Still a Safe and Promising Technique in Mostly Unpromising Complex Urethral Strictures." J Clin Med. 2022;11(20):5989. doi:10.3390/jcm11205989

31. Figler BD, Gomella A, Hubbard L. "Staged Urethroplasty for Penile Urethral Strictures From Lichen Sclerosus and Failed Hypospadias Repair." Urology. 2018;112:222-224. doi:10.1016/j.urology.2017.10.020

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33. Furr JR, Wisenbaugh ES, Gelman J. "Long-Term Outcomes for 2-Stage Urethroplasty: An Analysis of Risk Factors for Urethral Stricture Recurrence." World J Urol. 2021;39(10):3903-3911. doi:10.1007/s00345-021-03676-8

34. Azuma R, Horiguchi A, Ojima K, et al. "Triangular Extension of Hinge Flaps: A Novel Technique to Resolve Stomal Stenosis and Prevent Restenosis in Staged Buccal Mucosal Urethroplasty." Int J Urol. 2021;28(8):806-811. doi:10.1111/iju.14582

35. Patel BJ, Asher CM, Bystrzonowski N, Healy C. "Safeguarding Skin Grafts: An Evidence-Based Summary of Fixation Techniques." Ann Plast Surg. 2021;87(6):e180-e188. doi:10.1097/SAP.0000000000002937

36. Cao X, Hu Z, Zhang Y, et al. "Negative-Pressure Wound Therapy Improves Take Rate of Skin Graft in Irregular, High-Mobility Areas: A Randomized Controlled Trial." Plast Reconstr Surg. 2022;150(6):1341-1349. doi:10.1097/PRS.0000000000009704

37. Marsidi N, Boteva K, Vermeulen SAM, van Kester MS, Genders RE. "To Tie or Not to Tie-Over Full-Thickness Skin Grafts in Dermatologic Surgery: A Systematic Review of the Literature." Dermatol Surg. 2021;47(1):18-22. doi:10.1097/DSS.0000000000002549

38. Malone PR, Thomas JS, Blick C. "A Tie-Over Dressing for Graft Application in Distal Penectomy and Glans Resurfacing: The TODGA Technique." BJU Int. 2011;107(5):836-840. doi:10.1111/j.1464-410X.2010.09576.x

39. Liu Q, Liu X, Ho IH, Guan S. "Extra-Wound Fixation: A Modified Tie-Over Dressing Technique for Skin Graft." J Wound Care. 2020;29(Sup12):S23-S27. doi:10.12968/jowc.2020.29.Sup12.S23

40. Richards P, Yadav K, Coakes C, et al. "Rook to the Rescue: A Case Series on the Novel Use of Eggcrate Foam Bolsters for Skin Grafts in Penile and Genital Reconstruction." Ann Plast Surg. 2026. doi:10.1097/SAP.0000000000004649

41. Schardein J, Scott KA, Bratslavsky G, Blakley S, Nikolavsky D. "A Surgical 'Sewing Machine' for Rapid Graft Quilting and Suturing in Challenging Spaces." Urol Video J. 2020;6:100027. doi:10.1016/j.urolvj.2020.100027